NP "collaboration"

[wolfvgang22]

I've been asked to be the supervising psychiatrist for an NP I used to supervise at my clinic who is now considering opening a private practice clinic. They are in the exploratory phase of making a business plan and so haven't given any compensation or role details yet. I said I would be interested to learn more about the opportunity as it develops. My initial thought is to decline unless I receive an ownership stake and significant compensation, though I'm not sure how much I would need to make supervision and associated liability worthwhile. I'm not really interested in running a private practice clinic day to day at this time. My state doesn’t have independent practice authority for midlevels.

Does anyone have any experience with this, or opinions?

---

Members don't see this ad.

 

[Celexa]

What is your clinical experience with this NP? Are they good? Do they know their own limits? Do you trust them?

 

[whopper]

I'd liken working with NPs like being a psych professor and working with residents. They could be good, they could be terrible, and everything in-between.

A lot of the supervision depends on individual state laws. Due to this there's a grey zone on what is and what is not allowable because there's no across the board consensus. Even within a state there will be few avenues of discussion of what is the norm. I got no bank of information to tap other than the laws when it comes to the legal stuff with NPs.

 

[PikminOC]

It's hard enough for me with my own patients, why would I trust someone else's judgement? And they aren't even smart enough to be a resident. And a resident is highly supervised in MD training. Not out on their own. Do not want. My license is too important to me. It's just there to take the fall as it's the deepest pocket

Many np have come to me for this. I'm in my forties. I need my license. No.

 

[comp1]

Totally second this being really, really tied to state laws. However, even with that, I don't get this. The NP would be the owner of this business...but the MD would be supervising their work?

 

[whopper]

Many np have come to me for this. I'm in my forties. I need my license. No.

I got NPs. If they got a tough one I tell them to either terminate the case or have me take over. They like it and I like it.

 

[forchinet121]

I got NPs. If they got a tough one I tell them to either terminated the case or have me take over. The like it and I like it.

You have your own PP with NPs?

 

[Sushirolls]

How much is one full time day of work worth to you?
Block out one full day per week, to be in their office, and review every chart.
Have a means to stamp/sign/document you reviewed the note.
Essentially you shift from clinical work 1 day per week, to being a complete supervisory, and perhaps teaching role 1 day per week. Have a calendar mapped out for the whole year of contract, and be sure that you are there on those days, and means to get paid, etc.
Pricey... but that's what I might consider it worth. It'll take you all day to review 5 days worth of notes.

 

[Celexa]

It's hard enough for me with my own patients, why would I trust someone else's judgement? And they aren't even smart enough to be a resident. And a resident is highly supervised in MD training. Not out on their own. Do not want. My license is too important to me. It's just there to take the fall as it's the deepest pocket

Many np have come to me for this. I'm in my forties. I need my license. No.

The bolded is unfair. I have worked with some very smart NPs and some very dumb residents. Some of the worst med lists I've ever seen came from MDs.

What is certainly true is that the NPs do not have the same quality or depth of training of residents, and I would not work with one whose clinical skills I had not assessed at length or if I lacked the time for regular supervision or if I was not appropriately compensated for my time.

 

[TexasPhysician]

If NP’s aren’t within your pp, I would say that this arrangement doesn’t work for both of you.

The NP’s revenue will lend toward wanting you to rubber stamp everything and provide the state minimum at the lowest price you will accept.

You accept the liability. I require time for education, discussing cases, and signing charts. I also want compensation for the liability risk and being on call 24/7 for the NP’s needs. In my state, the minimum % of charts is based off of knowing the NP and supervising for a long time. They want you doing well above the minimum until safety is well established. You’ll also need a supervision agreement and a lawyer to review it. This costs $.

Now it’s easy to see that doing this well and accepting a low amount of money to keep the NP happy isn’t going to happen. This is why midlevels should be employed by physicians supervising them.

 

[TexasPhysician]

The bolded is unfair. I have worked with some very smart NPs and some very dumb residents. Some of the worst med lists I've ever seen came from MDs.

