Collaborative agreement with NP-Job in rural midwest

[rockyhill99]

Hi All,

I have a job offer for outpatient child/adult mix 30 hours/week (3 hour admin time/week) for 262 K in rural mid-west while providing telepsychiatry care from the South. 60/90 min for intakes(adult/child) and 30 min for follow-ups. They are also offering a 30 K bonus and 4K in CME besides sponsoring my H1B visa.

The job also requires collaboration with two NPs. I have never worked with NPs before and would like to learn more from your experience/knowledge.

What factors should I consider in agreeing to collaborative care? How much admin time/week would you suggest asking for?

Does malpractice insurance and tail cover collaborative care with NPs or should I be asking for that?

Any other considerations that would lead you to say yay or nay to this job or collaborative work with NPs?

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[Stagg737]

I'll let more experienced people speak to specifics regarding contract details or insurance coverage. I would not accept the collaborative care position simply because I don't know the quality of the NPs being overseen. If I were to oversee an NP, it would either be someone I had already worked with and knew was competent or someone I could interview myself and have direct input regarding hiring them and supervision. There is a wild amount of variation in terms of the quality and competency of NPs, so much so that there are those I would not want my license associated with in any way.

My personal opinion is that they should be able to function like residents, requiring closer supervision initially and then gaining more independence as you work with them. Imo the goal should be to get them to the point where they can function like a second semester PGY-3 or early PGY-4; meaning they should reach the point that you can trust them to treat straightforward patients with minimal or no supervision and identify potential urgent issues and complex situations needing to be addressed by you immediately.

 

[splik]

"Collaboration" is a euphemism for supervision and a dangerous one at that. They are trying to minimize the fact that the NPs are required to be supervised by claiming it is a "collaborative practice agreement". This inevitably means that they probably will resent being supervised and having someone reviewing their care (the good NPs welcome this and value the input). If you are on a visa, I will assume you are an IMG (though I know foreign nationals who went to medical school in the US would also be on an H1 visa). That means you have to be especially careful. Firstly, and unfortunately, I do think that some NPs do look down on foreign doctors and will resent even more being supervised by one which can cause problems. Secondly, if there are any egregious issues in the NPs care, you will be on the chopping block, and IMGs (particularly ones without PR or citizenship) may be especially vulnerable to discipline/scapegoating by the medical board. In short, one always has to be careful about supervising NPs (and I am not anti-NP and have worked with some good ones), but especially so if on a visa.

 

[rockyhill99]

I'll let more experienced people speak to specifics regarding contract details or insurance coverage. I would not accept the collaborative care position simply because I don't know the quality of the NPs being overseen. If I were to oversee an NP, it would either be someone I had already worked with and knew was competent or someone I could interview myself and have direct input regarding hiring them and supervision. There is a wild amount of variation in terms of the quality and competency of NPs, so much so that there are those I would not want my license associated with in any way.

My personal opinion is that they should be able to function like residents, requiring closer supervision initially and then gaining more independence as you work with them. Imo the goal should be to get them to the point where they can function like a second semester PGY-3 or early PGY-4; meaning they should reach the point that you can trust them to treat straightforward patients with minimal or no supervision and identify potential urgent issues and complex situations needing to be addressed by you immediately.

Agree with the variance in the quality of the NP's. Several of them are established in that practice for a few years. They may be great but I do not know much about their personalities, competence, and ability to handle constructive feedback. The Medical Director stated that it should be a collaborative and not a supervisory role. My concern is if I noted practice issues or patterns of concern, my feedback may not be well received as they were described as independent practitioners by the management.

 

[rockyhill99]

"Collaboration" is a euphemism for supervision and a dangerous one at that. They are trying to minimize the fact that the NPs are required to be supervised by claiming it is a "collaborative practice agreement". This inevitably means that they probably will resent being supervised and having someone reviewing their care (the good NPs welcome this and value the input). If you are on a visa, I will assume you are an IMG (though I know foreign nationals who went to medical school in the US would also be on an H1 visa). That means you have to be especially careful. Firstly, and unfortunately, I do think that some NPs do look down on foreign doctors and will resent even more being supervised by one which can cause problems. Secondly, if there are any egregious issues in the NPs care, you will be on the chopping block, and IMGs (particularly ones without PR or citizenship) may be especially vulnerable to discipline/scapegoating by the medical board. In short, one always has to be careful about supervising NPs (and I am not anti-NP and have worked with some good ones), but especially so if on a visa.

