California NP scam is only getting worse

[calvnandhobbs68]

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New University of California Program Will Double Pipeline of Specialized Mental Health Providers in Response to Growing Crisis

UCSF, UC Davis and UCLA Partner to Expand Care to Underserved Communities by Training 300 Psychiatric Mental Health Nurse Practitioners, Starting Fall 2020 Important Note: Due to the COVID-19 pandemic, the UCSF, UC Davis and UCLA Schools of Nursing have postponed the start date for the new...

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So now instead of even doing a real PMHNP program they’re going to take regular NPs and let them take some online classes in psychiatry and call it a day. Beautiful.

My favorite part is when they sprinkle “psychiatrist” in there a few times to make it seem like they’re the same thing.

I’m gonna vote next that they start a “dermatology” or maybe “cardiology” online certification.

 

[FatherPsychiatry]

I’m gonna vote next that they start a “dermatology” or maybe “cardiology” online certification.

No way. Those fields are very nuanced and challenging. A simple rash can be anything from eczema all the way to melanoma and you don't want to miss that. There are no quick diagnostic tests - they require a keen eye honed by many years of training and experience to make the right diagnosis. In fact, they should probably make dermatology a 7 year residency like neurosurgery because it so complicated. This is unlike psychiatry, which is very simple and straightfoward. If someone comes in saying they are depressed, you prescribe an antidepressant. Doctors call these "SSRIs" for some reason, I'm not really sure why, I mean only scientists should be studying receptors and hormones stuff. If someone says they can't focus, you prescribe Adderall. Actually, why do NPs need to take extra psych courses at all, especially if they majored in psychology in college? NPs - mind of a doctor, heart of a nurse!!

 

[Stagg737]

No way. Those fields are very nuanced and challenging. A simple rash can be anything from eczema all the way to melanoma and you don't want to miss that. There are no quick diagnostic tests - they require a keen eye honed by many years of training and experience to make the right diagnosis. In fact, they should probably make dermatology a 7 year residency like neurosurgery because it so complicated. This is unlike psychiatry, which is very simple and straightfoward. If someone comes in saying they are depressed, you prescribe an antidepressant. Doctors call these "SSRIs" for some reason, I'm not really sure why, I mean only scientists should be studying receptors and hormones stuff. If someone says they can't focus, you prescribe Adderall. Actually, why do NPs need to take extra psych courses at all, especially if they majored in psychology in college? NPs - mind of a doctor, heart of a nurse!!

There are already NPs in the UK performing cardiac catheterizations. With how powerful their lobby is in the US, the sky is the limit for them.

 

[deleted941485]

There are already NPs in the UK performing cardiac catheterizations. With how powerful their lobby is in the US, the sky is the limit for them.

They’re taking surgical courses to take out gallbladders too. What a joke.

 

[Jules A]

So now instead of even doing a real PMHNP program they’re going to take regular NPs and let them take some online classes in psychiatry and call it a day. Beautiful

The post masters NPs I have seen are generally awful and often worse than psych NP with no RN psych experience if you can believe that. They come chock full of the additional delusion that FNPs can do anything and therefore are convinced they know what they actually don't know.

 

[finalpsychyear]

Can we please let Nps start doing Neurosurgery since there is such a massive shortage of them.

I feel sorry for what is to come for those in early med school or just starting residency for everyone else it won't really matter but still I will fund any and all lobbying to get NPs the rights to do heart and brain surgery.

 

[Ironspy]

I work with a few good NPs. Definitely less training than a psychiatrist but they ask for help when needed.

All of them see only physicians for their own care.

 

[heysexylady]

I work with a few good NPs. Definitely less training than a psychiatrist but they ask for help when needed.

All of them see only physicians for their own care.

Have you asked them why? I know the answer just wonder if they have insight to their hypocrisy.

 

[MisterKitty]

I’m so ready to jump ship to another specialty

 

[nowaysanjose]

Can we please let Nps start doing Neurosurgery since there is such a massive shortage of them.

I feel sorry for what is to come for those in early med school or just starting residency for everyone else it won't really matter but still I will fund any and all lobbying to get NPs the rights to do heart and brain surgery.

It’s really disheartening always hearing this ‘i feel sorry for all those in med school and residency...’ why cant we actually do something about it? Stop training them, stop hiring them, stop this MD vs DO nonsense and let’s band together to make the clear delineation of who is a physician and who is not. What about hard rebukes of these terrible outcome studies they are always pandering about to state legislatures? What about a union? Can we gather some courage to fight back?

