Almost ten years ago I spoke of the biggest problem facing us psychiatrists.....

[blue.jay]

All that is required to cure mental illness is heart of a nurse and the prescription rights of a psychiatrist.

---

Members don't see this ad.

 

[myPsychAlt]

It's kind of telling that the the only time I end up thinking about NPs are when I log onto SDN or the occasional bananas Rx that comes in every 6 months or so from intake

When I'm not on here it's mostly just me living in a job market that's only gotten better and more lucrative for me since residency.

 

[psychic_hearts]

I always assumed that insurance rates going up for hospitals after the increase in NP malpractice cases and their increased ordering of unnecessary tests would be a balancing factor as well as likely a decreased reimbursement rate for NPs (theirs is now 85% of ours for medicare which seems pretty ridiculous given the deficit in training but they will likely continue to lobby for rates equal to ours as theirs plunge due to their MANY future malpractice cases. Do insurance companies really wanna eat all the costs they create? People on here feel that these insurance pushbacks are a "drop in the bucket" compared to their overall threat. So we need to lobby more effectively and go above the ineffectual APA which has sided with them. Have read many people drop their membership due to their lack of lobbying against the NP threat. Im a resident member but also joined a different group that was founded for the purpose of lobbying against midlevel encroachment. I also dont understand why many on here minimize their threat, say "im just happy I did blablabla. Its only a threat for the new grads." This is the attitude that continues to allow them to make gains at physician and patient expense and is pretty selfish.

 

[Bartelby]

I agree with PsychApp777, these concerns seem overblown. Taking a look at some of the posters mentioning how dire the threat is, Vistaril mentioned in another thread making >$400k per year not working "that hard," and finalpsychyear above mentions working working 30-35 hours per week for less than 10 years and reaching financial independence. My experience has also been that even in an in-demand area (many people want to move where I am, which should make employers less desperate) I could easily find many jobs paying from $240k/yr to mid-low $300k/yr, and if I wanted I could easily add high-paid moonlighting on top of that. I currently make a salary I am quite happy with working a true 40-hour week, which works for me.

That is not to say the NP issue may not eventually decrease salaries. That seems possible, and with how expensive medical care has become generally as a share of GDP I think all physicians need to brace for the possibility of income reduction one way or another. There is a lot of political motivation to bring prices down, and I think financial independence is a great goal for everybody given that no one really knows our personal or collective futures. Still, warning medical students away from the field or acting like psychiatry is already in dire straights seems extreme. If anything, my physician colleagues tend to be pretty jealous of the lifestyle I have in psych, and I don't see that changing any time in the near future.

 

[Bartelby]

Also from an administrative perspective, all of the psychiatric NPs I have worked with took longer while doing a lower-quality job than the psychiatrists (I worked with them in the ER and on consults). Given that their salary is not *that* low, I am not convinced the hospital even saved money short-term.

 

[TexasPhysician]

A large hospitalist group I know is looking into replacing 1/2 of their IM hospitalists with midlevels. That’s just scary. If I’m ever admitted to a hospital, I hope my wife ensures I get a physician. The pay and shift work will be a huge draw for midlevels.

 

[Splenda88]

Let's be honest here guys! The system has failed us. 11-12 years training is overkill to become a PCP/psychiatrist. 8-9 (3 yrs prerequisite, 3 yrs med school and 2-3 yrs residency) years would have been good enough. Don't blame the nurses for being smarter than us.

 

[splik]

Also from an administrative perspective, all of the psychiatric NPs I have worked with took longer while doing a lower-quality job than the psychiatrists (I worked with them in the ER and on consults). Given that their salary is not *that* low, I am not convinced the hospital even saved money short-term.

This is my experience. We are learning that NPs are not cheaper than physicians, and are less productive. Our NPs are unionized as well which makes them more of a nuisance for the administration than physicians. On my service an NP costs nearly 250k which is as almost as much as a physician, for fewer hours worked and far less productivity and versatility. We were recently looking for a locum NP and they have outpriced themselves. most of the candidates in addition to being totally unqualified, were ridiculously entitled and demanding. I found it very offputting. Because of the huge increase in training of NPs in the past few years most NPs on the market now have little or no nursing experience, are fresh out of their programs, and most of these programs are online. In some markets at least, their increasing costs is making them less attractive. I was told by one of our graduating NP students the typical rates for a newly minted NP is 160-200k with pay increasing with experience...