What is certainly true is that the NPs do not have the same quality or depth of training of residents, and I would not work with one whose clinical skills I had not assessed at length or if I lacked the time for regular supervision or if I was not appropriately compensated for my time.

While there are bad apples in any field, a simple barometer is looking at the percentage of people that accepted jobs at Cerebral. 1500 prescribers. 5 were psychiatrists. This alone tells me that NP’s don’t know what is appropriate and what isn’t as a field. This compared to 5 bad apple psychiatrists.

 

[whopper]

You have your own PP with NPs?

No. I have a therapist that wanted an NP so he asked me to be her collaborator and thankfully he handles all of the managerial BS like pay, and I get 10% of what the NP brings. in. Then another practice asked me to do the same thing. I currently have 3 NPs. I'm not their employer. So while I have my own PP, the NPs are merely collaborators and I'm not the employer.

 

[forchinet121]

No. I have a therapist that wanted an NP so he asked me to be her collaborator and thankfully he handles all of the managerial BS like pay, and I get 10% of what the NP brings. in. Then another practice asked me to do the same thing. I currently have 3 NPs. I'm not their employer. So while I have my own PP, the NPs are merely collaborators and I'm not the employer.

How much do you make per NP under this arrangement?

 

[whopper]

1 NP about $25 K a year. The other 2 about only $500 a month per NP. The latter 2 is a rip off and I know it. I'm doing it more as a favor to the NPs cause I know them, they're good, and they're nice people. Also I have the selfish design that maybe one of them may leave the place they're at that's paying me crap amounts.

I'm working on filling up my NP slots (I can carry up to 6 in the state where I live) but only if the NP is high quality. I'm not pushing to make this go faster. I'd rather have no NPs than bad to average ones. I only want good ones.

 

[MacDonaldTriad]

Run away fast and don't look back. My analogy is; if you had 10 years of sobriety and saw a DUI check point, wouldn't you avoid it because nothing good could come from the encounter?

Many NPs will take your advice as long as they agree with you, but when they don't..., that is what you need to know.

 

[wolfvgang22]

What is your clinical experience with this NP? Are they good? Do they know their own limits? Do you trust them?

Excellent question. I think this NPs clinical skills are good (for a mid-level) as I supervised them for a couple of years. I think fundamentally they are a good and conscientious person and work hard for patients. I do have some questions about this person knowing their limits or willingness to accept the level of supervision I would require again, based on a past minor incident. On the other hand, they know what I have required before and should not be surprised I haven't changed. So, yeah...I think I'd need an iron clad contract drawn up by an attorney if I proceeded with it.

 

[Stagg737]

What is your clinical experience with this NP? Are they good? Do they know their own limits? Do you trust them?

This is everything. I've met one particular psych NP who is better than (probably) most psychiatrists I've met and a couple who are better than most residents I've met. However, most fall into the mediocre to the prescribing Nystatin for hyperlipidemia category. Honestly, anything short of the cream of the crop is too much of a headache, imo.

Excellent question. I think this NPs clinical skills are good (for a mid-level) as I supervised them for a couple of years. I think fundamentally they are a good and conscientious person and work hard for patients. I do have some questions about this person knowing their limits or willingness to accept the level of supervision I would require again, based on a past minor incident. On the other hand, they know what I have required before and should not be surprised I haven't changed. So, yeah...I think I'd need an iron clad contract drawn up by an attorney if I proceeded with it.

And that would make it a hard no from me, especially knowing it will be their PP. They're going to want to run things their way, what happens when you two disagree again?

Imo, if you're supervising them then they should be working for you or for some system with you that can hold them accountable. The idea of them employing you to supervise them just doesn't make sense to me.

 

[Celexa]

Excellent question. I think this NPs clinical skills are good (for a mid-level) as I supervised them for a couple of years. I think fundamentally they are a good and conscientious person and work hard for patients. I do have some questions about this person knowing their limits or willingness to accept the level of supervision I would require again, based on a past minor incident. On the other hand, they know what I have required before and should not be surprised I haven't changed. So, yeah...I think I'd need an iron clad contract drawn up by an attorney if I proceeded with it.

