prescribing psychologists/NPs

[Merovinge]

Is this something to be genuinely worried about as a Med student?

It's absolutely not. Finding a job in psychiatry is easier than almost every other field of medicine. I have family/peers in about a dozen different specialties and many of them have such an incredibly different experience with job hunting that I have (i.e. way more restrictions/lack of options). Almost everyone I know is at a minimum in the 250k range for psych (and many around 300k), including in large cities, unless they explicitly wanted to work in a setting that paid less but had perks (VA, county health). That's for working 40 hour/week jobs with minimal call and great lifestyle, provide you actually like being a psychiatrist.

Even for profit systems shifting to add NPs/PAs are very mindful of the branding. Many patients do not like having their critical care being performed by midlevels, even in low health literary areas I have seen patients get upset about this. I currently work somewhere where most of the CAP work is done by PCPs and midlevels due to poor access and I hear multiple times each week a comment like "it's nice to finally see a specialist" which I can only infer is related to my actual discussion of the psychopathology, etiology, and treatment.

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[Sushirolls]

Is this something to be genuinely worried about as a Med student?

Not really. But you should at least prepare yourself for what it means. For me that meant getting exposure as a student and resident to the business of medicine. Ranging from the level of private practice office to larger health system delivery. The more you understand how the system turns the better off you are able to find your place in the cog work. Or to pivot and find a new place if your plan A fails. Pay attention to dentistry and how they market and fight for every dollar they get. Listen to your patients and the frustrations they have - in those frustrations are opportunities that could be your future business plan.

 

[LadyHalcyon]

Not in my area. We are in DESPERATE need of psychiatrists, especially child and adolecent trained psychiatrists. It's gotten to the point where the nurse practitioner(there are a few large pediatrician groups in the area and they mainly utilize nurse practitioners) and I are frequently communicating, collaborating, and reviewing research in order to determine the best medication(s). There are barely any providers and if you send the patient to the local CMHC they will receive a bipolar diagnosis, in addition to 3 to 4 different meds. In order to even see a psychiatrist at the CMHC, the patient has to attend therapy. Therapist turnover is extremely high (not unusual for a patient to have 5 therapists in a year) and if you miss, cancel, or reschedule 2 appointments in 6 months you are banned for a year. We definitely need psychiatrists. Psychiatry is not pharmacy.

 

[FlowRate]

Pay attention to dentistry and how they market and fight for every dollar they get.

And are currently fighting a battle against midlevels, themselves, although it's not as widely publicized. (Because they're mostly winning so far.)

 

[d2305]

I've never met a mid level dental practitioner.

 

[clausewitz2]

I've never met a mid level dental practitioner.

Maine’s independent dental hygienists may fill a void, but not a cavity

 

[chocomorsel]

With CRNA's, there is usually an anesthesiologist supervising several rooms to be their for induction and emergence and anything in between where it gets complex.
Not so with other midlevel treatment.

Plenty of CRNAs practicing independently. Or who are supervised by the surgeon/proceduralist. But usually they are in an ACT model with physicians.

 

[chocomorsel]

Not in my area. We are in DESPERATE need of psychiatrists, especially child and adolecent trained psychiatrists. It's gotten to the point where the nurse practitioner(there are a few large pediatrician groups in the area and they mainly utilize nurse practitioners) and I are frequently communicating, collaborating, and reviewing research in order to determine the best medication(s). There are barely any providers and if you send the patient to the local CMHC they will receive a bipolar diagnosis, in addition to 3 to 4 different meds. In order to even see a psychiatrist at the CMHC, the patient has to attend therapy. Therapist turnover is extremely high (not unusual for a patient to have 5 therapists in a year) and if you miss, cancel, or reschedule 2 appointments in 6 months you are banned for a year. We definitely need psychiatrists. Psychiatry is not pharmacy.

This is a good thing for the psychiatrists but a bad thing for the patients. Unfortunate really.

