NP "collaboration"

[TheRightMedication]

What if we all employed NPs in our outpatient practice and supervised them closely - by which I mean constant, ongoing supervision and review of each and every note/encounter?

Then we'd define what quality looks like when if comes to NP practice, and answer the "what do we do about the shortfall of psychiatrists" question on our own terms, or as near to our own terms as we're going to get.

---

Members don't see this ad.

 

[randomdoc1]

I know I’ve given some emotional responses. But yesterday saw some moving social media posts in honor of July 1st. I have met some great NPs. So much of this also boils down to the character of the person you are supervising, which is fluid over time. My general experience unfortunately is that NPs and PAs in current just have so little experience/knowledge and the culture is so different. As others have said, you just really cannot have a high quality medical education or be able to practice safe medicine in what I consider to be very watered down “medical education”. So the onus is on that graduate to keep it going and my take on the supervision is that it would be time intensive even with those with the best hearts meaning I’d expect some darn good compensation. One gal used to work at my office. Awesome clinical intuition, great character, studied hard in her program and saved her notes for future reference (lol, I just tossed mine soon as the course was over!). But she still could not recognize rhabdo or why it was a major medical concern! That’s just one example! And this was supposed to be one of the better programs. So antipsychotic management, she’d need extensive training on and I bet that’s just the tip of the iceberg. But some of the most bright eyed and bushy tailed individuals I see go into these programs, many already feel burned out and don’t look interested in continuing to learn. As I said, many thought they were ready for situations like pediatric ERs! I’ve seen some leave healthcare altogether. Some of it is a combination of their individual journey…but some of it feels like the culture that is fostered. There’s a sense of overconfidence, life of peaches and cream, which is dangerous and in addition to supervising to provide the medical knowledge—medical trainees also need a level of personal guidance and support to foster resilience and the right attitude. And this unspoken friction with physicians that creates almost a knee jerk reaction to resist and be offended when we suggest there’s a lot more learning to be done. Some take it so personally and that’s not a good sign this early in the career.

No shortcuts to real medical education and hence the safe practice of medicine. Even I felt nervous to be an attending after all the training we had.

Edit: my office now has had some years of training PsyD and PhD students. I’m starting a psych residency rotation here. I’ve learned there’s a lot of helping with character development as well in good medical training. It sets to stage for self learning, self improvement and good ethical and thorough decision making because even as an ongoing supervisor and employer, we’re just not able nor should we be watching their every move. I’ve really started to hammer in with employees and trainees that character and growth is a crucial part of all our job descriptions including my own. All that is guaranteed is change and we must get used to adapting. I do get the title sometimes if being like a drill sergeant or running the training like some sort of dojo/dojang for medical trainees lol.

 

[Celexa]

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.

Ugh, you're reminding me that one of the things I despise in my current institution is the way that access to prescribers of any type is gate kept by the therapists, who often have NO IDEA what meds can genuinely help with and what they can't. Additionally, since I mainly work inpatient CL, not infrequently I will have a patient who needs medical assessment at discharge for med adjustment, independent of any therapeutic needs (ie, catatonic on benzo taper; forced to come off lithium due to medical condition, switched to new mood stabilizer, etc) and I can't schedule them for rapid follow up IN OUR OWN CLINICS because they need to establish with a therapist first, and God forbid they have their own therapist already, then they can't see one of our psychiatrists unless they terminate with their current therapist and establish with one of ours.

What bothers me the most is how few people in the dept understand how ****ed up this is.

 

[Stagg737]

Ugh, you're reminding me that one of the things I despise in my current institution is the way that access to prescribers of any type is gate kept by the therapists, who often have NO IDEA what meds can genuinely help with and what they can't. Additionally, since I mainly work inpatient CL, not infrequently I will have a patient who needs medical assessment at discharge for med adjustment, independent of any therapeutic needs (ie, catatonic on benzo taper; forced to come off lithium due to medical condition, switched to new mood stabilizer, etc) and I can't schedule them for rapid follow up IN OUR OWN CLINICS because they need to establish with a therapist first, and God forbid they have their own therapist already, then they can't see one of our psychiatrists unless they terminate with their current therapist and establish with one of ours.

What bothers me the most is how few people in the dept understand how ****ed up this is.

