Psych NP "settles" the debate

[comp1]

Studies involving the best deployment of NPs and MDs are only a waste of time if you're happy with the exact current status quo or just particularly nihilistic. That seems to be a relatively small number of NPs or MDs based on comments here.

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[G Sheb]

Studies involving the best deployment of NPs and MDs are only a waste of time if you're happy with the exact current status quo or just particularly nihilistic. That seems to be a relatively small number of NPs or MDs based on comments here.

Meh. I wouldn't take SDN comments as evidence for anything.
70% of psychiatrists believe that NPs have had no influence on their income, per the latest medscape survey.
Yes, there are better and more urgent things to throw money at than "who's superior NPs or MDs".
No need to give desperados with no actual experience ammunition.

 

[WisNeuro]

Studies involving the best deployment of NPs and MDs are only a waste of time if you're happy with the exact current status quo or just particularly nihilistic. That seems to be a relatively small number of NPs or MDs based on comments here.

Pssh, why should we study how to efficiently and effectively deliver healthcare? Now, hand me some leeches and my trephination drill.

 

[clausewitz2]

Pssh, why should we study how to efficiently and effectively deliver healthcare? Now, hand me some leeches and my trepanning drill.

FTFY

 

[allantois]

I think we lose track of what being a PMHNP really means.

In a PMHNP (psych trained NP) program, they do a 6 month adult and 6 month child training year to get certified as a PMHNP. This is typically a part-time training gig, so they work a job while they get their training.

A fresh PMHNP has had at most ~1000 hours of psych training by the time they graduate. Even a psych intern at the end of the year has roughly double the amount of clinical exposure in raw hours compared to an NP (avg 2.2-2.5k clinical hours yr 1). I know as at the end of my PGY2 year, I had around 5700 hours of clinical work under my belt. In overnight work alone (by the end of pgy2) I covered almost the same amount of clinical work that a PMHNP completes in their entire training program.

I know my ivory tower program has a reputation as being one of the highest workload residencies in the country (rightfully so). However, even compared to a run of the mill IM or surgery residency program, it isn't that much work. It is no question why even at the generic, raw exposure level, an average MD just blows NPs out of the water. Every MD graduate who completes residency has essentially completed 4-5x the literal hours of work at the minimum - not even touching on the differences in amount of general reading/knowledge base, etc.

This would actually be great. They actually just do 3 clinical rotations: adult, child and inpatient. Roughly 500 hours on a part-time basis.
FNPs do IM, FM and Peds

 

[Merovinge]

This would actually be great. They actually just do 3 clinical rotations: adult, child and inpatient. Roughly 500 hours on a part-time basis.
FNPs do IM, FM and Peds

Yes at my last job they wanted to have NP students come to my CAP clinic for 1/2 day/week for 6 months as the entirety of their "CAP" training. 3 clinical hours/week of pure observation makes someone apparently qualified to prescribe psychotropic medication to children.

 

[comp1]

I mean, is that amount of time and exposure sufficient for similar cost and care outcomes? That's kind of the question we need to answer.

 

[G Sheb]

I mean, is that amount of time and exposure sufficient for similar cost and care outcomes? That's kind of the question we need to answer.

Don't mean to sound offensive or condescending, but have you actually practiced psychiatry and/or supervised NPs?
Because if you need a study to answer that question (1/2 a day a week for 6 months to provide similar care as a trained CAP psychiatrist), then I guess you can go on, and do it yourself.

 

[comp1]

Yes, of course, I've done/am doing both. However, I'm very specifically not making it personal. That's where we lose both the argument and credit with the public. I'm saying anecdotes or appeals to common sense are apparently very hard or impossible to sell to the general public and policy makers.

 

[G Sheb]

Yes, of course I've done both, but I'm very specifically not making it personal. I'm saying anecdotes or common sense are apparently very hard to sell to the general public and policy makers.

The public and the policy makers already know the answers.
The reality is there's a huge shortage of mental health providers and someone needs to fill that gap.

 

[TheRightMedication]

I trained a few NP students (back in my nice guy days) who would show up for a half day here and there, similar to above.

There's an issue aside from the number of hours though, and I think it's a bigger deal.

You can't follow cases that way!

And if you can't follow a case you're not learning the whole course of an illness, which is a huge problem if you're a medical professional who needs to manage those courses.