Yes, I am an IMG on an H1b visa, and appreciate your feedback. Agree, with the variable response to feedback.

 

[BACyeahyouknowme]

Hi All,

I have a job offer for outpatient child/adult mix 30 hours/week (3 hour admin time/week) for 262 K in rural mid-west while providing telepsychiatry care from the South. 60/90 min for intakes(adult/child) and 30 min for follow-ups. They are also offering a 30 K bonus and 4K in CME besides sponsoring my H1B visa.

The job also requires collaboration with two NPs. I have never worked with NPs before and would like to learn more from your experience/knowledge.

What factors should I consider in agreeing to collaborative care? How much admin time/week would you suggest asking for?

Does malpractice insurance and tail cover collaborative care with NPs or should I be asking for that?

Any other considerations that would lead you to say yay or nay to this job or collaborative work with NPs?

So, I "collaborate" with some NPs, and it's been a good experience. The reason for that is they are competent, careful people. They have years of experience. And my schedule generally allows for realistic collaboration--not a lot, but we generally have time to talk the patients over, address concerns, etc.

On the other hand, I could envision a situation where admin wanted me to work with a bunch of inexperienced or low-quality NPs, and they might refuse to make space in the schedule for meaningful supervision. In that sort of situation, you are a liability sponge. I would not do that.

So, questions I might ask--How much experience do the NPs have? Where were they trained? How much time will you get for supervision? How will you be compensated? If all that looks okay, I'd do it.

 

[nexus73]

IMO doctors should get paid to have this responsibility. But the MBAs feel like you’re somehow stealing their kids candy when you ask for supervision compensation.

 

[deleted456421]

It's really sad. I went into medicine to treat people and worked my butt off to feel comfortable doing so. Yet every job I've worked at so far has requested that I oversee NPs. Most of the midlevels find such arrangements egregious in the first place, especially when paired with someone as young as myself. Maybe they're right; I'm not trained to be middle management and I constantly doubt my own skills at this stage.

I don't have a point, really, other than to commiserate with you. My next, and hopefully long-term, job also requires such supervision and I'm dreading it. I know everyone here recommends finding something without these requirements, such options are increasingly rare and may very well vanish within the next few years. Almost every inpatient job now requires midlevel supervision. I much prefer hospital work so I'll bite the bullet and hopefully it won't kill me.

 

[smalltownpsych]

It's really sad. I went into medicine to treat people and worked my butt off to feel comfortable doing so. Yet every job I've worked at so far has requested that I oversee NPs. Most of the midlevels find such arrangements egregious in the first place, especially when paired with someone as young as myself. Maybe they're right; I'm not trained to be middle management and I constantly doubt my own skills at this stage.

I don't have a point, really, other than to commiserate with you. My next, and hopefully long-term, job also requires such supervision and I'm dreading it. I know everyone here recommends finding something without these requirements, such options are increasingly rare and may very well vanish within the next few years. Almost every inpatient job now requires midlevel supervision. I much prefer hospital work so I'll bite the bullet and hopefully it won't kill me.

My first job as a licensed psychologist involved supervising several midlevel therapists with up to 20 years of experience so I get the challenge of supervising that you are relating. I found that my skill set from my education and training gave me a considerable edge and eventually I was able to supervise effectively. For example, one of the guys I supervised was arguably a better therapist than myself, and I’m pretty good 😊 , but he recognized that my diagnostic skills and knowledge of legal and ethical issues far outstripped his and although he was skeptical of me at first, he eventually learned to rely on my skills set and it was also really nice that I didn’t have to worry about teaching him how to be a therapist like some others I have had to supervise.

If any particular midlevel doesn’t appreciate what you bring as a psychiatrist who got into medical school, then made it through all of those hurdles to get an MD and then had four years of residency training, then that is just the narcisstic defenses against their own feelings of inadequacy. In that case, they are likely going to be an ongoing problem and either you get a chance to address their shortcomings with management or you have to look for a better situation.