 

[DynamicDidactic]

That’s just the beginning. At first NP’s all required supervision, and there weren’t many of them.

Psychology has been fighting a battle within itself over RxP. There is about a 50/50 divide, meaning there is active debate and resistance to RxP. I don't think NPs have had a similar internal struggle.

 

[OldPsychDoc]

Maine’s independent dental hygienists may fill a void, but not a cavity

I see what you did there...

 

[clausewitz2]

I see what you did there...

Ha, that's a link to a newspaper article, so I can't take any credit!

 

[Jules A]

Maine’s independent dental hygienists may fill a void, but not a cavity

Maryland had a bill on the docket this year also. It didn't go through but it will be back.

 

[ridethecliche]

Imho... A lot of this goes back to and will continue to go back to the fact that physicians are poorly organized and that management often has their own best interest in mind. It's the same deal as the board recert bs. These decisions don't have longitudinal impact on those making them so they have nothing to lose.

 

[WisNeuro]

Can't discount the lack of healthcare research. If you can't prove that a certain level of training leads to superior medical care and outcomes, hard to stop encroachment in some areas. Sometimes for the better, sometimes for the worse.

 

[Stagg737]

Can't discount the lack of healthcare research. If you can't prove that a certain level of training leads to superior medical care and outcomes, hard to stop encroachment in some areas. Sometimes for the better, sometimes for the worse.

True, but common sense should also play a role as well. NPs have a fraction of the didactic education as physicians and only a portion (usually about 1/3 to 1/2) of those credits in the "doctoral" part of their degree are in clinical practice with the rest being in administration or healthcare systems. Additionally, in some states NPs are required to have less clinical hours than cosmetologists or dog groomers before they're allowed to treat patients independently. Do we really need studies to show that NPs who fall into that category should not be seeing patients independently (but still are in over 20 states)?

The problem with psych NPs is that they can provide the same exact services as a psychiatrist with a fraction of the training. In cards, surgery, et cetera they are not performing the same procedures as the MD, and they never will achieve that level of autonomy. You won't ever see an NP stenting arteries or repairing an aneurysm. Sure they may be refilling meds started by the specialist or doing post op follow up visits, but from my experience the MDs dont want to deal with this stuff.

Don't be so sure...

Meet the nurse who will soon perform surgery on patients alone

Unlike other nursing roles, a surgical care practitioner is involved with the patient every step of the way

www.theguardian.com

There are also NPs who have performed cardiac catheterizations solo. Welcome to the future of medicine, buckle up.

 

[WisNeuro]

True, but common sense should also play a role as well. NPs have a fraction of the didactic education as physicians and only a portion (usually about 1/3 to 1/2) of those credits in the "doctoral" part of their degree are in clinical practice with the rest being in administration or healthcare systems. Additionally, in some states NPs are required to have less clinical hours than cosmetologists or dog groomers before they're allowed to treat patients independently. Do we really need studies to show that NPs who fall into that category should not be seeing patients independently (but still are in over 20 states)?

Common sense plays a role, but it's also been wrong countless times in medicine and healthcare over the years. I think we really do need studies to see what is necessary and sufficient training in healthcare positions. I imagine some findings would argue for more training, and some would argue for far less for some specialties. And honestly, until I see a change in the wide variety of dangerous prescribing practices, it's hard for me to see how midlevels could do much worse than what already exists, so it's hard for me to accept a greater level of harm/lowered standard of care argument until I see some data that contradicts what I have seen over the years.

 

[deleted736562]

Common sense plays a role, but it's also been wrong countless times in medicine and healthcare over the years. I think we really do need studies to see what is necessary and sufficient training in healthcare positions. I imagine some findings would argue for more training, and some would argue for far less for some specialties. And honestly, until I see a change in the wide variety of dangerous prescribing practices, it's hard for me to see how midlevels could do much worse than what already exists, so it's hard for me to accept a greater level of harm/lowered standard of care argument until I see some data that contradicts what I have seen over the years.

