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Hi, just wondering if any of you have experience with working with or hiring psych NPs. Does it seem like they are competent? And usually how much are they paid?
Do you guys think Psych NPs are competent?
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Competent enough for follow ups and progress reports. I've worked with a few on my rotations in psych and they're helpful on the floor, but their scope of practice is pretty limited compared to the psychiatrist they're working under.
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Too broad of a question to answer simply. The quality is highly variable (just as it is with psychiatrists by the way). Some NPs are fantastic and better than many psychiatrists. Some are absolutely atrocious and shouldn't be anywhere near a patient. I think the bias is likely in favor of poorer quality NPs due to the relative lack of clinical training, but I don't think it's fair to say that NPs are incompetent across the board.
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I have seen many terrible nps but just as many terrible psychiatrists. What it seems like they lack in their training is the psychological component. I see a lot of checklist diagnoses from them.
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Competency varies in every field.
NP’s are like MS2’s. They need a lot of education, monitoring, and reviewing. If you have hours to do this every week, they can be helpful for follow-ups.
NP’s are like MS2’s. They need a lot of education, monitoring, and reviewing. If you have hours to do this every week, they can be helpful for follow-ups.
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Training is highly variable for NPs, though at the same time, invariably far, far less than a psychiatrist. You're looking at 500 clinical hours max for a psych NP v. 20,000 or more for a psychiatrist. They have very limited exposure to medical conditions that may overlap psychiatric conditions. On top of that, you have far easier standards to get into nursing school and some extremely crummy online NP schools. The idea that you could mail-in medical school with a bunch of YouTube videos and open-book exams is preposterous and digging up whatever pre-ceptor wherever, but you can do that with many a NP program. I'm tired of doctors degrading the quality of their training, as there is a vast difference in the quality of education, demands placed upon psychiatrists v. NPs, and the extent of clinical training. I have seen some major misses from NPs that I consider inexcusable, and I don't feel comfortable signing for them when my license and liability are on the line.
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A dually certified psych/family np is usually pretty good
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Except, like with all other physicians, you're getting a certain baseline level of clinical exposure. Are there bad physicians out there? Absolutely. However, all of them had to complete a residency program with minimum ACGME requirements and pass Step1/Step2/Step3/board certification in their field (however clinically relevant that is....).
The NP rotations ARE A JOKE. No kidding, I've seen the NP students drop in for a couple mornings a week, know nothing about the patients, write "med student" notes on a couple patients and usually duck out by early afternoon because they "have to work an afternoon/night" RN shift or some crap. They definitely do less work than any of our medical students. They then get to count that as their "clinical hours" and get let loose on the world.
Even the ones I've seen do real inpatient rotations following around NPs on medicine and peds services don't do basic medical student things like present patients during rounds and definitely don't carry as many patients as the medical students do. Did I mention they get to come in 2-3 days a week and call that a rotation?
Thats the problem people have. There are great nurse practitioners and PAs. There are bad physicians. However, on the whole, their training is incredibly inadequate, especially all the new grads who've been nurses for all of a year or even go straight from BSN to NP programs. All the subspecialty and general boards pushing for more training/subspecialization are going to screw us over while these midlevel programs keep pumping grads out with less clinical experience than a 4th year medical student. That's the other major problem, I see a lot of super confident NP grads ready to prescribe all kinds of crap without a second thought. How many of us were scared ****less as an intern double checking tylenol dosing or thumbing through our medicine books/uptodate for everybody with stomach pain and a fever? A lack of that healthy respect for the effect of your medications and diagnoses is a problem.
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To answer this question, I think it's usually 100-110K but pretty location dependent. Also depends on what fields actually have openings in areas. I know where I was before, a lot of the nurses graduating from NP programs were having problems finding jobs (and still working as RNs after they had finished their NP) because few places were hiring relative to the amount of people trying to get NP degrees.
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this would be quite low. our academic psych NPs get about 135k and our salaried NPs 180k or so. they actually make comparatively more than the academic psychiatrists when you factor in hours worked etc...