 

[Ironspy]

Have you asked them why? I know the answer just wonder if they have insight to their hypocrisy.

They fully admit a huge disparity in education

 

[Sushirolls]

It’s really disheartening always hearing this ‘i feel sorry for all those in med school and residency...’ why cant we actually do something about it? Stop training them, stop hiring them, stop this MD vs DO nonsense and let’s band together to make the clear delineation of who is a physician and who is not. What about hard rebukes of these terrible outcome studies they are always pandering about to state legislatures? What about a union? Can we gather some courage to fight back?

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 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

 

[FatherPsychiatry]

5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection

Agreed. Unlike the APA, which discounts conference admission to NPs

 

[finalpsychyear]

It’s really disheartening always hearing this ‘i feel sorry for all those in med school and residency...’ why cant we actually do something about it? Stop training them, stop hiring them, stop this MD vs DO nonsense and let’s band together to make the clear delineation of who is a physician and who is not. What about hard rebukes of these terrible outcome studies they are always pandering about to state legislatures? What about a union? Can we gather some courage to fight back?

Yes but its going to have to start from med students and residents so all incoming new physicians can change the course of the field. Those out in practice don't really care that much because they aren't going to be effected and they are already too busy with one thing or another.

We need it to start at that point in the field so then with no supervision they are going to have issues and our other lobbyists will try there best to prevent their solution to just be 100% autonomous via law change.

Nps organizations have their lobbyists and if they can't get supervision they will immediately turn to legislation bills to get around it. We need to anticipate and fight them on both fronts simultaneously. Maybe then we can send them back to what they are trained for... changing bed pans and drawing blood.

 

[Duloxetini]

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 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

Might want to add in a bit about reducing costs for undergrad and med school education.

 

[splik]

Agreed. Unlike the APA, which discounts conference admission to NPs

This is a massive distortion. The APA has rates for psychiatrists and non-psychiatrists. They don't mention anything about a rate for NPs at all. Some petty people have this fantasy that they should somehow charge NPs more. The rate for all non-psychiatrists (including nonpsychiatric physicians, psychiatric patients, nurses, social workers etc) is the same. You will find almost all medical conferences charge a lower rate to non-physicians because they have to charge extra to cover the cost of CMEs which are expensive. non-MDs dont get CMEs.

 

[keolu hills]

New University of California Program Will Double Pipeline of Specialized Mental Health Providers in Response to Growing Crisis

UCSF, UC Davis and UCLA Partner to Expand Care to Underserved Communities by Training 300 Psychiatric Mental Health Nurse Practitioners, Starting Fall 2020 Important Note: Due to the COVID-19 pandemic, the UCSF, UC Davis and UCLA Schools of Nursing have postponed the start date for the new...

nursing.ucsf.edu

So now instead of even doing a real PMHNP program they’re going to take regular NPs and let them take some online classes in psychiatry and call it a day. Beautiful.

My favorite part is when they sprinkle “psychiatrist” in there a few times to make it seem like they’re the same thing.

I’m gonna vote next that they start a “dermatology” or maybe “cardiology” online certification.

That is nuts!!! I wish these midlevels were never created in the first place.

 

[MacDonaldTriad]

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 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

Essentially that would make medicine look like law. There are fine law schools and there are flyby night ones that flood the market and create ambulance chasers. Dropping step III and reducing licensure requirements in order to raise the level of training doesn't seem intuitive to me. Unless more medical graduates come to Jesus about going into psychiatry and the number of training slots go up, more schools will just create unemployed untrained graduates.

 

[Sushirolls]

If states change their independent licensure, at behest of broad physician lobbying, then newly minted physicians can practice medicine independently. They have more experience and training than an ARNP or PA who either do, or will likely have independent practice. Fresh MD/DO grads are the superior product. They will also be preferential in practices to the roles that ARNPs and PA-C are filling.

Ambulance chasers already exist. Look at some of the ARNP clinics out there or ND clinics...

Residencies can still exist for specialty training. By decoupling residency and fellowship GME funding from CMS the arbitrary limits that exist no longer will. CMS funding is crippling us. We can open more residencies, and fellowships that are unfunded but we choose not too. Get rid of the money from that, and a painful but necessary adjustment to GME will take place. Simply put, do you get more labor from a resident or an ARNP? Residencies will continue to exist and I posit that they will flourish in this greater service focused training structure.