 

[bGMx]

We should do these studies. If it turns out two years of residency is sufficient, I would be all for reducing residency length. Then I could do a fellowship without the same opportunity cost. Or maybe many fellowships could be eliminated and folded into a four year psychiatry residency. I say this with humility and in good faith for finding the best solution and best patient care outcomes, for individuals and society.

 

[Stagg737]

Many of us psychiatrists work with NPs, social workers and psychologists.
I think such studies are a complete waste of time, money and energy. Those with actual experience know what they are dealing with.

I don't disagree with you, but the problem with that line of thought is that we're not trying to convince the people with actual experience. We're talking about the general public and oftentimes policymakers, who are almost always ignorant and oftentimes stupid when it comes to understanding the practice of medicine and medical training. Kind of a weird appeal to authority from you when you're so adamant about EBM.

I mean, is that amount of time and exposure sufficient for similar cost and care outcomes? That's kind of the question we need to answer.

While the question is fair, looking at requirements for other fields and using basic common sense should be enlightening/enraging. There are states that require hairdressers and dog groomers to have more "clinical" hours than DNPs. When a state requires 750 hours to cut hair but only 500 hours to prescribe a controlled substance, there is something very wrong happening there...

ETA: My current state requires NPs to complete 1,000 direct clinical hours for licensure and 1,500 hours to be a licensed cosmetologist. I'm in a FPA state.

 

[tr]

Yes at my last job they wanted to have NP students come to my CAP clinic for 1/2 day/week for 6 months as the entirety of their "CAP" training. 3 clinical hours/week of pure observation makes someone apparently qualified to prescribe psychotropic medication to children.

I have gotten requests like this a number of times. Apparently it is standard practice for the NP schools to provide some period of lecture-based instruction, and then tell their students to go find some random psychiatrist out in the community to shadow for 6 months, which will constitute the entirety of their clinical training. SMH.

Shadowing/observation is a resume-filler used by applicants to demonstrate interest and commitment. It isn't actually training to perform clinical work.

 

[G Sheb]

I don't disagree with you, but the problem with that line of thought is that we're not trying to convince the people with actual experience. We're talking about the general public and oftentimes policymakers, who are almost always ignorant and oftentimes stupid when it comes to understanding the practice of medicine and medical training. Kind of a weird appeal to authority from you when you're so adamant about EBM.


While the question is fair, looking at requirements for other fields and using basic common sense should be enlightening/enraging. There are states that require hairdressers and dog groomers to have more "clinical" hours than DNPs. When a state requires 750 hours to cut hair but only 500 hours to prescribe a controlled substance, there is something very wrong happening there...

ETA: My current state requires NPs to complete 1,000 direct clinical hours for licensure and 1,500 hours to be a licensed cosmetologist. I'm in a FPA state.

There's no appeal to authority.

Resources are not unlimited. You can't conduct a study for every question that comes into your head. There's a reason why such 'studies' don't exist. Everyone with actual experience in psychiatry knows the answers.
The question is whether it's better to have no care at all vs care by mid levels. It's not psych NPs vs MDs.
You're also arguing something entirely different here. How many hours are necessary for psych NPs to become remotely competent. It's not the superiority or lack of it of MDs.

I don't think we're trying to convince anyone. Who exactly are you appealing to and why? Banning mid levels completely is not going to help us or mental health. I actually think this is a very stupid way for doctors to go about it.
If it gets to a point where we have to 'appeal' that we have better training, then I'll be ready to quit medicine. But this is not an issue in the actual world, imo.
Talking about evidence, I have literally seen ZERO evidence that midlevel encroachment on psychiatry jobs is a thing. Our salaries keep going up. I think the stats are that slightly less than half opt for independent practice. We have one of the most dynamic job markets in all of medicine. Yet all of this hand wringing, why?

Those who are pushing for this have ulterior motives and naive MDs fall for it.

 

[Stagg737]

There's no appeal to authority.

Resources are not unlimited. You can't conduct a study for every question that comes into your head. There's a reason why such 'studies' don't exist. Everyone with actual experience in psychiatry knows the answers.
The question is whether it's better to have no care at all vs care by mid levels. It's not psych NPs vs MDs.
You're also arguing something entirely different here. How many hours are necessary for psych NPs to become remotely competent. It's not the superiority or lack of it of MDs.

