So, our hospital admin is pushing us to hire 2 NPs that would work exclusively as ED/consult psych. We're currently setup with a mix of MDs/NPs who work the adult unit and share coverage of ED and consults. My concerns are I don't think NPs actually want this job (none of our current NPs do), and how can we hire someone into these roles, which IMO are the more challenging places to work in psych, with the least experience/training? What do you think?
NPs for inpatient consult service
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Consult psychiatry is the face of your department to the rest of the hospital. I would avoid hiring NPs to run that. ER may be more reasonable, though in my experience NPs see patients so inefficiently that they are not cost effective replacements for psychiatrists.
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NPs are popping up in all facets of Psychiatry at big/small/academic/etc/etc locations. Let's get to the real issues here. Do you have the will to push back against hospital admin? Do you even want to push back? Are you ready to quit or be fired?
Good luck in the Big Box shop rodeo. Glad I'm off the Bull and in the stands. Tie that rope down tight.
Good luck in the Big Box shop rodeo. Glad I'm off the Bull and in the stands. Tie that rope down tight.
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I've seen four NPs perform c/l consults, most of them were pretty experienced. 3 out of 4 were pretty competent.
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We have been through several rounds of hiring NPs for the ED. It is extremely difficult to find vaguely qualified applicants. They basically need to be trained up from scratch and need to know their limits and when to ask for help. We had an excellent NP who was the only vaguely qualified applicant (with crisis and prior C/L experience) but they needed to be trained and I saw all their patients for the first month or so for supervision. ER Psych is not rocket science so with sufficient training most of it can be done by an NP. Hell in many places there is only a SW. True general hospital C-L psychiatry however cannot be done by NPs. We are talking about highly complex patients with multiple medical and psychiatric comorbidities and a lot of nuance to it. It's popular on this forum to shït on C-L as a subspecialty, but most psychiatrists who don't do this regularly don't do a very good job either, because there is a specialized knowledge and skills base that comes with the more complex aspects. Of course there is a lot of bread and butter stuff that is easy (e.g. suicide risk assessments, delirium management, basic capacity assessments) but there's a lot of complexity too.
NPs in some settings (e.g. academics) cost as much as junior faculty and do much less work. So they are not cost effective though leadership seems to be obsessed with them.
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What NPs functioning like residents on a C/L service where they see a patient, present to an attending, and then see the patient with the attending and write the note themselves? I realize that a large percentage of NPs are still not knowledgeable enough to function at this level, but for the better ones what are your thoughts?
Then make sure to stay away from the NP-run ICUs without physician supervision. And no, I'm unfortunately not making that up.
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Np run ICU is about 1000x scarier than an NP run CL service. God help us all.
The other consideration is about 4 years ago we had 2 very strong inpatient NPs, the then medical director pushed to change hospital bylaws for psych NPs so they could see patients independently and he would no longer be supervising them. Which was fine for those 2 NPs but now we've got the potential to hire 2 new grads...to run a psych consult service...with apparently no requirement from the hospital they have any physician supervision. Am I the crazy one?
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Yes if you mean crazy for working for an organization like that.
This was conversation with the CMO of the organization I work for about a year ago
CMO "You know, using NPs is how we get patient's access to care around here, [insert snotty exhalation]"
Me "Okay"
Me later with office manager "Nowhere in my contract or hospital bylaws does it state that I am required to supervise mid-levels"
Office manager "That's correct"
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NPs running-anything is the stuff of nightmares.
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Do they actually understand what CL is? Do they think that CL is just going onto the floors to commit suicidal patients? You have to have a broad knowledge of complex medical issues to do CL. Since when are psych NPs getting that in their training? At least primary care NPs actually learn medicine as part of their schooling. Do psych NPs? Not last I checked.
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You are not. This is absurd particularly if the new grad NPs don't have solid inpatient psychiatric RN experience which few do now.
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Eh, most EDs are the ER doc with a SW and maybe a psychiatrist on call by phone if they're lucky if they really need them. Many private psychiatric hospitals have SW doing the ED assessments and staffing the patient with the psychiatrist on call by phone.
People in residency programs don't tend to get exposed to what happens in the real world in most ERs.
