Current Practice Environment

[OldPsychDoc]

That's not much. I meant that it added to income, but I guess $292 isn't worth mentioning. Of course with 1 child, it's over $3000, but I guess Vistaril's example was without kids.

If you're earning $10, 500, it darned well IS worth mentioning.

Perhaps to occupy ourselves between now and Match Day we could all read this and discuss...

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[PikminOC]

Although I can't read V's posts, I've heard the arguments before. I have a fundamentally different philosophy.

V's argument goes like this: Patients don't care about quality, they want outcomes. If an NP can Rx a drug, set up an appt and do all that for cheaper than a doctor - then where does the physicians value come in? Why train so long for such a simple job? Writing Rx for simple Dx and setting up further appointments?

My counter argument would be, there are people who WILL and DO pay more for higher quality services. This can be seen in any industry in the world. If the patient sees value in what they pay for, they will buy it.

What is the added value? If a psychiatrist is exceptional at what they do, exceptional with communication, therapy, knowledge base, knowing other medical problems that present like psychiatric problems, exceptional at marketing and networking, and caring for the patients - then this individual WILL have plenty of patients vying to use their services for a lifetime. How much more would they pay compared to an NP? Well, it depends on their income.

In a doomsday scenario that NPs are nationally accepted to practice like an MD, I would not fear. My strategy? I will just market myself to individuals earning 100k -500k or more. If the government forces me to have a practice that is not viable to the general public, I can play that game. In fact, I think my earnings would increase in this doomsday scenario. That's business and marketing, networking. Do you think a single guy earning 300k cares if he pays $100 or $200 for psych? Nope. He wants a quality product.

What we are venturing into is like evolution or computer hacking. Throughout the millions of years of evolution, certain changes forced the organisms that could thrive to adapt and become better. The organisms that adapted reached new levels of performance. In computer hacking, every time a new security update is made there is a hacker somewhere trying to break it - and they do. They find the way in.

Welcome to the game of life.

If everything goes wrong, I don't know what the solution is yet. But I do know the sure way to failure. Believe and tell everyone that your extra training has no value, that all you do is Rx drugs and that there is no reason for your job if plenty of NPs come along. That's an attitude that's sure to land you in the bottom 10%'tile in earnings.

In summary: V thinks so little of what he does, I on the other hand think so highly of what a psychiatrist can do.

Exactly.
I can't solve all the mental health problems.
But I can help the people who want my help and appreciate it.

 

[PikminOC]

this isn't a subdural hematoma grover. These are community med mgt pts who don't have a lot of access and are going to take what they get. They aren't generally all up in arms when they see a psych np, a psychologist, a sw, or a psychiatrist. They just want to be treated fairly, processed through the system as efficiently as possible, get a case manager to help them out with the things that really concern them, etc......

many of these patients in these settings don't even know who is a psychiatrist and who isn't. And the ones that do mostly don't care.

I think you should have saved yourself a lot of education and become an NP.

 

[PikminOC]

Vistaril is exactly the reason why I do not post on here or come on SDN much anymore. I thought he had calmed down, but I see I was wrong. This thread started off very well.


Fonzie to my original point, NP's malpractice insurance fees are a pittance compared to ours. So the business costs for them are much less to start with. They also may be able to start their businesses earlier than our (more productive years since we spent so much time on our educations) and their loan debt is usually much less as well. This way they can also devote more time to their pp practice, marketing, etc. And the standard of care they are held to is not physician standards: no MD will be be testifying against them. They are held to much lower standards. So even if there is a bad outcome, it is not the same standard we are held to.

 

[IamPsychiatrist]

Vistaril is exactly the reason why I do not post on here or come on SDN much anymore. I thought he had calmed down, but I see I was wrong. This thread started off very well.


Fonzie to my original point, NP's malpractice insurance fees are a pittance compared to ours. So the business costs for them are much less to start with. They also may be able to start their businesses earlier than our (more productive years since we spent so much time on our educations) and their loan debt is usually much less as well. This way they can also devote more time to their pp practice, marketing, etc. And the standard of care they are held to is not physician standards: no MD will be be testifying against them. They are held to much lower standards. So even if there is a bad outcome, it is not the same standard we are held to.

Yeah, he's an annoying person.

 

[heyjack70]

Vistaril is exactly the reason why I do not post on here or come on SDN much anymore. I thought he had calmed down, but I see I was wrong. This thread started off very well.


Fonzie to my original point, NP's malpractice insurance fees are a pittance compared to ours. So the business costs for them are much less to start with. They also may be able to start their businesses earlier than our (more productive years since we spent so much time on our educations) and their loan debt is usually much less as well. This way they can also devote more time to their pp practice, marketing, etc. And the standard of care they are held to is not physician standards: no MD will be be testifying against them. They are held to much lower standards. So even if there is a bad outcome, it is not the same standard we are held to.

I thought a nurse practitioner and physician were held to the same standard of care, that is, we're not comparing an RN or social worker with an MD because then there's definitely a difference. If not, it's funny...one of the few times an NP doesn't want to be considered equal to a physician (that and when paying malpractice premiums).

 

[Tyrone Slothrop]

If you're earning $10, 500, it darned well IS worth mentioning.

Perhaps to occupy ourselves between now and Match Day we could all read this and discuss...

OPD good reading suggestion. I read "Nickle and Dimed" a few years after it was written, I remember being shocked at what modern poverty looked like. I grew up working class, but nothing like what was described. In the twelve years since, I can only imagine things have gotten much bleaker.

We have a real problem with how we treat our poor. I think if more people understood the realities of poverty we'd show a lot more compassion.