 

[calvnandhobbs68]

As a psychologist reading this thread, it seems to parallel our issues with midlevels taking over psychotherapy practice and organizations being able to pay them far less with subpar training as well. In my cash pay private practice, a master’s level social worker charges the same fee that I do with 3-4 years less training overall before licensure, and what I charge is actually sort of above what the market will bear in my area (few can pay my rate out of pocket, and it’s about 1/2 of what local psychiatrists charge although I’ve been in school/training for a total of 12 years from bachelor’s to master’s to doctorate and postdoc).

I do find it interesting that someone pointed out that NPs have no psychotherapy training, because I was under the current system, psychiatrists have far less psychotherapy training than psychologists. Much in the same way that most psychiatrists don’t want psychologists encroaching on prescribing rights, I think the same can be said about psychiatrists with minimal training in psychotherapy practicing psychotherapy.

Ultimately, though, we are both facing similar problems, and this seems to be a major issue among several career tracks in the medical/mental health field: organizations choosing the bottom line over quality care. Both your APA and our APA have failed to lobby effectively protect our niche, perhaps? It’s a hard sell to do so when midlevel lobbyists can argue that it’s more cost effective to hire midlevels. Then again, I‘d like to see the numbers on lawsuits of midlevels vs. PhDs/PsyDs and MDs (both total numbers and per capita) to see if there is any data to Indirectly back up the argument about quality of care. Not sure if anyone has this data floating around, but I’d love to see it.

I agree it's very similar to the psychologist vs LPC/social worker therapy situation. In terms of therapy training, psychiatrists may have minimal therapy training but it's honestly leaps and bounds above what you see with most of these psych NP programs...like even if I haven't formally trained in the modalities I can at least tell someone what CBT, psychodynamic, psychoanalytic, DBT, MI, ACT, etc etc approaches are and think about what they might benefit from. From my experience, the psychiatrists who go out and do a certain proportion of actual discrete therapy as part of their practice go get extra training either during residency or right afterwards.

I'm NOT talking about the psychotherapy add-on code which is basically there to capture billing to make our 30 min visits equivalent to other specialities since we spend half our time talking about social issues/doing basic MI techniques with patients. Nobody's pretending that's psychologist level "therapy" there.

Honestly same thing is happening to nurses and they're all pissed about it, which is the definition of ironic. CNAs are trying to expand their scope and RNs are pushing back with a "don't you want a real nurse taking care of you" campaign.

 

[Stagg737]

So, is there any way that current residents can expect to still find compensation of ~250k+ throughout their attending career despite the midlevel surge? I have a very high student debt burden and have been banking on making at least low 200s outside of academia; this thread is frightening, and I haven’t really seen many people expressing any disagreement that this is a big problem. I realize no one can predict the future, but I’m curious about people’s opinions on what could happen to compensation in terms of actual numbers. Is it likely that psychiatrist salaries could decrease to that of an NP’s, or NP’s increase to that of a psychiatrist’s? etc. What has happened in other specialties that have been facing this problem longer?

I really love psychiatry and part of the reason I went into it is because of the awesome job market compared to other specialties. Now this.... great! Just my luck

I wouldn't be as worried. If you're geographically flexible and willing to work in private practice or start your own practice the money will be there for many years. Yes, there are areas that are hurting because of mid-level encroachment, but other areas are sticking to docs or only hiring NPs at rates too low for them to accept. One of our nurses on the psych unit has had her NP degree for 2 years and has been unable to find a job since getting the degree. Meanwhile, there are a couple dozen openings for psychiatrists in the area. This may be due to me being in a state that does not allow FPA for mid-levels (this being the most important stand for any field of medicine to take IMO).

Also, a large chunk of my new patients/consults (maybe 1/3) are coming to our clinic to be treated by residents because they were previously seen by mid-levels who weren't helping. Some of the medication regimens I've seen are terrifying and probably worthy of being reported to the state boards. Given how bad most of the ones I've come across are at actually treating mental illness, I'm not overly concerned for my future job prospects yet.

If there aren't too many psychiatrist, then PMHNPs will take over the roles of psychiatrist and who knows in 20 years psych might become a nurses job. After all what is the point of studying most of basic sciences in medschool (anatomy, biochemistry, pathology) to practice psychiatry.

Strongly disagree. As I said above in the second paragraph, the quality of PMHNP I've seen is atrocious overall. Unless the quality of education changes drastically soon, I don't see that changing. We may get pushed out of many salaried positions, but at the same time psychiatry is in the best position of any field to make private practice work . I'm not saying there is no threat or that we shouldn't be lobbying hard to stop as much of this garbage encroachment and inappropriate practice as possible. I do think it's important to maintain perspective on the reality of the situation though.