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Shoulda replied with "hiring actual doctors will get patients access to care around here too".
Yes, but still at least the Psychiatrist is taking some responsibility and will ask the right questions of the SW doing assessment. After all, the Psychiatrist is liable if the patient is discharged and goes and kills themselves the next day.
In the NP's case, they can do whatever they want without any supervision. I routinely fix the NP's nightmare med management nonsense so I am aware of how well versed they are in the art of Psychiatry.
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Terrible idea. Time to look for new employment in my opinion. If a hospital is willing to give CL to midlevels, quality went out the window. It is all about $ which means your job is on the line.
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We had two very experienced psych nps who did ED consults only. They functioned at about the level of a late PGY1 or early PGY2. Depends on the resident really, as didn't hold a candle to any of the strong early PGY2's in terms of quality or speed.
Had an NP as the only available psych consult (C/L) at the community hospital where I did my IM rotations. Her consults were completely useless and actually rather terrifying.
Had an NP as the only available psych consult (C/L) at the community hospital where I did my IM rotations. Her consults were completely useless and actually rather terrifying.
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What you'll start to seen on some interviews are feeler questions where people/admin are vetting if you are pro-ARNP midlevel or anti. Many Big Box shops want people who will support their use...
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I had these questions and I just said no to NP supervision. I will supervise med students and residents. It’s not on my contract and hasn’t come up. It’s a hard pass for me. They are still giving psychiatrists here a choice about supervision of NPs and I don’t see it changing as it’s not a super desirable area to live and there’s a huge psych shortage that NPs can’t/won’t fill.
Same thing with remote work. They were going to tell everyone to come back to on site working until they realized that half the dept has young kids and schools are closed. Remote work is here to stay indefinitely now.
Update. I successfully pushed back on the 2 NP position back in Sept/Oct 2020.
Jump ahead to now, we're meeting again to discuss admins desire to have 2 psych NPs to run a psych ED service.
It seems a little overkill to me... I'm 90% sure an ED doc can restart an established home med regimen for patients awaiting psych admission. At this point, I clearly feel like any bump in the road with ED psychiatric patients will be taken as an opportunity to try and install unneeded midlevels onto our service.
I'm hoping I can spin this into a hiring a dedicated consult psychiatrist who could also help cover the ED, which given our hospital volume would be an incredibly chill job. It's astonishing they think we need 2 NPs for a psych ED because many days there wouldn't be any patients to see.
Jump ahead to now, we're meeting again to discuss admins desire to have 2 psych NPs to run a psych ED service.
It seems a little overkill to me... I'm 90% sure an ED doc can restart an established home med regimen for patients awaiting psych admission. At this point, I clearly feel like any bump in the road with ED psychiatric patients will be taken as an opportunity to try and install unneeded midlevels onto our service.
I'm hoping I can spin this into a hiring a dedicated consult psychiatrist who could also help cover the ED, which given our hospital volume would be an incredibly chill job. It's astonishing they think we need 2 NPs for a psych ED because many days there wouldn't be any patients to see.
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LOL. Oh, they definitely are capable of ordering home meds ... but they don't want to. They will moan and groan and be like, 'buttttt thee patient isn't dyiinnng I don't do that...." Psychiatric patients are kryptonite to EM doctors.
In classic Admin fashion their solution is not to expect an EM doc and department to do their job, but instead figure out how to dump on the lower hierarchy specialty which happens to be Psychiatry.
In the past when I've touched on some of these issues, try to remind all people involved that as long as a patient is in the ED, they are the patients of the EM and it is their 'unit' conceptually. The must be the 'admitting' physicians and you and Psych are merely the consultants. Psychiatrists in the hospital privileging card do not have EM nor EM 'admitting privileges.' Can starting dropping consult notes on these patients simply saying that this patient is here boarding in ED until dispo, and the EM attending are the attending of record, and we as consultants advise to medication changes at that this time, for reasons XYZ, but recommend EM docs order/start home meds. Discussed this with EM attending of record Dr. XYZ at #### face to face.
A place I used to work at, the EM docs wouldn't even put the boarding patients down for who was attending of record. Mind boggling medico legal, they were just there. But Big Box shop doesn't care when point out such scat - because you are Psych.