 

[heyjack70]

It's not just psychiatrists. A family medicine doctor I talked to yesterday told me that he got a job in a larger city right after residency. A locums position at a community primary care clinic was paying him $70/hr (as a contracted worker, 1099, no benefits, etc). He took the job because it was the best available that allowed him to work only 3 days a week, so he could take care of the kids while his partner finished a residency in pediatrics. Interestingly, the clinic was contracting with the disability office to perform evaluations at $180 each, and would schedule a few of these evals a week into 30 minute slots. Otherwise he was seeing 3 patients an hour. So he was clearly getting way underpaid. He's since moved on, and out of the city, to a less densely populated place that is paying him better.

 

[vistaril]

Well you win...

I really had no idea that those particular affluent Chicago suburban districts would be considered representative of Midwestern teachers' salaries--but I challenged you to find me one example, and clearly you did. I have friends who've raised their kids in a couple of these top 5 districts, btw. Definitely exemplary, outstanding schools, funded in part by high property values in the communities, and characterized by their ability to "employ teachers who have longer-than-average careers, as well as a large number of teachers who have earned advanced degrees, which boosts salaries."

Now as to whether our mythical self-supported 4-year education BS student would be raking in these salaries when the "usual" state average salary for a teacher is ~$66K...I'll leave that as a speculative exercise for the reader, though it appeared to me that these districts are actually fairly UNusual in a number of respects. But your definitions of what might be "not unusual" are fairly different than mine. I'd have to add that it's also clearly "not unusual" for a student to graduate from, say, the University of Alabama with more than $20 grand in debt(1), and be going to work for $36k or less (2), maybe looking forward to making an average of $50k or so later in their career(3).

1-http://www.wbhm.org/News/2012/collegedebt
2-http://www.nea.org/home/2012-2013-average-starting-teacher-salary.html
3-http://www.teachingdegree.org/alabama/salary/

well yeah, but here for anyone with even the slightest bit of motivation, people skills, and desire to do so they can move into administration rather quickly....within 6-7 years after getting their BS. And then it's a slow stepwise progression up to district level administration, which will pay around 100k here + benefits that are too good to believe. Districts in this area are also ridiculously top heavy, so there are tremendous numbers of such district level jobs. I'm not talking about being *the* superintendent of course(that probably requires some luck and skill and politics)...

I'm not saying that people in education are all rolling down the road in new porsches, but for someone of average intelligence who plans things out even decently, a nice lifestyle with nice things(cars, houses, vacations, security) is very attainable.

As for the student debt issue, regardless of what the actual numbers are from individual to individual, the most important thing is to realize that there debt compared to ours is zero after college is considered. People in education go to grad school part time and in the evenings to get their pay boosts and move into admin if they want, and thus almost never borrow significant loans because of this. Whereas we of course do.....

 

[PikminOC]

Many midlevels have collaboration agreements with physicians so the physicians take the malpractice hit. If the midlevel is truly independent they still aren't held to our standards as they don't have our educations. Be careful if you are asked to supervise or collaborate.

 

[vistaril]

If you're earning $10, 500, it darned well IS worth mentioning.

Perhaps to occupy ourselves between now and Match Day we could all read this and discuss...

I actually read that book, and while reading it I kept thinking to myself that she could have done a lot better in several situations had she really been trying. It's almost like she came into those situations trying to create a situation that would go to ****, just so she could then document it in her book.

Vistaril is exactly the reason why I do not post on here or come on SDN much anymore. I thought he had calmed down, but I see I was wrong. This thread started off very well.


Fonzie to my original point, NP's malpractice insurance fees are a pittance compared to ours. So the business costs for them are much less to start with. They also may be able to start their businesses earlier than our (more productive years since we spent so much time on our educations) and their loan debt is usually much less as well. This way they can also devote more time to their pp practice, marketing, etc. And the standard of care they are held to is not physician standards: no MD will be be testifying against them. They are held to much lower standards. So even if there is a bad outcome, it is not the same standard we are held to.

what state are you in where malpractice(for psych) is such a massive expense? Most people out of residency I talk to pay like 4-5 k a year...total. That's less than 400/month. Not trivial, but hardly exhorbitant.

For all the talk about what we as psychiatrists offer that NP's don't, they pull the same stuff on us. I know several nps who think they can offer an american education as a positive over many psychs who don't have that. And let's be real.....every NP went to school in the United States and there is a stigma(sometimes fair and sometimes not) against foreign trained doctors, and psych obviously has a lot of imgs. I'm not saying this is important or valid, but when the NP can state "I went to school at (insert well known/respected american medical center/undersity) and they went to a carribean school or some school in india/china/phillipines/etc", that has value amongst many patients. Especially if there is a cultural disconnect(sometimes is, sometimes isn't)

 

[OldPsychDoc]

well yeah, but here for anyone with even the slightest bit of motivation, people skills, and desire to do so they can move into administration rather quickly....within 6-7 years after getting their BS. And then it's a slow stepwise progression up to district level administration, which will pay around 100k here + benefits that are too good to believe. Districts in this area are also ridiculously top heavy, so there are tremendous numbers of such district level jobs. I'm not talking about being *the* superintendent of course(that probably requires some luck and skill and politics)...

I'm not saying that people in education are all rolling down the road in new porsches, but for someone of average intelligence who plans things out even decently, a nice lifestyle with nice things(cars, houses, vacations, security) is very attainable.

As for the student debt issue, regardless of what the actual numbers are from individual to individual, the most important thing is to realize that there debt compared to ours is zero after college is considered. People in education go to grad school part time and in the evenings to get their pay boosts and move into admin if they want, and thus almost never borrow significant loans because of this. Whereas we of course do.....

