NPs training alongside residents

[doc swiftly]

Don't worry, I'm also tired of this topic. I just think we need to keep discussing the major shifts occurring in psychiatry, especially residency training.

The VA affiliated with my psychiatry residency has started allowing NP "residents" to rotate on the inpatient unit, which was previously covered by 2 attendings and 4 residents. Right now the NPs are primarily shadowing a preceptor, although I'm sure this will change over time.

They have also started attending didactics offered to both psychiatry residents and medical students, but are currently requesting to be involved in all residency didactics. The chief resident on the unit has thus far prevented them from attending resident-only lectures, but at least one attending has encouraged their unfettered inclusion.

This feels like a significant shift in training to me. I'm a bit worried, would like to get your thoughts.

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[Sushirolls]

Vocalize to your chief resident, and also your PD or aPD if their ears are open that this is unacceptable.

Titrate your concerns to the appropriate level of political sensitivities so as not to backfire upon yourself.

 

[wolfvgang22]

The writing is on the wall. Unless action is taken, employers will continue to try to replace as many physicians with NPs and PAs as possible to save costs and/or increase profits.

 

[Sushirolls]

If they continue to do this or expand it, post the program here on SDN so others are aware. Vocalize to med students when they interview thru your program does this. Continue to vocalize to your Chief Resident that the recruitment for your program will suffer as a result.

 

[doc swiftly]

If they continue to do this or expand it, post the program here on SDN so others are aware. Vocalize to med students when they interview thru your program does this. Continue to vocalize to your Chief Resident that the recruitment for your program will suffer as a result.

Will definitely follow your advice. I'm fortunate to have an amazing PD, but the VA is a monstrous force. Given their recent push to allow independent CRNA practice, not to mention the number of my patients currently seeing NP "residents" overseen by DNPs in the primary care clinic, I'm not sure if the residency program has that much power. Hopefully I'm wrong.

 

[Sushirolls]

You and all your colleague residents need to put in feedback on the end of rotation evaluations, poor ratings and that as long as ARNPs are being included you don't want to rotate there.

Your residency doesn't HAVE to feed at the VA trough, and can opt out of the VA as a residency training site. If the VA wants ARNPs then let them have ARNPs. Let the ARNPs take the calls and middle of night admissions, etc, etc.

 

[comp1]

I'm not sure advocating for NPs to get less education is a very good idea for patient care.

 

[Sushirolls]

I'm not sure advocating for NPs to get less education is a very good idea for patients.

ARNP existence isn't a good idea for patients. I already opt out of ARNP care for myself, and encourage my own family to do so. No sense in furthering their expansion. Remember the ARNP you train today will be the poorly trained ARNP of tomorrow who instructs X amount more of ARNPs and will eventually be the ones who treat you and your family.

I am truly am sadden about the future and what my own geriatric care will eventually be/get.

 

[Sushirolls]

Conceptually an ARNP has less education then a medical student about to complete their 3rd year. If we are so adamant that a 4th year medical student can't practice independently, nor an intern, or PGY-II, etc then why are we as a whole supporting a single ARNP in their training pathways?

Pure mindboggling that we have blinders on for physician training minimums compared to ARNP.

 

[doc swiftly]

I'm not sure advocating for NPs to get less education is a very good idea for patient care.

I totally understand this sentiment. However, they simply don't have the background knowledge to manage an inpatient unit independently. I'm constantly using my medical knowledge to generate differential diagnoses, treat HTN and diabetes, consider medication interactions, arrange appropriate consults/outpatient follow-up. It seems like the VA is trying to push independent NP practice when they should never work without direct supervision.

Also, when does it stop? Why not give them a pathway, obviously paid, where they get a couple more years of "advanced medical diagnoses and pharmacology" training? Sure, they could have gone to medical school at some point, but why do that when doctors are willing to teach them this stuff for free?

 

[doc swiftly]

Conceptually an ARNP has less education then a medical student about to complete their 3rd year. If we are so adamant that a 4th year medical student can't practice independently, nor an intern, or PGY-II, etc then why are we as a whole supporting a single ARNP in their training pathways?

Pure mindboggling that we have blinders on for physician training minimums compared to ARNP.

I remember working with NPs as a 3rd or 4th year. They clearly had an inferior understanding of pathophys and treatment, yet they were being paid to work while I spent $50k a year for a malignant experience. Even had an IR NP threaten to "cut my throat" if a patient wasn't prepped for a procedure in time.

 

[Mass Effect]

I remember working with NPs as a 3rd or 4th year. They clearly had an inferior understanding of pathophys and treatment, yet they were being paid to work while I spent $50k a year for a malignant experience. Even had an IR NP threaten to "cut my throat" if a patient wasn't prepped for a procedure in time.

If an NP actually threatened to cut your throat, did you report it? Something like that can be reported to the state nursing board and would likely result in licensing issues.

