NPR segment on DNP's - make your voices heard!

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I don't have much of a problem with NPs as I do with this DNP thing. DNP is an ill-concieved fraud designed to sneak subpar candidiates into the physician's role.

 

[zenman]

So a patient with suicidal ideation AND a plan was sent home to get some antidepressants which take time to kick in usually with followup in a week? Makes me question your reasoning behind such an action. Also, what medication did you recommend? You should know since you ordered it right? Maybe there were details left out but I personally would want a more detailed assessment than just go on what you said if i were the attending physician. Secondly, do you even know what qualifies as a Bipolar II? The patient came back with a much improved mood and automatically you think Bipolar II without re-assessing the patient to figure out if they even meet the DSM criteria? I guess that's the difference between a physician and a wanna-be-physician

Reasoning behind my action was that I'm in BFE (Bangladesh) so don't have all the laws and options available to you; she had already seen four psychiatrists and refused to see any more; she had a supportive family; we did a contract and I wrote a script (on a Post-it note) for escitalopram 10 mg/day and sent her to a local pharmacy. Also made the quickest appt I could with a non-local doctor for a week later. The fact that she was elated with her much improved mood after a week of escitalopram and due to the "rest of the story" which you aren't privy to, I think she is Bipolar II. Yes, she meets DSM criteria. And of course we'll see what has transpired when she shows up this week. I'll bet a mood stabilizer is on the horizon. Any more questions?

 

[EternalMD]

Reasoning behind my action was that I'm in BFE (Bangladesh) so don't have all the laws and options available to you;

While true, it doesn't excuse the proper course of action which you didn't take (even assuming that you couldn't hospitalize her, your medical management/decision making was questionable)

she had already seen four psychiatrists and refused to see any more

and yet there was a followup scheduled with another one?

she had a supportive family; we did a contract and I wrote a script (on a Post-it note) for escitalopram 10 mg/day and sent her to a local pharmacy.

😱 so i'm assuming you made a verbal contract (or maybe on a post-it note for legal purposes) and gave a script you scribbled down -- i guess everyone can just write a script and send someone to the pharmacy. Must be nice not to be regulated. There are reasons why we tend to hospitalize patients in the US for psychiatric disorders and one of them is danger to self. I still don't know whether you attempted to determine the underlying cause for her SI and whether your plan was a sound one or not. Enough details missing that you could swing this argument your way. But lets say this patient had SI because voices were telling her to hurt herself. Your SSRI wouldn't be all that effective.

The fact that she was elated with her much improved mood after a week of escitalopram and due to the "rest of the story" which you aren't privy to, I think she is Bipolar II. Yes, she meets DSM criteria.

you can go right ahead and search for the exact criteria because i doubt you knew it when you determined Bipolar II and I question whether you know it at this point in time. An improved mood alone is NOT a criteria for mania but that's what it appears you seemed to jump on for the recommendation of changing her medical therapy. Also, where exactly was the psychological therapy which in conjunction to pharmacological therapy has been shown proven to be superior to either alone. Seems more like you threw drugs at her and then decided she needed different drugs rather than anything else.

 

[dragonfly99]

Delivering medical care in a place like Bangladesh is so different than doing so in the US that I don't even think you can try and apply the same standards.
As far as hospitalizing the patient, do they even have psychiatric wards in that country? Is there such a thing as "involuntary commitment" there?

 

[zenman]

While true, it doesn't excuse the proper course of action which you didn't take (even assuming that you couldn't hospitalize her, your medical management/decision making was questionable)

You know as well as I do that you can put four physicians in a room and they won't agree. So, what would you have done differently?

and yet there was a followup scheduled with another one?

Nope, I got her in to see a British GP.

😱 so i'm assuming you made a verbal contract

Verbal and a handshake

(or maybe on a post-it note for legal purposes) and gave a script you scribbled down -- i guess everyone can just write a script and send someone to the pharmacy. Must be nice not to be regulated.

I wrote it down so the pharmacy would get it correct. Script not even needed here. No regulations not always good when anyone can get whatever they want.

There are reasons why we tend to hospitalize patients in the US for psychiatric disorders and one of them is danger to self. I still don't know whether you attempted to determine the underlying cause for her SI and whether your plan was a sound one or not. Enough details missing that you could swing this argument your way. But lets say this patient had SI because voices were telling her to hurt herself. Your SSRI wouldn't be all that effective.