I would say the onus is on the NPs to show the data and justify why they should have independent access. Really, I'm not sure at all why it has to go the other way. At the end of the day, the stakes are patients' lives and that's the procedure we all follow when we have to change the standard of care. It's a judgement call, and you deal with what you have. Empirical evidence is one factor; when it's lacking, better defer to common sense.

 

[clausewitz2]

Common sense plays a role, but it's also been wrong countless times in medicine and healthcare over the years. I think we really do need studies to see what is necessary and sufficient training in healthcare positions. I imagine some findings would argue for more training, and some would argue for far less for some specialties. And honestly, until I see a change in the wide variety of dangerous prescribing practices, it's hard for me to see how midlevels could do much worse than what already exists, so it's hard for me to accept a greater level of harm/lowered standard of care argument until I see some data that contradicts what I have seen over the years.

Surely from a harm reduction perspective if you are seeing a lot of dangerous prescribing practices doing anything that stems the influx of new prescribers would be a net benefit.

 

[WisNeuro]

I would say the onus is on the NPs to show the data and justify why they should have independent access. Really, I'm not sure at all why it has to go the other way. At the end of the day, the stakes are patients' lives and that's the procedure we all follow when we have to change the standard of care. It's a judgement call, and you deal with what you have. Empirical evidence is one factor; when it's lacking, better defer to common sense.

Onus is on both, and they have some data, and also the sky has not fallen with NP/RXP,etc. So, I'd say the onus has shifted back to the other side if they want to prove something is dangerous.

 

[deleted736562]

Onus is on both, and they have some data, and also the sky has not fallen with NP/RXP,etc. So, I'd say the onus has shifted back to the other side if they want to prove something is dangerous.

You mean the onus is on the doctors after the fact NPs earned the right to practice independently without showing the necessary evidence that they are capable of doing this? That seems even more dangerous than NPs practicing to start with.

Who's to say the sky is not falling? We don't have the data.

From what I remember correctly, you've made claims in the past that one doesn't need the training doctors go through to do the majority of medicine; you're entitled to that opinion but obviously you're also starting from a non-empirical biased perspective (one that I happen to completely disagree with).

 

[WisNeuro]

Who's to say the sky is not falling? We don't have the data.

From what I remember correctly, you've made claims in the past that one doesn't need the training doctors go through to do the majority of medicine; you're entitled to that opinion but obviously you're also starting from a non-empirical biased perspective (one that I happen to completely disagree with).

We do have some data, people are not dying in droves as was predicted by some doomsayers. And there is some preliminary outcome data, while not great, is about equal to the quality of most healthcare outcome data in this country. So, by the standards that are available, they have shown efficacy/outcome data to support their position. At this point, it's mostly just a turf war, which I understand, let's just be honest about it.

 

[FlowRate]

We do have some data, people are not dying in droves as was predicted by some doomsayers. And there is some preliminary outcome data, while not great, is about equal to the quality of most healthcare outcome data in this country. So, by the standards that are available, they have shown efficacy/outcome data to support their position. At this point, it's mostly just a turf war, which I understand, let's just be honest about it.

Something you learn as a physician is that it's REALLY hard to (accidentally) kill people who aren't already dying on their own. Even then, it's a little hard to kill them. Which is why doing NP vs MD outcomes research on mortality is pretty much always going to end up with "no difference detected." (Because the NP's aren't going to pay for an adequately powered study.)

 

[WisNeuro]

Something you learn as a physician is that it's REALLY hard to (accidentally) kill people who aren't already dying on their own. Even then, it's a little hard to kill them. Which is why doing NP vs MD outcomes research on mortality is pretty much always going to end up with "no difference detected." (Because the NP's aren't going to pay for an adequately powered study.)

Fair enough, we all agree that the current state of healthcare outcomes research is sorely lacking. So, you can fight a futile turf war against encroachment from other providers, or do some quality outcomes research to see what is necessary and sufficient.