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Huh? Does someone just really love NPs there or something? This is one of the dumbest reasons I can think of to push for this. What was preventing the ED doc from picking up the phone and calling the psychiatrist on the adult unit you mentioned above who covers the intermittent consults as well and just asking “hey I’ve got this guy in the ER just waiting for a bed, you see any reason why I can’t restart X home med?”.
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This is business psychology 101. “Foot in the door” tactic. Admin doesn’t care about this incident, it’s an opportunity to insert psych NPs. Once they’re in, it’s a matter of time to expand their role. I saw it firsthand during residency. When I was an intern, they had just started with the first psych NP in our ED. “Just to take the pressure off.” (Never on nights and weekends when residents were working, of course, just during the day when there were attendings.” By my PGY-3 year, that very same NP was doing inpatient, de facto independently. My PGY-4 year, same NP had progressed to an independent outpatient clinic and there are talks to increase the number of NPs in that role.
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Lol this! And what attending psychiatrist wants to field repeated calls from the ED docs about whether to restart Seroquel 50mg qhs or not?
NPs can also bill for psych assessments in ED which is another reason for the push in many cases.
At most larger hospitals, the group that covers consults is basically playing rock, paper,scissors at the end of the day to see who has to do them.
Everywhere I have been out of residency consults are just something you do at the end of the day. Its not part of the regular schedule, and you don't get to cover fewer units/patients if you are doing consults that day. It's just an annoying thing tacked on.....
Also, most consults that they put in can really be handled with a phone call or just glancing at the chart rather than actually going over there. Patient is in the icu 2 days after she took 50 tylenol and is now medically cleared so they consult psych? Yeah....Im not going to see that patient as she is an auto admit. Whats the point of going to see her, doing a full consult note, etc when I can just see her on the adult unit when she transfers? That consult is handled by me picking up the phone, calling the MICU nursing station, and saying "yeah, just put a transfer order to psych in". Done....10 second consult.
then probably another 20% of consults put in can just be cancelled because they arent appropriate("do they have competency" type nonsense).....
Delirium you can usually just glance at the chart and throw in a scheduled med or prn without going to see them.
In the real world time = money, and I've seen some new psychs run around like a chicken with their head cut off trying to see consults. There is no money in that for a lot of reasons, and the group isn't going to appreciate them wasting all the time and it will only cause them to leave a lot later than they should be. Nobody is going to want to cover some of the consult guys regular patients because he can't figure out how to efficiently do the consults.....
Everywhere I have been out of residency consults are just something you do at the end of the day. Its not part of the regular schedule, and you don't get to cover fewer units/patients if you are doing consults that day. It's just an annoying thing tacked on.....
Also, most consults that they put in can really be handled with a phone call or just glancing at the chart rather than actually going over there. Patient is in the icu 2 days after she took 50 tylenol and is now medically cleared so they consult psych? Yeah....Im not going to see that patient as she is an auto admit. Whats the point of going to see her, doing a full consult note, etc when I can just see her on the adult unit when she transfers? That consult is handled by me picking up the phone, calling the MICU nursing station, and saying "yeah, just put a transfer order to psych in". Done....10 second consult.
then probably another 20% of consults put in can just be cancelled because they arent appropriate("do they have competency" type nonsense).....
Delirium you can usually just glance at the chart and throw in a scheduled med or prn without going to see them.
In the real world time = money, and I've seen some new psychs run around like a chicken with their head cut off trying to see consults. There is no money in that for a lot of reasons, and the group isn't going to appreciate them wasting all the time and it will only cause them to leave a lot later than they should be. Nobody is going to want to cover some of the consult guys regular patients because he can't figure out how to efficiently do the consults.....
I don't think NPs should manage a med floor consult service on their own, but they have some role for certain issues like capacity and suicidality. They can be a huge and amazing part of an ED psych service, particularly weekends and overnights. I'm really interested in where all of you work that jobs are so hard to come by that you're worried about NPs taking everything. Nobody in my area can fill stuff with NPs or MDs.