 

[calvnandhobbs68]

This is my experience. We are learning that NPs are not cheaper than physicians, and are less productive. Our NPs are unionized as well which makes them more of a nuisance for the administration than physicians. On my service an NP costs nearly 250k which is as almost as much as a physician, for fewer hours worked and far less productivity and versatility. We were recently looking for a locum NP and they have outpriced themselves. most of the candidates in addition to being totally unqualified, were ridiculously entitled and demanding. I found it very offputting. Because of the huge increase in training of NPs in the past few years most NPs on the market now have little or no nursing experience, are fresh out of their programs, and most of these programs are online. In some markets at least, their increasing costs is making them less attractive. I was told by one of our graduating NP students the typical rates for a newly minted NP is 160-200k with pay increasing with experience...

People should go look at the NP subreddit for the past couple months as well. Like every other day there's a post along the lines of "Just got fired from my urgent care/ED/primary care clinic, who's hiring right now?". I just got an email recently asking if I knew about any available psych NP positions from a recruiting company. What's playing out right now is that NPs are the ones who get let go first when volume goes down (esp in a clinic setting) bc the physicians will just absorb and consolidate all the remaining patients (and are typically willing to see more patients as well, so they can pay one person to see everyone left rather than two people to see half the patient load each).

 

[calvnandhobbs68]

A large hospitalist group I know is looking into replacing 1/2 of their IM hospitalists with midlevels. That’s just scary. If I’m ever admitted to a hospital, I hope my wife ensures I get a physician. The pay and shift work will be a huge draw for midlevels.

Agreed but IMO these are the MOST vulnerable positions, not the outpatient side. It's the hospital based, hospital employed positions that are going to end up being very vulnerable (ER, Gas, Hospitalist, hospital based specialist consult services). Why? Because they have no patient base and patients have no choice about who they see. If you even have a halfway decent outpatient doctor and they get straight up replaced with an NP, patients end up pissed off...I mean patients get pissed when residents rotate out of clinics every year much less someone they've seen for 10 years get replaced. Patients also have choice in the outpatient setting. I don't get to choose who sees me in the ER or who rounds on me on the medicine floor (and honestly if you tried, the answer would just be "too bad, that's who's rounding today" unless you're a VIP or something). Lack of actual patient base, hospital employment and lack of patient choice are all major problems when you're thinking about NP encroachment.

Also "collaboration" is way easier. You have a whole hospital system with a whole crew of employed physicians. You just tell them all either they have to "collaborate" and sign off the charts of a certain number of midlevels or else they can find another job. Simple from an admin perspective.

 

[Stagg737]

Agreed but IMO these are the MOST vulnerable positions, not the outpatient side. It's the hospital based, hospital employed positions that are going to end up being very vulnerable (ER, Gas, Hospitalist, hospital based specialist consult services). Why? Because they have no patient base and patients have no choice about who they see. If you even have a halfway decent outpatient doctor and they get straight up replaced with an NP, patients end up pissed off...I mean patients get pissed when residents rotate out of clinics every year much less someone they've seen for 10 years get replaced. Patients also have choice in the outpatient setting. I don't get to choose who sees me in the ER or who rounds on me on the medicine floor (and honestly if you tried, the answer would just be "too bad, that's who's rounding today" unless you're a VIP or something). Lack of actual patient base, hospital employment and lack of patient choice are all major problems when you're thinking about NP encroachment.

Also "collaboration" is way easier. You have a whole hospital system with a whole crew of employed physicians. You just tell them all either they have to "collaborate" and sign off the charts of a certain number of midlevels or else they can find another job. Simple from an admin perspective.

Agree with most of this except the bolded, at least for psychiatry. I feel like a large portion of inpatient psych consults are either for capacity or "we gave this very agitated and possibly delirious patient Haldol/Ativan and they're still agitated, help!" Neither of which I think would be appropriately managed by NPs and have a high enough liability risk to the hospital that most admins will want to be able to say that a psychiatrist (seen as an expert, even if not) managed that aspect of the patient's care. I could certainly see hospitals hiring NPs as part of those teams to cover the lower liability cases that likely just need referral for outpatient follow-up, but at least where I'm at the major behavioral problems and issues covering high legal liability are going to give physicians job security for a while.

Would be interested to hear if others have similar experiences thoughts in their locations (I'm in midwest).

 

[Sushirolls]

I've seen NPs doing full hospital C/L work, and Admin and the Psychiatrist Med Dir were totally fine with it.

Big Box Shops will essentially keep one Medical Director physician around for the specialty, and replace most if not all with mid-levels.

Best for Physicians to start opening up their own practices now while things are already slow during a Covid-19 down turn, perfect timing.

Don't like it? Then be the boss, reclaim your profession and your future.