 

[Stagg737]

We do have some data, people are not dying in droves as was predicted by some doomsayers. And there is some preliminary outcome data, while not great, is about equal to the quality of most healthcare outcome data in this country.

Have you read these studies? If so, you should see how terrible their quality is and that they if you're suggesting that it would be enough to allow an entire set of individuals with a minimal education to treat patients independently and prescribe medications (including psychotropic ones) then I worry about the threshold of expectations you have.

For reference, I've read about 40-50 studies to date which make claims regarding NP outcomes. Of those studies I only consider 2 of them to really be credible and their outcomes didn't really prove much. One showed that NPs who were supervised by physicians had similar outcomes to physicians, which kind of defeats the purpose of the study. The other showed that NPs had similar outcomes over the course of 1 year when treating relatively stable diabetic patients, which is a mostly useless study because the major concern with management of diabetes are the chronic problems associated with the condition.

So let me ask this question. If you or a loved one had a significant medical concern or condition, would you want it to be managed by someone with minimal education and less clinical experience or someone who has undergone rigorous training to be an expert in the field?

Fair enough, we all agree that the current state of healthcare outcomes research is sorely lacking. So, you can fight a futile turf war against encroachment from other providers, or do some quality outcomes research to see what is necessary and sufficient.

The major problem with this is that mid-level autonomy is growing at such a rapid pace that by the time those studies are completed non-physicians will already have independent practice rights in almost every state if not every state. So the "turf war" is necessary to ensure there is actually time to gather data and conduct legitimate studies.

 

[WisNeuro]

I have read some of these studies, I probably read about 30+ varied articles a week. I agree that many leave something to be desired, but also that they mirror healthcare research in general in terms of quality. As far as the hypothetical of if I or someone I was caring for needed care in this field where I needed a psych condition managed? Doesn't really matter to me who I see because I would already have in mind what needed to be done and essentially just need someone to sign off on it. As for other people, I truly am not convinced that they are worse off if they had to pick without a knowledgeable referral. I have both trusted psychiatrists and NPs who I refer to. But, if someone had to pick a name out of a hat, from what I've seen in my decade plus, it's all about equal in terms of quality from what I work with.

As far as time, not something I think anyone has in this country's healthcare system. I take a cynical approach. This country decided to sell out its healthcare a long time ago, I'm fine doing the best I can for myself and building my own referral networks. I'll do what I can to help shape the system, but I'm not going to kill myself for it. This is what these people are voting for, let them deal with the choices they make.

 

[clausewitz2]

Have you read these studies? If so, you should see how terrible their quality is and that they if you're suggesting that it would be enough to allow an entire set of individuals with a minimal education to treat patients independently and prescribe medications (including psychotropic ones) then I worry about the threshold of expectations you have.

For reference, I've read about 40-50 studies to date which make claims regarding NP outcomes. Of those studies I only consider 2 of them to really be credible and their outcomes didn't really prove much. One showed that NPs who were supervised by physicians had similar outcomes to physicians, which kind of defeats the purpose of the study. The other showed that NPs had similar outcomes over the course of 1 year when treating relatively stable diabetic patients, which is a mostly useless study because the major concern with management of diabetes are the chronic problems associated with the condition.

So let me ask this question. If you or a loved one had a significant medical concern or condition, would you want it to be managed by someone with minimal education and less clinical experience or someone who has undergone rigorous training to be an expert in the field?

This is not the question policymakers are going to ask. People with money and institutional savvy are probably always going to want to see people with more impressive credentials and will figure out a way to do this. What they will ask is "is there clear evidence that this is a terrible idea that will cause harms that are clearly attributable to implementing this as a policy?" Over time if the institution is incentivized to reduce their wage bill and there is a sufficiently low chance of negative consequences that are going to lead to blowback directly affecting the people making the decisions and/or their careers, there is going to be a drift to more and more mid-level empowerment.

