Do MD's fear psych being overrun by NP's?

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I've downgraded my thoughts of all of Medicine (not just psychiatry), and would no longer recommend to my own family or kids, unless they knew with certainty they would do Psychiatry and potentially take over my practice some day. Other than that, no, its not worth it.

I fear and lament my hopeful approach to being geriatric some day. To know that I likely won't ever see an MD/DO/MBBS in acute moments when I would most hope to. Knowing this, and the deficiencies of ARNPs, I keep coming back to the thought I'll be better off avoiding hospitals and risking demise due to the natural illness course rather than risk an iatrogenic death by ARNP? Especially when considering how much undoing of diagnosis and treatment planning I do from people who were previously being managed by psych ARNPs. I don't see anything today that shows this trend reversing or slowing down, but only worsening.

There will be pockets of MD/DO/MBBS value in the future system, but not enough to save it as a profession.

The historic simplistic equation of intelligent + hard work + medical career = long list of benefits; simply just doesn't apply anymore.

Intelligent hard workers who are just starting, are better off in so many other industries or career trajectories.
 
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In some ways though, people who view themselves as business person first, could enter medicine to preserve that identity as a business person first, and not drink the koolaid of a profession with tradition and values for patient care. Doing so, the future can be bright for those who view it as nothing more than business transaction and willing to gloss over the rest of the nuances. These will be some of the physician 'survivors' in decades to come.
 
It is being seen more and more by the public than NPs (when inappropriately autonomous) are causing real harm. The litigations are starting as well...so to be completely honest I see it progressing a little bit more then starting to swing the other way because the ads write themselves (not to mention liability insurance will go up). "Why go to clinic X and see a dangerous, unqualified practitioner when WE have fully board certified physicians because we care about your safety" or whatever.

Either that, or they go back into the roles that they were initially designed for and life goes on. Maybe its just because I'm already in the thick of things with no way to change it now that I'm hopeful haha
 
I'm going to respectfully disagree with @Sushirolls

I had another career before medicine. I'm also a law school drop out. In my actual career, I saw tons of intelligent hard workers all fighting for the promotion. I saw the vast majority of them overlooked time and time again. It was a literal rat race. During my time in law school, I saw the ruthlessness of classmates fighting for summer internships at big law firms in hopes they would eventually be hired upon graduation. Starting salaries were in the 140-160k range for 80-90 hour weeks. For every partner, C-level exec, or VP, there are 100+ very smart people who just didn't schmooze hard enough to get the job. And then when you do get the job, layoffs are much more a thing than they are for doctors.

At least in medicine, things are very straight forward. Get good grades, do well on the MCAT, make it through med school and you're essentially guaranteed a residency spot. There really aren't many career paths this straight forward and sure. Essentially any doctor out there can earn 300k a year. Want to work those big law hours, you're looking at a heck of a lot more than 160k a year my friend. Eventually get so burned out and overrun by NPs? Leave medicine all together and use your medical degree to join some biotech or related firm and enter the rat race. There's no way medicine still isnt head and shoulders above everything else out there 9 times out of 10. Would absolutely still recommend going into medicine at this juncture.
 
I've never seen a topic where real life and SDN vary by more (which is saying something). On here, NPs are taking over and the sky is falling. In my real life, every single hospital in my city (in the Northeast, already pretty dense with psychiatrists) is desperate for psychiatrists and always has openings, and a hospital system in my city just raised psychiatry salaries by like 25% to attract more MDs.
Can't predict the future of course, but I don't see any indication that this is changing anytime soon, and I imagine it's even more favorable in lower COL cities and regions.
 
Agreeing with the above. Unclear why SDN is freaking out. I guess there just aren't enough administrators who post here to comment on the complete inability to recruit enough clinicians OF ANY TYPE for mental health jobs pretty much anywhere. I can't imagine a safer job choice right now than pursuing an MD or NP with post grad psych training. You're going to be paid what you're worth either way and probably a good deal more.
 
I believe the variance of opinions on SDN can partially be recognized for the differences in geography, and secondly expectations of the psychiatrist for a job. I'm in a saturated area next to an ARNP school pumping out grads, and I have higher expectations. I'm also next to one of the Big Box health systems that has done an excellent job of making national news repeatedly for uniquely different reasons every year or so - but in a bad way.