Ah yes, easy peasy...
Too bad you're stuck racing to the bottom in psychiatry.

 

[MacDonaldTriad]

It is my personal opinion that this NP paranoia is much exaggerated. Yes, I have seen NPs with very questionable quality of care, but I can say the same thing about some psychiatrists. Yes, they can do some of what we do for less cost, and they have much less educational expenses, but they haven’t driven down our incomes that much. The supply is still so sparse compared to the demand, the world is probably better off with NPs than without.

When my GP isn’t getting me better, I go to a specialist even if it is out of pocket. NP psych patients probably do the same when they have money. A lot of psychiatry patients get better, but not completely well. We still get to tackle these. If patients can’t afford us, then bless NPs for seeing them. They aren’t robbing our pockets that much. If we cannot help refractory patients any better than an NP, maybe NPs should dominate the business.

Just ask a drug rep where his or her market is. He/She will tell you that ¾ of their psych meds are written by primary care doctors. Primary care providers already out number NPs and psychiatrists by a couple of orders of magnitude. With so many doctors already doing psychiatry with less skill, I don’t see how NPs will turn our world upside down.

 

[Nasrudin]

It is my personal opinion that this NP paranoia is much exaggerated. Yes, I have seen NPs with very questionable quality of care, but I can say the same thing about some psychiatrists. Yes, they can do some of what we do for less cost, and they have much less educational expenses, but they haven’t driven down our incomes that much. The supply is still so sparse compared to the demand, the world is probably better off with NPs than without.

When my GP isn’t getting me better, I go to a specialist even if it is out of pocket. NP psych patients probably do the same when they have money. A lot of psychiatry patients get better, but not completely well. We still get to tackle these. If patients can’t afford us, then bless NPs for seeing them. They aren’t robbing our pockets that much. If we cannot help refractory patients any better than an NP, maybe NPs should dominate the business.

Just ask a drug rep where his or her market is. He/She will tell you that ¾ of their psych meds are written by primary care doctors. Primary care providers already out number NPs and psychiatrists by a couple of orders of magnitude. With so many doctors already doing psychiatry with less skill, I don’t see how NPs will turn our world upside down.

I think it's easier to talk about paranoia as an attending. Your trained, competent, and putting money in the bank. Your debts are decreasing. You're an established product in the market place and you can be confident about your ability to stay there for the foreseeable future.

A future I would maintain is foreseeable only in some handful of years ahead. So your potential audience--me, entering training, and your medical students 3-4 years behind--what can you really say to them with any certainty.

NP's need YOU to complete their training. So they adore you as non-combative overseer who views them benignly. And you can feel sanguine in your beneficence. But forgive us our vulgarity as they warp speed past us in training. Started after-finished before. Demanding the same practice rights for it. Able to work at a fraction of the price because of their low investment in time, money, and effort.

In no situation does it make sense to pave the way for your competitors. Yes competitors. Let's stop playing footsy with words. That's the naked truth of how our potential bosses will view us.

As far as the public goes, they can suck it. They benefit from residents keeping the lights on in Americas hospitals then then they can pay for it. It and the years of effort and sacrafice it takes to make a doc. They want to replace us. F@ck them.

I think until we arrive at this less sanguine, less regal, more fisticuffs point of view. We'll just keep getting the shaft.

 

[Doctor Bagel]

If you're earning $10, 500, it darned well IS worth mentioning.

Perhaps to occupy ourselves between now and Match Day we could all read this and discuss...

Ditto on this suggestion. It's a super readable book as well. Her book about Positive Psychology is also pretty interesting although maybe a little controversial around here.

I think people in medicine come from pretty sheltered (and generally affluent) backgrounds, which can limit our work with our patients.

 

[notdeadyet]

As far as the public goes, they can suck it. They benefit from residents keeping the lights on in Americas hospitals then then they can pay for it. It and the years of effort and sacrafice it takes to make a doc. They want to replace us. F@ck them.

Unfortunately, doctors being entitled and telling the public they treat to just suck it is one of the reasons we're fighting the things we're fighting.

 

[notdeadyet]

I think people in medicine come from pretty sheltered (and generally affluent) backgrounds, which can limit our work with our patients.

Amen. I was flabbergasted to learn how many medical students typically come from parents from professional backgrounds or even the percentage that are children of physicians themselves.

Sheltered backgrounds can be overcome, but it takes conscious effort, and if folks aren't willing to do the work, they're really limiting the work they do.

 

[Nasrudin]

Unfortunately, doctors being entitled and telling the public they treat to just suck it is one of the reasons we're fighting the things we're fighting.

Narrowly on the issue of equal practice rights. Not my mail man. My barber. Or, of course, my patients.

Also I refute your assertion that having been nickled and dimed means you have to roll over and go belly up for equal practice rights.

That smells like affluent guilty liberal nonsense in its own right.

I feel for those less fortunate. I want to do public psychiatry. I just think the public has their end of the contract to. Their tax base should support a difference in MD and NP training or there shouldn't be one in the first place. One or the other is a fair deal.

 

[notdeadyet]

Also I refute your assertion that having been nickled and dimed means you have to roll over and go belly up for equal practice rights.

You are refuting an assertion neither cast nor implied, my friend. No belly up philosophy here. Nor any guilt. But I also am not going to get my feelings hurt and have it lead to bad decisions.