Got that. Denied hallucinations...

you can go right ahead and search for the exact criteria because i doubt you knew it when you determined Bipolar II and I question whether you know it at this point in time. An improved mood alone is NOT a criteria for mania but that's what it appears you seemed to jump on for the recommendation of changing her medical therapy. Also, where exactly was the psychological therapy which in conjunction to pharmacological therapy has been shown proven to be superior to either alone. Seems more like you threw drugs at her and then decided she needed different drugs rather than anything else.

Yes, I could search for it as I have Kaplan & Sadock's right here on my mac. Oh yes, the DSM - a book of labels created by a committee with connections to big pharm. And to think I've actually had two courses on the thing...six semester hours on nothing but the DSM - 20 years apart and it's still not very exciting, lol!

Her miraculous improved mood, along with other history, really pointed in that direction. The GP agrees. Bipolar is probably easily misdiagnosed by family docs, especially if they just see the depression. I've seen her at major depression and hypomania. For now, that's what we're going with...until we see something different. I threw the meds at her for several reasons, one of them being to provide her hope that she would get better. Now that I've seen the hypomania, I don't want to keep her on antidepressant monotherapy. Would you?

 

[zenman]

Delivering medical care in a place like Bangladesh is so different than doing so in the US that I don't even think you can try and apply the same standards.
As far as hospitalizing the patient, do they even have psychiatric wards in that country? Is there such a thing as "involuntary commitment" there?

You got that right. There is one psych hospital, if you can call it that. No involuntary commitment. Actually I see very few mentally ill out begging or standing in the streets. I don't think they would last very long.

 

[EternalMD]

I could sit here all day and go back and forth with you zenman as I did once prior in order to get you to answer a simple question which you eventually evaded (and yet somehow you were the only one who believed you actually answered my question). I could waste my time and give you a reply to your previous post, but I'm going to go have some dinner instead since it shall be much more fruitful to me at the end of this day than a shaman wanna-be (some great chinese food just in case you wanted to know). Enjoy your bats wings and eyeballs of a toad - or whatever you deem to work when medical management fails.

 

[zenman]

I could sit here all day and go back and forth with you zenman as I did once prior in order to get you to answer a simple question which you eventually evaded (and yet somehow you were the only one who believed you actually answered my question). I could waste my time and give you a reply to your previous post, but I'm going to go have some dinner instead since it shall be much more fruitful to me at the end of this day than a shaman wanna-be (some great chinese food just in case you wanted to know). Enjoy your bats wings and eyeballs of a toad - or whatever you deem to work when medical management fails.

You made many comments which I broke down and answered. Now, maybe I missed one. So, if you don't think I've answered you then post your questions like this:

1.
2.
3.

I think you might have a reading problem though as you kept bringing up a psychiatrist when I never said I consulted one.

Now, based on the info I can give you why don't you just pony up and admit that maybe me and my doctor might be halfway safe.👍

Do enjoy your Chinese food and I'll enjoy my pot of chai.

 

[doc4life95]

I don't have much of a problem with NPs as I do with this DNP thing. DNP is an ill-concieved fraud designed to sneak subpar candidiates into the physician's role.

I agree .. like a virus infecting the foundations of medicine
but I disagree the plan to increase public focus on DNP is quiet well conceived

as MD'S we should be working hard to DECREASE their credibility

 

[silas2642]

You know as well as I do that you can put four physicians in a room and they won't agree. So, what would you have done differently?



Nope, I got her in to see a British GP.



Verbal and a handshake



I wrote it down so the pharmacy would get it correct. Script not even needed here. No regulations not always good when anyone can get whatever they want.



Got that. Denied hallucinations...




Yes, I could search for it as I have Kaplan & Sadock's right here on my mac. Oh yes, the DSM - a book of labels created by a committee with connections to big pharm. And to think I've actually had two courses on the thing...six semester hours on nothing but the DSM - 20 years apart and it's still not very exciting, lol!

Her miraculous improved mood, along with other history, really pointed in that direction. The GP agrees. Bipolar is probably easily misdiagnosed by family docs, especially if they just see the depression. I've seen her at major depression and hypomania. For now, that's what we're going with...until we see something different. I threw the meds at her for several reasons, one of them being to provide her hope that she would get better. Now that I've seen the hypomania, I don't want to keep her on antidepressant monotherapy. Would you?

No, but if I was a nurse/shaman, there is no way in hell I would prescribe her a mood stabilizer without someone who knew what they were doing supervising me (i.e. a board certified psychiatrist); I don't care what country I was in, what nursing psychopharmacology class I was currently taking, or what psych textbook I had on my laptop. Sure, it looks like everything worked out right now, but what if something goes wrong? Everything is great until the crap hits the fan?