The trajectory as evidenced by Emergency Medicine, Pathology, Radiation Oncology isn't reassuring.
-I've witnessed a health system change from a true calling, organization run by a religious order, to being completely over taken by admin that don't care about health. I can't get in to specifics with out risking my illusion of anonymity.
-The rise of private equity seen by the for profit hospitals like UHS and its wannabes. Now there appears to even be a new player in the outpatient arena, Lifestance that I don't have high hopes for.
-An ever increasing tide of what constitutes a normal work week in the wRVU mine. I'm still 'early career' and in my time I've seen it creep up from ~3400 to 4000 before I stepped out of the wRVU game. What will you be chiseling away towards in the coming years? Will you have a chisel? An ax? A jack hammer? Dynamite? Modern era equipment?
-I believe an inpatient full time job should be 10-12 patients at most for a typical unit. I'm seeing inpatient units pushing more and more and more. 15? 18? 20? Oh, and you get clinic time, or C/L or ED consults on top of that, too!
-I'm witnessing 100% ARNP clinics, and TMS clinics 100% ARNP run.
-I'm seeing more therapists tell patients they have diagnosis XYZ and you need to talk with your psychiatrist about medicine ABC or DEF is all wrong, tell your doc.
-The various doctors connected with the previous Big Box health system I was with, has lost so many good doctors who were pushed out. FM, Gen Surg, Anesthesiology, Pain, etc. Their EM group was getting pushed around contractually hard, and as some have seen in EM forum, not much they can push back on. Gen Surg with fellowship coming in, lied to about doing niche, pushed into Gen surg, and then colleagues leave. Anesthesiology? Hospital politics in that field, but at that place they got rocked hard. Pain medicine? Bless there hearts when they try to push back and not prescribe any opioids.
-I have a sleep doc subleasing from me, and that's another field that has been on the slow decline and close to being saturated if not already. I'm sure @michaelrack could chime in on that field, too.
-I know of personally 2 doctors that were let go during early covid, and one they are now willing to replace but with an ARNP. The other simply closed up for that specialty at that location.
-UHC, continues to have solid growth with their stock. This company is gobbling up market share and laterally with surgery centers, hospitalist groups, PCP groups, Optum, Molina, now the billing company connected with my EMR, etc, etc. This company also has popped up on national news for large court cases against hospitals / health systems /medical groups for contractual rates. The power and dominance these companies can leverage is jaw dropping.
-Nationally the push against "balanced billing" only serves to gift more power to insurance companies.
-The large disparate fee schedules of Big Box shops (which are usually non-profits and get tax deductions!) are well in excess of small independent docs. One entity in my area is a wannabe Cleveland Clinic (for profit) and they get amazing rates. This makes it harder to strike out on your own, almost forces a dichotomy of Big Box shop employment or cash only.

Things in some places of the country may be okay or fine now. But look at the trajectory folks.

I wish/hope I'm wrong, but too many dots in different facets of our industry are pointing not towards positivity. We just simply get a little more time than the other specialties before things implode.

As of right now, I'm more inclined to recommend my kids pick a trade or open their own business from the start post high school. Tree faller for suburbs. Landscape. Plumber. Mason. Electrician. Commercial real estate.

*Years from now, if I'm still on SDN and I'm completely wrong, please drawn attention to my trajectory predictions. I'll celebrate with y'all.
 
No. And I always preface these conversations by saying I am in Boston which has the highest psychiatrist to patient ratio in the world.

The demand for psych is so incredibly high that an army of mid-level practitioners will not make a dent in it. Just this week we are trying to make referrals for teens from inpt and not even community run NP-prescribing or SW-therapy practices have intakes in the NEXT FOUR MONTHS.

With the widening inequality, social turmoil, and now seemingly endless pandemic, people's mental health will get a lot worse. Even if we somehow got hundreds of new mid-level mental health practitioners each year for the next decade, the quality may be variable and anyone of means will be flocking to MDs first.

If you are a halfway competent MD psychiatrist you will be fine in the foreseeable future.
 
I'll second the notion of geography likely playing a big role. Our major hospital systems are definitely going the route of NPs/APRNs. I'd be interested to see some sort of breakdown of per capita distribution in systems by region.
 
If you aren't here to troll why keep posting similar topics?
 
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WisNeuro said:
I'll second the notion of geography likely playing a big role. Our major hospital systems are definitely going the route of NPs/APRNs. I'd be interested to see some sort of breakdown of per capita distribution in systems by region.
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I'm not acutely concerned, but could certainly see it being an issue 20 years down the road. I'd also think that geography would play a role and that level of practice autonomy would make a big difference.
 
Most employers don't want to hire NPs in place of us. They just can't find enough of us to hire. Our high salaries inflate the NP pay rate and employers don't like it and they understand the liability and quality isn't at all a bargain when they hire NPs. The sky isn't falling and it would take a lot more of us to saturate the demand. NPs can't and don't do what we do. If they could, we should really change the pipeline and dumb it down.
 
I actually think the dramatic increase of residency spots will be more of a problem. This aspect has been hidden except when you read the fine lines in the report.