ANY business that tells customer to "suck it" and "f@ck them" is stupidity that leads to financial suicide. Particularly when your customers make up the voting block that collectively helps determine your reimbursement. This holds less true if you're literally a monopoly, but, as this thread highlights nicely, we are not. And one reason for that is that medicine has turned a blind eye to what patients want and need for too long in the past.

Hyperbole is fun, but I'm just trying to keep it real here. There's a very old adage in business: "If you ignore your customers long enough, they'll stop calling."

 

[vistaril]

As far as the public goes, they can suck it. They benefit from residents keeping the lights on in Americas hospitals then then they can pay for it. It and the years of effort and sacrafice it takes to make a doc. They want to replace us. F@ck them.
.

ummm yeah, let me know how that works out for you.

What a lot of this arguments miss is that the public doesn't view all 'physicians' as irreplaceable. They don't mind in most cases going to an NP or PA for their upper respiratory infection. Or management of their chronic and decently controlled stage 1 htn or dyslipidemia. Or seeing a psych np(or alternatively lcsw for therapy) for an snri. This is especially true if the psychiatrist they would end up seeing in a med mgt capacity is not american and doesn't culturally connect with them like the american NP.

That said, they will *never* view certain things the same way.....nobody is going to say "I don't mind if a surgical PA is in charge of my dad's cerebral bleed as opposed to the neurosurgeon" or "let the np handle my PCI".

This is a problem that some fields are going to experience MUCH MORE than others.

 

[Nasrudin]

You are refuting an assertion neither cast nor implied, my friend. No belly up philosophy here. Nor any guilt. But I also am not going to get my feelings hurt and have it lead to bad decisions.

ANY business that tells customer to "suck it" and "f@ck them" is stupidity that leads to financial suicide. Particularly when your customers make up the voting block that collectively helps determine your reimbursement. This holds less true if you're literally a monopoly, but, as this thread highlights nicely, we are not. And one reason for that is that medicine has turned a blind eye to what patients want and need for too long in the past.

Hyperbole is fun, but I'm just trying to keep it real here. There's a very old adage in business: "If you ignore your customers long enough, they'll stop calling."

So let's be clear about what I meant:

As nickeled and dimed so eloquently points out--America has foreclosed on its middle class. There is no public support for our professional goals. People are too busy subsisting to care. And nurses enjoy enormous public mandate to run rough shod over any attempt to thwart them in gaining independence. So what I mean is that Joe Public is to us what a burnt out public defender is to black man on felony charges in rural Georgia. Sure that's an obnoxious metaphor. But logically it fits are political position--minus the oppression but then also then ironically our lack of sympathy by inversion.

So aligning ourselves with forces that don't align with us is what I am saying to hell with. We should dump our alcoholic public defender and bring in some guns with better suits than ours.

It's that or join the pretty white boys in a state prison crew that Vistaril cheer leads.

 

[Tyrone Slothrop]

Narrowly on the issue of equal practice rights. Not my mail man. My barber. Or, of course, my patients.

Also I refute your assertion that having been nickled and dimed means you have to roll over and go belly up for equal practice rights.

That smells like affluent guilty liberal nonsense in its own right.

I feel for those less fortunate. I want to do public psychiatry. I just think the public has their end of the contract to. Their tax base should support a difference in MD and NP training or there shouldn't be one in the first place. One or the other is a fair deal.

I read your posts, you're a sharp guy. You know nothing in life is fair though. People act in their own self interest. If we provide value above a NP we'll be paid for it, if we don't then we won't. Personally I think I offer more than a nurse can.

You spoke earlier about sanguinity and fisticuffs. I come from a pretty working class background, my uncle is a teamster rep and my father was a shop steward. If someone tries to drive truck when they're not allowed, their truck gets torched. If they persist, their house is next. We're not those people though, we're physicians. We'll never play it like that, so none of that language will serve us.

This battle will have to be won via value not protectionism. Our professional organizations need to be educating the public, and we need to be increasing the value we provide. Medicine is certainly changing, but it'll always need physicians.

 

[vistaril]

So let's be clear about what I meant:

As nickeled and dimed so eloquently points out--America has foreclosed on its middle class. There is no public support for our professional goals. People are too busy subsisting to care. And nurses enjoy enormous public mandate to run rough shod over any attempt to thwart them in gaining independence. So what I mean is that they are to us what a burnt out public defender is to black man on felony charges in rural Georgia. Sure that's an obnoxious metaphor. But logically it fits are political position--minus the oppression but then also then ironically our lack of sympathy by inversion.

So aligning ourselves with forces that don't align with us is what I am saying to hell with. We should dump our alcoholic public defender and bring in some guns with better suits than ours.

It's that or join the pretty white boys in a state prison crew that Vistaril cheer leads.

as some others have pointed out, there is only one way to stem the tide and stand out above psych nps:

provide a level of care that so exceeds their level that cash pay customers will fork out good money for it.

That is a very high standard; a standard most of us(including myself) simply do not have the skills, drive, energy, etc to provide. If you are going to bring special skills to the table and do this, good for you. I respect that.

But trying to get things to where medicare and insurers and third party payers and state legislatures recognize our value and protect it over psych nps in most situations.......lmao, good luck with that over time. That is a losing battle to be sure.

 

[Nasrudin]

I read your posts, you're a sharp guy. You know nothing in life is fair though. People act in their own self interest. If we provide value above a NP we'll be paid for it, if we don't then we won't. Personally I think I offer more than a nurse can.

You spoke earlier about sanguinity and fisticuffs. I come from a pretty working class background, my uncle is a teamster rep and my father was a shop steward. If someone tries to drive truck when they're not allowed, their truck gets torched. If they persist, their house is next. We're not those people though, we're physicians. We'll never play it like that, so none of that language will serve us.