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The county hospital that my institution is affiliated with has extensively expanded the role of NPs such that they essentially see patients independently on the C/L service and have done so for quite some time on our ED services. I am less familiar with how the C/L service operates but am quite intimately familiar with how the ED service has been doing since expanding the number of midlevel "providers," and I would say that the change has generally not been positive.
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We had a couple of extremely experienced NP's who worked in our ED at one of our residency hospitals. And despite being very good for NP's they were still also not particularly productive/useful in comparison to any level of resident, not to mention attending, which is why they were not replaced when they retired.
I rotated at a hospital where the NP was the CL service and was actively detrimental to patient care vs what the primary teams likely would have done on their own volition. (e.g. oh this delirious ICU patient s/p TCA overdose says she's not suicidal anymore so you should send her home.)
I rotated at a hospital where the NP was the CL service and was actively detrimental to patient care vs what the primary teams likely would have done on their own volition. (e.g. oh this delirious ICU patient s/p TCA overdose says she's not suicidal anymore so you should send her home.)
lmao....the only place it is called a 'consult SERVICE' is at an academic hospital where residents and attendings work and are divided up that way, partly because the rotations are divided up that way. Same thing for an 'ED psych service'......
these are academic creations.
In the real world the psychiatrist who rounded on the psych unit at the hospital that morning just logs on and sees what consults were put in and swings by and does them before lunch. Maybe a psych np rounds instead if they were covering inpatient too that day, and the psych will sign off on their consult notes.
But nobody in the real world outside of an academic hospital is going around talking aout a consult or ED 'service' lol. They are just things you find time somehow to squeeze in if you have to.
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My hospital doesn't have any psych residents within it and we have a consult service and an ED psychiatrist. As usual, your experiences seeing the worst the field has to offer aren't representative of everything out there.
a few questions:
1) This consult service....it's staffed by a psychiatrist who does nothing but consults? what does this 'consult service' consist of? If you want to play games
with words I suppose the hospitals I cover have a 'consult service' too. I look on the computer and go see the consults....I guess that constitutes a 'service'
2) Who pays this psychiatrist? The hospital? The psychiatric group? Where does the money for their salary come? If it's a group staffing
it that way that's essentially just the people in a group taking a hit.
3) How many beds does the hospital have? How many average consults per day?
In the end, money is what usually talks. When working with idealized theoretical numbers, the idea of supporting a consult psychiatrist in a large private hospital is iffy. But then when you actually look at the actual collections from consults(and we have at multiple different sites) and the revenue just isn't there, so it goes from iffy to absurd. At the vast vast vast majority of non-academic non-govt hospitals consults are done by the psychiatrist as a throw in at the end or middle of the day......and thats how it works in *every other* specialty too.
I'm also not sure why you believe this way would be 'the worst the field has to offer'. I don't look at that as a bad thing at all. Sacrificing $ for such inefficiency would actually fall within that and not the other way around.
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1) There are 2 full time psychiatrists and 2 APNs (1 full time, 1 part time) who work exclusively doing consults. We have 1 full time psychiatrist who works exclusively in the ED. I'm not playing any word games. We also have a 24 bed inpatient adult psychiatric unit staffed by 3 full time psychiatrists. The 6 psychiatrists here all cover for each other when someone's out, but they otherwise stay in their roles.
2) They are paid by the hospital.
3) Hospital is 693 beds. I don't know how many consults there are daily but they are busy.
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We have a team of like 3-5 psychiatrists who cover floor/ED consults at our three affiliate hospitals and also are involved in regional UR (for inpt admissions and TMS) and providing ECT during the day. We are not an academic center. No residents or students in sight.
so you have a hospital with a 24 bed inpatient unit and they have 6 full time psychiatrists? And the hospital is footing the bill for all this/hospital employed?
that situation is in serious jeopardy of being poached....and bigtime. A motivated psychiatrist with his own small group is very likely to come in there at some point and pitch a deal to the c-suite people in that hospital that they can't resist. It would involve the hospital giving the contract to the group for a stipend + the codes.
There was a similar setup(but not that wasteful) in a town about an hour from me. They had a larger psych units but a similar size hospital, but probably 1.4million or so in MH provider salaries(I mean just psychs, nps...not therapists and SWs). Our group swooped in and we assumed the contract and hospital employment went away there..... If you guys have 6 psychs and some nps, they have a lot more than 1.4 million annually tied up in salaries....
