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As are podiatrists and dentists (doctors of dental surgery, after all).
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psych np's taking over
Started by cherryalmond
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As are podiatrists and dentists (doctors of dental surgery, after all).
actually very very very few podiatrists actually get decent surgical exposure in training where they perform what could be reasonably called foot 'surgery'. Most of the surgery on the foot complex enough to be called as such is done by orthopods....who do go to medical school.
Were you a podiatrist in another life? How did you gather this sage wisdom?
Three 'verys' in one sentence is pretty confident.
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My sense is that mid-levels in any specialty function at the level of a senior resident pretty much throughout their careers. So far that's been the case in peds, surg, onc, EM, inpatient gen med; I've only really encountered psych NPs by chart review and collateral phone calls. Maybe its different in other specialties? I don't know why thats the case, or what allows MD's to ascend past PA's and NP's post-residency.
I'm just curious what cases people would feel uncomfortable taking on as a senior resident.
I'm just curious what cases people would feel uncomfortable taking on as a senior resident.
sticking up for medicine, no way does a typical medicine PA function at the level of most medicine pgy-3s.........maybe more like the average pgy-2 at the very beginning of their second year.
It might be comparing apples to oranges, since PGY-3's are responsible for much more supervision/teaching, but I haven't noticed to much of a difference in mortality/outcome between the PA-run service and the resident-run. The bed admin definitely sends more "academic" cases to the resident-side, so that skews things, and the similarity is more apparent with the subspecialties. Bear in mind that some of the PA's have 20+ years of clinical experience, so this isn't a knock on medicine and I don't think you need to "stick up" for them. The medicine residents at my program are also incredibly accomplished and brilliant, I'm just looking at clinical functionality.
And I think the literature bears this out, at least in the outpatient setting, with limited studies performed at Columbia.
Anyway, the point was what cases would you feel uncomfortable handling as a senior reident.
I wouldn't go that far, but he does rile me up. I guess I can understand where he is coming from. It is frustrating to think that all the hard work we are going through may be worth much less than expected.
I'm pretty sure there is a bit of uncertainty in all of medicine right now and lots of my peers (students) seem frustrated.
'hard work'(by this I assume you mean going through medical school) by itself isn't worthy of reward. It would be very hard work for me(since Im no good at such things) to solve a rubix cube, but that doesnt possess any value. It would also be hard work for me to dig a 20 foot ditch and then fill it back in....but again no value there.
The uncertainty in some fields is much less than others. Surgeons, for example, have nothing to fear from midlevels going foward. Even looking way forward. Most medicine subspecialties like cards, gi, hemonc have little to fear as well....sure there will continue to be midlevel involvement in these fields(increasingly so), but the lines will never be blurred in terms of who has a unique skill set on the team. An np/pa working for an interventional cardiology practice in *no* was has a similar skill set or does the same thing as the cardiologist. At the va though the outpt psychiatrists and outpatient psych nps do do something very similar. Same for in the outpt fam med clinics.
Or the midlevels will create more work for us. I hear all the time how mental health care in this country is inadequate. If the midlevels are increased, making it easier for the general population to get mental healthcare, more people will seek care that they need. More people in the system= more people that need to be seen by Psychiatrists.
Why would they see a psychiatrist if they could just see the NP that does the exact same thing you might ask (amongst other complaints I'm sure). I will let you answer that question. What unique set of skills do psychiatrists possess that NPs and PAs don't? If you say none, then come up with some on your own. Maybe your med school training could actually be of use? If you can't come up with anything, you are still probably going to be fine, but those of us who adapt and overcome will do better. You can't fight progress so why not just jump in head first?
that's not reality though....in fact, just because something is 'in need' or 'inadequate'(both of which by the way are vague and debatable in many ways) doesn't neccessarily mean that that creates a good position for physician level providers from a growth standpoint.
As it relates to psychiatry, midlevels won't be bringing new patients into the fold(if anything fewer patients will be coming into the fold) but rather siphoning off some of the easier(and more efficient patients in terms of how they are reimbursed) from us for cost efficiency reasons...all related to ACA and the way things are moving in health care overall.
I give up dude, you win the battle, I quit. You are right, it's all pointless, nobody should go into psychiatry. Future psychiatrists will have to resort to Lucy from Peanuts style booths, offering analysis for a nickel while the NPs treat all the patients. Actually everyone currently in psychiatry should quit now and kill themselves. No wait, they should be gathered up and shot for lying to the public about what they actually do.... It must suck to be so ****ing pessimistic. The glass isn't half empty, it's full of piss.