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Again, I think that must be pretty location dependent. 135-180 sounds really, really good for an NP. Most surgical NPs dont even make that much and they tend to be on the higher paid end (since they can offload all the follow up work the surgeons don't want to do). A lot of the NPs at my old institution were complaining that the nurses were making more than them at times on an hourly basis.
As recently as 2016, the average full time salary for all NPs was like 100K and psych NPs were about the same. This is also coming from an NP site where they have an incentive to make NP salaries look as juicy as possible.
https://www.nursepractitionerschools.com/faq/how-much-does-a-psychiatric-np-make
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Our salaried NPs are roughly 150k in a moderate sized Midwest Metro locale.
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Depends. I will not work with NPs (usually) for one simply reason.
I don't understand the medical/legal infrastructure. E.g. if an NP messes up but I reviewed their case and it turned out the NP didn't alert me to things I would've caught had I saw the patient myself am I responsible? No one's ever answered this. I've had NPs approach me and ask me to work with them and I asked them to provide me with sources of information to get my legal questions answered and they told me they didn't even know. They told me how it works is they work with me, they do the work and I sign off. I told them that's not good enough. I need to have a fundamental knowledge of the responsibilities in a legal sense so we could set our appropriate boundaries of who does what and I never got straight answers.
While I'm sure the information is out there no one has yet given it to me. I never had training in this in medschool or residency.
Addendum: I asked several NPs and even training programs to provide me with the legal information and no one had an answer for me. I'm not touching this issue with a 10 foot pole until it's answered. It's not just about CYA. It's about responsible medicine.
I don't understand the medical/legal infrastructure. E.g. if an NP messes up but I reviewed their case and it turned out the NP didn't alert me to things I would've caught had I saw the patient myself am I responsible? No one's ever answered this. I've had NPs approach me and ask me to work with them and I asked them to provide me with sources of information to get my legal questions answered and they told me they didn't even know. They told me how it works is they work with me, they do the work and I sign off. I told them that's not good enough. I need to have a fundamental knowledge of the responsibilities in a legal sense so we could set our appropriate boundaries of who does what and I never got straight answers.
While I'm sure the information is out there no one has yet given it to me. I never had training in this in medschool or residency.
Addendum: I asked several NPs and even training programs to provide me with the legal information and no one had an answer for me. I'm not touching this issue with a 10 foot pole until it's answered. It's not just about CYA. It's about responsible medicine.
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Yes, we are responsible for the NP’s work. Many MD’s have lost their license over not catching mistakes or as the board calls it “inappropriate supervision”.
Oh I wholeheartedly agree with you, I figured it out sometime in the past, I think the standard hour amount for psych NPs to graduate is something like 700 hrs of clinical time, if we say average of 60 hrs per week, that is equivalent to about three months of clinical training... We get more in med school, not even counting residency. My point is, after a few years on the job, you start to see which are the good ones, same with psychiatrists
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In my state NPs work independently—they don't need physician oversight.
There's a psych NP near me doing private pay (no insurance) medication and therapy with prices that are comparable to the same services from a psychiatrist (225 new patient, 130 followup). They have full prescribing rights. There's such a shortage that I have not seen a location where NPs are working in service of another doctor, whether it's primary practice or psychiatry.
As to the original question, to me it's like a koan (e.g., Does a dog have buddha nature?).
At a less ethereal level, I tend to think people are essentially who they are before they even go to medical school or whatever school you go to to become an NP. You guys know the nitty-gritty more than I do about those differences. But what I'm talking about is whether a person is the type to go on a pharma speaking circuit and then mindlessly prescribe that drug to all their patients regardless of validity, are they liable to do more than they are legally obligated to when it means better care, etc. The state doesn't screen for *ssh*les or people who don't care.
There's a psych NP near me doing private pay (no insurance) medication and therapy with prices that are comparable to the same services from a psychiatrist (225 new patient, 130 followup). They have full prescribing rights. There's such a shortage that I have not seen a location where NPs are working in service of another doctor, whether it's primary practice or psychiatry.
As to the original question, to me it's like a koan (e.g., Does a dog have buddha nature?).