1) Don't supervise or train ARNP
2) End CMS funding for GME - this reliance on funds is choking our GME system with the concept of 'golden handcuffs'
3) petition states to reduce licensure requirements from PGY 1 (or 2), to that of Medical school graduates, and to drop step/level III
4) Ramp up MD/DO schools and/or class sizes, flood the market with MD/DO grads who will then become the new mid levels
5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection
6) Create medical groups that advertise they are physician only

 

[Hosut]

Why dont more docs reap the benefit of supporting PA practice. I see the trend of PAs being replaced with NPs. Physicians fail to realize that PAs are their answer to compete with the growing number of Np providers. Support legislation that allows PAs independent but collaborative practice and use the PAs to offset the changing /decreasing profitability of being an MD. PAs are being pushed out and if it continues as is, PAs wont be and option for you as hospital systems are heavily controlled by nursing amd already changing. They are not hiring PA s because of administrative burdens. If you have licensed independent coolaborative PAs, you have a collaborative team yet less legal responsibilty. It's a win win. Otherwise you will see more practices gobbled up by NP only groups. That is writing on the wall my friends. Guaranteed. Why wouldnt 1 physician use 2 or 3 PAs and siphon off that agreement. Pa's are trained by physicians, have a strong tie, amd help you guys level the playing field. I'm not against NPs, my daughter will be one, I actually see one. The seasoned ones are pretty good.
But I think if you are complaining about NPs taking over, why are you collaborating with them in the psych realm and not collaborating with PAs? Its nearly impossible for PAs to break into psych. PAs are your answer. I mean if yourcomplaining, you camt change the legislation. what you can do is use the available tools (PAs) to keep the practice in your hands. Independence but collaboration gets PAs in the door of health systems but then at least you have a group that supports physician leadership and the team. Not clamdestinely usurping it. For those that train and collaborate with psych NP friends, what happens to your pay when they domt need collaboration? Your fired. Basically use PAs, its really your viable option. No I domt wish to put NPs out of business (my daughter is going to be one) I'm saying if your complaining, why squash and forget about PAs or let the practice tell you what to do? Why not form a strong alliance with a couple of PAs? If the hospital generates the salary pool to cover say 750k in provider salaries, Why not use 2 PAs, pay them 125-150 and you keep the 500k? As a Pa , I generate 3 to 400k collections, not including all the revenue I generate that are transparent and the spin off revenue!! Its huge. You get ALOT of practice leverage with an independemt but collaborative Pa. What stops businesses in the states that have independent NP practice from.saying "we domt need the doc, and hire one more Np. Then boom they made the practice a huge portion of of what was your salary amd the NPs get raises as well.
I see some of you guys slamming PAs on here, i.e Assistants, never have independence (w collaboration) why get a doctorate as a PA, etc.. but your really shooting yourselves in the feet. You've lost control in 40 states and soon all 50. Other than complaining, what's the reasonable viable answer to keeping your MD/DO cash value for a business/health system, etc?
PAs!!!! Trained medicine, strong MD /PA team core value, we just need "independence " w collaboration. It benefits us an equal footing to get jobs as the NPs. It Benefits docs as it frees the physician from legal responsibility for all actions of PA, only actions/outcomes the PA presents to the doctor. Plus by supporting Pa MD Optimal team practice You can still dictate at a practice level, AND since PAs value physician ties, this collaboration will give you better leverage with the bean counters.

Do you guys not see this? Am I wrong? I'm open to constructive criticism. Just dont blast me.


So have u asked yourself, what's the answer to these complaints of NP advancement? Nursing is the single most aggressive political lobbying machine I've ever seen. Hell, I'd rather battle the Teamsters. I'm offering an Idea thats a viable option, IF you guys want to stand up for what you want and not just complain, consider being more vocal about hiring PAs and support PA legislature for optimal team practice. It frees liability, keeps collaboration, and strengthens your team. Just as the initial poster said they could see it coming, I can see it as well. I think this is a good option to consider. Id Love to.hear your thoughts?

God Bless
..

 

[Hosut]

Sorry for spelling/syntax im tryng this on my phone wo glasses and I have eyes that are creeping up on 50 years.

Also, I'm just stating this as facts and wjat I see as an option.. I'm not going to be I medicine forever. I have other irons In the fire. So none of this is Coming from self servimg place. Its altruistic. Not saying to put Nps out either. Physicians need to use PAs to balance this out. I love the docs I work w, I love the NPs amd PAs I work with. Im speakimg from a business standpoint. you guys are lost a huge amount of ground and your not really gonna get it back u less you create a value based team that you have control over at a practice level.