The biggest losers out of this plan will be FM. The flood of MD/DO independent grads will become the GPs of old. FM board certification will still be valuable in rural communities, but many places will default quickly to these MD/DO grads as they are already trending to do now with ARNPs.

Residencies and fellowships will benefit from having a more competitive pool to select from. Similar to Dentistry and those who seek out OMFS or ortho or endodentics, etc.

 

[Sushirolls]

Essentially that would make medicine look like law. There are fine law schools and there are flyby night ones that flood the market and create ambulance chasers. Dropping step III and reducing licensure requirements in order to raise the level of training doesn't seem intuitive to me. Unless more medical graduates come to Jesus about going into psychiatry and the number of training slots go up, more schools will just create unemployed untrained graduates.

I've reflected on this comment for several days now, 'medicine look like law.'

I actually believe this would be a good thing. With so many MD/DO flooding the market, we'd also increase the percentage the enters hospital and health system admin and State Legislative bodies and Congress. Representation leads to positive change. Look at nursing as the example, how many are in elected positions and also in hospital admin? This could be a good thing. Bring on the flood.

Personally I would consider hiring an intern licensed doc/GP or if laws changed, a med school graduate with an independent license to assist me in my office. They would get my 3 month follow up patients who are doing stable, and essentially have instructions that if the patient presents worsening of symptoms to staff it with my or flip them back over to my patient panel. I know I can train and trust an MD/DO grad because they get the educational process, and their skill level limitations. I could also be a source of letter of recommendation to their future application to specialty residency training if that's what they wanted.

 

[CosmeticLeFort3]

I've reflected on this comment for several days now, 'medicine look like law.'

I actually believe this would be a good thing. With so many MD/DO flooding the market, we'd also increase the percentage the enters hospital and health system admin and State Legislative bodies and Congress. Representation leads to positive change. Look at nursing as the example, how many are in elected positions and also in hospital admin? This could be a good thing. Bring on the flood.

Personally I would consider hiring an intern licensed doc/GP or if laws changed, a med school graduate with an independent license to assist me in my office. They would get my 3 month follow up patients who are doing stable, and essentially have instructions that if the patient presents worsening of symptoms to staff it with my or flip them back over to my patient panel. I know I can train and trust an MD/DO grad because they get the educational process, and their skill level limitations. I could also be a source of letter of recommendation to their future application to specialty residency training if that's what they wanted.

AND MAKE IT EASIER FOR ME TO GET INTO MEDICAL SCHOOL!!!!!!!!!!!! LETS DO THIS!

 

[Splenda88]

It’s really disheartening always hearing this ‘i feel sorry for all those in med school and residency...’ why cant we actually do something about it? Stop training them, stop hiring them, stop this MD vs DO nonsense and let’s band together to make the clear delineation of who is a physician and who is not. What about hard rebukes of these terrible outcome studies they are always pandering about to state legislatures? What about a union? Can we gather some courage to fight back?

There are a bunch of physicians that are making money of them. Some will join them to push back.

 

[Stagg737]

I've reflected on this comment for several days now, 'medicine look like law.'

I actually believe this would be a good thing. With so many MD/DO flooding the market, we'd also increase the percentage the enters hospital and health system admin and State Legislative bodies and Congress. Representation leads to positive change. Look at nursing as the example, how many are in elected positions and also in hospital admin? This could be a good thing. Bring on the flood.

Personally I would consider hiring an intern licensed doc/GP or if laws changed, a med school graduate with an independent license to assist me in my office. They would get my 3 month follow up patients who are doing stable, and essentially have instructions that if the patient presents worsening of symptoms to staff it with my or flip them back over to my patient panel. I know I can train and trust an MD/DO grad because they get the educational process, and their skill level limitations. I could also be a source of letter of recommendation to their future application to specialty residency training if that's what they wanted.

I agree that having more physicians in legislative and administrative positions would likely help, but simply flooding the market isn't necessarily going to increase that. Part of why NPs are so good at it is because the majority of their NP degree deals with administrative and systemic education and not clinical education. So unless we're also going to add a significant non-clinical aspect to medical school, I'm afraid that we'd just be creating more people to fill the PA-like positions without really increasing the political presence very much.