The fine lines within the fine lines are that most of these new residency programs are open in low desirability areas, whereas established cities are not having a dramatic increase of spots. This means that if you end up in one of the low desirability areas, your job options if you want to stay become more questionable, and salaries get pushed downward. This is a real effect: psychiatrist is one of the few, if not the only, medical specialty where the rural/small city-big city salary differential is often non-existent, or even negative. The top top incomes in psychiatry are DEF not in small cities. I called around and was shocked by how low salaries are in small cities in the south, etc.

Job market is very fragmented right now, and the expectation is that certain jobs will be more competitive and more NP dominant than others (i.e. hospital inpatient jobs at a lower-tier community hospital, Big Box telepsychiatry, etc.).

More broadly, the NP problem is also much more of a rural/small city problem than a big-city problem. If hospitals can hire MDs they won't hire NPs. Salaries of MDs are related to productivity, which will have a floor, and they are typically more efficient at hitting "quality metrics" than NPs, so if there are candidates available and willing, hospitals would prefer MDs.

Many jobs NPs will also not be able to touch: administration, subspecialty practice, cash practice, practice ownership, research, industry, government. Generally, an MD who practices in a community facility who works troublefree for 3 years will get the chance to be promoted to medical director. These jobs are not available for NPs. There are lots and lots of clinical and non-clinical jobs for psychiatrists in the public sector, and those jobs are in general very safe from encroachment.
 
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im not even remotely worried about it. First, the law of supply and demand: there simply is not enough midlevels willing to go into this field that would even meet the unmet need. My facility is an extremely large facility, one of the largest in the state. We have trouble even getting enough midlevels..let alone psychiatrists.

There are still quite a few patients out there that refuse to see NPs/PAs at my facility and I end up having to see them as well. So many patients would not be satisfied with this.

Personally my biggest current fear is that, maybe in 10 years or so the idea of a single payer really catches on, the government becomes a monopoly with healthcare, and they start to dictate physician salary by being the predominant payor source.
 
Monocles said:
No. And I always preface these conversations by saying I am in Boston which has the highest psychiatrist to patient ratio in the world.

The demand for psych is so incredibly high that an army of mid-level practitioners will not make a dent in it. Just this week we are trying to make referrals for teens from inpt and not even community run NP-prescribing or SW-therapy practices have intakes in the NEXT FOUR MONTHS.

With the widening inequality, social turmoil, and now seemingly endless pandemic, people's mental health will get a lot worse. Even if we somehow got hundreds of new mid-level mental health practitioners each year for the next decade, the quality may be variable and anyone of means will be flocking to MDs first.

If you are a halfway competent MD psychiatrist you will be fine in the foreseeable future.
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That's what I have been thinking.

They are going to need to churn out psychiatrists and there are still not going to be enough.
 
At worse out salary's will get dilute, but we will never be out of work. The sheer amount of adolescent depression out there is staggering and family's are more than willing to medicate these days. There's less stigma against pharmacotherapy overall.
 
Yes there are jobs. But another way to look at the argument of, "Look! There are jobs!" is McDonalds is always hiring. But in the food service industry how many waiters, cooks, etc are clamoring for McDonalds versus Hyde Park Steakhouse?

So, yes, demand will never be met in mental health either...
 
I think the restaurant industry right now pretty clearly mirrors mental health. There are needs for MDs and NPs in ALL types of mental health positions, good and bad. Morton's and McDonald's are both in desperate need.
 
I have almost 4 decades of watching this. The psychiatry job market is stronger than it has ever been in my life time. You can get worked up, but it doesn't get better than it is now. Some jobs might be better than others, but you can work anywhere you choose. There is no credible evidence things will get worse soon.
 
MacDonaldTriad said:
I have almost 4 decades of watching this. The psychiatry job market is stronger than it has ever been in my life time. You can get worked up, but it doesn't get better than it is now. Some jobs might be better than others, but you can work anywhere you choose. There is no credible evidence things will get worse soon.
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Well I hope it keeps getting better 😏
 
From the outside looking in: I don't see demand changing for psychiatrists despite ongoing midlevel hiring. I do wonder if hospitals getting hurt by diminished revenue last year has caused them to be even more cost-averse now and push for more NP hiring, possibly combined with increased MH need and burnout causing more doctors to finally hit their "f- it" cap and walk out or retire (i.e., need for a stopgap).

All I've seen where I work is the creation of umpteen new mid-level management and administrative positions such that they probably now outnumber frontline clinical staff. And Teams meetings. Ungodly amounts of Teams meetings. But they're still hiring psychiatrists (and psychologists).
 