What? This seems totally backwards and insane. Where I'm at the only restriction is that if they want to receive free therapy from one of our residents they have to be receiving their med management in our clinic.

 

[vanfanal]

So I was Googling tips for psych private practice and to be honest was blown away some of what I saw from some NPs In terms of how they market themselves vs psychiatrists.

can someone enlighten me as to was “board certified” actually means for an NP? Are they specialty specific? How long? Standardised? And what exactly does NP training involve?

 

[Merovinge]

So I was Googling tips for psych private practice and to be honest was blown away some of what I saw from some NPs In terms of how they market themselves vs psychiatrists.

can someone enlighten me as to was “board certified” actually means for an NP? Are they specialty specific? How long? Standardised? And what exactly does NP training involve?

I'm triple emeritis twice knighted omgea fraternal order boarded in all areas of medicine, science, and healing with an additional four certifications in chakra medicine, hypnosis, healing spiritual rifts, and psychodelics.

 

[comp1]

Yes, NPs have specialization training beyond general NP training and sit for board exams in that specialty. Here's info on an example program that makes an already licensed NP eligible to sit for their mental health boards: Psychiatric Mental Health Nurse Practitioner Remote-Access Post-Master’s Certificate | Nursing Schoo

 

[calvnandhobbs68]

Yes, NPs have specialization training beyond general NP training and sit for board exams in that specialty. Here's info on an example program that makes an already licensed NP eligible to sit for their mental health boards: Psychiatric Mental Health Nurse Practitioner Remote-Access Post-Master’s Certificate | Nursing Schoo

Yeah their "board exam" is 3x shorter than the actual initial psychiatry board exam lol...oh and they get a "across the lifespan" certification so don't even add on the child/adolescent board exam from all the NPs I know they're qualified to treat anyone 6-90yo without any additional training

 

[vanfanal]

Yes, NPs have specialization training beyond general NP training and sit for board exams in that specialty. Here's info on an example program that makes an already licensed NP eligible to sit for their mental health boards: Psychiatric Mental Health Nurse Practitioner Remote-Access Post-Master’s Certificate | Nursing Schoo

Thanks. I jumped to some sample board questions and…good god Lemon….those were some very basic first order questions; similar to med student shelf exams.

The link didn’t specify much about clinical experience. Other sites have say 500 hours?? Anyone know what that involves?

 

[Stagg737]

Thanks. I jumped to some sample board questions and…good god Lemon….those were some very basic first order questions; similar to med student shelf exams.

The link didn’t specify much about clinical experience. Other sites have say 500 hours?? Anyone know what that involves?

Getting a physician to say you shadowed them/supervised you for 500 hours. I've heard NPs straight up say they showed up to the site, got the doc to sign the paper, and then went home. That's part of the problem with the curriculum, at most schools they require you to get clinical hours but don't provide any assistance with getting them. I actually got e-mailed earlier this week by an NP student asking if I would supervise them. Hard pass.

I'm curious where you found the sample board questions. Would be interested in seeing them given how terrible NP pass rates were when previously given the watered down Step 3 exam.

 

[comp1]

So NP clinical education is indeed more focused on hours than on months like resident physician education. It's also not as setting prescribed, ie one month of CL psychiatry, one year of outpatient psychiatry. If there is a focus, it tends to be age based like 180 hours of child mental health supervision. It's a different model, to be sure, and somewhat more didactics focused than medical student clerkships or resident site rotations. I think it actually works the absolute best when the facility training the person for their NP residency also ultimately employs them.

 

[vanfanal]

Getting a physician to say you shadowed them/supervised you for 500 hours. I've heard NPs straight up say they showed up to the site, got the doc to sign the paper, and then went home. That's part of the problem with the curriculum, at most schools they require you to get clinical hours but don't provide any assistance with getting them. I actually got e-mailed earlier this week by an NP student asking if I would supervise them. Hard pass.

I'm curious where you found the sample board questions. Would be interested in seeing them given how terrible NP pass rates were when previously given the watered down Step 3 exam.