I don't think we're trying to convince anyone. Who exactly are you appealing to and why? Banning mid levels completely is not going to help us or mental health. I actually think this is a very stupid way for doctors to go about it.
If it gets to a point where we have to 'appeal' that we have better training, then I'll be ready to quit medicine. But this is not an issue in the actual world, imo.
Talking about evidence, I have literally seen ZERO evidence that midlevel encroachment on psychiatry jobs is a thing. Our salaries keep going up. I think the stats are that slightly less than half opt for independent practice. We have one of the most dynamic job markets in all of medicine. Yet all of this hand wringing, why?

Those who are pushing for this have ulterior motives and naive MDs fall for it.

The question comes into play when discussing FPA of mid-levels, ie can mid-levels like NPs safely and appropriately address MH patients without supervision of physician. The reason the studies are relevant is because NPs have gained FPA in over half of the US because they have successfully argued to legislatures, repeatedly, that they provide equal care as physicians. If the argument was just about increasing numbers of NPs and access, then you can do that with supervising physicians. If you don't believe it's an issue in the real world, join PPP and look into the legislation being passed and the arguments made. You'd probably be shocked based on your post.

All that being said, I'm not really anti-midlevel or anti-NP. I think they can, and often do, play a very important role in our system when utilized appropriately. The problem I have is when the independent practice argument comes into play, which is really the core reason for NPs claiming equivalency irl. I'm not worried about job security or earnings and I agree that the doom and gloom related to this is overblown. However, we shouldn't act like these arguments aren't being made and used to further an agenda without real life consequences. There's plenty of examples, but the more obvious is the advent of companies like Cerebral.

At this point though, I think the ship has sailed and conducting these studies now is probably pointless as you're saying. They were needed 20 years ago before FPA was the norm in the majority of states. There's not point in trying to hold back the floodgates now, and like much of history meaningful change going forward will come from suffering, in this case the suffering of many patients d/t poor care. Which is unfortunately why I don't worry, because being someone who provides thoughtful and good care who can alleviate suffering from others doing harm through poor practice of medicine is something that decent psychiatrists will be able to do for a long time going forward.

 

[G Sheb]

The question comes into play when discussing FPA of mid-levesl, ie can mid-levels like NPs safely and appropriately address MH patients without supervision of physician. The reason the studies are relevant is because NPs have gained FPA in over half of the US because they have successfully argued to legislatures, repeatedly, that they provide equal care as physicians. If the argument was just about increasing numbers of NPs and access, then you can do that with supervising physicians. If you don't believe it's an issue in the real world, join PPP and look into the legislation being passed and the arguments made. You'd probably be shocked based on your post.

All that being said, I'm not really anti-midlevel or anti-NP. I think they can, can often do, play a very important role in our system when utilized appropriately. The problem I have is when the independent practice argument comes into play, which is really the core reason for NPs claiming equivalency irl. I'm not worried about job security or earnings and I agree that the doom and gloom related to this is overblown. However, we shouldn't act like these arguments aren't being made and used to further an agenda without real life consequences. There's plenty of examples, but the more obvious is the advent of companies like Cerebral.

At this point though, I think the ship has sailed and conducting these studies now is probably pointless as you're saying. They were needed 20 years ago before FPA was the norm in the majority of states. There's not point in trying to hold back the floodgates now, and like much of history meaningful change going forward will come from suffering, in this case the suffering of many patients d/t poor care. Which is unfortunately why I don't worry, because being someone who provides thoughtful and good care who can alleviate suffering from others doing harm through poor practice of medicine is something that decent psychiatrists will be able to do for a long time going forward.

I wouldn't want to supervise an NP if you ask me.
Look they got independent practice for a while now and the reality is that it's NOT because everyone thinks they provide equal care, regardless of what their lobbyists claim. If that was the case, their salaries would be equivalent to ours and they would be taking our jobs which is, again, I have seen zero evidence of. This issue is not new and has been going on for more than a decade now. The flood gates were already open.

So to sum it up, I can conduct a study to see whether a plumber can do an equal job as a GI. But why would I? It's not a question that I'm genuinely perplexed about, and I don't see anyone I need to 'appeal to' to argue this. You can apply the same logic with NPs.

 

[comp1]

I don't think studies are pointless. At the very least they aren't as pointless as hand wringing about NPs and their limited extent of training in general. Studies would help us figure out what and how much training is actually required to provide the highest level of cost efficient care. Studies can still guide both physician and NP training programs. There's no binary here.