What mood stabilizer did you give her? What are the possible side effects? Is it possibly teratogenic? If so, is it possible that your pt may be pregnant? Are there baseline tests that you needed to order before starting this medication? Are there any kind of life threatening reactions she could have? Did you give her valproic acid? If so, and her LFT's are elevated, how high are you going to let them go before you d/c the medication? Did you take a good MEDICAL hx or do a physical exam before you started her on a medication? Why did you choose the mood stabilizer that you did?

Did you choose lithium? If so, who is going to monitor her levels? Can she overdose on the medication you prescribed her? Are there contraindications to the drugs that you prescribed her? Are there any CYP450 interactions you need to be concerned about? If so, which ones? Are they going to lower or raise any other of the medications that she's on?

What scares me about you is that you're not scared and that you think you know a lot. You know a lot for a nurse, but you don't know jack for a provider. You don't know anything compared to a psychiatrist. You're in over your head and you don't know it. If your pt gets in trouble, presents differently, has an unusual drug reaction that you caused, etc., you may not recognize it and you don't even know what you don't know. It's frightening.

 

[zenman]

No, but if I was a nurse/shaman, there is no way in hell I would prescribe her a mood stabilizer without someone who knew what they were doing supervising me (i.e. a board certified psychiatrist); I don't care what country I was in, what nursing psychopharmacology class I was currently taking, or what psych textbook I had on my laptop. Sure, it looks like everything worked out right now, but what if something goes wrong? Everything is great until the crap hits the fan?

If there was no one but you would you just let the patient suffer and possibly die? I took action based on what I knew and what I could do, what she would do, and got a referral to a physician. You can fault me for that if you want. But I work with what I got, which is not much around here. In the biggest "modern" hospital here (450 beds), there is one psychiatrist and no psych unit.

What mood stabilizer did you give her?

None. I said I bet there is a mood stabilizer in her future.

What are the possible side effects? Is it possibly teratogenic?

No answer needed

If so, is it possible that your pt may be pregnant?

No, but if she was of childbearing age I'd certainly want a pregnancy test.

Are there baseline tests that you needed to order before starting this medication?

NA but you can be sure I'd order the appropriate baselines for what drug I considered appropriate.

Are there any kind of life threatening reactions she could have?

NA

Did you give her valproic acid?

No

If so, and her LFT's are elevated, how high are you going to let them go before you d/c the medication?

NA

Did you take a good MEDICAL hx or do a physical exam before you started her on a medication?

Had recent exam

Why did you choose the mood stabilizer that you did?

Haven't yet, but it would be symptom-based treatment if I did. But, since the GP is in the picture now it will be up to her.

Did you choose lithium?

No, but my first exposure to Lithium was around 30 years ago.

If so, who is going to monitor her levels?

NA

Can she overdose on the medication you prescribed her? Are there contraindications to the drugs that you prescribed her? Are there any CYP450 interactions you need to be concerned about? If so, which ones? Are they going to lower or raise any other of the medications that she's on?

Yes. Do you want me to copy and paste them?

CYP450 not significant

What scares me about you is that you're not scared and that you think you know a lot. You know a lot for a nurse, but you don't know jack for a provider. You don't know anything compared to a psychiatrist. You're in over your head and you don't know it. If your pt gets in trouble, presents differently, has an unusual drug reaction that you caused, etc., you may not recognize it and you don't even know what you don't know. It's frightening.

I'm not scared because I've worked Level I trauma and have been a helicopter flight nurse in the Gulf of Mexico. If I got scared I would not be of much use. What I am is very concerned about everything I do and my responsibility to a person, which I take very seriously and is one of the reasons that, at my age, I continue to "hit the books."

Now, I'm in the middle of an Influenza A outbreak and just waiting for piggy flu. Want to come help me? I'm really tired!

 

[scab]

i'm not scared because i've worked level i trauma and have been a helicopter flight nurse in the gulf of mexico. If i got scared i would not be of much use. What i am is very concerned about everything i do and my responsibility to a person, which i take very seriously and is one of the reasons that, at my age, i continue to "hit the books."

now, i'm in the middle of an influenza a outbreak and just waiting for piggy flu. Want to come help me? I'm really tired!

i would be verry scared.
Am right now

 

[dacrocytic]

Delivering medical care in a place like Bangladesh is so different than doing so in the US that I don't even think you can try and apply the same standards.
As far as hospitalizing the patient, do they even have psychiatric wards in that country? Is there such a thing as "involuntary commitment" there?