At a less ethereal level, I tend to think people are essentially who they are before they even go to medical school or whatever school you go to to become an NP. You guys know the nitty-gritty more than I do about those differences. But what I'm talking about is whether a person is the type to go on a pharma speaking circuit and then mindlessly prescribe that drug to all their patients regardless of validity, are they liable to do more than they are legally obligated to when it means better care, etc. The state doesn't screen for *ssh*les or people who don't care.
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Even if the NP were excellent, you still can't sign off on a note on their behalf. So much of psychiatry depends on the interview, actually seeing and interacting with the patient, that it goes beyond "this is a great NP". If this were Radiology, then yes. All the data is right in front of you along with the same patient history. But being asked to lay our liability at the foot of an unseen patient encounter is daft.
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Medicine/nursing/malpractice are all regulated by the individual states- it would be nice if the state medical societies pulled together this info for their individual states.
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Likely there is some sort of attorney you could find to answer the questions. Lol, but would you want to anyway even if they could? I wouldn't.
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Might be nice if they didn't in some ways. Discourage NP usage by docs? Just the sort of thing I'm sure the medical boards are in favor of (or should be to protect the profession). Does this end up hurting patients when docs and NPs don't understand their respective responsibilities with supervision? Probably.
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Yeah and they'll charge me mucho money for about something that really should've been 5 minutes of their time that they dragged into 3 hrs of their time that they're billing me.
I just talked to a lawyer about a patient (patient gave permission) and the lawyer dragged it out into a 45 minute conversation that really should've just been a few minutes. I'm sure that lawyer is charging my patient for every minute of that talk. I told the lawyer I wasn't going to charge cause the issue was so stupid and asinine thinking it was just going to be a few minutes. That a-hole ticked me off.
I know enough of the law to read it myself if someone directed me to the appropriate laws and regulations. I've been in several situations where I knew the laws behind a health issue better than the judge or lawyers reviewing the case.
When a freaking professional or a training program can't direct me to the regulations that govern their own field that's really bad, and I don't have any intent on following them down their path that they themselves don't seem to know about. No way am I going to get an NP to work with me when I got to pay a lawyer to know the rules. And if the NP doesn't know the rules? Heck that further indemnifies them as clueless.
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Just a comment that someone somewhere knows more on the skinny, but I get where you're coming from.
I've had great experiences with all the attorneys I've worked with/hired, but it could be outlier. I've also had to work closely with one where I was basically helping to inform them on how the law worked in a particular instance they didn't have experience in.
I agree, if people really want a job they shouldn't leave it up to a potential employer to do the legwork in situations like these. Understandably most physicians without a PA or NP wouldn't know how that works unless they really wanted to get one and be educated about it, I guess, and the PA or NP should certainly be familiar with their own dang profession, but there it is.
Plus, there probably isn’t even a statute on supervision. It’s at best written in some nursing board or medical board guidelines which will be minimal help in a lawsuit. There should be statutes exempting physicians from liability if they supervise an NP.
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Or at least a reasonable set of legally accepted guidelines that let me as the doc know where my responsibilities lie vs the NP's. Then I can at least entertain the idea of working with one.
I've seen several good NPs. Like any field there's good and bad, but that's not what I'm talking about. Further most NPs from my experience, even the good ones, cannot handle seriously complex cases, but I will say from my experience most physicians cannot either. In the physician case it's more so due to lack of commitment, desire or time, where as with NPs it's more so from lack of training in seriously complex cases. Virtually all physicians are capable of some seriously incredible brain-work but many won't commit to invest the time into their patients.
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Or just not willing to invest unbillable time. Which I can totally understand.
Maybe post the question on a lawyer forum or subreddit. Chances are good that you'll get something useful for free.
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Corporatization of medicine, strong nursing boards, and weak medical boards have created a more dangerous and also more profitable competitor to PA's. On the spectrum of competency, I trust PA's more than NP's in terms of general medical skills, although their mental health training is usually severely lacking and probably inferior to a psych NP. It's just strange to me that we let NP's be independent doctor-lite's while PA's have a more limited scope of practice.