This battle will have to be won via value not protectionism. Our professional organizations need to be educating the public, and we need to be increasing the value we provide. Medicine is certainly changing, but it'll always need physicians.

Now that's a counterpoint to mine that doesn't ignore what I'm saying completely in favor of issuing a dutiful admonishment of improper style.

I still think our flank is perpetually open due to a large constituency of bleedy heart professional class people with no fighting spirit. We could be playing a hell of a lot tougher than we are because of it.

I say this in complete obliviousness to the yapping troll in our midst.

 

[vistaril]

Now that's a counterpoint to mine that doesn't ignore what I'm saying completely in favor of issuing a dutiful admonishment of improper style.

I still think our flank is perpetually open due to a large constituency of bleedy heart professional class people with no fighting spirit. We could be playing a hell of a lot tougher than we are because of it.
.

what exactly could we do to 'play a lot tougher'???

Look at fonzie's initial post in this thread....if psychs make up 25% of cmhc positions in some regions, would your idea be to 'play tougher' by refusing to help staff them at all?? Great idea....then that 25% would drop even further.

We don't have a lot of leverage on third payer systems. That is the reality. Acting as if we do is silly, and would only hurt us.

 

[MacDonaldTriad]

I think it's easier to talk about paranoia as an attending. Your trained, competent, and putting money in the bank. Your debts are decreasing. You're an established product in the market place and you can be confident about your ability to stay there for the foreseeable future.

A future I would maintain is foreseeable only in some handful of years ahead. So your potential audience--me, entering training, and your medical students 3-4 years behind--what can you really say to them with any certainty.



As far as the public goes, they can suck it. They benefit from residents keeping the lights on in Americas hospitals then then they can pay for it. It and the years of effort and sacrafice it takes to make a doc. They want to replace us. F@ck them.

I think until we arrive at this less sanguine, less regal, more fisticuffs point of view. We'll just keep getting the shaft.

What I can say for certain is that before you were born, we were saying and thinking the same things as you. Medicine had only a few more good years before it would implode and managed care would ruin everything we were working hard to achieve. I think our parents told us they were saying the same things about medicine in the 50s

 

[Nasrudin]

I acknowledge and concede 2 points put forth by you and NDY as I understand them:

1. There are cyclical patterns of how we see our profession's future and this might be but another go round. (you)
2. Publicizing your weakness, gentility, and equanimity is perhaps the best play and the best style of communication to the world as a form of deceptive power. (he)

For your point I don't deny it. Although I question whether this a revolving door of ideas or a more complex recycling of reactions to completely novel situations. I don't think we have a precedence for the NP independence movement. Nor do I know of a time since the 1950's that we have ever had a lower public esteem. Nor do I think we have since that same time had a more bleak financial picture than now. There is, of course, some universality to this on the American landscape but I think given the size of our investment we cannot afford to chalk this up to the direction or currents or the movements of tides or the swinging of a rhetorical pendulum.

As to his point I'm open to all manner or strategy that runs counter to my previous aggressive language. My only point with that was to direct it inwardly at the sheepish notion that the NP independence movement is not a threat. They are poised to change the game. We cannot simply point to the trickle and forget the glacier above our heads--That only awaits the change of season. I think we approach that season. Where there is an easier route into a solid profession, where are all others drying up before our eyes, we should expect that trickle to become a river. You don't wait until then to form a committee to draw up plans for a dam.

I don't share the bashful regard for the use of power in the work place. If nurses taught me one thing. It was this.

 

[Tyrone Slothrop]

I acknowledge and concede 2 points put forth by you and NDY as I understand them:

1. There are cyclical patterns of how we see our profession's future and this might be but another go round. (you)
2. Publicizing your weakness, gentility, and equanimity is perhaps the best play and the best style of communication to the world as a form of deceptive power. (he)

For your point I don't deny it. Although I question whether this a revolving door of ideas or a more complex recycling of reactions to completely novel situations. I don't think we have a precedence for the NP independence movement. Nor do I know of a time since the 1950's that we have ever had a lower public esteem. Nor do I think we have since that same time had a more bleak financial picture than now. There is, of course, some universality to this on the American landscape but I think given the size of our investment we cannot afford to chalk this up to the direction or currents or the movements of tides or the swinging of a rhetorical pendulum.

As to his point I'm open to all manner or strategy that runs counter to my previous aggressive language. My only point with that was to direct it inwardly at the sheepish notion that the NP independence movement is not a threat. They are poised to change the game. We cannot simply point to the trickle and forget the glacier above our heads--That only awaits the change of season. I think we approach that season. Where there is an easier route into a solid profession, where are all others drying up before our eyes, we should expect that trickle to become a river. You don't wait until then to form a committee to draw up plans for a dam.

I don't share the bashful regard for the use of power in the work place. If nurses taught me one thing. It was this.

You're right. Like I said before, I come from a working class background. We should have been unionized, and we should have closed the shop. We didn't, and it's too late.

The rats are in the house. Whatever ground has been lost, will stay lost. In my mind now is the time to win on quality. Demand more regulation, more examinations. If they want to play doctor make them jump the same bars. We need a campaign of public education to highlight their deficiencies. I think we've lost the competition on price-point. We can't afford to lose on the issue of quality.

As vulgar as it sounds, the goal should be to brand NPs as proles who treat proles.

It's a terrible shame for medicine as I think all people should have access to quality healthcare. However, if the market won't bear that, then we at the very least have to preserve medicine as a profession. If we don't retain a distinction then medicine as a career is disincentivized. I don't want the next generation of leaders in medicine to be fancy nurses. We'd be taking a massive step backward.