"good for a mid-level" and "minor incident" related to not taking feedback well would probably be enough for me to flat out not hire someone, much less provide supervision in some type of setup where you have even less control and they probably want to give you less of the take (otherwise, they'd just get an employed position). Pass.

 

[annoyedpsychiatrist]

My last job I supervised 5 NPs. Objectively, two were solid and I agreed with their plan 99% of the time. One was just awful, and would try to augment SSRis with SNRis. She would literally pull out stahls and look things up in front of the patient. She was also attempting to treat ADHD/insomnia in people actively abusing meth/cocaine on UDS. Another I had would put people on 3-4 subtherapuetic doses of antipsychotics and increase all at once if the patient endorsed any issues. She did not know how to do an AIMs.

My point is, as far as quality goes its such a big spectrum. I have trust and faith in some because they have experience and have applied themselves and really learned. The problem is, many others are completely awful. Even the best NP still makes mistakes. So let me ask you this, what amount of money would you make you sleep easier at night knowning that someone is attaching your name to charts of patients youve never seen? Because for me, that number would have had to been something ridiculous, like one million dollars. No matter how much you trust this person I promise you there will always be cases you dont agree with, and it only takes one to keep you up at night.

Supervising midlevels would be a fine gig if you were at the end of your psychiatry career and you were pretty much seeing less and less patients and actually put in the effort to review their cases consistently and frequently. Otherwise I would not recommend it.

 

[sloh]

While there are bad apples in any field, a simple barometer is looking at the percentage of people that accepted jobs at Cerebral. 1500 prescribers. 5 were psychiatrists. This alone tells me that NP’s don’t know what is appropriate and what isn’t as a field. This compared to 5 bad apple psychiatrists.

“Brains of a doctor, heart of a nurse.”

“Brains of a cognitive eunuch, heart of a nurse.”

 

[Merovinge]

My last job I supervised 5 NPs. Objectively, two were solid and I agreed with their plan 99% of the time. One was just awful, and would try to augment SSRis with SNRis. She would literally pull out stahls and look things up in front of the patient. She was also attempting to treat ADHD/insomnia in people actively abusing meth/cocaine on UDS. Another I had would put people on 3-4 subtherapuetic doses of antipsychotics and increase all at once if the patient endorsed any issues. She did not know how to do an AIMs.

My point is, as far as quality goes its such a big spectrum. I have trust and faith in some because they have experience and have applied themselves and really learned. The problem is, many others are completely awful. Even the best NP still makes mistakes. So let me ask you this, what amount of money would you make you sleep easier at night knowning that someone is attaching your name to charts of patients youve never seen? Because for me, that number would have had to been something ridiculous, like one million dollars. No matter how much you trust this person I promise you there will always be cases you dont agree with, and it only takes one to keep you up at night.

Supervising midlevels would be a fine gig if you were at the end of your psychiatry career and you were pretty much seeing less and less patients and actually put in the effort to review their cases consistently and frequently. Otherwise I would not recommend it.

This is what occurred in the last place I worked, it was quite frustrating watching the should-be-retired psychiatrist phone it in by "supervising" the NPs and see zero patient's themselves. I think the actual thought process was so what if I lose my license, I will just retire. Turns out a lot of 70 year olds aren't looking to put in a lot of effort to review cases by folks with 1/10th the training they had and 40 years less experience.

 

[calvnandhobbs68]

This is what occurred in the last place I worked, it was quite frustrating watching the should-be-retired psychiatrist phone it in by "supervising" the NPs and see zero patient's themselves. I think the actual thought process was so what if I lose my license, I will just retire. Turns out a lot of 70 year olds aren't looking to put in a lot of effort to review cases by folks with 1/10th the training they had and 40 years less experience.

Right, your main concerns are malpractice and revoking your medical license in terms of consequences. If you've got pretty good asset protection by the time you're 65-70 (most retirement accounts can't be touched by malpractice lawsuits, lots of ways to protect primary residence, property, etc) so you don't have to worry about a lawsuit going over your limits and you're just doing it for extra money so you don't care if you lose your license, you can get really loosey goosey.