AcronymAllergy said:
From the outside looking in: I don't see demand changing for psychiatrists despite ongoing midlevel hiring. I do wonder if hospitals getting hurt by diminished revenue last year has caused them to be even more cost-averse now and push for more NP hiring, possibly combined with increased MH need and burnout causing more doctors to finally hit their "f- it" cap and walk out or retire (i.e., need for a stopgap).

All I've seen where I work is the creation of umpteen new mid-level management and administrative positions such that they probably now outnumber frontline clinical staff. And Teams meetings. Ungodly amounts of Teams meetings. But they're still hiring psychiatrists (and psychologists).
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No major hospitals lost money last yr, they all made a lot of money and got extra cash from the government too! It didn't hurt that insurance was paying for telehealth with parity and waived copays and covered all covid-related costs. additionally, psychiatry departments did better last yr because there were fewer no shows, higher demand, and telehealth parity.
 
splik said:
No major hospitals lost money last yr, they all made a lot of money and got extra cash from the government too! It didn't hurt that insurance was paying for telehealth with parity and waived copays and covered all covid-related costs. additionally, psychiatry departments did better last yr because there were fewer no shows, higher demand, and telehealth parity.
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Well that's one less excuse, then. Not that it won't still be used somehow, of course.
 
splik said:
No major hospitals lost money last yr, they all made a lot of money and got extra cash from the government too!
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My hospital is either lying to me or they really lost a lot of money last year. Yes, we had outpatient visits, but the ED was much emptier and we had a great reduction in elective procedures. We eventually filled up inpatient with COVID patients but went some time before that with an unusually low census. We actually capped our inpatient psych unit at a low census.

Maybe my hospital won't count as major to you, but it is nearly the largest in my state and possibly the most popular.

Edit: getting too late for me to think this through more, but now I'm throwing myself off as to how much was money lost versus just being under the budgeted expected amount of revenue
 
Not in my country. One of the reasons I joined SDN was to get an idea of potential trends in psychiatry, as there might be developments happening in the US that eventually come down under. Psychologist prescribing rights was probably the initial one, as we don’t really have a huge NP culture. As it stands, the academic requirements to qualify for a NP are high, with the costs and study often not worth it as our nursing union is already quite strong.

Our governments have recognised a big increase in demand for mental health service even before Covid, but in typical misguided fashion they’ve chosen to put money towards building new infrastructure so we are still faced with a shortage of clinicians. Even if they pump out more psychiatrists, I can’t see demand falling. We’ve had a surge in ADHD referrals, probably exacerbated by working from home/home schooling changes in addition to the usual sources. We’ve had 2 newly minted psychiatrists join our hospital, neither interested in this kind of work. However, one of them is sweeping up all the new inpatient referrals and assisting with ECT (which we need) and the other has found herself taking on a lot of the younger adult borderlines (which we definitely need).

My initial fears about the broader economy have been allayed given my earnings over the last 18 months. For next year I will be quite confident in raising my initial consultation fee. During our covid response, psychiatric services were untouched while surgery and procedures were cancelled. There is also a long waitlist to get appointments to see psychologists. I believe they doubled the amount of subsidised appointments to 20, which of course meant that slots for new patients dried up.
 
Hospitals lost a lot of money last year. Telepsych visits do NOT make up for cancelled elective surgeries. That said...they can and will still pay very well for NPs and MDs to do psych.
 
comp1 said:
Hospitals lost a lot of money last year. Telepsych visits do NOT make up for cancelled elective surgeries. That said...they can and will still pay very well for NPs and MDs to do psych.
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comp1 said:
Hospitals lost a lot of money last year. Telepsych visits do NOT make up for cancelled elective surgeries. That said...they can and will still pay very well for NPs and MDs to do psych.
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Yeah that is what some hospitals were saying as they encouraged physicians to adjust their contracts.
 
Our rural Hosp was hurting and laid off a bunch of execs, I thought of it like ‘cutting the fat’, those systems that didn’t lose money certainly didn’t profit as much as they would I feel
 