Here, let me predict your retorts so you don't have to bother.
"I'm just being real, this is reality, if you can't handle reality then it is your problem" " I never said we lie to the public." " I'm not trying to get people to quit, I'm just trying to prevent all the other cheerleaders from giving you false hope"
I could predict the rest because you are very predictable, but I should really be using my time elsewhere.
you're engaging in lots of black and white and all or nothing thinking. And some distortions of what I have said as well.
we're not going to work for 20 dollars an hour in the future.....but as health care changes in the form of more salaried employees and more payments being bundled(the two are obviously related) that is going to put downward pressure on salaries and in most settings blur the lines between the practical realities of practicing as a psych np/pa vs a psychiatrist.
This model is already seen in the VA, where people who work there will tell you that there isn't much practical difference between the day to day duties of most of the psychiatrist and the psych nps. There are some subtle differences, some administrative differences sure. This is a model as health care moves forward(and more psychiatrists in the outpt world become salaried...for some entity...still a little unclear what that form will be) will expand greatly. Which for the psychiatrists at the VA now isn't a terrible thing because they still get paid more like outpt psychiatrists than psych nps(meaning they start at 160ish k).....but the problem is that the VA doesn't(at least currently or in the past) give a flip about cost efficiency or the bottom line. Other entities that expand this model will care about those things....and it doesn't take a brain surgeon to see that if a psych np can serve x number of outpts and a psychiatrist is serving that same number of outpts, it makes a lot more sense from a bottom line standpoint to hire psych nps at 75k than psychiatrists at 170k.
I see what you did there. Hmmmm. I admire your fellatiotic expertise, relish, and tear jerking commitment.
Repulsion of that aside. All of these things exist pervasively, not just in psychiatry.
My response to these conditions is to say challenge accepted. I know my training is better so how can I use it. How can I develop a niche that allows, nay demands, that I use it.
The repulsion you've caused me has had an inspirational side effect. So....thanks?...I guess.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816922/
A very thoughtful and well written article. It's a few years old(but certainly recent enough to be relevant as nothing has changed).
Now if one is *really* into psychiatry and/or can't see themselves doing anything else, it may still be irrelevant. And if one went to medical school knowing they were going to do psychiatry, same thing. I've always maintained that the true number of 3rd/4th year med students(or even many preclinicals) who are truly trying to decide between psychiatry and something else is fairly low, but for the few who are actually on the fence the above article is a good one to read.
Just thought I would point something out because you specifically said GI in one post.
http://www.ncbi.nlm.nih.gov/pubmed/19251011
The seed has been planted. There is no reason to believe it won't occur in the future.
http://www.ncbi.nlm.nih.gov/pubmed/19251011
The seed has been planted. There is no reason to believe it won't occur in the future.
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that is one tiny pilot program.
Additionally, even in this pilot program they are just doing screening scopes.....even if this did take hold(and I dont see it happening), GIs have many ways to get around the butting in on this one particular procedure(screening colonoscopies)....just refuse to contract with facilities where that happens for one.
yeah I read the thread......nothing in the least concerned me that GI was at risk for np enrcoachment
By no means do I think this is the near future, but we can see how quickly CRNA's took over anesthesia as soon as I tasted the money in the air...
With the new ACOs, it doesn't take a brain surgeon to see that if a gi np can serve x number of scopes and a gi is doing that same number of scopes, it makes a lot more sense from a bottom line standpoint to hire gi nps at 100k than GIs at 350k.
With the new ACOs, it doesn't take a brain surgeon to see that if a gi np can serve x number of scopes and a gi is doing that same number of scopes, it makes a lot more sense from a bottom line standpoint to hire gi nps at 100k than GIs at 350k.
the difference is that OR(and outpt surgery center/procedure room) anesthesia is the majority of anesthesia. It was ripe for the picking due to this very nature. Not only in terms of revenue, but in terms of scope of knowledge and daily practice it makes up the bulk of what anesthesia does. Furthermore, with OR anesthesia that is it and it isn't seen as just one step in the process of care. For screening colonoscopies, that isn't always the case on both fronts.
Yes, since the vast majority of screening colos are negative, the PCP can refer out to the gi or colorectal surgeon when the pathologist finds something abnormal. Like you said, it's more cost effective. It doesn't take an MD to put a camera up someone's butt.
my point was that, unlike anesthesia, this is just a slice of GI. And family physicians have been occasionally foraying into screening scoping for decades.....it hasn't changed the dynamics of GI.
Can't read the writing on the wall eh? Sorry buddy, GI is toast along with FP, Rads, Gas and psych.