 

[Merovinge]

Right, your main concerns are malpractice and revoking your medical license in terms of consequences. If you've got pretty good asset protection by the time you're 65-70 (most retirement accounts can't be touched by malpractice lawsuits, lots of ways to protect primary residence, property, etc) so you don't have to worry about a lawsuit going over your limits and you're just doing it for extra money so you don't care if you lose your license, you can get really loosey goosey.

People do and it's just gross to see. These are human beings being treated not widgets or numbers on a spreadsheet.

 

[MacDonaldTriad]

There are awesome NPs and I would send family members to them. There are also nightmares that should not be allowed a pen or a prescription pad. Like us, it is all about training and not schools. It is all about who trained them and what they learned. My mixture of left and right wing opinions say that this social media has been off the mark worried about mid levels destroying our industry. I would like to think that if mid levels can perform well, we need their help and so much the better for man kind. Unfortunately, this isn't the case from what I see in many examples. This may make me sound snooty, but I would say the same thing about many psychiatrist out there. Unfortunately, bad care isn't rare.

If I had to focus my efforts for education and change, it would be focused on the current polypharmacy nutsville. The younger the faculty, the more rationalization they seem capable of. We have almost no studies that look at multiple combinations vs. sane practice. Open up the Betty Crocker cookbook and it will say add this for that, but that isn't good cooking. Michelin star restaurants don't have a copy of Betty Crocker in the kitchen. If you are too young to know who Betty Crocker is, substitute Home and Garden. If that doesn't help, you probably need to stay out of the kitchen a little longer.

 

[wolfvgang22]

There are awesome NPs and I would send family members to them. There are also nightmares that should not be allowed a pen or a prescription pad. Like us, it is all about training and not schools. It is all about who trained them and what they learned. My mixture of left and right wing opinions say that this social media has been off the mark worried about mid levels destroying our industry. I would like to think that if mid levels can perform well, we need their help and so much the better for man kind. Unfortunately, this isn't the case from what I see in many examples. This may make me sound snooty, but I would say the same thing about many psychiatrist out there. Unfortunately, bad care isn't rare.

If I had to focus my efforts for education and change, it would be focused on the current polypharmacy nutsville. The younger the faculty, the more rationalization they seem capable of. We have almost no studies that look at multiple combinations vs. sane practice. Open up the Betty Crocker cookbook and it will say add this for that, but that isn't good cooking. Michelin star restaurants don't have a copy of Betty Crocker in the kitchen. If you are too young to know who Betty Crocker is, substitute Home and Garden. If that doesn't help, you probably need to stay out of the kitchen a little longer.

I think prescribers would all be much less likely to overprescribe if patient satisfaction wasn't the chief key metric at most organizations. I feel like I work at Burger King psychiatry a lot of the time; "Have it your way" is our unwritten mission statement.

 

[mistafab]

The issue with NPs is the “training” is not done by the program they graduate from (most are even part time). It must be done post-graduation by thoughtful supervisors.

Our department has exactly 1 NP that has met the quality threshold and has been hired in the past 5 years. They were trained by the program for 3 years, with daily supervision among 3 attendings after being hired. They have ongoing supervision each day via table rounds in the service.

That’s what it actually takes to have an excellent NP. You have to train them. They do not have the 6000-8000 hours of supervision a generic psychiatry resident has by the time they graduate. They are lucky if they’ve even had 800 hours after completing a program. You just can’t make up for those hours with intelligence or skill.

 

[Stagg737]

There are awesome NPs and I would send family members to them. There are also nightmares that should not be allowed a pen or a prescription pad. Like us, it is all about training and not schools. It is all about who trained them and what they learned. My mixture of left and right wing opinions say that this social media has been off the mark worried about mid levels destroying our industry. I would like to think that if mid levels can perform well, we need their help and so much the better for man kind. Unfortunately, this isn't the case from what I see in many examples. This may make me sound snooty, but I would say the same thing about many psychiatrist out there. Unfortunately, bad care isn't rare.