Sushirolls said:
better off avoiding hospitals and risking demise due to the natural illness course rather than risk an iatrogenic death by ARNP?
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Although I overall have way more confidence in the average PA than the average NP, I always think back to my 4th year EM sub-I working with the PA's in big-name-academic-hospital. They were very good at 90-95% of the cases we saw together. But the stories from myself and many of my colleagues of the PA strongly insisting we were wrong and that we shouldn't include something in our presentation then not standing up for that opinion when we were presenting to the attending... Of poor interviews that missed key differentials... Throwing us under the bus to avoid looking less competent... I would definitely prefer to be seen by an MD except in very minor situations.
jbomba said:
Starting salaries were in the 140-160k range for 80-90 hour weeks.
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I usually compare to my undergrad colleagues (engineers) which is a bit more of a favorable comparison in some ways (not spending 20's on intense training, typically reasonable work hours) but not in others (higher job turnover, lower salary cap unless winning the corporate rat race.) I think it's hard to put a monetary value on the lost time of medical training. Some people manage work-life balance during medical training better than others.
sluox said:
Many jobs NPs will also not be able to touch: administration, subspecialty practice, cash practice, practice ownership
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Around here there are TONS of both cash and insurance based small PP NP groups. Most patients don't really know the difference and I often wonder if the NP's introduce themselves as "Dr." or at least don't correct the patients (based on how many of my patients call their former NP by Dr.).
Liquid8 said:
We’ve had a surge in ADHD referrals,
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Just some interesting facts... Lately about 20% of our new pt appointments are for "ADHD." Despite how much we try to find alternative likely diagnoses, most end up on stimulants. With our electronic CS prescribing, it takes a minimum of 30sec to renew a stimulant Rx. Several of the MD's who have been around for a while have about 200-400 patients on stimulants. That's a pretty decent amount of time every month spent just renewing stimulants (3hrs).

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As for the thread as a whole, I think NP's are proliferating exactly because the demand for MH services is astronomical. It won't be a problem until we're seeing signs of saturation but I don't think we're anywhere close to that yet.
 
I am neither physician nor a “mid level” so don’t have a dog in this fight. But once in a while I check out local physicians’ websites out of curiosity and local practices are usually run by couple of physicians and then there is an army of 6-7 nurse practitioners. Psychiatrists and dermatologists are the worst offenders. And I don’t live in boonies. I live in a metro area of 6 million so it shouldn’t be difficult to recruit physicians if owner is motivated. Reasons for this are clearly financial. I regularly see high dose lithium and antipsychotics being prescribed by NPs.

So, if your own people are selling out your profession for $, it’s kinda difficult to sympathize as an outsider. There is no cure for greed.
 
It is ALWAYS difficult to recruit, NPs or MDs.
 
Chrish said:
I am neither physician nor a “mid level” so don’t have a dog in this fight. But once in a while I check out local physicians’ websites out of curiosity and local practices are usually run by couple of physicians and then there is an army of 6-7 nurse practitioners. Psychiatrists and dermatologists are the worst offenders. And I don’t live in boonies. I live in a metro area of 6 million so it shouldn’t be difficult to recruit physicians if owner is motivated. Reasons for this are clearly financial. I regularly see high dose lithium and antipsychotics being prescribed by NPs.

So, if your own people are selling out your profession for $, it’s kinda difficult to sympathize as an outsider. There is no cure for greed.
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What about empathy for the patients? Psych patients are so ripe for exploitation.
 
LimpSpatula said:
What about empathy for the patients? Psych patients are so ripe for exploitation.
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Of course I feel for patients. When I see prescriptions for lithium Er 300 and Abilify come through my pharmacy, I often scratch my head thinking are these people in good hands? Probably not. I know how dangerous some of these drugs are if not handled appropriately. And I can imagine how vulnerable this patient population is.

But mid-levels taking over the whole medicine is a common theme on sdn and I also scratch my head when these topics come up. Like weren’t the physicians the ones who hired them in the first place and still continue to this day? Why are you now complaining all of a sudden? Trend started with anesthesiologists and spread to entire medicine since everyone wanted the piece of pie.
 
The impact of NP’s replacing physicians is slowly moving along. New Mexico created parity laws. I knew 2 psychiatrists that were working in a relatively under-served area in NM. I’d have said that their salary was on the lower end, but they liked their location that had few job opportunities there. Both were replaced by mid-levels at a lower cost despite being at their positions 5+ years. No performance issues. Upon termination, they could not find any positions in their area, and the result was leaving NM. This is happening in other fields in NM as well. Instead of improving access, NM is decreasing access to care.

Peds was hit hard in DFW. A larger group fired the majority of pediatricians and replaced them overnight with mid-levels.

In my local suburb, there are shockingly 4 new mid-levels that have entered the field on their own in the last 1-2 years. It has certainly effected demand and advertising costs.

Many patients end up transferring to us for better care, but if the influx of midlevels continue, the business plan may need to change. On the positive side, the patients we do get will likely be ok with higher fees. It’s possible we may increase fees and reduce advertising costs. Instead of keeping the volume we do the same, we will cut some hours and increase rates. The result again is that mid-levels will have successfully lowered access to care by physicians.
 
TexasPhysician said:
The impact of NP’s replacing physicians is slowly moving along. New Mexico created parity laws. I knew 2 psychiatrists that were working in a relatively under-served area in NM. I’d have said that their salary was on the lower end, but they liked their location that had few job opportunities there. Both were replaced by mid-levels at a lower cost despite being at their positions 5+ years. No performance issues. Upon termination, they could not find any positions in their area, and the result was leaving NM. This is happening in other fields in NM as well. Instead of improving access, NM is decreasing access to care.