Who knows maybe the C-suite people at your hospital are not driven by money or cost savings/efficiency and all they care about is quality of care, money be damned. If so, thats great for you. In my experience though that's not the sort of thinking that drives C-suite hospital admin types.....
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To clarify, only 3 of the psychiatrists are on the inpatient unit. The other 3 do consults/ED. I imagine the hospital pays them because they see patients and make money (either directly or through shortening lengths of stay).
I don't know how common this is but your doom and gloom scenarios are clearly not universal.
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But then the hospital can't bill for the encounter...
I mean, it's not that hard to meet criteria for 99222 or even 99223 in many patients. So at worst probably averaging ~$150/encounter. Then every day after that you bill 99231-33 for f/up. 99233 can take all of 10-15 minutes including walking time and pulls in around $100/encounter. 5 new consults + 5 follow ups pulls in around $300k/yr at Medicare rates and isn't particularly busy. Hospitals getting 15 new consults per day (thats $585k/yr at medicare rates only accounting for weekdays) + follow-ups could easily support hiring a couple psychiatrists. Sounds like a busy enough hospital can easily justify a team if they've got a large enough patient load.
Where I rotated in med school (private hospitals, my school wasn't affiliated with an academic center), about half of the hospitals had a consult "team", though at one place this was just the psychiatrist and an NP with 1-2 med students. Sure, plenty of places just have someone coming through in the mornings or afternoons and just poking their heads in, but plenty of places can justify having teams too. Especially places where just asking the time of day triggers a full psych work-up.
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Depends on your location. In most parts of the US these hypothetical psychiatrists with a group practice large enough to "poach" and then cover a hospitals multiple services doesn't exist. Plus, a lot of psychiatrists don't even particularly like ED/CL work.
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Yeah there is a sizable group in a few hospitals in my area. They undercut by using new grad NPs with one or two psychiatrists and are known for high readmission rates. I hear negative comments frequently although the hospitals continue to use them so follow the dollar I suppose.
C-level executives may not care about quality when strangers get the care. But they will certainly care about quality when it is their family members and friends getting care. I treat their family members and friends.
As a whole, I bill higher codes than my partners. But my feedback from patients are excellent. I'm on time with my appointments. I build rapport. I listen. I answer questions. I educate them. I joke around with them. I take time with them. Maybe one or two patients complained about my billing but they are welcome to find someone else who fit their budget. I don't compete based on price. I'm booked out for a month already.
You're so concerned about NPs taking over. So the question is what can you do that the NPs can't or won't do? You have to find your competitive advantage.
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Yes and yes. I'm not sure that I would describe our psych ED as "run" by NPs, however they do work on all of our ED service lines and see their patients independently. Some will ask more questions or run things by the attending more than others (most do not).
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That's how they staffed consults at my hospital prior to there being a residency. No NP lasted more than two months before quitting
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A good consult service pays for itself by reducing length of stay and floor staffing requirements (less agitated patients need less supervision). If you're giving that service away for free as an add-on you're getting shafted
Thank you. So there is psychiatrist presence in the ED running that department, and for informal supervision, but not physicians staffing each patient and signing notes? Is there officially a supervising doctor assigned in the event of a lawsuit or are NPs flying solo? Also, how big is your system to have multiple ED psych service lines?
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The first part is correct. I'm in a state that requires "supervision" of some type with a collaborating physician but in day-to-day clinical work the attendings don't see or staff the patients and don't cosign notes.
This is in a large county hospital that is the primary destination for police-initiated psychiatric holds, so our psychiatric ED service is busy. We have a medical ED consult service, a separate PED (with 2 teams), and a PED that functions sort of like an observation unit, also with 2 teams. All of those service lines fall under the PES umbrella. There are typically 3-4 "providers" on the medical ED consult service, so when fully staffed we have 7-8 "providers" on service at any one time. On a typical day, at least 3 of them are physicians. The rest are midlevels.
Do you know if the the NPs have a physician supervisor or are they completely independent?