If I had to focus my efforts for education and change, it would be focused on the current polypharmacy nutsville. The younger the faculty, the more rationalization they seem capable of. We have almost no studies that look at multiple combinations vs. sane practice. Open up the Betty Crocker cookbook and it will say add this for that, but that isn't good cooking. Michelin star restaurants don't have a copy of Betty Crocker in the kitchen. If you are too young to know who Betty Crocker is, substitute Home and Garden. If that doesn't help, you probably need to stay out of the kitchen a little longer.

My biggest problem with NPs in general is the horribly inconsistent formal training. If you look at actual NP curricula, it is uniformly less than 40% clinical education and I've seen program curricula which only have about 25% of courses being clinically relevant with the remainder being administrative courses or "research". The best thing that could happen to improve the situation would be a modern-day Flexner Report for NP programs to create actual educational standards, but with the power of the nursing lobby there is absolutely no chance that this will happen.

 

[allantois]

I haven't seen a single solid NP program..

 

[FlowRate]

The issue with NPs is the “training” is not done by the program they graduate from (most are even part time). It must be done post-graduation by thoughtful supervisors.

Our department has exactly 1 NP that has met the quality threshold and has been hired in the past 5 years. They were trained by the program for 3 years, with daily supervision among 3 attendings after being hired. They have ongoing supervision each day via table rounds in the service.

That’s what it actually takes to have an excellent NP. You have to train them. They do not have the 6000-8000 hours of supervision a generic psychiatry resident has by the time they graduate. They are lucky if they’ve even had 800 hours after completing a program. You just can’t make up for those hours with intelligence or skill.

This. If there was some way to require NP's spend 1-2 years working on an inpatient unit with good attending supervision I would advocate for it being a requirement. Without time and reps you'll never see the handful of real true hit-you-in-the-face (literally) mania to actually know that one thing is mania and another is a borderline patient with mood reactivity...

 

[wolfvgang22]

This. If there was some way to require NP's spend 1-2 years working on an inpatient unit with good attending supervision I would advocate for it being a requirement. Without time and reps you'll never see the handful of real true hit-you-in-the-face (literally) mania to actually know that one thing is mania and another is a borderline patient with mood reactivity...

Let's also add one year of basic science. Then we can call them NP+, and charge licensure fees. We'll be rich!
Wait...how about MPs (medical practioners)?
They could be the high mid-levels.

 

[Celexa]

This. If there was some way to require NP's spend 1-2 years working on an inpatient unit with good attending supervision I would advocate for it being a requirement. Without time and reps you'll never see the handful of real true hit-you-in-the-face (literally) mania to actually know that one thing is mania and another is a borderline patient with mood reactivity...

And with diligence they'd be in a decent place to do inpatient care, and then go outpatient and cause havok thinking they know psychiatry.

We lost SO MANY good inpatient nurses to online NP schools who then went blithely on to outpatient unaware that the portion of all psych patients who needs high doses of antipsychotics for any reason is actually quite small.

 

[annoyedpsychiatrist]

I think prescribers would all be much less likely to overprescribe if patient satisfaction wasn't the chief key metric at most organizations.

x1000. This is another thing that kills our field

 

[WisNeuro]

Let's also add one year of basic science. Then we can call them NP+, and charge licensure fees. We'll be rich!
Wait...how about MPs (medical practioners)?
They could be the high mid-levels.

They've already beat you to the punch

https://careers.state.gov/career-paths/foreign-service/specialist/medical-and-health/medical-provider/

 

[Stagg737]

And with diligence they'd be in a decent place to do inpatient care, and then go outpatient and cause havok thinking they know psychiatry.

We lost SO MANY good inpatient nurses to online NP schools who then went blithely on to outpatient unaware that the portion of all psych patients who needs high doses of antipsychotics for any reason is actually quite small.

I see this so much with patients coming from our county CMHC. It doesn't matter what your diagnosis is there, you're almost guaranteed to be on one antipsychotic and you're luck if it's not two or more. I saw one patient who the NP had started on 3 antipsychotics at the first appointment (Abilify and Olanzapine for psychosis, seroquel for anxiety and sleep). Turns out they had PTSD and did fine once switched to prozac and prazosin.