Peds was hit hard in DFW. A larger group fired the majority of pediatricians and replaced them overnight with mid-levels.

In my local suburb, there are shockingly 4 new mid-levels that have entered the field on their own in the last 1-2 years. It has certainly effected demand and advertising costs.

Many patients end up transferring to us for better care, but if the influx of midlevels continue, the business plan may need to change. On the positive side, the patients we do get will likely be ok with higher fees. It’s possible we may increase fees and reduce advertising costs. Instead of keeping the volume we do the same, we will cut some hours and increase rates. The result again is that mid-levels will have successfully lowered access to care by physicians.
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Thanks for sharing how it affected your practice. I suspect others share a similar experience.

How does mid-levels decrease access to care? Is it that no new jobs are created and physicians are being replaced by mid-levels? And mid-levels don't work as hard or as competently as physicians?
 
AD04 said:
Thanks for sharing how it affected your practice. I suspect others share a similar experience.

How does mid-levels decrease access to care? Is it that no new jobs are created and physicians are being replaced by mid-levels? And mid-levels don't work as hard or as competently as physicians?
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Mid-levels usually see fewer patients per hour. These are also patients known to the psychiatrist moved to a midlevel that knows no one and wasn’t updated on patients. The total practitioners in the area stayed net zero. Therefore access to care in that region decreased.

Midlevels champion increased access to care, but often they aren’t going to rural areas or being “added” to clinics. They are replacing physicians in many clinics. These discarded psychiatrists often slow down and open PT cash practices at higher rates +/- lucrative locum work. This decreases access in the long-run.

I know a psychiatrist in Texas that was one of few private psychiatrists accepting Medicaid. Midlevels opened up next door and focused on marketing better. Shinier, new clinic with earlier appointments and less wait time. The commercial insurance patients moved to the new clinic. Now with more Medicaid and less commercial insurance, the psychiatrist closed shop. You can argue that these are just market forces and poor business, but that clinic was a savior to many. It destroyed access to care for Medicaid patients when he left.

The frustrating trend in many areas is for psychiatrists to transition to more expensive, upscale care that see fewer patients. Midlevels are replacing them to save money at community clinics, insurance pp, etc. Most psychiatrists that I see are going that way because of the midlevel push taking away jobs, not midlevels being forced to fill when psychiatrists look for better pastures.
 
I don't know about the word "fear" cause it's loaded and implies the person's negative thoughts or feelings are irrational. Do I have apprehension? Yes. That all said there's a positive value NPs and PAs can add to the field, especially if they are talented and in turn working with a good physician.

The problems here are bigger than our fields and to blame it on NPs and PAs is too simplistic. There is a shortage. Some of the use of NPs is based on a lack of supply and pay for psychiatrists in areas where providers are needed. Often times where NPs are relied upon, perhaps too much, there's not enough psychiatrists in the area to fill the void.
 
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MacDonaldTriad said:
Most employers don't want to hire NPs in place of us. They just can't find enough of us to hire. Our high salaries inflate the NP pay rate and employers don't like it and they understand the liability and quality isn't at all a bargain when they hire NPs. The sky isn't falling and it would take a lot more of us to saturate the demand. NPs can't and don't do what we do. If they could, we should really change the pipeline and dumb it down.
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I wish I believed this. My employer recently hired a number of novice PAs and NPs who are practicing without meaningful supervision or even triage, seeing dangerously complex patients. Faculty consider it an acute patient safety concern and are raising the alarm. Admin either doesn't get it, or just doesn't care, no matter how we try to explain it. It does feel like the sky is falling. I just read Patients at Risk and highly recommend it--very depressing and eye-opening. I'm not worried about being able to make a living (and I used to write off these complaints as turf wars) but I am growing really worried about people who need and deserve actual psychiatric care increasingly having no way to access a competent clinician due to the trend towards independent practice for those with inadequate training. I don't want to live in a society with a two tiered medical system, where only the independently wealthy receive medical care from physicians.
 
There's no escaping them. I'm not trying to be hyperbolic, but it feels like they've invaded every part of healthcare within every system I work. Not only that, they make my life (and patients' lives) harder.

Just from the last week: I held a patient overnight in the ED because a physician called to say she’s worried for her life since the patient threatened her. NP discharges them in the morning without a risk assessment or consulting me. The next day I responded to a behavioral code to find out another NP told staff to restrain a patient rather than give an IM medication the patient was requesting (the patient has a long history of causing injury when restrained, happily agreed to take Thorazine 25 mg IM in addition to PO medications). The NP didn't understand that IM medications can be used even without a court order (she got confused about medications against will). Then I get the report back from a urology referral for a patient with enuresis. The NP simply agrees with my diagnosis of enuresis and recommends continuing desmopressin without any additional input, despite the fact I sent them for a more thorough workup and better understanding of etiology.