And urology http://www.uroweb.org/?id=188&act=showfull&aid=104
Of course you can never provide evidence to the contrary, just some things you think are most likely. mmmhmmm
And urology http://www.uroweb.org/?id=188&act=showfull&aid=104
Of course you can never provide evidence to the contrary, just some things you think are most likely. mmmhmmm
I don't actually believe any of this. I'm just pointing out how easy it is to think the sky is falling when it is merely raining.[\spoiler]
True. But it is their cash-cow spammable procedure. They won't get thrown out of a job, they'll just treat the more complex cases... kind of like the psychiatrists and psych nps?
True. But it is their cash-cow spammable procedure. They won't get thrown out of a job, they'll just treat the more complex cases... kind of like the psychiatrists and psych nps?
it's not neccessarily an issue of complexity.....I also think you underestimate the training required to do a screening colonoscopy.
furthermore there is nothing in the future(even in the distant future) suggesting which nps will be able to bill for such things.
Finally, the problem with the psychiatrist/psych np analogy is that in psychiatry the vast majority of patients seen in many settings are *not* complex. In this is it more similar to family medicine.
Dude.... Can you just say 1 good thing about psychiatry/psychiatrists? I honestly can't figure out why you went into this profession. Were you forced into it? What the hell.
AB, if you want to be a psychiatrist a good first step is being ok with not knowing why Vistaril went into Psychiatry. If you cannot overcome that obstacle you will have a rough road ahead my friend.
HA! Not sure how to respond to this, I think that is a silly thing to say. Is this like how you aren't supposed to ask other prisoners why they are in prison? Of all the reasons why I should or should not go into psych, getting into it with a random dude on the internet is pretty low on my list.
Ok though, I get it. He is just one guy on the internet sharing his opinion. At the end of the day it really is just his opinion. He can't see the future and neither can I.
I'd blame it on stress, but that would be disingenuous. I'd argue with him any day of the week, just like he would argue back.
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i've explained on several occasions why i went into psych. i find the subject matter interesting in many cases, some of the pts entertaining(seeing a manic girl/guy is always fun), didnt enjoy medicine/surgery, don't lose sleep at night because it's not as challenging as surgery or something, and like the day to day work better than other things. I don't really even always compare it to medical specialties but also occupations in general....I like being a psychiatrist better than a social worker, architect(well I think I would), teacher, detective, etc.....
Vistaril is manifestly doubtful about the future of psychiatric practice. He has reason to think this way based on his experience and observatrions. I don't blame him for that, but I don't think it's as dire as he thinks.
It is in Vistaril's advantage for there to remain a vast shortage of psychiatrists.
Vistaril, like all human beings, tends to act out of self-interest.
In his desire to preserve whatever his piece of the psychiatric pie may be, he overstates the present and potential future problems of psychiatry to prevent others from joining the field. This may be partially unconsciously driven.
That's my theory, anyway. It's mostly a joke, but this formulation allows me to be more empathic toward his state of mind and conduct on this forum.
It is in Vistaril's advantage for there to remain a vast shortage of psychiatrists.
Vistaril, like all human beings, tends to act out of self-interest.
In his desire to preserve whatever his piece of the psychiatric pie may be, he overstates the present and potential future problems of psychiatry to prevent others from joining the field. This may be partially unconsciously driven.
That's my theory, anyway. It's mostly a joke, but this formulation allows me to be more empathic toward his state of mind and conduct on this forum.
I think that this 'shortage of psychiatrist' some keep talking about isn't neccessarily a good thing for us.....for starters, you could easily argue that there isn't a shortage but rather a surplus(how many patients do I see who could be managed by their pcp or an np? A lot imo)....but that's another story and one I don't want to argue now.
What would be nice if we could do a lot better in terms of recruiting more amgs to do psychiatry. That would elevate the field somewhat imo.
If psychiatry was on a winning streak in terms of compensation for about 10 years I can see AMGs starting to have more interest. We've seen these basic trends in other specialties. Right now we're leaders among the lowest paid primary care specialties and dealing with ongoing questions about stigma and prestige.
I'm going to wade into this analysis of Vistaril and suggest that he (or his wife) is a foreign graduate, which would complete the picture of self-loathing quite nicely.
you would be very wrong
Yes, but we all need our fantasies.
Stigma is something our patients struggle with. This isn't something we need to take on personally.
Prestige is something folks need to outgrow.
I don't think he's a foreign medical grad, but he must have a lot of personal (negative) experience training with enough FMGs and DOs to cause his passion for the topic. The clinical exposure/experiences, systems, and social support he describes does not gel with the "top NE program" claim.