 

[MacDonaldTriad]

I think prescribers would all be much less likely to overprescribe if patient satisfaction wasn't the chief key metric at most organizations. I feel like I work at Burger King psychiatry a lot of the time; "Have it your way" is our unwritten mission statement.

A couple of decades ago, I ran a public outpatient clinic and coined the term, "this isn't Burger King". The staff had a lot of learned helplessness and needed some guidance about when to be flexible

 

[wolfvgang22]

I know we are way off the original topic now, but I have a lot of stress and burn out because I struggle with every psychologist and social work therapist and a few nurses in my organization sending me patients for "a medication change or adjustment" to solve their problems, mainly when the patient just refuses to make significant investment in psychotherapy or lifestyle changes.

When I then tell the patient and document something like "The risks of additional medication at this time outweigh the potential benefits, further improvement is more likely to occur with participation in _____ therapy and reduction of Monster energy drink and heavy cannabis use" the sense of disappointment and that I'm an uncaring or incompetent doctor in my organization is palpable. Maybe I just need therapy myself but with our high turnover I don't think it's just me. The problem is our patients aren't required to meet us half way in their own recovery. Maybe 10% of the way and that just doesn't work very well. But patient satisfaction metrics look good! Circling back around, this is why the NP wants to go into private practice.

 

[mistafab]

Thats the thing about NP to MD comparison. It is more of a close comparison to view the NP school as MD, MS3/4 clerkships in terms of hours. An intern 6 months in has already met or doubled the direct supervision time of an average NP program. There is just no comparison to residents. Their training must be done post-grad - which wasnt as big of an issue until politicians/nurses lobbied for unsupervised practice. This essentially equates to a fresh MD grad starting unsupervised practice after medical school. Luckily they have started some PMHP or whatever the acronym is for psych training after NP school. At least they get some reps of actual psychiatry as a base.

This is why there is percieved “inconsistency” in training. It isnt about the actual NP school, it is what they have done afterwards to build their own training/experience.

God forbid they were supervised for years by another NP. Blind leading the blind.

This. If there was some way to require NP's spend 1-2 years working on an inpatient unit with good attending supervision I would advocate for it being a requirement. Without time and reps you'll never see the handful of real true hit-you-in-the-face (literally) mania to actually know that one thing is mania and another is a borderline patient with mood reactivity...

 

[Candidate2017]

Why do we give away so cheaply what we worked so hard to earn through years, sweat, blood, and tears and tuition?

 

[Merovinge]

Why do we give away so cheaply what we worked so hard to earn through years, sweat, blood, and tears and tuition?

Because surgeons wanted someone to see their post-op patients while they make money in the OR/Clinic and then from their other docs found ways to make money off of NPs. In the end, when you are attending, most docs only seem to care about their own pay (which is what our capitalistic setup is trying push us towards), and there were numerous steps to where we are now paved by doctors who found away for mid levels to improve their bottom line or lifestyle.

 

[calvnandhobbs68]

Because surgeons wanted someone to see their post-op patients while they make money in the OR/Clinic and then from their other docs found ways to make money off of NPs. In the end, when you are attending, most docs only seem to care about their own pay (which is what our capitalistic setup is trying push us towards), and there were numerous steps to where we are now paved by doctors who found away for mid levels to improve their bottom line or lifestyle.

Right this was really the original use of NPs/PAs. Basically take the more experienced staff nurses and have them work as residents for inpatient units, it's extremely beneficial for surgeons because they can just spend all day doing the procedures and put all the "scut work" on the midlevels. The staff nurses liked it too because it was typically a bump in pay, they were working with doctors they had lots of experience with and they recognized what they knew and what they didn't. If you talk to the older NPs in hospitals (like the ones in their 60s+) they tend to be pretty good, very experienced for their department but also recognize when they need to talk to the attending about things.

 

[Stagg737]

I know we are way off the original topic now, but I have a lot of stress and burn out because I struggle with every psychologist and social work therapist and a few nurses in my organization sending me patients for "a medication change or adjustment" to solve their problems, mainly when the patient just refuses to make significant investment in psychotherapy or lifestyle changes.