 

[doc swiftly]

If an NP actually threatened to cut your throat, did you report it? Something like that can be reported to the state nursing board and would likely result in licensing issues.

Didn't mean to drag up stuff from medical school, but of course I told my residents and attending. Also submitted it via the anonymous abuse report form. Nothing happened, far as I know.

 

[AD04]

I remember working with NPs as a 3rd or 4th year. They clearly had an inferior understanding of pathophys and treatment, yet they were being paid to work while I spent $50k a year for a malignant experience. Even had an IR NP threaten to "cut my throat" if a patient wasn't prepped for a procedure in time.

You can take a person out of a ghetto but you can't take the ghetto out of a person.

 

[Mass Effect]

Didn't mean to drag up stuff from medical school, but of course I told my residents and attending. Also submitted it via the anonymous abuse report form. Nothing happened, far as I know.

Should that ever happen again (including to any med student who may be reading), I'd go to resident, attending, anonymous abuse report form, AND medical board. That NP was likely just being sassy, but sass in the form of threats has consequences.

 

[doc swiftly]

Should that ever happen again (including to any med student who may be reading), I'd go to resident, attending, anonymous abuse report form, AND medical board. That NP was likely just being sassy, but sass in the form of threats has consequences.

Look, I'm a fairly seasoned PGY4 now. I wish that was the worst abuse I got. I didn't mind an empty threat like this as much as I did the insults about my readiness as medical provider. An NPs insult was just a blip on my radar.

We're derailing the thread. This was just an illustration of how "heart of a nurse, brain of a doctor" isn't real.

*Edited to remove unnecessary details.

 

[Mass Effect]

Look, I'm a fairly seasoned PGY4 now. I wish that was the worst abuse I got. As someone at a top 25 public medical school who matched at their top psychiatry program, I didn't mind an empty threat like this as much as I did the insults about my readiness as medical provider. An NPs insult was just a blip on my radar.

We're derailing the thread. This was just an illustration of how "heart of a nurse, brain of a doctor" isn't real.

You seem upset by input but I'm not entirely clear on why. Do what you want. I was mentioning this for anyone else reading who may face this.

 

[doc swiftly]

You seem upset by input but I'm not entirely clear on why. Do what you want. I was mentioning this for anyone else reading who may face this.

Not upset at all! Sorry if my tone came across that way. This is just something that happened 5 years ago and I only mentioned it because of Sushirolls comment about NPs having the medical knowledge of a MS3. I was an MS3 at the time and vividly remember the NP threatening me and my team for requesting an IR procedure. It really does illustrate how MD education diverges from that of NPs (I never saw an NP treated the way medical students were), but I don't want to derail my discussion about the integration of NPs in residency education.

I totally agree that no medical student or resident should accept this kind of treatment, but we live in a system that values established "providers" over trainees.

 

[Monocles]

Even had an IR NP threaten to "cut my throat" if a patient wasn't prepped for a procedure in time.

Whoaa that's unprofessional..! Criminal even.

How do you even respond to that? Tell your supervisors? File a report? Sit across from the NP during lunch and stare at them excitedly with bloodlust eyes while licking a butter knife?

 

[doc swiftly]

Whoaa that's unprofessional..! Criminal even.

How do you even respond to that? Tell your supervisors? File a report? Sit across from the NP during lunch and stare at them excitedly with bloodlust eyes while licking a butter knife?

Is stare in shock over the televideo system we were forced to use an acceptable answer? Told the relevant people, then rotated off service.

I'm honestly surprised this comment is gaining so much attention. Wasn't even the worst treatment I received, certainly not the worst I heard from my colleagues.

 

[Doctorows]

I'm not sure advocating for NPs to get less education is a very good idea for patient care.

First they are allowed to rotate at the VA with residents. Next thing you know, they will be claiming to have the "same training as resident doctors." Not sure that this is a very good idea for patient care either.

We're actually advocating for NPs to get MORE education, aka go to med school to be able to do this job.

 

[ridethecliche]

I guess the message that needs to be spread is that the VA is okay with veterans getting substandard care by replacing their physician team with new and untested 'providers'.
Might be worth getting the APA involved if they actually still do psychiatry advocacy in any way.

 

[wolfvgang22]

I guess the message that needs to be spread is that the VA is okay with veterans getting substandard care by replacing their physician team with new and untested 'providers'.
Might be worth getting the APA involved if they actually still do psychiatry advocacy in any way.

This is the way.
"The heroes that protect our nation should receive the best care, which means physician care."

 

[deleted1100659]

I don’t agree with nps practicing independently, but I don’t see a huge problem with allowing them to sit in on lectures. We can’t point out their lack of training, then actively block it when they seek it out, if it’s done in a responsible way.