 

[Sushirolls]

NPs aren't so inherently good at admin positions or legislative positions. Both are born by thru the trials of fire. Trump? AOC? Sanders? These aren't exactly paragons of political acumen. Look at even your own local district elected officials, or go meet them some time and you'll be surprised that they are in the positions of power, but at least the power of democracy you get the power of numbers to smooth out the inadequacies.

Physicians are better suited for admin positions because they see and understand the bigger picture of delivery of care. Part of the problem we have now is some of the folks climbing the admin ladder are from other areas of healthcare and they just don't get the breadth of exposure that a medical education does. In summary I disagree that a market flooded with MD/DO grads would only fill PA like positions.

 

[deleted941485]

Essentially that would make medicine look like law. There are fine law schools and there are flyby night ones that flood the market and create ambulance chasers. Dropping step III and reducing licensure requirements in order to raise the level of training doesn't seem intuitive to me. Unless more medical graduates come to Jesus about going into psychiatry and the number of training slots go up, more schools will just create unemployed untrained graduates.

I totally get the law analogy and on some level I agree. You’ll have to go to the top 10 schools to get a job or a decent salary. It’ll be a total dog**** of a profession for 90% of the people who get out and great for the other 10% who went to the top programs.

 

[MisterKitty]

To any med students or pre-meds, going to medical school and specializing in FM, Peds, psych or anything non-procedural is a complete waste of time compared to NP school. Our training is obviously much better, but it is hardly valued, unappreciated, and not necessary to practice medicine at this point. Financially it doesn’t make a lick of sense either

 

[Cath Up]

To any med students or pre-meds, going to medical school and specializing in FM, Peds, psych or anything non-procedural is a complete waste of time compared to NP school. Our training is obviously much better, but it is hardly valued, unappreciated, and not necessary to practice medicine at this point. Financially it doesn’t make a lick of sense either

TCOM, Texas College of Osteopathic Medicine.
Resident yearly tuition + room and board: 32k
Average graduate indebtedness: 120k
In the context of the average psychiatrist salary (and potential, if you work surgeon hours), that definitely makes a lick of sense, when considering long-term job security anywhere in the USA.

I am in my fourth year and have 200-250k debt graduating from another school. The current average psychiatrist salary in the city I'm from is >300k (obtained from someone that advises regional hospitals on physician compensation). Does this translate to the best financial decision? Of course not. But working however much or as little as I want, doing something I actively enjoy (allowing for low burnout and high quality of work/life balance), with high adjustability over time (every psychiatrist I have met has worked in multiple realms within psych), doing something that is probably at least slightly helpful to society as a whole is a lot better than a miserable desk job, programming job, or sales job in my opinion.

I also don't want to contribute to the destruction of a profession. I don't want to "not know what I don't know" to the extent that a psych NP might. I want to provide the best possible care to people I attempt to treat- my understanding is that perceived competence is big part of job satisfaction.

Of course there will be disruption via psych NPs, flooding of the market with new residencies, and reimbursement changes. An entrepreneurial/adaptive/creative psychiatrist is better equipped to deal with this than most or all other physicians in other specialties, who will continue to experience similar pressures.

I think your post was the waste of time.

 

[Psychresy]

To any med students or pre-meds, going to medical school and specializing in FM, Peds, psych or anything non-procedural is a complete waste of time compared to NP school. Our training is obviously much better, but it is hardly valued, unappreciated, and not necessary to practice medicine at this point. Financially it doesn’t make a lick of sense either

From a purely financial perspective, and with all due respect, wtf are you talking about?

I'm getting offers at 220/hr. A colleague sent me a (admittedly very busy) job that paid 600. I have a moonlighting gig that pays 10k a weekend.

Even at 300k debt, you refinance to 2 something percent, pay it off slowly, and invest the difference getting at least 3x that rate in returns.

You guys are crazy if you think becoming a psychiatrist isn't financially smart.

 

[michaelrack]

From a purely financial perspective, and with all due respect, wtf are you talking about?


You guys are crazy if you think becoming a psychiatrist isn't financially smart.

It is financially smart now, but probably not a good plan for current pre meds and M1's

 

[hamstergang]

It is financially smart now, but probably not a good plan for current pre meds and M1's

We've been hearing this for how many years now? Have average salaries started to go down yet?

 

[dl2dp2]

Essentially that would make medicine look like law. There are fine law schools and there are flyby night ones that flood the market and create ambulance chasers. Dropping step III and reducing licensure requirements in order to raise the level of training doesn't seem intuitive to me. Unless more medical graduates come to Jesus about going into psychiatry and the number of training slots go up, more schools will just create unemployed untrained graduates.