 

[calvnandhobbs68]

If any particular midlevel doesn’t appreciate what you bring as a psychiatrist who got into medical school, then made it through all of those hurdles to get an MD and then had four years of residency training, then that is just the narcisstic defenses against their own feelings of inadequacy. In that case, they are likely going to be an ongoing problem and either you get a chance to address their shortcomings with management or you have to look for a better situation.

Unfortunately this describes....a lot of NPs

They often very much resent this "collaboration" and view it as a legal hurdle to practice that they just have to suffer through by having some physician sign of on the decisions they make (which they think they could do just fine by themselves anyway). Which is why I'm actually at this point fine with independent practice and hate the stupid collaboration requirements like OP is talking about because you're basically just being used as a liability sponge (it's "collaboration" in name only).

 

[RomeoNP]

Unfortunately this describes....a lot of NPs

They often very much resent this "collaboration" and view it as a legal hurdle to practice that they just have to suffer through by having some physician sign of on the decisions they make (which they think they could do just fine by themselves anyway). Which is why I'm actually at this point fine with independent practice and hate the stupid collaboration requirements like OP is talking about because you're basically just being used as a liability sponge (it's "collaboration" in name only).

Pretty wide brush there. I think it just depends on the school they went to and experience as well as their own self awareness, while some NP are similar to what you described there are many that sought experienced attendings to work with and learn from. I did, as did many of my class mates. It really just depends on the individual, OP should screen the prospective NPs seeking collaboration and move accordingly.

 

[nexus73]

Pretty wide brush there. I think it just depends on the school they went to and experience as well as their own self awareness, while some NP are similar to what you described there are many that sought experienced attendings to work with and learn from. I did, as did many of my class mates. It really just depends on the individual, OP should screen the prospective NPs seeking collaboration and move accordingly.

Is it an option for np's to not choose experienced attendings for clinical experience? That is a huge problem.

 

[calvnandhobbs68]

Pretty wide brush there. I think it just depends on the school they went to and experience as well as their own self awareness, while some NP are similar to what you described there are many that sought experienced attendings to work with and learn from. I did, as did many of my class mates. It really just depends on the individual, OP should screen the prospective NPs seeking collaboration and move accordingly.

Yeah, it's a pretty wide brush on purpose. I find very few NPs are interested in being supervised like we'd supervise a resident despite NP programs requiring less clinical hours in the field than an intern, despite liability for us being pretty similar in that the attending's name always ends up on the lawsuit. "Collaboration" is a joke and misnomer, it should be "supervision" or nothing. Collaboration implies working with peers on cases, not overseeing decision making and absorbing liability. That is residency and that is supervision.

I'd be much more interested in letting NPs at this point sink or swim on their own with the ones who are actually interested in real supervision and learning for a few years being able to seek that out rather than everyone being required to "collaborate" which incentivizes services likeeee

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[Merovinge]

It's really sad. I went into medicine to treat people and worked my butt off to feel comfortable doing so. Yet every job I've worked at so far has requested that I oversee NPs. Most of the midlevels find such arrangements egregious in the first place, especially when paired with someone as young as myself. Maybe they're right; I'm not trained to be middle management and I constantly doubt my own skills at this stage.

I don't have a point, really, other than to commiserate with you. My next, and hopefully long-term, job also requires such supervision and I'm dreading it. I know everyone here recommends finding something without these requirements, such options are increasingly rare and may very well vanish within the next few years. Almost every inpatient job now requires midlevel supervision. I much prefer hospital work so I'll bite the bullet and hopefully it won't kill me.

This isn't the case in my area at all. You can get a job at many many sites without NP supervision, in fact the majority of IP/PHP/IOP jobs do not have NP supervision attached. The people working with NPs typically do so to expand their own income rather than being forced to. I don't see any of these positions vanishing in my area of the past 5 years.

 

[deleted456421]

This isn't the case in my area at all. You can get a job at many many sites without NP supervision, in fact the majority of IP/PHP/IOP jobs do not have NP supervision attached. The people working with NPs typically do so to expand their own income rather than being forced to. I don't see any of these positions vanishing in my area of the past 5 years.