 

[adiradirim]

I don’t agree with nps practicing independently, but I don’t see a huge problem with allowing them to sit in on lectures. We can’t point out their lack of training, then actively block it when they seek it out, if it’s done in a responsible way.

They lack the prerequisite education level to be able to understand the didactics properly. The point of residency didactics is to add on the baseline medical school education that only physicians have. The risk is that they would slow down the residents by having to ask questions that all of the physicians would already know, but NPs never learned.

 

[wolfvgang22]

They lack the prerequisite education level to be able to understand the didactics properly. The point of residency didactics is to add on the baseline medical school education that only physicians have. The risk is that they would slow down the residents by having to ask questions that all of the physicians would already know, but NPs never learned.

But many of them think they understand everything just fine. That's the scary part to me. They don't know what they don't know, with confidence.

 

[deleted1100659]

They lack the prerequisite education level to be able to understand the didactics properly. The point of residency didactics is to add on the baseline medical school education that only physicians have. The risk is that they would slow down the residents by having to ask questions that all of the physicians would already know, but NPs never learned.

Well you’re entitled to your opinion, but respectfully I disagree. They could email their questions later on, and they could be addressed at a later point. I think many lectures are presented in a way that is easily understood.

I don’t think medical school in general contributed to my ability to understand psychiatry lectures. It was more my own reading.

 

[Sushirolls]

One ARNP in clinical training rotation or didactic lecture seat, is one less physician getting training.

I've been advocating a model wherein states remove step/level III exams for state licensure. We produced more DO/MD, flood the market with these graduates who can then become the replacements for ARNPs and PAs. These graduates would all have independent licenses.

MD/DO graduate = licensed physician capable of full independent practice.

A complete physician delivered medical system.

Those who are motivated enough and have the CVs, will apply for the very few residencies available.

 

[deleted1100659]

But many of them think they understand everything just fine. That's the scary part to me. They don't know what they don't know, with confidence.

I do agree with this part. Hence why I think if they’re going to be independently (which they already are in many areas) we should at least try to give them some level of training

 

[wolfvgang22]

I do agree with this part. Hence why I think if they’re going to be independently (which they already are in many areas) we should at least try to give them some level of training

From a patient safety standpoint right now, today, I would agree. But the fact is that if you participate in teaching or training mid-levels as a physician, you are contributing to employers replacing you or your colleagues with an NP or PA in the not too distant future. Not only is that bad for doctors and our income and influence on healthcare, it will result in worse care for patients in the long term. Now is not the time to capitulate and give away our profession, if you value it. I know some doctors don't care because they are personally secure and will retire before it affects them and don't care. I care.

I used to teach NP students a lot, but not anymore after I had a student open my eyes to the fact they mean to replace us. I encourage all physicians to leave NP training to NPs.

 

[clausewitz2]

One ARNP in clinical training rotation or didactic lecture seat, is one less physician getting training.

I've been advocating a model wherein states remove step/level III exams for state licensure. We produced more DO/MD, flood the market with these graduates who can then become the replacements for ARNPs and PAs. These graduates would all have independent licenses.

MD/DO graduate = licensed physician capable of full independent practice.

A complete physician delivered medical system.

Those who are motivated enough and have the CVs, will apply for the very few residencies available.

You will be just as broke if your practice gets priced out of the market by a vast swarm of people with DO or MD after their names as you will be by a swarm of ARNPs.

 

[watto]

Well you’re entitled to your opinion, but respectfully I disagree. They could email their questions later on, and they could be addressed at a later point. I think many lectures are presented in a way that is easily understood.

I don’t think medical school in general contributed to my ability to understand psychiatry lectures. It was more my own reading.

Ehhhh...I went to a lecture with a bunch of NPs and was the only MD in the audience. The lecturer started shooting off all these neuroanatomy questions and it became comical when no one was able to answer him. I took on the first few just to break the silence but no one seemed to have a clue what the dorsal raphe nucleus was or what it did. The rigors of medical school put that type of knowledge into my semantic memory pretty efficiently, and the constant link between pathology / anatomy / physiology reinforced those memories. The NPs had no idea what autoreceptors were, or that there were different serotonin subtypes. It was eerie being in that audience and made me consider that maybe they are really just learning algorithms in their training.

It reminded me of my son coming home last week from Kindergarten and telling me that a girl in the class didn't believe that the number 141 existed. They had only learned to count to 100 (we have him working ahead). People don't know what they don't know.

 

[Sushirolls]

You will be just as broke if your practice gets priced out of the market by a vast swarm of people with DO or MD after their names as you will be by a swarm of ARNPs.

So be it. But this outcome means that when I or my family get sick, the basic training that a GP MD/DO has will still be enough that I will want to seek help. Currently the future trajectory of ARNP takeover, I'm better off letting my future ailments kill me off slowly than risking an immediate iatrogenic death from a midlevel.