You need to protect yourself. Work hard, match well, go with prestige and selectivity whenever you can--exactly the same as law school.

To any med students or pre-meds, going to medical school and specializing in FM, Peds, psych or anything non-procedural is a complete waste of time compared to NP school. Our training is obviously much better, but it is hardly valued, unappreciated, and not necessary to practice medicine at this point. Financially it doesn’t make a lick of sense either

This is too extreme, IMO. It's fine for now, especially upper mid-level program grads and up. You are right in that what I've observed is an across-the-board deterioration of the quality of facilities-driven jobs. But fewer and fewer high-quality candidates are now in facility-driven jobs (think academia, VA, large chains, etc). Facilities are having a very hard time recruiting, which is why they are digging deeper into the NP pool. There's also a foundational misalignment between facilities jobs salary model (lined salary, little increase to market demand, not open to re-negotiation, supported by pension/other benefits etc) and market reality, which is an increase in both access and demand.

From a purely financial perspective, and with all due respect, wtf are you talking about?

I'm getting offers at 220/hr. A colleague sent me a (admittedly very busy) job that paid 600. I have a moonlighting gig that pays 10k a weekend.

Even at 300k debt, you refinance to 2 something percent, pay it off slowly, and invest the difference getting at least 3x that rate in returns.

You guys are crazy if you think becoming a psychiatrist isn't financially smart.

I think the effect will gradually trickle up. The lower tier program grads will start to feel the pinch first as they compete against NPs at lower-tier facilities jobs. Private group/hospital jobs that pay good salary will have less NP competition since the quality/content of jobs are not all that comparable. Higher-end private jobs will be more or less immune to this dynamic.

Since COVID, I'm getting an increasing amounts of inquiries, many from patients outside of my geographical area due to wider acceptance of telemedicine, for what I think of as astronomical cash rates, which is prompting me to consider raising my fees even higher. I'm most certain no one is paying NPs for my rates. The lessons I've learned through the years: don't underestimate the amount of private money available in America that's willing to pay for truly quality products.

 

[Psychresy]

You need to protect yourself. Work hard, match well, go with prestige and selectivity whenever you can--exactly the same as law school.



This is too extreme, IMO. It's fine for now, especially upper mid-level program grads and up. You are right in that what I've observed is an across-the-board deterioration of the quality of facilities-driven jobs. But fewer and fewer high-quality candidates are now in facility-driven jobs (think academia, VA, large chains, etc). Facilities are having a very hard time recruiting, which is why they are digging deeper into the NP pool. There's also a foundational misalignment between facilities jobs salary model (lined salary, little increase to market demand, not open to re-negotiation, supported by pension/other benefits etc) and market reality, which is an increase in both access and demand.



I think the effect will gradually trickle up. The lower tier program grads will start to feel the pinch first as they compete against NPs at lower-tier facilities jobs. Private group/hospital jobs that pay good salary will have less NP competition since the quality/content of jobs are not all that comparable. Higher-end private jobs will be more or less immune to this dynamic.

Since COVID, I'm getting an increasing amounts of inquiries, many from patients outside of my geographical area due to wider acceptance of telemedicine, for what I think of as astronomical cash rates, which is prompting me to consider raising my fees even higher. I'm most certain no one is paying NPs for my rates. The lessons I've learned through the years: don't underestimate the amount of private money available in America that's willing to pay for truly quality products.

This brings up a curious point. I'm at a solid mid-tier university program with a lot of well-known faculty and researchers. Grads from my program do very well if they go private in our geographic area (this isn't to say they don't do well out of state - I just don't have any information on this). I'm wondering if it would make sense to do a fellowship in something I'm interested in if I am able to do so at a UCSF, NYU, etc. I would essentially be doing this for the name brand. Thoughts on the value of this if I intend to have at least a part-time private practicer after graduation?

 

[dl2dp2]

This brings up a curious point. I'm at a solid mid-tier university program with a lot of well-known faculty and researchers. Grads from my program do very well if they go private in our geographic area (this isn't to say they don't do well out of state - I just don't have any information on this). I'm wondering if it would make sense to do a fellowship in something I'm interested in if I am able to do so at a UCSF, NYU, etc. I would essentially be doing this for the name brand. Thoughts on the value of this if I intend to have at least a part-time private practicer after graduation?