 

[Stagg737]

I don't think studies are pointless. At the very least they aren't as pointless as hand wringing about NPs and their limited extent of training in general. Studies would help us figure out what and how much training is actually required to provide the highest level of cost efficient care. Studies can still guide both physician and NP training programs. There's no binary here.

I think that's fair and frankly the nursing education system needs a modern-day Flexner report given how ridiculously inconsistent and often irrelevant to clinical practice many NP training programs are.

 

[G Sheb]

I don't think studies are pointless. At the very least they aren't as pointless as hand wringing about NPs and their limited extent of training in general. Studies would help us figure out what and how much training is actually required to provide the highest level of cost efficient care. Studies can still guide both physician and NP training programs. There's no binary here.

This is imprecise.
Your original point was that there were no study showing superiority of physician training to NP training.
Any study needs a rational. It's easy to say 'you need a study for this or that'. You really have to think that there's a possibility that shadowing someone for half a day in a clinic for 6 months can provide the same level of psychiatric care as a fully trained CAP psychiatrist.

 

[clausewitz2]

This is imprecise.
Your original point was that there were no study showing superiority of physician training to NP training.
Any study needs a rational. It's easy to say 'you need a study for this or that'. You really have to think that there's a possibility that shadowing someone for half a day in a clinic for 6 months can provide the same level of psychiatric care as a fully trained CAP psychiatrist.

The problem is without outcome studies of some kind, we are always vulnerable to the counterargument of 'Sez you.'

In a society that invests less and less trust in institutions and authority of any kind, relying on deference from state legislators and hospital admins seems like a bad strategy.

It'd also be nice to do dismantling studies of residency training to figure out what is useless and what isn't, but one thing at a time.

 

[WisNeuro]

The problem is without outcome studies of some kind, we are always vulnerable to the counterargument of 'Sez you.'

In a society that invests less and less trust in institutions and authority of any kind, relying on deference from state legislators and hospital admins seems like a bad strategy.

It'd also be nice to do dismantling studies of residency training to figure out what is useless and what isn't, but one thing at a time.

Becoming much more salient as healthcare is becoming ever more specialized.

 

[Stagg737]

The problem is without outcome studies of some kind, we are always vulnerable to the counterargument of 'Sez you.'

In a society that invests less and less trust in institutions and authority of any kind, relying on deference from state legislators and hospital admins seems like a bad strategy.

It'd also be nice to do dismantling studies of residency training to figure out what is useless and what isn't, but one thing at a time.

And this is the argument NPs have used to get FPA passed. They point to the few studies out there (typically poorly conducted) which have shown "equal outcomes" and say they are equal to physicians and when anything else like education, experience, knowledge base, etc is brought up they ask where the studies are. Doesn't matter if they can't pass a watered-down version of Step 3 or can't discuss the most basic clinical information, they point to their studies and say we don't have any. This has repeatedly happened in states where NPs have gained FPA in the past decade and it will continue to happen as FPA expands further.

 

[tr]

There actually are numerous reasonably well designed studies that expose the situations where the physician training matters. @VA Hopeful Dr has dropped plenty in the past.

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare

Varies by patient and presentation of course, but I think the standard emerged because old-school psychoanalysis set an outrageously high opening bid. Amazed we have come down as much as we have from 1-2 hours 3x/week. I often feel like my therapy sessions are maybe 15-20 minutes of actual...

forums.studentdoctor.net

 

[G Sheb]

And this is the argument NPs have used to get FPA passed. They point to the few studies out there (typically poorly conducted) which have shown "equal outcomes" and say they are equal to physicians and when anything else like education, experience, knowledge base, etc is brought up they ask where the studies are. Doesn't matter if they can't pass a watered-down version of Step 3 or can't discuss the most basic clinical information, they point to their studies and say we don't have any. This has repeatedly happened in states where NPs have gained FPA in the past decade and it will continue to happen as FPA expands further.

And FPA has been there for decades in some states and I haven't seen any evidence that this has badly impacted physician compensation or job outlook.
Even for PCPs, who theoretically should be the most 'threatened', they are by far the most recruited and sought after physicians.
My guess is that FPA will continue to expand because the question policy makers face isn't whether they can provide 'equal' care but whether it's better than no care at all.

 

[Stagg737]

My guess is that FPA will continue to expand because the question policy makers face isn't whether they can provide 'equal' care but whether it's better than no care at all.

Which I think is a separate but very valid question.