STQ-PMHNP

Review sample questions for the Psychiatric-Mental Health Nurse Practitioner exam from the American Nurses Credentialing Center (ANCC).

www.nursingworld.org

 

[vanfanal]

So NP clinical education is indeed more focused on hours than on months like resident physician education. It's also not as setting prescribed, ie one month of CL psychiatry, one year of outpatient psychiatry. If there is a focus, it tends to be age based like 180 hours of child mental health supervision. It's a different model, to be sure, and somewhat more didactics focused than medical student clerkships or resident site rotations. I think it actually works the absolute best when the facility training the person for their NP residency also ultimately employs them.

So it’s like observing? Do they take ownership of patients from admission to discharge like residents?

 

[nexus73]

So it’s like observing? Do they take ownership of patients from admission to discharge like residents?

hahahahahahahahahahaha

 

[comp1]

Ideally they do take ownership just like a resident physician. https://nursing.uc.edu/content/dam/...ate/psych-mental-health-pmc-before-SS2019.pdf The specifics are going to vary a great deal from program to program.

 

[Stagg737]

So it’s like observing? Do they take ownership of patients from admission to discharge like residents?

Some of the places I rotated through in med school (DO with no core hospital, so rotated all over the city) also had NPs rotating there. They had equal or less ownership of patients as med students and in one or two cases they just shadowed for their "clinical" hours much like I did as a pre-med student. Could be different elsewhere, but I've never seen or heard of them taking ownership of patients at that level.

 

[nexus73]

Yes, NPs have specialization training beyond general NP training and sit for board exams in that specialty. Here's info on an example program that makes an already licensed NP eligible to sit for their mental health boards: Psychiatric Mental Health Nurse Practitioner Remote-Access Post-Master’s Certificate | Nursing Schoo

My understanding as a non np is this is not really accurate. Nps have various degree focuses, fnp, pmhnp (psych), crna, cert nurse midwife, not sure if others. When they finish training and 500 hours of clinicals they take a test which is really a licensing exam (which FYI physicians take 3 licensing exams called USMLE, which are colloquially called boards but are actually not board exams but licensing exams). This is a licensing exam because nps must pass this test to get their license to practice; however, the licensing exam also somehow confers board certification. It may be in the semantics because a board does put together their licensing exam, but it's not equivalent of a physician's board exam, just obscuring the reality by using the same language.

The nps call their licensing exam their boards and equate that with a physician's board certification which is wrong. Physicians take 3 licensing exams, then do at least 3 intensive years of residency training and upon graduation are board eligible and can practice in their specialty of training. Many/most physicians then go on to take yet another grueling test for board certification, which is above and beyond the basic requirements and shows (at least theoretically) a level of expertise of a higher echelon. Nps don't have this. They have a licensing exam.

My understanding is nps are able to add on training to expand into other specialties, so an fnp can take mental health courses, get enough clinical hours (500 again?) and take the mental health licensing exam, and call themselves board certified as a pmhnp. But all of this can be done online and the hour accumulation is the same sketchy process where they find their own preceptors (which can be nps) and whether they are really completing even 500 hours is questionable. For a physician to do this they would have to complete a 3 year family med residency, then retrain doing another 3 full years of psych residency, full time, then when done they would take the psychiatry board exam if they chose to, but would not be required for licensure.

At the end of the day the nps are doing whatever they want but the reality of board certification between physicians and np's is not equivalent. But the np's (and various hospital admins) seem happy to let people believe it is.

 

[comp1]

First and foremost, none of NP training at any level is completely identical in content or amount to medical school and a physician residency. There is a reason that salaried physicians are paid 2-3x more than NPs practically everywhere. In terms of NP specialty training, there is a significant degree of variability in how this is done structurally. The NP was originally a masters level degree. As it has moved to a doctoral level format, you will now sometimes, but not always, see a particular specialty (eg MH) integrated into the doctoral program so the NP sits for that particular board exam directly at the end of the doctoral program. This contrasts with something that could more directly be conceptually related to physician residencies where the specialty training is a separate program completed following graduate school. The original UCD link and description I gave was the latter which still very much exists even years after the DNP rollout because masters level clinicians are still common and because this particular structure allows for transition to different roles during the NP's career depending on their own or their employer's goals. The job opportunities after either route are essentially the same.

 

[sloh]

healing with an additional four certifications in chakra medicine, hypnosis, healing spiritual rifts, and psychodelics.

Lots of patients love this and gobble it up. In fact, many seek this out haha

 

[sloh]

more didactics focused than medical student clerkships or resident site rotations.