I am skeptical of our current outcome measures and their ability to capture much of interest for mental health but I agree with @WisNeuro that "just trust us" and gestures towards our fancy diplomas are not going to cut it. The analysts fought really hard against empirical evaluation of their work and look what happened to them. Even if you see their overthrow and exile to the margins as a tragedy, it is clear that argument from authority and years of formal education/erudition is not worth that much when money is on the line and Leviathan turns its gaze on you.

Personally I am on a trajectory to working with more complicated patients as a matter of course but I think a reckoning is going to come where psychiatrists are going to need to demonstrate specialized skills and/or high risk tolerance to earn their crusts. General private practices of the high-functioning depranxious is the space that is going to be invaded most quickly and where the battle will be lost first I imagine.

I would listen when psychologists warn that this is coming because they have been dealing with masters-level therapists for a very long time now, it is not a problem on the distant horizon.

 

[Stagg737]

This is not the question policymakers are going to ask. People with money and institutional savvy are probably always going to want to see people with more impressive credentials and will figure out a way to do this. What they will ask is "is there clear evidence that this is a terrible idea that will cause harms that are clearly attributable to implementing this as a policy?" Over time if the institution is incentivized to reduce their wage bill and there is a sufficiently low chance of negative consequences that are going to lead to blowback directly affecting the people making the decisions and/or their careers, there is going to be a drift to more and more mid-level empowerment.

I am skeptical of our current outcome measures and their ability to capture much of interest for mental health but I agree with @WisNeuro that "just trust us" and gestures towards our fancy diplomas are not going to cut it. The analysts fought really hard against empirical evaluation of their work and look what happened to them. Even if you see their overthrow and exile to the margins as a tragedy, it is clear that argument from authority and years of formal education/erudition is not worth that much when money is on the line and Leviathan turns its gaze on you.

Personally I am on a trajectory to working with more complicated patients as a matter of course but I think a reckoning is going to come where psychiatrists are going to need to demonstrate specialized skills and/or high risk tolerance to earn their crusts. General private practices of the high-functioning depranxious is the space that is going to be invaded most quickly and where the battle will be lost first I imagine.

I would listen when psychologists warn that this is coming because they have been dealing with masters-level therapists for a very long time now, it is not a problem on the distant horizon.

I don't disagree with anything in the first two paragraphs, especially the financial points. Even a capitalistic healthcare system should look heavily at patient outcomes though, even if it's not being shown to affect the bottom line. I think there should be some common sense implemented as well though, especially when one sees the shocking levels of incompetence from some NPs which I have (the extent to which I've only personally encountered with a physician once).

I'm curious about the bolded though. I would think that outpt PPs with high-functioning patients would be one of the last areas to be hit by NPs as most of those patients I've encountered are financially stable and are in the position to demand to be seen by a physician if they want to (which several I've met have). I realize that's counterproductive with how an optimal system would work, but I'd imagine it would be much easier for a highly trained psychiatrist to establish a private practice than an NP with weaker credentials who may have to exaggerate or falsely advertise themselves to attract patients.

 

[clausewitz2]

I don't disagree with anything in the first two paragraphs, especially the financial points. Even a capitalistic healthcare system should look heavily at patient outcomes though, even if it's not being shown to affect the bottom line. I think there should be some common sense implemented as well though, especially when one sees the shocking levels of incompetence from some NPs which I have (the extent to which I've only personally encountered with a physician once).

I'm curious about the bolded though. I would think that outpt PPs with high-functioning patients would be one of the last areas to be hit by NPs as most of those patients I've encountered are financially stable and are in the position to demand to be seen by a physician if they want to (which several I've met have). I realize that's counterproductive with how an optimal system would work, but I'd imagine it would be much easier for a highly trained psychiatrist to establish a private practice than an NP with weaker credentials who may have to exaggerate or falsely advertise themselves to attract patients.

In this area we have a number of NPs who have moved into this area and at least one MD has a practice that seems to consist mainly of cranking out high volumes by having patients primarily seen by one of 6 NPs. You're probably right in the sense of this space not so much being dominated by NPs as competition becoming much fiercer.