Very important points.

Zenman... are you going to try and practice in the US in the near future?

 

[TTPHUS]

No, but if I was a nurse/shaman, there is no way in hell I would prescribe her a mood stabilizer without someone who knew what they were doing supervising me (i.e. a board certified psychiatrist); I don't care what country I was in, what nursing psychopharmacology class I was currently taking, or what psych textbook I had on my laptop. Sure, it looks like everything worked out right now, but what if something goes wrong? Everything is great until the crap hits the fan?

What mood stabilizer did you give her? What are the possible side effects? Is it possibly teratogenic? If so, is it possible that your pt may be pregnant? Are there baseline tests that you needed to order before starting this medication? Are there any kind of life threatening reactions she could have? Did you give her valproic acid? If so, and her LFT's are elevated, how high are you going to let them go before you d/c the medication? Did you take a good MEDICAL hx or do a physical exam before you started her on a medication? Why did you choose the mood stabilizer that you did?

Did you choose lithium? If so, who is going to monitor her levels? Can she overdose on the medication you prescribed her? Are there contraindications to the drugs that you prescribed her? Are there any CYP450 interactions you need to be concerned about? If so, which ones? Are they going to lower or raise any other of the medications that she's on?

What scares me about you is that you're not scared and that you think you know a lot. You know a lot for a nurse, but you don't know jack for a provider. You don't know anything compared to a psychiatrist. You're in over your head and you don't know it. If your pt gets in trouble, presents differently, has an unusual drug reaction that you caused, etc., you may not recognize it and you don't even know what you don't know. It's frightening.

you know , I'd like for these so called " doctor nps" to sit down for two weeks in one semester of medical school and see if they know what a real doctorate in medicine is all about . There's a reason not everyone can be a doctor , but almost anyone can be an NP..hell can even do it online .
WHy bother with medical school then ?

 

[benjee]

It seems most allied health professions reguardless of their incompetence eg. Dnps, psychologists want/demand to prescribe medicine independently with the excuse of reducing shortage of docs while their own fields have more problems . And somehow, the law makers encourage this kind of irresponsible act by passing regulations while putting public health at risks.

 

[zenman]

Very important points.

Zenman... are you going to try and practice in the US in the near future?

We're moving to Bangkok in August for a minimum of two years. After that, I'm thinking about coming back to the states. I try not to plan too much. There are a lot of expats though that need some help.

 

[thedrjojo]

All you MD/Medical students out on this thread attacking Zenman have quite large EGOs my friends. What gives any of you the right to be attacking Zenman like that? Get off your high horses. Silias, your a med student... you think every doctor in the US thinks of all the interactions, even knows what P450 is if they are more than like 5 years out of med school? There is never a drug interaction or reaction in the US eh? Atleast none caused by MD's. How can you know how much Zenman actually knows? Zenman stated they have 30 years experience providing care. Medicine in 3rd world countries (or in urban areas of our country for that matter) is much different than the theory in classroom.

That being said, DNP's handling acute visits and chronic stable conditions might be a nice way to extend physicans to spend time on more severe and time intensive stuff.

DNP's and PA's doing even minor surgeries unsupervised might become tricky to accomplish, and for more advanced, open abdominal, oncological, cardiac, vascular, neurological, orthopaedic, head and neck cases, no DNP is going to replace they 5-8 years of training required to be certified to do them.

 

[benjee]

All you MD/Medical students out on this thread attacking Zenman have quite large EGOs my friends. What gives any of you the right to be attacking Zenman like that? Get off your high horses. Silias, your a med student... you think every doctor in the US thinks of all the interactions, even knows what P450 is if they are more than like 5 years out of med school? There is never a drug interaction or reaction in the US eh? Atleast none caused by MD's. How can you know how much Zenman actually knows? Zenman stated they have 30 years experience providing care. Medicine in 3rd world countries (or in urban areas of our country for that matter) is much different than the theory in classroom.

That being said, DNP's handling acute visits and chronic stable conditions might be a nice way to extend physicans to spend time on more severe and time intensive stuff.

DNP's and PA's doing even minor surgeries unsupervised might become tricky to accomplish, and for more advanced, open abdominal, oncological, cardiac, vascular, neurological, orthopaedic, head and neck cases, no DNP is going to replace they 5-8 years of training required to be certified to do them.

yup, agree. Let DNps and PAs screw up and let MDs clean up the mess and get sued, very simple.