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I don't.
It's made pretty explicit in joining the profession, and indeed, what profession means vs "job," that your duties are not strictly tied to reimbursement. That covers a lot of why we aren't reimbursed for CME (some employers pay for it, I know, not my point) and that professional memberships, database access like U2D, or journal subscriptions, paid or not, are expected, or whatever it is that you do to maintain being on top of your field and not only keeping your practice relevant but continually striving to improve it.
If you did not have an employer paying for those things, it would be expected that it come out of not only your pocket, but also be time without reimbursement.
This goes into how reading and other studying in residency doesn't count towards work hours. Practice is covered, purely self-education in the form of home reading and the like, is not.
If investment of time will improve patient care, and especially needed to make you competent, then you are expected to do it to carry out your fiduciary duties to the patient, regardless of money or when you are clocked in or out.
I think you might have misunderstood. They were saying that they aren't putting in the time into the case, not that they weren't putting time into training. In other words (if I understood @whopper correctly), complicated cases take quite a bit of time and effort, and many physicians would rather spend their time on a greater number of more straightforward cases particularly since (if I understand @WisNeuro correctly) in complex cases they will need to apply more time and expertise without being commensurately compensated.
Professional obligations vs. reimbursement would be an interesting discussion, but might be more appropriate for it's own thread.
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Thats the thing though, Doctors don't "Let" nurses do anything because nurses have put themselves in a position where they dont answer to doctors, and they found out a long time ago the way you get what you want is through the lobby. Somehow nurses have figure out a way to be independent from doctors, while at the same time, having physicians take the liability hit if they screw up. Thats amazing to me and could only come about when the lobby gets people to continually take the side of nurses, and physicians are to busy thinking things will never change to fight back.
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Yes, this is in line with my thoughts, somewhat. In complex cases, there is always more that we can do, outside of the regular scope of the visit/eval/whatever. Comes down to your bottom line. Do I want to work a 40 hour week for my salary, or do I want to work 60 hours a week for the same salary? I've already spent many years being underpaid to serve a population I used to believe in, I'm ok with pulling back from unpaid hours outside of the regular scope of my job. I'll save those hours for volunteer work that I enjoy and family time.
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I guess I think that if you get a complicated case and have to go home and research it and think about it in order to provide what you think is at least adequate care, you do just that. Clearly you can only then do so many cases like that.
I thought @whopper was implying that he sees many physicians not really putting in that effort for complex thinking beyond reimbursable time. To which a resident agreed that they thought that was understandable. I don't agree.
I've had patients that I could just bulldoze or treat in my sleep, and plenty where care of the patient extended beyond the time that was reimbursed, not because of after hours calls or the like, but that the work day ended, I went home, and then had to spend some of my "free" evening time reading or thinking more about it. Them's the breaks. You can't always leave work at work, is all I mean.
Bringing this around to the OP, I guess how much a physician will put into deciding to bring on an NP, will be related to how much they care to bother with it, and it's likely a financial decision or a practical one when it comes to managing load. Aspects brought up, is the training quality and the legalities surrounding it. I would suspect the experience and perceived track record of the candidate would factor in.
I think overall in the whole profession, you find physicians that use NPs or PAs, but it seems like on the whole most feel sorta underwhelmed with their training and express doubts and mixed feelings about how much autonomy they get, even amongst those that use them.
Psych I imagine is no exception.
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I was trying to do some reading on this last night but couldn't find a good source quickly. How much did medical boards push back on NP's continuing to be under nursing boards? I used the word let because it seems to me that medical boards didn't really object to letting nurses practice medicine...
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I think you misunderstand the power medical boards have. remember medical boards of often made up heavily of lawyers. they aren't a guild per se and thus dont engage in internecine turf wars between health professionals like the AMA. they are part of the state government just like nursing boards. the decision of who has what authority is governed by the state legislature. in general legislatures have been reluctant to pose too onerous requirements for licensure in any field (this is especially true for more conservative legislatures). NPs have been very effective in developing their own guidelines for regulation (which is pretty standard for professions) and these have generally been accepted by state legislatures. any opposition typically comes from state medical associations (which can lobby) and not state medical boards (which cannot lobby).