 

[Basis]

I've seen NPs doing full hospital C/L work, and Admin and the Psychiatrist Med Dir were totally fine with it.

Big Box Shops will essentially keep one Medical Director physician around for the specialty, and replace most if not all with mid-levels.

Best for Physicians to start opening up their own practices now while things are already slow during a Covid-19 down turn, perfect timing.

Don't like it? Then be the boss, reclaim your profession and your future.

1) Don't supervise or train ARNP
2) End CMS funding for GME - this reliance on funds is choking our GME system with the concept of 'golden handcuffs'
3) petition states to reduce licensure requirements from PGY 1 (or 2), to that of Medical school graduates, and to drop step/level III
4) Ramp up MD/DO schools and/or class sizes, flood the market with MD/DO grads who will then become the new mid levels
5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection
6) Create medical groups that advertise they are physician only

Definitely agree with this. Especially 2, 5, and 6. I am very much against midlevels, and I consider them to be illegally practicing medicine without the proper education and license. I also try to avoid the word 'provider' and will always make sure to use the word physician to refer to residents/attendings whenever possible. Sometimes I slip up because we would be writing 'provider' like a dozen times a day in notes in residency.

Similar to most people on this forum, I worked my absolute hardest all the way from university to med school to residency. Don't get me wrong, I was never some gunner or workaholic, but the sheer amount of determination, hard work, and resilience it takes to get through medical education is absolutely ridiculous. There are no shortcuts to becoming a doctor.

Anything that is a big hospital chain or corporately run is going to get more swamped by midlevels in the coming years. Who knows if they will collapse or how that'll go. It's honestly scary having to think of ever ending up in the ER being treated by a non-physician.

 

[randomdoc1]

I am in private practice. I've inherited a lot of train wrecks from patients who previously saw NPs. very scary that is the future of medicine.

Well, I try to make lemonade out of this situation. One nice thing about having so many NPs is that if you need to transfer a pt, there’s always an NP willing to take it since they’re so ignorant of the risk they’re taking on. I’ve had to close off the relationship for various reasons and you gotta love it when pts make no effort to find a new provider and act like they have to stay with you. I give them the NP info and a firm termination date. If med management is the risk NPs wanna take, let them have it. Let them dig their own graves. In private there is just no shortage of good patients and most of the ones you want to work with know the difference and far prefer the MD.

also on this note, I’m not a fan of a lot of the LPCs I’ve come across. Low quality therapy if you even want to call it that and poor diagnostics. Patients I’ve worked also know the difference and prefer the doctorate.

All that is required to cure mental illness is heart of a nurse and the prescription rights of a psychiatrist.

Roflcakes! Ugh, if patients only knew the unresolved conflicts so many of them have, huge chips on the shoulder, lack of brains, and poor psychological insight causing countertransferance and boundary crossing and negatively affecting quality of care...
There’s certainly good NPs but tons of cases of horrid care where I frankly feel the pt would have been better off not establishing care at all.

 

[finalpsychyear]

I've seen NPs doing full hospital C/L work, and Admin and the Psychiatrist Med Dir were totally fine with it.

Big Box Shops will essentially keep one Medical Director physician around for the specialty, and replace most if not all with mid-levels.

Best for Physicians to start opening up their own practices now while things are already slow during a Covid-19 down turn, perfect timing.

Don't like it? Then be the boss, reclaim your profession and your future.

1) Don't supervise or train ARNP
2) End CMS funding for GME - this reliance on funds is choking our GME system with the concept of 'golden handcuffs'
3) petition states to reduce licensure requirements from PGY 1 (or 2), to that of Medical school graduates, and to drop step/level III
4) Ramp up MD/DO schools and/or class sizes, flood the market with MD/DO grads who will then become the new mid levels
5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection
6) Create medical groups that advertise they are physician only

All of the above and also don't take the existing opportunity for granted. Starting PP is no joke and takes balls and courage and you may be not making as much $ as otherwise but to the bold goes the gold. I guarantee that 10 years from now your PP will at a minimum make more what you would have over the standard pay in the same 10 year period including the build up!!

We will come back to this forum and prospective students will bump threads like how did these guys know the end was only 10 years away...

Bottom line i keep telling everyone and no one believes or listens. Most admin or hospital with some exceptions are not really going to distinguish NP and psych in the next few years. It will be a simple psych med director with maximum NP minions under him and don't be surprised with full autonomy and even scratch the psych med director. If your looking at dollars only and forget about actual quality of care it makes business sense which is all these folks care about.

If I am wrong oh well. If you watch "the last dance" you'll see Jordan used to make up shiit to motivate himself.