When I then tell the patient and document something like "The risks of additional medication at this time outweigh the potential benefits, further improvement is more likely to occur with participation in _____ therapy and reduction of Monster energy drink and heavy cannabis use" the sense of disappointment and that I'm an uncaring or incompetent doctor in my organization is palpable. Maybe I just need therapy myself but with our high turnover I don't think it's just me. The problem is our patients aren't required to meet us half way in their own recovery. Maybe 10% of the way and that just doesn't work very well. But patient satisfaction metrics look good! Circling back around, this is why the NP wants to go into private practice.

This is why I wouldn't want to work in the VA system, especially outpatient. There's an attitude of entitlement for the patient (not even always by the patient themself) that anything less than bending over backwards to do everything possible for them is a failure when in reality many of them need stronger boundaries and someone to tell them "no". I remember at one point in residency our VA clinic was trying to implement procedures to get our vets just to show up to their appointments after inpatient admissions when many of them were just antisocial patients who didn't care.

Outside of the VA in other continuity clinics, you would just discharge those patients, but like you mentioned at many VA clinics that isn't acceptable.

 

[smalltownpsych]

I know we are way off the original topic now, but I have a lot of stress and burn out because I struggle with every psychologist and social work therapist and a few nurses in my organization sending me patients for "a medication change or adjustment" to solve their problems, mainly when the patient just refuses to make significant investment in psychotherapy or lifestyle changes.

When I then tell the patient and document something like "The risks of additional medication at this time outweigh the potential benefits, further improvement is more likely to occur with participation in _____ therapy and reduction of Monster energy drink and heavy cannabis use" the sense of disappointment and that I'm an uncaring or incompetent doctor in my organization is palpable. Maybe I just need therapy myself but with our high turnover I don't think it's just me. The problem is our patients aren't required to meet us half way in their own recovery. Maybe 10% of the way and that just doesn't work very well. But patient satisfaction metrics look good! Circling back around, this is why the NP wants to go into private practice.

Just wanted to say that the psychologists you work with suck. 😁 Every time I have seen a therapist advocating for a medication increase it’s because they have weak skills. It’s almost never because of something obvious like increased psychosis or clear manic episode because a psychiatrist would not need to have that pointed out. I would be tempted to tell the patient that they don’t need a “med change”. (I hate that phrase), maybe they need a psychotherapy change.

I personally would be embarrassed if that dynamic was playing out with my patients. Most of the time. I want my patient stabilizing and telling the psychiatrist that I could potentially use less medication because I am doing better because I have made changes in my life thanks to my therapy and am no longer a total s-show.

 

[forchinet121]

Just wanted to say that the psychologists you work with suck. 😁 Every time I have seen a therapist advocating for a medication increase it’s because they have weak skills. It’s almost never because of something obvious like increased psychosis or clear manic episode because a psychiatrist would not need to have that pointed out. I would be tempted to tell the patient that they don’t need a “med change”. (I hate that phrase), maybe they need a psychotherapy change.

I personally would be embarrassed if that dynamic was playing out with my patients. Most of the time. I want my patient stabilizing and telling the psychiatrist that I could potentially use less medication because I am doing better because I have made changes in my life thanks to my therapy and am no longer a total s-show.

I don’t even know what a psychologist like this would look like, all of the others I have worked with are like the former..that would be quite amazing

 

[randomdoc1]

I get a sadistic pleasure out of turning down NPs who want to do preceptorship or have supervised work. Well then...it should have been thought out better before churning out all these diploma mills.

 

[randomdoc1]

I think prescribers would all be much less likely to overprescribe if patient satisfaction wasn't the chief key metric at most organizations. I feel like I work at Burger King psychiatry a lot of the time; "Have it your way" is our unwritten mission statement.

Tell this to my family. They demand antibiotics so much, it's insane. But then they complain that western medicine is "too invasive with side effects" but it doesn't apply to them when they demand inappropriate imaging and antibiotics but refuse to take metformin. My mother experienced antibiotic resistance for the first time...scared the pants out of her and I happily said "and that is why...".