Innate intelligence differences aside, therein lies the issue.

 

[nexus73]

First and foremost, none of NP training at any level is completely identical in content or amount to medical school and a physician residency. There is a reason that salaried physicians are paid 2-3x more than NPs practically everywhere. In terms of NP specialty training, there is a significant degree of variability in how this is done structurally. The NP was originally a masters level degree. As it has moved to a doctoral level format, you will now sometimes, but not always, see a particular specialty (eg MH) integrated into the doctoral program so the NP sits for that particular board exam directly at the end of the doctoral program. This contrasts with something that could more directly be conceptually related to physician residencies where the specialty training is a separate program completed following graduate school. The original UCD link and description I gave was the latter which still very much exists even years after the DNP rollout because masters level clinicians are still common and because this particular structure allows for transition to different roles during the NP's career depending on their own or their employer's goals. The job opportunities after either route are essentially the same.

Bolded may be the understatement of the decade.

You're still talking about board exams as if there are separate licensing exams. The exam for mental health for np's is the licensing exam, which they call boards. There isn't a separate licensing exam for nps. Board exam=licensing exam for nps. It's literally impossible for a practicing np not to be board certified because there is only one exam for them to take which is required to get licensed. At best you could describe the mental health exam as a separate licensing exam with different focus, but calling it a board exam is deceptive.

I've worked with nps with masters degrees who are pmhnp specifically and they are locked in as psych nps. Dnp vs masters is irrelevant to this. And no, a dnp program is not "conceptually related" to a physician's residency, what a completely disingenuous description of reality. The dnp is likely more of a cash grab from training programs to charge more and/or require more time in school to bolster revenue, and maybe sells the program because the nps can now demand to be called doctors.

The program you linked just highlights how easy np training is they can transition to a different specialty focus with some classes and clinical hours (however those are defined), all while maintaining full time employment. A physician would take 3 years full time to do this. Nps should feel bad about this. In fact, the nps I work with who are honest are open about how much their training was lacking 10 years ago, and they can't believe how much worse it is for nps going through all the online programs now.

 

[randomdoc1]

Lots of patients love this and gobble it up. In fact, many seek this out haha

I get offended that one of the reasons patients are drawn to psychiatric care at my office is that myself and another psychiatrist here are of Asian ancestry. We are allopathic physicians who practice evidence based medicine. But quite a few come to their new patient appointments expecting herbs, a naturopathic approach or anti-prescription approach. Nowhere does it say anywhere that we do that. Our training is at a domestic MD school with residency in psychiatry and board certification. I mean, the traffic is nice. But that generalization is offensive. All I can do is laugh at it though!

I just say "sorry, nope, I agree with all the other MDs you saw. You're severely depressed, never had med management and an SSRI is what we recommend for starters too" : P

The shock and horror on those faces....

 

[WisNeuro]

I get offended that one of the reasons patients are drawn to psychiatric care at my office is that myself and another psychiatrist here are of Asian ancestry. We are allopathic physicians who practice evidence based medicine. But quite a few come to their new patient appointments expecting herbs, a naturopathic approach or anti-prescription approach. Nowhere does it say anywhere that we do that. Our training is at a domestic MD school with residency in psychiatry and board certification. I mean, the traffic is nice. But that generalization is offensive. All I can do is laugh at it though!

I just say "sorry, nope, I agree with all the other MDs you saw. You're severely depressed, never had med management and an SSRI is what we recommend for starters too" : P

The shock and horror on those faces....

You're missing a golden opportunity here. You can mark up junk like ginseng and turmeric supplements a few hundred percent and just tell them to take it with their SSRIs.

 

[JKinSC]

You're missing a golden opportunity here. You can mark up junk like ginseng and turmeric supplements a few hundred percent and just tell them to take it with their SSRIs.

Better yet: mix them in some random ratio, call it a "proprietary formula," and make an infomercial

 

[allantois]

The only good nursing programs are CRNA with actual experience requirements and having to dedicate full-time to studying. The rest is the downfall of American healthcare and education

 

[FlowRate]

The only good nursing programs are CRNA with actual experience requirements and having to dedicate full-time to studying. The rest is the downfall of American healthcare and education

For some reason I thought you were a NP/APN/PMHNP/whatever, are you a PA or just saying you thought your educational/degree program was inadequate?