That said, say you are the kind of person who would like to have some Concerta or Xanax just 'cause. Who do you think you will more successfully badger into prescribing this for you, on average?

 

[WisNeuro]

That said, say you are the kind of person who would like to have some Concerta or Xanax just 'cause. Who do you think you will more successfully badger into prescribing this for you, on average?

PCP's, no question. In psych though, I see no different prescribing habits between NPs and psychiatrists when it comes to benzos.

 

[Stagg737]

In this area we have a number of NPs who have moved into this area and at least one MD has a practice that seems to consist mainly of cranking out high volumes by having patients primarily seen by one of 6 NPs. You're probably right in the sense of this space not so much being dominated by NPs as competition becoming much fiercer.

I can see that, but I also think a psychiatrist who wanted to append a PP and was decent in psychotherapy or really any area of psych beyond basic med management of stable patients could successfully break in. I get what you're saying though, and I do think people are utilizing mid-levels to increase volume rather than physicians for their financial benefit.

That said, say you are the kind of person who would like to have some Concerta or Xanax just 'cause. Who do you think you will more successfully badger into prescribing this for you, on average?

I don't disagree with this point either. Going back to the high-functioning depranxious patient though (or really anyone who isn't drug seeking or malingering), do you think they'll want to be seen by someone with more training and more advanced/prestigious credentials or someone with less if price is the same? Given the choice, why would anyone in that situation choose an NP over a physician (assuming they could get a timely appointment)?

 

[Stagg737]

PCP's, no question. In psych though, I see no different prescribing habits between NPs and psychiatrists when it comes to benzos.

Man, you need to come visit out VA hospital that we rotate at. On the inpatient unit we can usually tell which mid-level our new admits see just based on what benzos are prescribed. It's the same algorithms and treatment plans being recycled with minor changes for everyone with PTSD or anxiety. We see benzos a lot less often when our patients are coming from one of the psychiatrists, though this will likely vary a lot based on region or even within different hospitals.

 

[WisNeuro]

Man, you need to come visit out VA hospital that we rotate at. On the inpatient unit we can usually tell which mid-level our new admits see just based on what benzos are prescribed. It's the same algorithms and treatment plans being recycled with minor changes for everyone with PTSD or anxiety. We see benzos a lot less often when our patients are coming from one of the psychiatrists, though this will likely vary a lot based on region or even within different hospitals.

I'd be interested to see it, because that was not the case at any of the 4 VAs that I trained/worked at, nor in my current system. If anything, I see more geographic variability than provider variability in benzo prescribing patterns. Seems like some low hanging fruit to run a study on.

 

[Stagg737]

I'd be interested to see it, because that was not the case at any of the 4 VAs that I trained/worked at, nor in my current system. If anything, I see more geographic variability than provider variability in benzo prescribing patterns. Seems like some low hanging fruit to run a study on.

I think the bolded is probably also true, though I honestly did not pay much attention to specific medications at places I worked before med school and my med school rotations were relatively limited geographically, so I can't really give a valid opinion on that. The VA would probably be a perfect system for that study though and I may actually steal this idea when I start working with the QI team (also want to look at the monstrosity that is the tertiary screening policy). Seems like a project a med student could easily get involved with as well (chart diving/data input).

 

[WisNeuro]

I think the bolded is probably also true, though I honestly did not pay much attention to specific medications at places I worked before med school and my med school rotations were relatively limited geographically, so I can't really give a valid opinion on that. The VA would probably be a perfect system for that study though and I may actually steal this idea when I start working with the QI team (also want to look at the monstrosity that is the tertiary screening policy). Seems like a project a med student could easily get involved with as well (chart diving/data input).

Easy study, just tedious for data input. Perfect for student work. If I were you, I'd write up an IRB now, though, the VA IRB can be a lengthy process at some sites.