 

[randomdoc1]

@finalpsychyear I second that! It is totally worth the investment and a way for us physicians to gain back our autonomy! Focus on what we are passionate about, negotiate fee schedules, make our vision a reality and show what we are really about. My patients know I'm no candy man and in PP it's much easier to hold your ground and go the evidence based approach than feel like you have to churn RVUs to make the higher ups rich. And medicine is precisely about care, it should not be treated like a service industry in much the same way A PASSENGER doesn't dictate a pilot how to fly the plane just because they want to get somewhere faster.

As many have seen in my other posts, I'm not even two years into starting my practice and my income has already nearly doubled with a cut down in the actual hours worked per year. It IS worth it and it's time for physicians to claim their territory back. From mid levels, admin, insurance companies, etc. Although I bill insurance, you CAN prove your worth and get paid what you actually deserve.

 

[birchswing]

it should not be treated like a service industry in much the same way you don't dictate a pilot how to fly the plane.

Ask your pilot if flying at 50,000 feet is right for you on your next vacation.

The rubicon has been crossed. There are web-sites now where all they do is rubber stamp the med you want and send it directly to you.

I sometimes wonder what innovations might occur if no one needed authorization to provide medical treatment, if the market were totally opened up. There would be disasters but probably also some new efficiencies and solutions. I feel like there would probably be new private thought schools of medicine that would open up, like in ancient civilizations where you had competing philosophies. Right now there's just medicine (and chiropractic). But what if everyone had access to work in the areas that that medicine now has exclusive claim to. It's hard to think through it. I'm not saying it should happen. I think interesting things could happen, though.

I don't know if you all have seen but the last two big drug recalls were caught by a private pharmacy up in Maine that tests all the meds they distribute. They caught Zantac and metformin. The ineffective Wellbutrin XL tablets were caught by ConsumerLab, another private for profit company.

 

[clausewitz2]

much the same way you don't dictate a pilot how to fly the plane.

Uh, you might want to reconsider that metaphor. Pilots get told how to fly their planes all the time. There is a forest of regulation about exactly when, where, and how they can fly. They have to file flight plans detailing their routes every time they want to go up in the air. Also, what do you think air traffic controllers do? There is a whole international system of people on the ground telling them what to do and where to go that they are in constant contact with.

Pilots are really not the comparison you want to be making.

 

[randomdoc1]

Uh, you might want to reconsider that metaphor. Pilots get told how to fly their planes all the time. There is a forest of regulation about exactly when, where, and how they can fly. They have to file flight plans detailing their routes every time they want to go up in the air. Also, what do you think air traffic controllers do? There is a whole international system of people on the ground telling them what to do and where to go that they are in constant contact with.

Pilots are really not the comparison you want to be making.

I'm talking about a passenger. Regulation and safety is one thing. A passenger telling you to fly faster because they want to get somewhere faster is another.

Fine, here's the other metaphor. It ain't a fast food chain where you can "have it your way," and the places that go by that motto ... the quality of the care speaks for itself.

 

[birchswing]

I might have told the story before about how my very first psychiatrist used that exact line on me, "You don't tell the pilot how to fly the plane do you?" I was asking about what the medicine was he was prescribing and the side effects, which he did not like. He said I would never take an aspirin if I knew the side effects (and this was accurate: I never took anything for headaches because I was scared of pills and didn't see the point since the headache would go away anyway). I can't remember exactly what I said that led to the pilot line. But I know it was something about wanting to know what I was taking. It was Ativan, and retrospect it would have been good to know a lot about that. He used a lot of metaphors in that one brief session. I remember the other one he gave was one to my dad (who was at the appt with me). He said something about us having two choices. We could round up all the horses and get them in the barn fast. Or we could get some in right away and the rest later. It doesn't hold up to memory well.

For reference I went to see him because I thought my extreme anxiety in school was because I and everyone around me perceived me as gay and I was being bullied and started developing a feeling like I couldn't breathe at school (to which he told me to never tell anyone again I might be gay--which given the school I went to was not bad advice for the times). Being anything other than monosyllabic at that school meant, "You talk like a f**." It didn't have anything to do with rounding up horses.

I do generally trust pilots. They generally land planes. There was one rogue pilot a while back who crashed the plane on purpose. But generally I don't think there's as much to worry about as there is with medical care. Probably because in medicine the stakes are lower. It's kind of hard to kill someone with a psychiatric drug unless you're really going out of your way to do it, and if you significantly hurt someone's quality of life or misdiagnose them, etc., there's not really any recourse and it may not be evident for years to come and by that point it's all sort of a fog of war type thing.