I'm biased, but especially if you plan to practice cash in a larger market, I vote yes. There's no guarantee that you'll do well 10 years down the line, one way or the other. Right now it seems unnecessary and the yield is perhaps questionable, given all else held equal. But if 1. you are planning on doing a fellowship anyway. 2. you want to move to a big market post-training, then I think it's probably a good idea to do a fellowship at a "prestige" program.

 

[Psychresy]

I'm biased, but especially if you plan to practice cash in a larger market, I vote yes. There's no guarantee that you'll do well 10 years down the line, one way or the other. Right now it seems unnecessary and the yield is perhaps questionable, given all else held equal. But if 1. you are planning on doing a fellowship anyway. 2. you want to move to a big market post-training, then I think it's probably a good idea to do a fellowship at a "prestige" program.

I'm returning home to California after I graduate. Will be in one of the big three cities there almost guaranteed. I don't want to do CAP, so any other fellowship isn't really necessary. Id rather not due fellowship unless attaching myself to a big time name brand would help with a cash practice.

I'm guessing outside of private practice it really wouldn't matter all that much.

 

[dl2dp2]

I'm returning home to California after I graduate. Will be in one of the big three cities there almost guaranteed. I don't want to do CAP, so any other fellowship isn't really necessary. Id rather not due fellowship unless attaching myself to a big time name brand would help with a cash practice.

I'm guessing outside of private practice it really wouldn't matter all that much.

It matters for prestige jobs. Cash PP being one. Academic-industry research/leadership roles being another. Policy-admin job being a third. There's often crossing over between these roles.

It's really more so that prestige doesn't matter for an average job at an average location, right now. It might start to matter in 10 years, hard to know.

If you don't want to do a fellowship, being a voluntary faculty or part-time faculty at a prestige institution *can* be helpful. Research/policy fellowships, etc., *can* be helpful. Additional degrees (i.e. MBA), even, can be helpful. These are nothing more than having a declared area of subspecialty focus, which attracts patients and other partners (i.e. hospital admin, etc).

These are secondary metrics. What you want is to develop a network and a solid business plan. You can think of prestige as a marketing instrument. Marketing is important, but your energy should be spent on building the business in totality.

 

[TheaterOfTheme]

There will always be jobs that no one will trust an NP to do--prime example of this in nearly every rotation I've encountered in residency in CL and inpatient. For outpatient, there will always be patients who value their lives enough to avoid NPs.

In my state, NPs are reserved essentially to either private practice or outpatient community health clinics. We see their handiwork in every patient that presents to us with >2 antipsychotics, stimulants, and benzos on board all at once. They aren't at all competition for the positions / jobs that we want after graduation, to say the least. Sure they make more than their fair share, given they didn't do the difficult work of medical training, learn the craft of actual psychiatry, or experience the breadth of the field. It's totally BS, and the field as a whole should be against it.

 

[Merovinge]

There will always be jobs that no one will trust an NP to do--prime example of this in nearly every rotation I've encountered in residency in CL and inpatient.

Man I remember when I thought this was actually the case, what a nice world that was. Unfortunately, many private/community practice inpatient and CL jobs are absolutely being done by midlevels across all the specialties. One of the hospitals I worked at hardly had any MDs come for consults from any service, at least initially, nephrology, cards, ID, 1/2 the surgery specialties, etc. had NPs put worthless consults in when requested on the medical floor. Hospitalists were just left to deal with it, try and dump the patient out of the hospital and have some social worker try and get a real f/u for the patient.

That said, I agree with the rest of the sentiment that this does not mean the sky is falling, we will almost assuredly have a two tier system and when people are talking about their own mortality/morbidity (or of their children/loved ones) there will be plenty of opportunity to the physician to make their worth known and desired.

 

[deleted941485]

Man I remember when I thought this was actually the case, what a nice world that was. Unfortunately, many private/community practice inpatient and CL jobs are absolutely being done by midlevels across all the specialties. One of the hospitals I worked at hardly had any MDs come for consults from any service, at least initially, nephrology, cards, ID, 1/2 the surgery specialties, etc. had NPs put worthless consults in when requested on the medical floor. Hospitalists were just left to deal with it, try and dump the patient out of the hospital and have some social worker try and get a real f/u for the patient.