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Nevermind that this is basically determined by state laws and those lawmakers, and that the relevant boards might just have to lobby... It's a good question you ask. I know some boards have more broad powers to determine these sorts of policy under their state's law, but I dunno.
The really painful part of this, is that if you have lawmaker laypeople deciding how this stuff works regarding psych... it's such an underserved area of medicine that more than some things, the temptation is HUGE to open things up to meet need.
ETA: I see splik saying that medical boards cannot lobby re: law governing the practice of medicine... is this really the case?
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I know that medical boards exist to oversee how physicians practice medicine with the #1 concern being patient safety. But in fulfilling this mission, they only oversee physicians?
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Thanks for the primer. (Not sarcastically.)
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In some states also podiatrist and PA's
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In our state, the medical board has oversight and licensing authority for several professions, from physicians to radiology technicians. This includes physician assistants.
NPs, on the other hand, are regulated by the board of nursing. As far as I can tell the role is similar, but their functions are bureaucratically separated.
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It is only in very recent years that state medical boards have come to focus on "patient safety" or claim they have a role in such. Historically, medical licensing boards were meant to regulate the profession by essentially stating who was qualified to practice medicine (and thus by definition, who was not) that was more guild-like. Physician licensing became the model for licensure in other fields. Technically medical boards can intervene where people are practising medicine without a license, but they would not be successful in arguing that NPs are practising medicine without a license because NPs are licensed by governmental agencies following standards developed by their professional organizations and approved (to varying degrees) by legislatures across the country.
There was a recent supreme court case, North Carolina Board of Dental Examiners vs FTC (2015), where the dental board went after non-dentists offering teeth whitening services in shopping malls by sending them cease and desist letters. the FTC then sued them for breaching antitrust laws. The board claimed they were immune from antitrust laws. The Supreme Court disagreed, primarily because the board was seen as self-serving, composed almost entirely of dentists. Interesting, the NC medical board, by way of comparison, has one NP on its 13-member board, even though NPs are not regulated by the medical board. make of that what you will! (There are No MDs on the NC nursing board....)
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Wow
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"I thought @whopper was implying that he sees many physicians not really putting in that effort for complex thinking beyond reimbursable time. To which a resident agreed that they thought that was understandable. I don't agree."
Well yes but it's more complex than that.
Despite that we are paid for time. E.g. I give a patient 30 minutes of time, I do my billing and insurance compensates me, insurance contracts in general state that their coverage isn't supposed to be a minute to minute thing but also supposed to cover things associated with that meeting. So if, for example, I need to call the patient's PCP, I'm supposed to do that in the name of good care, and although insurance compensates me for the patient's visit, talking to the PCP is an associated responsibility I'm supposed to do.
What a lot of doctors DON'T do if is it's not directly tied to the patient's visit, they don't do it. E.g. call the other doctors involved to make sure there's good continuity of care. Again even though the doc usually doesn't get paid by insurance they're still supposed to do it but many docs won't.
And this in turn, not surprisingly leads to what I mean by they won't invest the time into the patient.
We of course know that there's sometimes very difficult cases that will require much more than the usual even 30 minute visits that seem to be above the standard of care given that so many doctors only spend literally 10 or less minutes with a patient. Such cases are rare. I'm not complaining about that but I am complaining about doctors that don't do things such as simply getting a complete medication list, talk to another physician about a case, or order things such as lithium without ordering labwork which are inexcusable.
I had a patient, brand new, just saw today who is demented and lives alone. He almost crashed his car on the way here. He saw his PCP yesterday and guess what the bozo did? He saw the guy, could tell he couldn't drive, offered to get him a cab but when the patient refused he let the guy go home himself despite that this guy can't tell left from right. The guy is so off he could've burned his house down.
I had the guy taken to the hospital.
Well yes but it's more complex than that.