I wish it was the same here. I’d say most community programs around me are 75-90% NPs with a smattering of docs.

 

[Merovinge]

I wish it was the same here. I’d say most community programs around me are 75-90% NPs with a smattering of docs.

I only point this out to say it is not universally the case. If you find yourself not liking the setup, there are certainly options for HLoC that are 100% independent of any NP involvement (I've had such a job and am in such a job right now). It's just not a foretold conclusion that this needs to be the case.

 

[comp1]

Those of you expressing frustration about supervision agreements...will also be expressing frustration with independent practice rights.

 

[calvnandhobbs68]

Those of you expressing frustration about supervision agreements...will also be expressing frustration with independent practice rights.

Not really. The cats out of the bag. Even in states where NPs need a "collaborator", on the outpatient side that's really in name only. There's nothing stopping a new grad NP from paying for "collaboration" from one of the sites I listed above and essentially setting up their own private practice. It's happening all over the place. So might as well cut em loose and let them take on their own liability.

 

[deleted456421]

I only point this out to say it is not universally the case. If you find yourself not liking the setup, there are certainly options for HLoC that are 100% independent of any NP involvement (I've had such a job and am in such a job right now). It's just not a foretold conclusion that this needs to be the case.

Didn't say it was. However, it's increasingly difficult to find employed positions of any type (especially inpatient opportunities) where supervision isn't required. I can only speak to the areas of the country I've looked into, but I've looked at dozens of job listings, worked in 5-6 different settings, and interviewed at several places. Most of them required full-time, non-locum physicians to provide supervision.

 

[heartsink]

Didn't say it was. However, it's increasingly difficult to find employed positions of any type (especially inpatient opportunities) where supervision isn't required. I can only speak to the areas of the country I've looked into, but I've looked at dozens of job listings, worked in 5-6 different settings, and interviewed at several places. Most of them required full-time, non-locum physicians to provide supervision.

Would you mind clarifying which part of the country you're in? It seems very region-dependent whether NP-saturation is a huge problem (you, @Sushirolls ) vs. not even on the radar (Merovinge)

 

[the5thelement]

Relax. Dont do it.

 

[whopper]

I have NPs.

It's like having residents. If they're awesome it's awesome. If they suck it sucks and everything in-between. Per my insurance carrier I do not have direct liability over them unless I pay them on my own payroll. So if another institution pays them this gives an added legal barrier over liability. (Again this is per my insurance carrier but I've asked lawyers about this and they don't know themselves. Further insurance carrier is THE insurance provider for the APA and they have lectures on NP liability so they are a recommended and respected source).

Although this is not what my insurance carrier stated, I would also assume there may be some directed liability towards you if it was a very tough case and they wrote down they consulted with you because it was a high risk situation and you were advised of it. Per the same insurance carrier, one of their NP liability lectures showed a case where there was a bad outcome but the physician was never told of it, nor the high risk factors involved, and the physician was removed from from the court case for this reason.

I've fired bad NPs. I'm the medical director for an addiction clinic. One of the NPs was terrible and we got rid of her. Do not carry an NP under your supervision unless they are very good.

 

[FlowRate]

It's really sad. I went into medicine to treat people and worked my butt off to feel comfortable doing so. Yet every job I've worked at so far has requested that I oversee NPs. Most of the midlevels find such arrangements egregious in the first place, especially when paired with someone as young as myself. Maybe they're right; I'm not trained to be middle management and I constantly doubt my own skills at this stage.

I don't have a point, really, other than to commiserate with you. My next, and hopefully long-term, job also requires such supervision and I'm dreading it. I know everyone here recommends finding something without these requirements, such options are increasingly rare and may very well vanish within the next few years. Almost every inpatient job now requires midlevel supervision. I much prefer hospital work so I'll bite the bullet and hopefully it won't kill me.

FWIW on the rare instances where a MHNP asks me for my advice on career steps, I tell them the first thing they should do out of school is inpatient work somewhere with a good attending who's given time to properly supervise. You have the potential to help people understand that mood lability doesn't itself mean bipolar 1 disorder and that patients with actual mania are actually pretty rare (at least that was my experience during inpatient months of residency)...