 

[PikminOC]

I'm talking about a passenger. Regulation and safety is one thing. A passenger telling you to fly faster because they want to get somewhere faster is another.

Fine, here's the other metaphor. It ain't a fast food chain where you can "have it your way," and the places that go by that motto ... the quality of the care speaks for itself.

Yes you are right. As physicians we deal with alot of regulation just like a pilot does. But it's from the board of med, not patients

 

[PikminOC]

Nps are setting up lots of private practices near me. They are obgyns one year, then do 300 hours of shadowing, and become a psych np. They are making alot of money as they bill insurance under a "collab" doc who has many of these agreements and is 50 miles away.

 

[PikminOC]

APA should do something but instead sides with NPs. Psychiatry residency should be 3 years instead of 4 but APA does nothing.

Psych nurses treat 6 years olds on up. That's an extra 2 year child fellowship for an md Psychiatrist

 

[PikminOC]

"concerned"? what does this mean??? there's little you can do about large scale movements in medicine.

I actually think fellowship training is one of the few ways to hedge this risk.

But nurses treat 6 yo and up. So even cap isn't safe

 

[PikminOC]

I'm talking about a passenger. Regulation and safety is one thing. A passenger telling you to fly faster because they want to get somewhere faster is another.

Fine, here's the other metaphor. It ain't a fast food chain where you can "have it your way," and the places that go by that motto ... the quality of the care speaks for itself.

There's always another "provider" who will give a patient what they want. And the patient will consider that "quality care"

 

[Psychferlyfe3000]

I always assumed that insurance rates going up for hospitals after the increase in NP malpractice cases and their increased ordering of unnecessary tests would be a balancing factor as well as likely a decreased reimbursement rate for NPs (theirs is now 85% of ours for medicare which seems pretty ridiculous given the deficit in training but they will likely continue to lobby for rates equal to ours as theirs plunge due to their MANY future malpractice cases. Do insurance companies really wanna eat all the costs they create? People on here feel that these insurance pushbacks are a "drop in the bucket" compared to their overall threat. So we need to lobby more effectively and go above the ineffectual APA which has sided with them. Have read many people drop their membership due to their lack of lobbying against the NP threat. Im a resident member but also joined a different group that was founded for the purpose of lobbying against midlevel encroachment. I also dont understand why many on here minimize their threat, say "im just happy I did blablabla. Its only a threat for the new grads." This is the attitude that continues to allow them to make gains at physician and patient expense and is pretty selfish.

What group did you join that is lobbying against mid-level encroachment? So I can join too.

 

[PikminOC]

What group did you join that is lobbying against mid-level encroachment? So I can join too.

Physicians for patient protection?

 

[SARIEBELLE]

the difference is endocrinology is specialized enough that the endo is going to have to train the np/pa they hire. So they control that to some degree. Not a single NP/PA comes out of np school having anywhere near the skill set or knowledge base where they can see endocrinology consults/patients independently. None.

Thats not true in psych, since psych nps come out of np school already specialized in psych.

That is debatable

 

[Splenda88]

I know someone who was a RN and then went to MD school in the Caribbean. That individual could not get a US residency and resorted to do what they call internado (non ACGME accredited internship in Puerto Rico). You can get a medical license in PR after these internships and in some mainland states (eg., FL, MI, AZ etc...), these people can be licensed (albeit restricted) in some circumstances.

Let say that individual go back to school (online) and become a psych NP. If he opens a clinic and advertises himself as "Mental Health Physician" because he is both an MD and a psych NP, will he be able to bill like a psychiatrist. Come to think of it: The system has a bunch of loopholes.

I don't think that person that I know would do anything like that since he is already making ~ 200k/yr working for Indian Health Service seeing less that 10 patients a day.

 

[Dryad8212]

I know someone who was a RN and then went to MD school in the Caribbean. That individual could not get a US residency and resorted to do what they call internado (non ACGME accredited internship in Puerto Rico). You can get a medical license in PR after these internships and in some mainland states (eg., FL, MI, AZ etc...), these people can be licensed (albeit restricted) in some circumstances.

Let say that individual go back to school (online) and become a psych NP. If he opens a clinic and advertises himself as "Mental Health Physician" because he is both an MD and a psych NP, will he be able to bill like a psychiatrist. Come to think of it: The system has a bunch of loopholes.

I don't think that person that I know would do anything like that since he is already making ~ 200k/yr working for Indian Health Service seeing less that 10 patients a day.

what was their boards scores, any red flags?

 

[Splenda88]

what was their boards scores, any red flags?

I don't know all the specifics, but had to take one of the boards twice.

 

[Dryad8212]

I don't know all the specifics, but had to take one of the boards twice.