 

[Esquire]

.

 

[PikminOC]

I only get occurrence based malpractice policies. And even 400 a month is alot when you're also paying back interest on your medical school debt.

 

[IamPsychiatrist]

This post makes me think about crossing psychiatry off the list of potential specialties. Only 1% from my school choose psychiatry in the last match, and I can't see how anecdotes of NP's replacing psychiatrists will do anything except scare off more med students and make psych even more unpopular.

The argument that psychiatrists don't have to worry about their jobs because they add more value than an NP would be laughable to a hospital MBA, owner of a practice group, or insurance exec. Adding value means adding money to the bottom line. NP's add more value than a psych if they cost less but generate the same amount of revenue and have the same malpractice risk.

Seems like the only people who care about "quality" are the very small subset of patients who can do cash pay. Otherwise, the general public has no say on the quality and value of their psych because their 3rd party payer dictates what is "value". The public only cares that someone in a white coat accepts their insurance, can see them in a timely manner, and won't kill them. It's a low standard that NP's can fulfill, just like the masses of IMG's and assorted folks who couldn't match into anything else are doing now.

I sense much fear in you. Fear leads to anger. Anger leads to hate. Hate leads to suffering.

There are no guarantees in life except one. If you are truly exceptional at what you do, you will always have work.

 

[SteinUmStein]

I thought it was death and taxes, but I like yours better.

 

[vistaril]

This post makes me think about crossing psychiatry off the list of potential specialties. Only 1% from my school choose psychiatry in the last match, and I can't see how anecdotes of NP's replacing psychiatrists will do anything except scare off more med students and make psych even more unpopular.

The argument that psychiatrists don't have to worry about their jobs because they add more value than an NP would be laughable to a hospital MBA, owner of a practice group, or insurance exec. Adding value means adding money to the bottom line. NP's add more value than a psych if they cost less but generate the same amount of revenue and have the same malpractice risk.

Seems like the only people who care about "quality" are the very small subset of patients who can do cash pay. Otherwise, the general public has no say on the quality and value of their psych because their 3rd party payer dictates what is "value". The public only cares that someone in a white coat accepts their insurance, can see them in a timely manner, and won't kill them. It's a low standard that NP's can fulfill, just like the masses of IMG's and assorted folks who couldn't match into anything else are doing now.

bingo. 1st rate post.
I will say that inpatient psych will always still have some need for psychs(but much reduced than now), and there will be a need for outpt psychs to serve as administators.

but the direction this is headed is pretty clear. Psych nps are about to explode. Right now it's a trickle compared to what it will be in 10 years.

Unfortunately as more amgs cross psych off their list, more fmgs/imgs come into the fold....which again doesn't help us vs psych nps in terms of public perception.

 

[MacDonaldTriad]

I acknowledge and concede 2 points put forth by you and NDY as I understand them:

1. There are cyclical patterns of how we see our profession's future and this might be but another go round. (you)
2. Publicizing your weakness, gentility, and equanimity is perhaps the best play and the best style of communication to the world as a form of deceptive power. (he)

For your point I don't deny it. Although I question whether this a revolving door of ideas or a more complex recycling of reactions to completely novel situations. I don't think we have a precedence for the NP independence movement. Nor do I know of a time since the 1950's that we have ever had a lower public esteem. Nor do I think we have since that same time had a more bleak financial picture than now. There is, of course, some universality to this on the American landscape but I think given the size of our investment we cannot afford to chalk this up to the direction or currents or the movements of tides or the swinging of a rhetorical pendulum.

Nasrudin, don’t get me wrong, I enjoy all of your posts and I am convinced you are a deep thinker. Your worry about the NP independence movement is exactly what fans flames of anxiety among people working so hard to protect what large investments in money, time, and sleep deprivation would be afraid of. Trust me; it would be hard to find an ebb in public esteem of psychiatry if such a graph existed. We seem to be capable of defying the regression to the mean theory for a very long time. Fortunately, I don’t care much. I think the 70s was about as close to a hay day as psychiatry will get. Psychiatrists have been pushing the biological movement very hard to find acceptance, but most of our value isn’t in writing meds. I hope someday we are successful enough to make our meds sufficient to deal with mental illness, but not in our lifetime probably. When that happens, NPs can take over.

 

[vistaril]

Nasrudin, don’t get me wrong, I enjoy all of your posts and I am convinced you are a deep thinker. Your worry about the NP independence movement is exactly what fans flames of anxiety among people working so hard to protect what large investments in money, time, and sleep deprivation would be afraid of. Trust me; it would be hard to find an ebb in public esteem of psychiatry if such a graph existed. We seem to be capable of defying the regression to the mean theory for a very long time. Fortunately, I don’t care much. I think the 70s was about as close to a hay day as psychiatry will get. Psychiatrists have been pushing the biological movement very hard to find acceptance, but most of our value isn’t in writing meds. I hope someday we are successful enough to make our meds sufficient to deal with mental illness, but not in our lifetime probably. When that happens, NPs can take over.

I agree with a lot of this....but the *problem* is much of our value(in terms of $ in the current model) is in writing meds. That's just the way it is......

 

[@JackShephard]

I agree with a lot of this....but the *problem* is much of our value(in terms of $ in the current model) is in writing meds. That's just the way it is......

I believe looking at the NPs as a threat is wise.

 

[F0nzie]

I still do not understand the rationale for the non-compete clauses in the current environment. For example, my pp could use receptionist for extra help. If there was a shortage of receptionists I wouldn't make the job position less desirable by adding a stupid restriction that prohibited outside employment.