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I'm guessing he got bumped down his rank list, and saw that his "top" programs took a few IMGs ahead of him.
Depends on whether you consider the Confederate States of America to still be a foreign country.
He's so darn red-blooded American he pees Jack Daniels and poops whole apple pies.
Thank you sir. That element of honor is one of the key attractions for me to this field.
And to bring that around to the original topic and also the criticism from Splik and others about the weaknesses in our knowledge foundation:
If our tools are weak and our diagnoses not that helpful in guiding treatment aren't we all the same leaky boat together? The patients, their families, us, NP's, psychologist, etc. So that a serious conversation about what we're doing is much different conversation than our character, our innate ability (or relative inability as some seem fixated on here), our intentions, our polyglot make up, and so on.
If we're using stone tools at the frontier of medicine. I don't see reason to indict us for it. And I don't see reason to give up our foundation in medicine. I'm one of these people that wanted to be a doctor and happened to find psychiatry the most interesting field. If we are headed to the frontier where not much is clear. Why wouldn't we take a viable skill set in general medicine basics with us.
Even in my short 2 years as a suitor for this profession I've seen patients get identified as a psych patient and get rushed half-hazardly off other services. They want to throw our patients out like garbage because many of us in medicine are uncomfortable with psychiatric illness.
Seems to me, basic medical knowledge will help us identify problems in our patients that others couldn't.
So I don't agree that NP's or psychologists can do what we can. And while the foundations of our knowledge structure may be in crisis, it seems to me, the essential problems of our patients will continue as well as the need for medical care for them from people who train specifically to take care of them.
Nobody else wants to both make the sacrafice to be a doc and work specifically with our patients. Seems like a scenario that engineers it's own scarcity and thus bounty of opportunity. Even as the field gets populated with other prescribers.
well you could apply this sort of argument to about everything.....most med students I talk to are great, and the reasons they arent interested in psychiatry are numerous, but a big one is that they feel it is so disconnected from medicine. In fact, many med students tell me that before the rotation they actually felt there was more of an overlap with medicine and viewed psychiatrists more as 'real doctors' than they do afterwards. And in trying to address this, you simply can't push a round ball through a square whole. On the flip side, a minority of students who are more interested in the psychological aspect of things were dismayed that psychiatrists didn't get to spend more time with their patients and do more intensive therapy. Of course their exposure is usually limited to inpatient, consults, and a little bit of outpt med clinic, so this skews things.....but still, they tell me that if they were interested in mental health they would find being a clinical psychologist or even lcsw/lpc therapist more interesting.
I was looking at some of those funny videos on youtube regarding mental health the other night, and stumbled across this....it's a med student describing how she felt after her psych rotation. Now sure her views are a bit simplistic, but this is certainly how the majority of medical students view our field, especially after their rotation. Skip ahead a minute or so if you are interested....
http://www.youtube.com/watch?v=kM5eEQIbPYM
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This has to say more about your program than it says about psychiatry, I've never heard anyone at my medschool say this.
well...watch the video..just the first 4-5 minutes....it is pretty good.
furthermore, I currently work in a total of 4 different settings(3 unrelated to my program)....and most of the people I work with didn't train at my program.
What I mean is it has to say more about whoever is designing your MS3 rotation and the people who are teaching the medstudents. If your MS3 rotation is so bad that students are coming away with the view that
"they actually felt there was more of an overlap with medicine and viewed psychiatrists more as 'real doctors' than they do afterwards"
Then it seems like you all have an awful teaching environment and its not surprising you all apparently get so little respect from other specialties at the hospital.
on the medical student forums(browing that board and using the search engine) it appears a lot of non-psych bound med students feel that way. I think it is safe to assume they are from a diverse group of med schools.....
Also, you shouldn't neccessarily view the phrase 'real doctor' as a compliment or a perjorative.
Somebody earlier--maybe Billy--pointed out that V extrapolates the lowest common denominator of our field and holds it up as the best it has to offer someone. I agree with that. But I also recognize that it's quite possible for someone to come away from a clerkship with that impression. My psych department has some good doc's but also has inspired a similar experience from my colleagues.
It's dismaying. And concerning.
But I still think an individual can create the space for themselves to engage more rigorously, to look for opportunities to elevate their service, and in short to be the person they want to be.
Not only does it reflect on the program's culture but also the individual to prostrate themselves in failure and worse to propagate that choice as some kind unalterable fate of making the choice to be a psychiatrist.