 

[Jules A]

Easy study, just tedious for data input. Perfect for student work. If I were you, I'd write up an IRB now, though, the VA IRB can be a lengthy process at some sites.

Anecdotally in my area it is the primary care NPs and old, 60+ yo, psychiatrists who are still handing out fistfuls of benzos and stimulants. Many of the 70+ seem to basically write whatever the patient asks for to the point that it is a nightmare when one finally retires and their patients start shopping around for a new prescriber. My guess is the older docs don't stay current with research and lose their edge which results in an inability to say no when patients are seeking inappropriate medications. The new primary care NPs seem to lacking with regard to recommended treatment of anxiety as well as identifying SUD or clusterB traits which I suspect will be especially problematic now that so many are bup certified.

 

[LadyHalcyon]

I am writing a report right now and 4 different psychiatrists have diagnosed an adolescent with the following (listed in order of age at time of diagnosis, starting with youngest): ADHD, Depression, Anxiety, ASD, OCD, and now Bipolar (thanks to good 'ol Dr. ***** who thinks mood swings=Bipolar). These were not midlevels. These were psychiatrists, and the majority of these physicians work at the same inpatient hospital for children and adolescents.

 

[TexasPhysician]

I am writing a report right now and 4 different psychiatrists have diagnosed an adolescent with the following (listed in order of age at time of diagnosis, starting with youngest): ADHD, Depression, Anxiety, ASD, OCD, and now Bipolar (thanks to good 'ol Dr. ***** who thinks mood swings=Bipolar). These were not midlevels. These were psychiatrists, and the majority of these physicians work at the same inpatient hospital for children and adolescents.

I don’t trust any diagnosis from an inpatient stay. The goal of inpatient these days is to quickly stabilize, not tease out all accurate diagnoses. Additionally many insurances won’t cover inpatient days unless the diagnosis is of sufficient severity. The end result of our poor mental health insurance-based inpatient coverage is worthless documentation to anyone but insurance companies. If you are trying to reach a final consensus on a diagnosis based on insurance covered records, you are doing it wrong.

 

[LadyHalcyon]

So where does one go for final consensus? I feel most midlevel clinicians simply go along with the inpatient diagnoses. They become a permanent part of the chart, and sometimes they unfortunately also become a permanent part of the patient's identity

I don’t trust any diagnosis from an inpatient stay. The goal of inpatient these days is to quickly stabilize, not tease out all accurate diagnoses. Additionally many insurances won’t cover inpatient days unless the diagnosis is of sufficient severity. The end result of our poor mental health insurance-based inpatient coverage is worthless documentation to anyone but insurance companies. If you are trying to reach a final consensus on a diagnosis based on insurance covered records, you are doing it wrong.

 

[nexus73]

So where does one go for final consensus? I feel most midlevel clinicians simply go along with the inpatient diagnoses. They become a permanent part of the chart, and sometimes they unfortunately also become a permanent part of the patient's identity

The outpatient doctor ultimately needs to own the patient and take the time to make sure they've got the diagnosis nailed down. This might mean a couple of extended sessions to get into greater history with the patient and/or interviewing family/friends for collateral.

 

[TexasPhysician]

So where does one go for final consensus? I feel most midlevel clinicians simply go along with the inpatient diagnoses. They become a permanent part of the chart, and sometimes they unfortunately also become a permanent part of the patient's identity

Midlevels are not adequately trained to develop a thorough diagnosis.

Good outpatient psychiatrists are where you’ll find the best diagnoses.

 

[LadyHalcyon]

Although, I will add that all of these diagnoses have been continued by her outpatient psychiatrist. But, his office is nextdoor to the inpatient facility and he does a lot of work at the hospital so.....

Midlevels are not adequately trained to develop a thorough diagnosis.

Good outpatient psychiatrists are where you’ll find the best diagnoses.

 

[TexasPhysician]

Although, I will add that all of these diagnoses have been continued by her outpatient psychiatrist. But, his office is nextdoor to the inpatient facility and he does a lot of work at the hospital so.....