 

[vistaril]

I still do not understand the rationale for the non-compete clauses in the current environment. For example, my pp could use receptionist for extra help. If there was a shortage of receptionists I wouldn't make the job position less desirable by adding a stupid restriction that prohibited outside employment.

part of it is that administrators don't have the ability or time to check up on psychs in many cases and actually make sure they are there are the job they have agreed to work. In other cases, cherry picking patients for the person's other job can be a real problem. In other cases if they are paying for run of the mill full time work(200kish), they expect all the attention to be paid to the primary job....that's what all that cash is for. Not just somewhere to show up, collect a check and benefits, and then spend ones mental energy on outside projects.

but most noncompetes(at least out of academia) are often only partial. At least around here.

also, think about what the 'current environment' really is in some areas. An environment with bunches of newly minted psych nps willing to grind isn't that bad of an environment from an employer's standpoint.

 

[vistaril]

I believe looking at the NPs as a threat is wise.

how so? Since there isn't anything we can do about it, I don't know that I would call it wise. I suppose one could work on moving towards an area where there is likely to be at least some protection from np encroachment(like forensics), but that's problematic if you have no interest in such things.

 

[PikminOC]

It is my personal opinion that this NP paranoia is much exaggerated. Yes, I have seen NPs with very questionable quality of care, but I can say the same thing about some psychiatrists. Yes, they can do some of what we do for less cost, and they have much less educational expenses, but they haven’t driven down our incomes that much. The supply is still so sparse compared to the demand, the world is probably better off with NPs than without.

When my GP isn’t getting me better, I go to a specialist even if it is out of pocket. NP psych patients probably do the same when they have money. A lot of psychiatry patients get better, but not completely well. We still get to tackle these. If patients can’t afford us, then bless NPs for seeing them. They aren’t robbing our pockets that much. If we cannot help refractory patients any better than an NP, maybe NPs should dominate the business.

Just ask a drug rep where his or her market is. He/She will tell you that ¾ of their psych meds are written by primary care doctors. Primary care providers already out number NPs and psychiatrists by a couple of orders of magnitude. With so many doctors already doing psychiatry with less skill, I don’t see how NPs will turn our world upside down.

Exactly.

 

[Shikima]

I believe looking at the NPs as a threat is wise.

I disagree. One with good business sense can profit from their particular skillset.

 

[ferning]

This post makes me think about crossing psychiatry off the list of potential specialties. Only 1% from my school choose psychiatry in the last match, and I can't see how anecdotes of NP's replacing psychiatrists will do anything except scare off more med students and make psych even more unpopular.

The argument that psychiatrists don't have to worry about their jobs because they add more value than an NP would be laughable to a hospital MBA, owner of a practice group, or insurance exec. Adding value means adding money to the bottom line. NP's add more value than a psych if they cost less but generate the same amount of revenue and have the same malpractice risk.

Seems like the only people who care about "quality" are the very small subset of patients who can do cash pay. Otherwise, the general public has no say on the quality and value of their psych because their 3rd party payer dictates what is "value". The public only cares that someone in a white coat accepts their insurance, can see them in a timely manner, and won't kill them. It's a low standard that NP's can fulfill, just like the masses of IMG's and assorted folks who couldn't match into anything else are doing now.

I dont totally disagree except from the CEO perspective that bottom lines dwindles because nurses have the strongest union in the country, more than teachers goinh forward if not currently.

Look at the anesthesia NP paradigm and how their salaries have outrisen their bottom line in light of their union contracted labor rights

Its quanitative nursing staff levels that dictate acuity of wards and licensing of hospitals and subacute rehabs. And now they are dictating orders and prescriptions that drive the healthcare economy with NP. All the while they farm out their former clinical duties to techs at $9 an hour. Thats what happens with one strong union in an otherwise unorganized and marginalized labor force.

they have lost their labor utility and become pointless middle management from my perspective in healthcare delivery. But like good middle management they carry out well other practice policies that fuel the bottom line, by keeping patients overly sedated with unneccesary lines for infection and future repeat business

Theres other bottom lines besides the hospital conglomerates who arent in direct competition with pharma, insurance, and medical devices. The nursing union is corrupted with too many ties to these related industry outside contracted agreements.

 

[ferning]

And for IMGs non us citizens, they have been a great labor force from a ceo perspective. They contribute to keeping physicians from organizing foand shaping healthcare because for a better part of their career visas and poor economics at home distort their perspective.

They also come from more overtly oppressed countries with fascist regimes (phillipines) or with more indoctrinated mentalities than our own (india). This is the labor force u want if you want maximize your profit margins and bottom line. Hence our countries big businesses supporting such neocolonialism in PI, south america, etc with dictators and a military presence

 

[@JackShephard]

how so? Since there isn't anything we can do about it, I don't know that I would call it wise. I suppose one could work on moving towards an area where there is likely to be at least some protection from np encroachment(like forensics), but that's problematic if you have no interest in such things.

I only said this from what I've seen. Psych always fascinated me, but I also see in many of the big family practices that I've worked in that they like "in house" therapy and psych care. I know some of these big organizations will hire MD's but many will hire NPs at half the cost.

Just in the direction I see healthcare going - large healthcare groups and referral based practices, I believe procedures will be paid less in the future and that NPs will be attractive for many of these large groups. I believe most psychiatric drugs are already given by Family Medicine or generalists, so when they need to hire in house psychiatric help, I'm just guessing who they will hire.

With that said, I'm a medical student and know very little.