Thats prolly why. I even know a DO student who failed his PE and still cant match into psych despite solid scores on COMLEX 1 and 2

 

[Splenda88]

Thats prolly why. I even know a DO student who failed his PE and still cant match into psych despite solid scores on COMLEX 1 and 2

Well, he is a physician (GP) and has been practicing in the US for a few years now.

 

[PikminOC]

I know someone who was a RN and then went to MD school in the Caribbean. That individual could not get a US residency and resorted to do what they call internado (non ACGME accredited internship in Puerto Rico). You can get a medical license in PR after these internships and in some mainland states (eg., FL, MI, AZ etc...), these people can be licensed (albeit restricted) in some circumstances.

Let say that individual go back to school (online) and become a psych NP. If he opens a clinic and advertises himself as "Mental Health Physician" because he is both an MD and a psych NP, will he be able to bill like a psychiatrist. Come to think of it: The system has a bunch of loopholes.

I don't think that person that I know would do anything like that since he is already making ~ 200k/yr working for Indian Health Service seeing less that 10 patients a day.

Don't np bill under a Physician now for Physician pay?

 

[Dryad8212]

Don't np bill under a Physician now for Physician pay?

which is stupid and unfair if you were the patient lol. I would be angry as a patient

 

[Splenda88]

Don't np bill under a Physician now for Physician pay?

I am still a PGY3 in IM so I have no idea how billing works...

 

[PikminOC]

which is stupid and unfair if you were the patient lol. I would be angry as a patient

Patients don't know. I see therapists in the community that are getting their hours to become a full fledged therapist who don't tell patients and charge full freight

 

[VA Hopeful Dr]

Don't np bill under a Physician now for Physician pay?

I don't think so

 

[PikminOC]

Isnt there a billing incident to Physician code?

 

[irondoc]

Insane how Psych NPs can practice across the lifespan. Psychiatrists should be fighting hard against midlevel creep given the nature of the problems, the patients and substances they deal with.

 

[PikminOC]

Insane how Psych NPs can practice across the lifespan. Psychiatrists should be fighting hard against midlevel creep given the nature of the problems, the patients and substances they deal with.

Apa american Psychiatric association isn't helping and that's the organization of Psychiatrists. Lone Psychiatrists have very little power

 

[Mass Effect]

Insane how Psych NPs can practice across the lifespan

I mean so can psychiatrists. It's a myth that you need a fellowship to do C&A or Geri. I'm no fan of NPs (usually they're horrendous with a capital H), but I say report the ones who are truly doing dangerous stuff and let the free market decide on the rest. You get what you pay for.

 

[Splenda88]

I mean so can psychiatrists. It's a myth that you need a fellowship to do C&A or Geri. I'm no fan of NPs (usually they're horrendous with a capital H), but I say report the ones who are truly doing dangerous stuff and let the free market decide on the rest. You get what you pay for.

How about doing a fellowship to become a peds hospitalist? There are a lot of absurd stuffs in medicine. Peds hospitalist fellowship is probably among the top ones.

 

[Mad Jack]

Hey, welcome back.

In my region it seems midlevels do the stuff psychiatrists don't want to do: take heavy call on the inpatient side, or mindlessly please patients with controlled substances on the outpatient side.

Inpatient for most specialties involves unpleasant amounts of call and its only been historically recent that inpatient psych has been considered a cush gig. Psychiatrists left the asylums a long time ago for better outpatient working conditions. If we want to take inpatient back I think it can easily be done by offering to do q1-q3 call for $500k.

q1 call? Sign me up for inpatient psych treatment

 

[Mass Effect]

Thats prolly why. I even know a DO student who failed his PE and still cant match into psych despite solid scores on COMLEX 1 and 2

The PE matters in psych more than most (if not all) other specialties, for obvious reasons.

 

[Doc with Courage]

I know someone who was a RN and then went to MD school in the Caribbean. That individual could not get a US residency and resorted to do what they call internado (non ACGME accredited internship in Puerto Rico). You can get a medical license in PR after these internships and in some mainland states (eg., FL, MI, AZ etc...), these people can be licensed (albeit restricted) in some circumstances.

Let say that individual go back to school (online) and become a psych NP. If he opens a clinic and advertises himself as "Mental Health Physician" because he is both an MD and a psych NP, will he be able to bill like a psychiatrist. Come to think of it: The system has a bunch of loopholes.

I don't think that person that I know would do anything like that since he is already making ~ 200k/yr working for Indian Health Service seeing less that 10 patients a day.

Interesting. THe Florida ACN(area critical need is an option. I have a similar history myself....