 

[wolfvgang22]

I get a sadistic pleasure out of turning down NPs who want to do preceptorship or have supervised work. Well then...it should have been thought out better before churning out all these diploma mills.

I won't teach NP students anymore (I did when I was more naive) and I avoid supervision without compensation now. But I get no pleasure from saying no. Most NPs are just people trying to make a living just like me.

I'll let you all know what happens with the request I originally posted about, if I ever do hear the proposed business plan.

 

[randomdoc1]

I won't teach NP students anymore (I did when I was more naive) and I avoid supervision without compensation now. But I get no pleasure from saying no. Most NPs are just people trying to make a living just like me.

It's not necessarily the all the people--I agree there are some good people (and there are bad people, and some that start good but decline in morale or vice versa). But how poorly thought out this whole situation was before legislation allowed all these diploma mills. That and, there are quite a few people enrolling in NP and PA schools who are looking for the quick buck. Them I have no sympathy for. Some even enter the field with pure hearts but get a big head very quickly too. That, I have no sympathy for. In the practice of medicine, we should always be appreciating how little we all truly know, and be ready to be life long learners. Many just want to be "done" and "make money." I understand it, but at the same time, we have an ethnical obligation and quite frankly, my philosophy on life is that, life long learning is the way. I've even seen some strong undergrads finish their PA or NP program and they wanted asap to get the big money and wanted to sign up for jobs like ERs of Children's Hospitals. I'm like, you guys are NOT ready for that! Some were so resistant to the idea of supervision after school and/or a fellowship (akin to a small child throwing a trantrum over not getting their candy right away). Clearly showing they truly had no clue of what they did not know. I'm getting a little deep in this discussion. Although it's about making a good living, yes. But I get a sinking feeling when I see some providers being so single minded about money and their own standard of living at the expense of quality of patient care. There can be a way to balance that. But I've literally seen providers engage in patient abandonment over a small overdue balance and passive aggressively let someone withdraw on their SSRI due to their own countertransferance or patient financial concerns. There's a peaceful and ethical way to draw boundaries and conclude relationships.

 

[randomdoc1]

Oh yes, I forgot to mention along the PA discussion. When I was in undergrad, there were quite a few strong PAs and the PA school curriculums were quite rigorous. Even that is getting watered down to basically appease people who don't want to be in school because it's "too long." The 2 year programs sell better than the 3 year programs. So more PA schools feel the pressure to water down their education too. SMH. And then they can be launched off to work in a pediatric ER?! Yikes...

 

[vanfanal]

This is why I wouldn't want to work in the VA system, especially outpatient. There's an attitude of entitlement for the patient (not even always by the patient themself) that anything less than bending over backwards to do everything possible for them is a failure when in reality many of them need stronger boundaries and someone to tell them "no". I remember at one point in residency our VA clinic was trying to implement procedures to get our vets just to show up to their appointments after inpatient admissions when many of them were just antisocial patients who didn't care.

Outside of the VA in other continuity clinics, you would just discharge those patients, but like you mentioned at many VA clinics that isn't acceptable.

I’m feeling this heavily.
Some know how to manipulate the system and make it seem like the doc is uncaring or unresponsive. Then the system wants a resolution because it’s a customer service mentality. Their answer is alway more more more more when the real answer may lie in cutting down on the online stimulant prescriptions. Emotionally exhausting.

 

[vanfanal]

Why do we give away so cheaply what we worked so hard to earn through years, sweat, blood, and tears and tuition?

1000%.
If a nurse can become competent with enough supervision training then it’s basically med school and a residency. Why are we okay with letting them pretend to do the same thing as us. I know some have said that they’re not feeling an impact. But if there’s an NP on an inpatient unit then that’s position that a psychiatrist could have been in. Same for opt. The lawyers shut down expansion of paralegals hard in several states. There’s a pilot shortage and airlines are increasing pay, offering loan forgiveness and better hours, not letting air hostesses fly planes.
But in medicine…nurses with barley adequate training are given the license to do what it takes a physician 12 years to do.