This is all before we even discuss their atrocious psychiatric diagnoses and treatment plans. Yet they literally replaced two psychiatrists at one facility, the state hospital has stopped posting for psychiatrists (filling roles with NPs instead), and they're working totally independently in most of the EDs I'm familiar with. No one seems to care they all have online degrees and can't even write SOAP notes (I literally had a new NP ask what kind of note I use for progress notes).

I know, I know, salaries for psychiatrists are at an all time high, as is recruitment. But guess what? ED physicians were making $300-400/hr just a few years ago before the sky fell. I'm not as worried about this occurring in psychiatry for a number of reasons, and I don't want to become as jaded as Vistaril since I'm happy to be a psychiatrist for whatever money I get, but let's not pretend these people aren't going to change the employment landscape and pay of psychiatrists over the next 10-20 years. Even if I'm totally wrong about this, I'll still feel sick seeing how patients are being mismanaged by independent-practice NPs.
 
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Kirby said:
There's no escaping them. I'm not trying to be hyperbolic, but it feels like they've invaded every part of healthcare within every system I work. Not only that, they make my life (and patients' lives) harder.

Just from the last week: I held a patient overnight in the ED because a physician called to say she’s worried for her life since the patient threatened her. NP discharges them in the morning without a risk assessment or consulting me. The next day I responded to a behavioral code to find out another NP told staff to restrain a patient rather than give an IM medication the patient was requesting (the patient has a long history of causing injury when restrained, happily agreed to take Thorazine 25 mg IM in addition to PO medications). The NP didn't understand that IM medications can be used even without a court order (she got confused about medications against will). Then I get the report back from a urology referral for a patient with enuresis. The NP simply agrees with my diagnosis of enuresis and recommends continuing desmopressin without any additional input, despite the fact I sent them for a more thorough workup and better understanding of etiology.

This is all before we even discuss their atrocious psychiatric diagnoses and treatment plans. Yet they literally replaced two psychiatrists at one facility, the state hospital has stopped posting for psychiatrists (filling roles with NPs instead), and they're working totally independently in most of the EDs I'm familiar with. No one seems to care they all have online degrees and can't even write SOAP notes (I literally had a new NP ask what kind of note I use for progress notes).

I know, I know, salaries for psychiatrists are at an all time high, as is recruitment. But guess what? ED physicians were making $300-400/hr just a few years ago before the sky fell. I'm not as worried about this occurring in psychiatry for a number of reasons, and I don't want to become as jaded as Vistaril since I'm happy to be a psychiatrist for whatever money I get, but let's not pretend these people aren't going to change the employment landscape and pay of psychiatrists over the next 10-20 years. Even if I'm totally wrong about this, I'll still feel sick seeing how patients are being mismanaged by independent-practice NPs.
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You have leverage to address this in a hospital system. That the state board of nursing allows for independent practice is irrelevant. Bylaws can be created to require patients are assessed by physicians, in most places it is mandated upon admission and prior to discharge. EMRs can have hard stops installed for co-signing documents. And most importantly vet the applicants. requiring inpatient psychiatric RN experience, while not a guarantee of quality, increases the chances you will get a decent mid level and will also automatically disqualify a large portion of new grads now. A psych RN would not have been confused about their ability to order emergency IM.
 
Just kinda interesting, I've seen them used as tools for splitting/demanding things recently. I suggested to one patient we focus on anxiety as a more likely cause of distraction/inattention. Apparently she didn't like that, so she went and got an NP to Rx a stimulant then, when seen in f/u with me, said she'd only work with me if it was to continue the stimulant Rx. Another patient recently was annoyed that I suggested he contact the doc prescribing his antabuse and gabapentin for refills of those meds since he's supposed to still be working with her on addictions issues. He expressed his annoyance by threatening to go outside of our system to see a private NP to Rx everything he wants as a one-stop.