 

[calvnandhobbs68]

I have NPs.

It's like having residents. If they're awesome it's awesome. If they suck it sucks and everything in-between. Per my insurance carrier I do not have direct liability over them unless I pay them on my own payroll. So if another institution pays them this gives an added legal barrier over liability. (Again this is per my insurance carrier but I've asked lawyers about this and they don't know themselves. Further insurance carrier is THE insurance provider for the APA and they have lectures on NP liability so they are a recommended and respected source).

Although this is not what my insurance carrier stated, I would also assume there may be some directed liability towards you if it was a very tough case and they wrote down they consulted with you because it was a high risk situation and you were advised of it. Per the same insurance carrier, one of their NP liability lectures showed a case where there was a bad outcome but the physician was never told of it, nor the high risk factors involved, and the physician was removed from from the court case for this reason.

I've fired bad NPs. I'm the medical director for an addiction clinic. One of the NPs was terrible and we got rid of her. Do not carry an NP under your supervision unless they are very good.

Yeah I mean maybe your insurance carrier has more case law on this now at this point but:

https://www.empr.com/home/features/can-a-doctor-be-liable-for-harm-to-a-patient-he-has-never-seen/

 

[MedMan80]

I supervise NP's and so far it's okay, they're competent but I have extra stress of making sure I take ownership of acute stuff regarding their patients when they're away.

 

[rockyhill99]

Hi All,

I have a job offer for outpatient child/adult mix 30 hours/week (3 hour admin time/week) for 262 K in rural mid-west while providing telepsychiatry care from the South. 60/90 min for intakes(adult/child) and 30 min for follow-ups. They are also offering a 30 K bonus and 4K in CME besides sponsoring my H1B visa.

The job also requires collaboration with two NPs. I have never worked with NPs before and would like to learn more from your experience/knowledge.

What factors should I consider in agreeing to collaborative care? How much admin time/week would you suggest asking for?

Does malpractice insurance and tail cover collaborative care with NPs or should I be asking for that?

Any other considerations that would lead you to say yay or nay to this job or collaborative work with NPs?

Job update... I asked the management to waive the requirement to supervise NPs and they agreed. Thanks to all for pitching in with your advice.

 

[ObsequiousAplomb]

Yeah I mean maybe your insurance carrier has more case law on this now at this point but:

https://www.empr.com/home/features/can-a-doctor-be-liable-for-harm-to-a-patient-he-has-never-seen/

I wonder if the decision would have been different provided the doctor performed the legal minimum of 5% chart audits.

 

[whopper]

Yeah I mean maybe your insurance carrier has more case law on this now at this point but:

I didn't see anything in that article that changed my mind on anything, but that's not a criticism. It's a great article. The physician should have some supervision and collaboration. Also another very complicating factor is that given that NP and physicians collaborations highly differ based on state law one state's case law vs another could be highly different. It's not fair to assume that if one case has a verdict it's supposed to be a national standard when a different state has very different collaboration laws.



If the physician wasn't doing the bare minimum to keep up with their collaboration, then heck yes, the physician can be nabbed. In my own state the collaboration requires a written agreement and written records showing the physician reviewed at least 10% of the NPs cases, 20% if those cases were on controlled substances, and be available for consultation with the NP if needed.

 

[painballer27]

You should have the nurse's RVUs added on to your own if you are required to supervise nurses.

 

[calvnandhobbs68]

I didn't see anything in that article that changed my mind on anything, but that's not a criticism. It's a great article. The physician should have some supervision and collaboration. Also another very complicating factor is that given that NP and physicians collaborations highly differ based on state law one state's case law vs another could be highly different. It's not fair to assume that if one case has a verdict it's supposed to be a national standard when a different state has very different collaboration laws.



If the physician wasn't doing the bare minimum to keep up with their collaboration, then heck yes, the physician can be nabbed. In my own state the collaboration requires a written agreement and written records showing the physician reviewed at least 10% of the NPs cases, 20% if those cases were on controlled substances, and be available for consultation with the NP if needed.

True and yes I don’t know how much of this decision hinged on the fact that the physician wasn’t doing the actual case review that was required.