 

[nancysinatra]

I haven't followed this whole thread so I apologize if I'm repeating anything. But I just wanted to jump in, because the issue about NPs interests me. I started a job last summer after finishing residency. It's mostly outpatient with some inpatient coverage. Overall it's going pretty well. Certainly it's an improvement upon the horrors of residency. But my fellow psychiatrists here each supervise one if not more NPs, and their NPs cover the inpatient unit too. Sometimes I come on call after them, and am then asked to discharge patients the NPs have admitted and followed. The thing is, they make some astonishingly poor medication choices and their notes are the worst notes I've ever seen. At times it's impossible even to understand why they are in the hospital and what has been done. So when I have to discharge these patients I am pretty nervous. They no longer meet commitment criteria and I end up having no choice. I try to document that I recommend they stay in the hospital and recommend they try medication X or whatever instead of whatever they're on, but I imagine this documentation only will protect me so far. Last week I had a patient bounce back after such a discharge. The guy was taking 20mg q4h PRN of zyprexa for anxiety. Yes, that was one of his meds. And risperdal BID. There was no good reason mentioned as to why. Obviously I did not continue the PRN zyprexa when he left. But I don't know if the antipsychotic effect was actually helping? There sure were no notes to guide me. The diagnosis wasn't consistent or justified by his presentation.

I do think the NPs have a good rapport with patients and I'm not trying to discredit them, but I worry about my own liability coming on after them. There's no way I'll bring this up with my colleagues - I'd quit before I'd confront them because I suspect they'll be defensive, not to mention they'll have illogical justifications rationalizing how they are "working with" the NPs, and I don't want to hear it. Plus I'm in a different part of the country than where I did residency, and the medication philosophies seem to be different here. Not that it was perfect where I was for residency, of course. But even from local psychiatrists I'm seeing these gigantic doses of layered on antipsychotics, and a lot of polypharmacy. Benzos and adderall are big. Psychotherapy is done by social workers largely and from what I hear, most patients aren't big fans. Can you blame them? Maybe it's because I'm not in an academic environment, maybe that's the problem. But academia has its problems too...

 

[Esquire]

.

 

[@JackShephard]

First observation: Psychiatric nurse practitioners out number Psychiatrists 4:1 in several of the community agencies.

Third observation: One of the major community mh providers laid off a large number of their child psychiatrists and replaced them with psychiatric nurse practitioners.

Fourth observation: Several large multispecialty practices in pediatrics, developmental pediatrics are hiring psychiatric nurse practitioners to perform the role of a child psychiatrist and self referring.

Fifth observation: Nurse practitioners are taking an entrepreneurial role and hiring large numbers of therapists and generating internal referrals for their private practices.

But my fellow psychiatrists here each supervise one if not more NPs, and their NPs cover the inpatient unit too.

To clarify my above statement, I believe what's already happening will happen more because there is a large shortage of psychiatrists and NPs can train in only a few years. Also, medicine is increasingly being taken over by large groups run by large administrators / business men who will suck every dollar of profit out of the system.

To be fair, the same thing is happening in anesthesia and many other fields. I think anesthesia just happened first because they were making twice the $.

 

[Armadillos]

I think a lot of this NP/PA stuff is demonstrating a problem (well really more of an inefficiency) of modern medical training. In general medical training right now is taking more and more time, but the longer you train, the more narrow your scope of practice becomes. Medical school/internship is 5 years of training us to be generalists and then we spend more and more time narrowing in on a smaller and smaller scope of practice that ultimately is applicable to fewer and fewer patients. Ultimately it just doesn't seem that efficient.

On the other hand you can get a NP/PA with a narrow focus of practice relatively quickly. For example at our hospital we have a PA who is the "pacemaker PA" and does almost all of the followup with pacemaker patients, but nothing else. There is a urology NP who has essentially the "non-surgical urology" clinic. There is the peds asthma NP. Each organ has its own "<organ> transplant clinic NP/PA", etc.

 

[@JackShephard]

I think a lot of this NP/PA stuff is demonstrating a problem (well really more of an inefficiency) of modern medical training. In general medical training right now is taking more and more time, but the longer you train, the more narrow your scope of practice becomes. Medical school/internship is 5 years of training us to be generalists and then we spend more and more time narrowing in on a smaller and smaller scope of practice that ultimately is applicable to fewer and fewer patients. Ultimately it just doesn't seem that efficient.

On the other hand you can get a NP/PA with a narrow focus of practice relatively quickly. For example at our hospital we have a PA who is the "pacemaker PA" and does almost all of the followup with pacemaker patients, but nothing else. There is a urology NP who has essentially the "non-surgical urology" clinic. There is the peds asthma NP. Each organ has its own "<organ> transplant clinic NP/PA", etc.

Agree completely. We all know that we can train faster. Now there is competition that maybe trains too fast but still in 1/3 the time, yet they aren't 1/3 of the skill or ability.

 

[nancysinatra]

Agree completely. We all know that we can train faster. Now there is competition that maybe trains too fast but still in 1/3 the time, yet they aren't 1/3 of the skill or ability.

But it's not just the length of training that makes doctors different from NPs or PAs. There's the SAT scores and high school grades required to get into 4 year colleges that teach the required premed classes, there's the premed classes themselves, some of which are "weeders," then there's the MCAT, the med school admission process which isn't exactly non-competitive, med school exams, the USMLEs, the match, and then not only getting through residency complete with rotations in neuro and IM, but also the PRITEs and later the boards (and renewal boards). I've met some stupid doctors in my day but not that many, and even the stupid ones are never all that dumb. I'm sure NPs and PAs have their own hoops to jump through but if I had to bet on which profession is more selective, hmmm...