I have to say that threatening to spend more money on an inferior product because our docs aren't catering to your every whim doesn't really work all that well...
 
bashir said:
I wish I believed this. My employer recently hired a number of novice PAs and NPs who are practicing without meaningful supervision or even triage, seeing dangerously complex patients. Faculty consider it an acute patient safety concern and are raising the alarm. Admin either doesn't get it, or just doesn't care, no matter how we try to explain it. It does feel like the sky is falling. I just read Patients at Risk and highly recommend it--very depressing and eye-opening. I'm not worried about being able to make a living (and I used to write off these complaints as turf wars) but I am growing really worried about people who need and deserve actual psychiatric care increasingly having no way to access a competent clinician due to the trend towards independent practice for those with inadequate training. I don't want to live in a society with a two tiered medical system, where only the independently wealthy receive medical care from physicians.
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I agree with you, without NPs, primary care was practicing poor psychiatry because there were very few of us. It is a classic dichotomy, and both are true. There is a great need and there aren't enough of us, and the vacuum has created a less than ideal solution but that was inevitable. In the past, the vacuum was filled by a different group, now it is filled by another. The new group is a target for our scorn, and the former wasn't doing it well. Primary care doctors have a small amount of mental health training and were adjacently trained in medicine theory, but just as inadequate in many ways. There are some RNs with decades of psych experience who do a good job as NPs, and there are some RNs who are without a clue. There are also family medicine doctors who are noble and doing their best and don't have a clue and some who are relatively competent. It is all about supervision and training. What ever your state plastic license card says that you are allowed to practice for what ever reason, there are good and bad practitioners. None of these are going to threaten our unique ability to handle the job.
 
TexasPhysician said:
Many patients end up transferring to us for better care, but if the influx of midlevels continue, the business plan may need to change. On the positive side, the patients we do get will likely be ok with higher fees. It’s possible we may increase fees and reduce advertising costs. Instead of keeping the volume we do the same, we will cut some hours and increase rates. The result again is that mid-levels will have successfully lowered access to care by physicians.
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TexasPhysician said:
The frustrating trend in many areas is for psychiatrists to transition to more expensive, upscale care that see fewer patients. Midlevels are replacing them to save money at community clinics, insurance pp, etc. Most psychiatrists that I see are going that way because of the midlevel push taking away jobs, not midlevels being forced to fill when psychiatrists look for better pastures.
Click to expand...

This is EXACTLY the same dynamics I'm seeing in my market as well. The weird nonlinear effect is that patients who started seeing NPs realize that they can't get the same quality of care, so they move back to cash MD, which causes an INCREASE in demand of cash MD. This then obviously leads to insurance MDs to drop insurance and focus on cash. NPs compete with insurance MDs for patients who can't afford to pay cash, whereas patients who can afford to pay cash leave these practices even if they were originally able to find an insurance MD.

Net-net is that cash MDs get paid EVEN more, and access to insurance-taking MDs drop. Patients are crawling back to me even though my rates are already high, telling me that other community psychiatrist raised their fees astronomically recently. This also may be COVID/inflation-related, tho.

It used to be that outside of major metros if you want an insurance-taking MD you can still get it, but it's increasingly that through all settings/geography if you want to use insurance at all you usually get an NP to start (at best--in a practice owned by an MD), and typically it'll have a wait. Patients for whom this level of care isn't working or can't wait now are willing to fork over even more cash to see an MD, or the alternative is one of the many national telemedicine shops, which overall have had worsening reviews. Due to telemedicine, affluent suburban patients who used to be able to see insurance-MDs now increasingly come to urban cash MDs!!

My recent experience has been that anything beyond straightforward antidepressant management is not well managed by an NP. I end up de-prescribing a lot on second-level self-referrals. NPs also don't know anything about when meds are not useful vs. therapy (i.e. many many PD patients on polypharmacy). Patients know they are getting bad care--it's pretty obvious to me that to be a good psychiatrist you need to be knowledgeable AND attentive and actually spend time listening and discussing, and any of the cost-saving alternatives just simply can't permit that, telemedicine or not. NPs also can't do combined treatment, which is the cash cow of cash PP, and for good reasons. Psychiatrists who are also good therapists (read: has low attrition for therapy patients) are in extraordinarily high demand from affluent patients who prefer to not have to try ten different bad therapists to find and keep a good one AND have to do the exact same for a prescriber that they can trust, AND ensure that they actually talk to each other and coordinate care--which they rarely do. I mean, just think about that for a second and put yourself in the patient's shoes--it's actually an extreme value add.
 
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TexasPhysician said:
The impact of NP’s replacing physicians is slowly moving along. New Mexico created parity laws. I knew 2 psychiatrists that were working in a relatively under-served area in NM. I’d have said that their salary was on the lower end, but they liked their location that had few job opportunities there. Both were replaced by mid-levels at a lower cost despite being at their positions 5+ years. No performance issues. Upon termination, they could not find any positions in their area, and the result was leaving NM. This is happening in other fields in NM as well. Instead of improving access, NM is decreasing access to care.
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This kind of effect, in my mind, will be dramatically changed by telemedicine. If they are high-quality psychiatrists, they can stay in NM and practice entirely on people outside of NM and make more money.
 
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