Another doc was recently telling me about how their patient was seen by the IM subspecialist ARNP, then by another IM subspecialty ARNP, and another IM subspecialty ARNP. Doc was wondering if there were any physicians left in their health system.

If market forces gut my practice to preserve the training, history, and quality that Physician tradition has stood upon for centuries, that is a small price to pay. That is a better future and one I can recommend my kids get behind and enter into. Lately I can't recommend my various family to enter medicine - so many better options.

 

[clausewitz2]

preserve the training, history, and quality that Physician tradition has stood upon for centuries

There is a tension between this and throwing wide the gates of medical schools to the extent that we produce more graduates than NP programs. The quality is not conferred magically by having the right initials or piece of paper. You are not only diluting the brand but if a larger proportion of the population are able to enter and complete medical school definitionally the median quality of medical school applicants and entrants will drop.

Maybe you think the education itself will correct any drop in quality but I am less confident that spending a month on the citric acid cycle is going to get the job done.

 

[Sushirolls]

There is far more difference than your quip about a kreb cycle understanding between medical school and ARNPs. The requirements of medical school wouldn't decrease, nor would their clinical hours - two solid years of clinical rotations which is close to 4000 clinical hours - compared to the sub 500 hours of low grade quality seen by ARNPs. Medical schools have no problem failing students, and I don't see that changing.

Will the quality of applicants to medical school drop in this scenario. Yes. But that's okay. Medical schools have turned away quality applicants for far too long and a greater swathe is capable of running the medical school gauntlet. One need only look to the MBBS/MBCh model, or DOs or Caribbean MD schools to see that a narrow restrictive swath of academic MD schools isn't the only path creating physicians.

I see my scenario as preserving a baseline level of minimal standards and quality. Watching the current trajectory continue unfettered there won't be any physicians, and it will be a complete race to the bottom of quality with midlevels running every thing, and only a tiny sum of MD/DO behind the scenes to take the fall. MD/DOs will be nothing more than a sports team coach (i.e. medical director at Big Box shop) that if your team is winning on the latest flavor of arbitrary metrics you keep your job, your team drops in arbitrary metrics you get replaced with the next fall guy. But even this future as 'team coach' isn't guaranteed either.

 

[Taurus]

I do agree with this part. Hence why I think if they’re going to be independently (which they already are in many areas) we should at least try to give them some level of training

Lol. That’s naive thinking. Besides what everyone has already said, I would add that if you allow NP’s to participate in your didactics and clinical rotations, they will claim in their CV’s, advertisements, etc that they underwent the same training as you did even though they don’t understand any of it. It’s the same reason why nurses put an alphabet soup behind their names. Nurse, RN, BSN, CCCN, etc. It’s like CV padding. Nurses have a “participation trophy” mentality. They just want to go through the motions so they can earn their participation trophy, ie, credential, so that they leverage it in some way. Such as, pressuring states to allow them to practice independently because they claim equivalency without having the knowledge and technical skills to back up such claims. This is why it’s so dangerous to allow these NP’s to participate in your training.

 

[birchswing]

NPs are dangerous to the people around them. They goof up. They suppress the betterment of mankind by those who are truly trying to make a difference.

If you find mistakes are being made in your vicinity or an argument between two psychiatrists, chances are there's an NP who covertly caused that situation and is unseen to the other parties.

There are ways to deal with NPs. You have to Confront and Shatter their suppression.

As has been suggested, disconnect from all NPs. Don't supervise them. Don't associate with them. Do not allow them to attend your functions.

If you are forced into contact with an NP, be polite and discuss fair roads and good weather—stay on the surface. And then go on your way.

Edit: This was much less subtle in my head. Now that it appears someone has liked it at face value, I should point out I substituted "NP" for "SP" and used Scientology doctrine as a joke.

 

[tellme_areyoufree]

Well you’re entitled to your opinion, but respectfully I disagree. They could email their questions later on, and they could be addressed at a later point. I think many lectures are presented in a way that is easily understood.

I don’t think medical school in general contributed to my ability to understand psychiatry lectures. It was more my own reading.

I can offer you a real world study of those arguments. Our pgy3 "advanced psychopharmacology" course was where the NPs rated their knowledge level, so that's what they started attending. The lecturer repeatedly had to dumb down material to three point of explaining pretty basic stuff about SSRIs. The actual (md/do) residents complained of course and the NPs had to get removed from those courses and wow, suddenly magically the level of info being taught went right back up. Thank God my PD didn't stand for the decreased quality of education.

They damage MD/DO education.

 

[doc swiftly]

You've made my point perfectly. They simply lack the background knowledge to attend the same didactics as psychiatry residents. This is further evidenced by the treatment habits I see from NPs; non-sensical prescribing arising from a complete lack of diagnostic knowledge. Sure, a resident-level didactic might help out, but why weigh down residents with an NP's inadequate training?