That said, I agree with the rest of the sentiment that this does not mean the sky is falling, we will almost assuredly have a two tier system and when people are talking about their own mortality/morbidity (or of their children/loved ones) there will be plenty of opportunity to the physician to make their worth known and desired.

It’s the same even at the well off hospitals. The PP groups and the employed docs…NP sees patient and gets the consult. Doc is thee for the recs. No one does the full history themselves anymore. It’s pathetic.

 

[TheaterOfTheme]

Man I remember when I thought this was actually the case, what a nice world that was. Unfortunately, many private/community practice inpatient and CL jobs are absolutely being done by midlevels across all the specialties. One of the hospitals I worked at hardly had any MDs come for consults from any service, at least initially, nephrology, cards, ID, 1/2 the surgery specialties, etc. had NPs put worthless consults in when requested on the medical floor. Hospitalists were just left to deal with it, try and dump the patient out of the hospital and have some social worker try and get a real f/u for the patient.

That said, I agree with the rest of the sentiment that this does not mean the sky is falling, we will almost assuredly have a two tier system and when people are talking about their own mortality/morbidity (or of their children/loved ones) there will be plenty of opportunity to the physician to make their worth known and desired.

Interesting, in the hospital systems I've worked in, I've seen PAs do the consults for like ortho or some surgery specialties sometimes. I can't imagine NPs doing that...But what you are describing really is a joke; I seriously feel bad for these patients. Even with my very good PPO health insurance, I'm on half a year wait-list to see a physician as a PCP. smh

Out of curiosity, are you mostly referring to non-academic hospitals where you see this?

Also to add to this, it really puts a TON of extra pressure on the primary medicine team. Can't believe what IM docs have to deal with sometimes.

 

[Merovinge]

Interesting, in the hospital systems I've worked in, I've seen PAs do the consults for like ortho or some surgery specialties sometimes. I can't imagine NPs doing that...But what you are describing really is a joke; I seriously feel bad for these patients. Even with my very good PPO health insurance, I'm on half a year wait-list to see a physician as a PCP. smh

Out of curiosity, are you mostly referring to non-academic hospitals where you see this?

Also to add to this, it really puts a TON of extra pressure on the primary medicine team. Can't believe what IM docs have to deal with sometimes.

Yeah it absolutely did for the hospitalists. There was essentially no attempt to make any diagnosis that wasn't painfully obvious and any lab results that could be punted to someone else were punted as hard as possible. The nephro NPs in particular weren't even supervised by any attending (the attending spent all their time at the dialy$i$ centers) and would actually just copy and paste all the consults with recommendations to avoid nephrotoxic agents. If the patient was consulted for dialysis then the attendings would come to $ign them up. This was at a non-academic hospital, which is where the majority of health care is delivered.

As an aside, being out of the hospital and multi-group system and working in a mental health only location has been an absolute breath of fresh air. It's more annoying to connect with other specialties but my blood pressure probably runs 10 points lower which is clearly worth it.

 

[hallowmann]

It's not unique to non-academic centers. There's the same issue in academia, and what's worse is its happening even more in outpatient. The only difference you sometimes see is with the services that have residents on them, in those cases half the time you might get a real physician. I can't tell you how frustrating it is to consult a service and scan the note only time the "assessment" is literally just the list of diagnoses and diagnostic codes the patient already had and the "plan" is clearly an unchanged template that doesn't even fit the issue or question.

 

[PikminOC]

Lots of nurses already do what op is talking about. They are obgyn one week and psych the next.

 

[calvnandhobbs68]

Lots of nurses already do what op is talking about. They are obgyn one week and psych the next.

There’s a huge difference between an RN doing this and an NP. Obviously the main difference begin that RNs are not establishing and ordering plans of care for patients, especially on the outpatient side.

 

[Mad Jack]

There will always be jobs that no one will trust an NP to do--prime example of this in nearly every rotation I've encountered in residency in CL and inpatient. For outpatient, there will always be patients who value their lives enough to avoid NPs.

In my state, NPs are reserved essentially to either private practice or outpatient community health clinics. We see their handiwork in every patient that presents to us with >2 antipsychotics, stimulants, and benzos on board all at once. They aren't at all competition for the positions / jobs that we want after graduation, to say the least. Sure they make more than their fair share, given they didn't do the difficult work of medical training, learn the craft of actual psychiatry, or experience the breadth of the field. It's totally BS, and the field as a whole should be against it.