This information gives nothing by which to make an opinion. Are the groups related? Are records often shared? Is a midlevel controlling the care? When was the last time the outpatient psychiatrist billed 90792 to re-evaluate the diagnoses? Is the patient often re-admitted? What psychosocial issues are clouding the picture? What liability issues could the psychiatrist be protecting against? Are inpatient adjustments working?

There are tons of issues at play that can contribute to a muddy diagnostic picture. Some of which are sometimes documented for legal, billing, or access reasons.

If you want a clear picture, refer to an unrelated cash-only psychiatrist that will be paid to spend time to clear up the picture.

 

[LadyHalcyon]

Well, I'm currently testing her and will re/un-diagnose her and her psychiatrist will receive a copy of the report. In the report I will explain why the diagnoses she currently has are not appropriate based on behavioral observations, assessment data, collateral info, and background history.

This information gives nothing by which to make an opinion. Are the groups related? Are records often shared? Is a midlevel controlling the care? When was the last time the outpatient psychiatrist billed 90792 to re-evaluate the diagnoses? Is the patient often re-admitted? What psychosocial issues are clouding the picture? What liability issues could the psychiatrist be protecting against? Are inpatient adjustments working?

There are tons of issues at play that can contribute to a muddy diagnostic picture. Some of which are sometimes documented for legal, billing, or access reasons.

If you want a clear picture, refer to an unrelated cash-only psychiatrist that will be paid to spend time to clear up the picture.

 

[nexus73]

Is there a general thought that psych testing is the gold standard for diagnosing? In my experience, it's a mixed bag. I only see adults so maybe the utility is more for kids.

 

[Sushirolls]

No, psych testing is not the gold standard for diagnosing. Its a tool to help delineate a specific differential you already have in mind.

 

[Merovinge]

It's the gold standard for things that you need psych testing for (learning disabilities, intellectual disabilities) and many people these days feel it is the gold standard for ASD testing (ADOS or similar). I think LadyHalcyon above is noting that she can spend long enough with the patient/chart biopsy to help clear up a patient who has gone through the revolving door of inpatient psych hospitalizations where diagnosis are led more by insurance reimbursement than DSM, ICD, or construct validity.

 

[WisNeuro]

Is there a general thought that psych testing is the gold standard for diagnosing? In my experience, it's a mixed bag. I only see adults so maybe the utility is more for kids.

If you differentiate psych testing from neuropsych testing, most likely it is. But, that's probably more of an artifact of having the adequate time to get a thorough history (developmental, sx, etc) rather than relying solely on old notes and a 10 minute conversation with someone, which is what usually happens. It's not hard for a competent clinician to diagnose psych issues correctly, if given enough time and give a damn.

 

[FlowRate]

We have a "complex diagnosis" referral clinic and that person often refers folks to get psychological testing (mostly projectives and personality metrics). I'm not sure that I've actually found it all that helpful, especially given the differential for those patients is usually "where do they fall on the bipolar - shizoaffective - schizophrenia - other psychosis spectrum?" and the answer usually ends up being "yes." It's probably most helpful in ruling out subtle formal psychosis in a very thorough way. On the other hand, I had a patient where it wasn't clear if the patient had ADHD or a specific learning problem (or both) and the neuropsych testing was very helpful with clarifying that and giving good treatment recommendations.

 

[Sushirolls]

I've found Neuropsych testing helpful in the geriatric population. How cognitively impaired is this person? I find it valuable to be an anchor to discussion pathology with the patient (and family?) and how they may need more help then they are currently willing to accept. Or in the people who've had a stroke that are just bumbling around the system, and really need more resources. Neurospsych testing helps to point out the deficits to further advocate for a level of care.

 

[LadyHalcyon]

I think for the majority of cases a in-depth clinical interview with a competent clinician is all that is required to obtain an accurate diagnosis. I'm curious about outpatient psychiatrists, how long do you spend on an intake/90792?