Despite that we are paid for time. E.g. I give a patient 30 minutes of time, I do my billing and insurance compensates me, insurance contracts in general state that their coverage isn't supposed to be a minute to minute thing but also supposed to cover things associated with that meeting. So if, for example, I need to call the patient's PCP, I'm supposed to do that in the name of good care, and although insurance compensates me for the patient's visit, talking to the PCP is an associated responsibility I'm supposed to do.
What a lot of doctors DON'T do if is it's not directly tied to the patient's visit, they don't do it. E.g. call the other doctors involved to make sure there's good continuity of care. Again even though the doc usually doesn't get paid by insurance they're still supposed to do it but many docs won't.
And this in turn, not surprisingly leads to what I mean by they won't invest the time into the patient.
We of course know that there's sometimes very difficult cases that will require much more than the usual even 30 minute visits that seem to be above the standard of care given that so many doctors only spend literally 10 or less minutes with a patient. Such cases are rare. I'm not complaining about that but I am complaining about doctors that don't do things such as simply getting a complete medication list, talk to another physician about a case, or order things such as lithium without ordering labwork which are inexcusable.
I had a patient, brand new, just saw today who is demented and lives alone. He almost crashed his car on the way here. He saw his PCP yesterday and guess what the bozo did? He saw the guy, could tell he couldn't drive, offered to get him a cab but when the patient refused he let the guy go home himself despite that this guy can't tell left from right. The guy is so off he could've burned his house down.
I had the guy taken to the hospital.
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While it sounds good on the surface most of the FNP to PsychNP have never worked as a RN in psychiatry. The opposite certification of PsychNP to FNP is probably a safer bet if looking for a psych competent NP. Largely two camps of FNPs who decided to get psych cert those who changed specialty because PsychNps are making significantly more money $150k-$200k and those who are bleeding hearts willing to take on psych in addition to their primary practice for their current $90k.
Look for significant inpatient adult psychiatric experience as a RN and even then no guarantees.
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I think competence can be argued all day long, but it's generally useless in the current healthcare system. This issue mirrors a lot of areas of healthcare in which mid-level providers are taking over some space that used to be exclusively provides by those trained at the doctoral level. We lack quality, unbiased outcome studies. We can point to anecdotes all day long, but we really can't point to anything of substance that proves a higher level of care, on average, with a doctoral level as opposed to mid-level for certain services.
It's actually a fairly interesting question, in terms of what level of training is actually sufficient to make someone competent to deliver X service. It just happens to be a very expensive and hard question to answer, so no one does it.
It's actually a fairly interesting question, in terms of what level of training is actually sufficient to make someone competent to deliver X service. It just happens to be a very expensive and hard question to answer, so no one does it.
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I'm just concerned by their level of training, in fellowship we literally had NP students SITTING IN on the rotation, with no patient interaction what so ever. They shadowed an NP..where is the learning at this point, I expect shadowing from an undergrad student/Highschool student thinking of going into healthcare, not as clinical hours to end up practicing with the same responsibilities as somebody who has spent 12+ years of training..
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I mean, it's not very different from what I have seen in some neuro clinics. Resident observes one neurological examination, and is then sent on their own to do it from there on out. Generally this and OTs are the reason I have no faith in MoCA scores that I get from most sources. I'm sure this isn't the way it happens everywhere, but the variability is pretty stark.
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"See one, do one, teach one" with someone more experienced monitoring you covertly and offering feedback is somewhat different than "see a bunch and then just go solo".
Should note in the neuro exam case the feedback is often of the form of an attending examining the same patient and finding things the resident missed or mischaracterized. Not happening always and with every patient in every setting but it is happening at some point in training for sure.
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Considering what I see missed, and the blatant things I catch on my exam that should have been caught in the neuro exam, I'm not so sure.
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Are we talking about motor findings or cognitive? My experience has been that most neurologists devote a lot more energy and time to the former (excepting the ones that want to go the Behavioral Neurology route). I can definitely believe you are picking up on cognitive deficits they have missed with the very crude bedside tests they tend to use.
If you mean motor signs, well, you and I have been down the toutetoute of discussing whether all MDs are terrible or just the ones in your area and I am not sure that needs to be revisited.
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