I've seen both NP-staffed inpatient and CL psych services in the Northeast

 

[PikminOC]

There’s a huge difference between an RN doing this and an NP. Obviously the main difference begin that RNs are not establishing and ordering plans of care for patients, especially on the outpatient side.

Lots of Apn I see.

 

[lockian]

Essentially that would make medicine look like law. There are fine law schools and there are flyby night ones that flood the market and create ambulance chasers. Dropping step III and reducing licensure requirements in order to raise the level of training doesn't seem intuitive to me. Unless more medical graduates come to Jesus about going into psychiatry and the number of training slots go up, more schools will just create unemployed untrained graduates.

The real bottleneck is number of residency slots.

I've reflected on this comment for several days now, 'medicine look like law.'

I actually believe this would be a good thing. With so many MD/DO flooding the market, we'd also increase the percentage the enters hospital and health system admin and State Legislative bodies and Congress. Representation leads to positive change. Look at nursing as the example, how many are in elected positions and also in hospital admin? This could be a good thing. Bring on the flood.

Personally I would consider hiring an intern licensed doc/GP or if laws changed, a med school graduate with an independent license to assist me in my office. They would get my 3 month follow up patients who are doing stable, and essentially have instructions that if the patient presents worsening of symptoms to staff it with my or flip them back over to my patient panel. I know I can train and trust an MD/DO grad because they get the educational process, and their skill level limitations. I could also be a source of letter of recommendation to their future application to specialty residency training if that's what they wanted.

You are basically describing a DIY residency process. This should be a thing, honestly. Because what is residency but work under supervision, basically?

 

[calvnandhobbs68]

Lots of Apn I see.

Sure I see the same thing. Derm clinic NP one year, Pulm clinic NP another year. Usually this is in the context of APNs going to go work for different clinics though.

Problem with this specific instance is that you can take some online classes and then say you’re “certified” as a PMHNP and set up your own shop in a way you can’t do for other specialities.

 

[lockian]

To any med students or pre-meds, going to medical school and specializing in FM, Peds, psych or anything non-procedural is a complete waste of time compared to NP school. Our training is obviously much better, but it is hardly valued, unappreciated, and not necessary to practice medicine at this point. Financially it doesn’t make a lick of sense either

It makes sense outcomes wise. But in my experience outside of this forum no one talks about it.

I am in a state with independent NPs and the culture is one where “you do not talk bad about the NPs.” This was both in residency in an academic setting and in my employed positions. The only talk is about what NPs can or cannot do from a regulatory standpoint. In both places, NPs and MD/DOs are basically interchangeable and the patients who care are few and far between. There was even a campaign I vaguely remember what was “mid level does not mean inferior care.”

And yet I’m the one who has to take patients with active eating purging type disorders off Bupropion and address side effects that were missed for years including severe/irreversible ones like TD.

I’m not sure what to do except be more vocal about the messes so administrators, boards and insurers, and even patients are aware, and the NPs themselves are aware of their errors. No one wants risk and liability. But of course the barrier is, I’m an early career doc and I don’t want to develop a reputation as a complainer.

 

[nexus73]

Doctors missed the boat on this one.

In a perfect world, in hindsight, the physician lobbies would have fought and prevented mid level independent practice, while also pushing through legislation that provided strong liability protections for physicians supervising mid levels. Without that protection many physicians refuse to supervise mid levels, which just gives them the chance to argue they can't get supervisors so need to be independent. The other problem is mid levels being reimbursed 85% of physician rates. It should be more like 50%, so that hiring a mid level isn't the financial boon it currently is for health care systems, the big box shops. Also could dissuade mid levels from graduating and hangle a shingle independently when they are grossly ill equipped to be practicing without oversight.

I'm doing my part, screaming into the hurricane of midlevels, by not taking any on to train, and I don't supervise at my current job because the hospital doesn't pay enough. But we do have several because a number of our older doctors brought them into the system, but unfortunately proceeded to create the worst possible arrangement for physicians and the best possible for np's....barely any pay for supevision and the np's basically function independently, but not fully as the hospital still requires an assigned supervisor on paper in the med staff office. So these doctors get peanuts and in the even of a lawsuit, they're still technically the supervisor even though they don't see any of the np's patients or cosign any notes/orders. Baffling to me why they would ever do this.

 

[liquidshadow22]

Ratio of new NPs to Psychiatrists: Must be minimum 6:1. Anyone have data on this?