Psych NPs - Threat or Asset?

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As a consumer of psychiatric services and someone who works with the chronically mentally ill, I do not think NPs and PAs should be doing anything except medication reviews (keeping people on the same meds or making tiny adjustments). I think NPs and PAs are tremendously valuable in some settings, but I have had terrible service with NPs in the psychiatric field personally and I don't trust them with the incredibly complicated organ that is the brain....I am confident I'm not the only one who feels this way.

I would also say, for those of you who are considering psychiatry or are in a program to be a psych doc, please don't be discouraged! We need you! It is taking me 3 months to get in to see a psychiatrist and the alternative was inpatient treatment. I think its ludicrous to go for inpatient treatment simply because there is not an outpatient psychiatrist to see me!! We need you! 🙂

Sorry for the weird tangential pep talk. I had to.

 

[zenman]

As a consumer of psychiatric services and someone who works with the chronically mentally ill, I do not think NPs and PAs should be doing anything except medication reviews (keeping people on the same meds or making tiny adjustments). I think NPs and PAs are tremendously valuable in some settings, but I have had terrible service with NPs in the psychiatric field personally and I don't trust them with the incredibly complicated organ that is the brain....I am confident I'm not the only one who feels this way.

I would also say, for those of you who are considering psychiatry or are in a program to be a psych doc, please don't be discouraged! We need you! It is taking me 3 months to get in to see a psychiatrist and the alternative was inpatient treatment. I think its ludicrous to go for inpatient treatment simply because there is not an outpatient psychiatrist to see me!! We need you! 🙂

Sorry for the weird tangential pep talk. I had to.

You realize of course that if there were more NPs you wouldn't have to wait 3 months for treatment. Yes, the brain is complicated but psychiatrists don't know half of how it works either. Sorry you have had terrible experiences with NPs but the same goes for any provider...there are good and bad ones. I work with a group of psychiatrists and NPs (no PAs) and we all do the same work...except I tend to prescribe antipsychotics to young soldiers at a rate far below some of my psychiatrist buddies. You sound like you favor a provider knowing the brain vs one knowing the person.

 

[xlithiumx]

You realize of course that if there were more NPs you wouldn't have to wait 3 months for treatment.

A shorter wait, yes... and one that ends with inferior treatment.

 

[Leo Aquarius]

... I work with a group of psychiatrists and NPs (no PAs) and we all do the same work...

I love nurses, and don't want to turn this into anything antagonistic.

Maybe you guys do similar work, but for the general population out there Psychiatrists and Psych NPs don't do the same work. One manages things like delirium, psychosis, and depression with 8 years of medical training, and the other manages them with nursing training.

Antipsychotics affect heart function, change seizure thresholds, affect white blood cell counts, have alpha blockade, cholinergic blockade, serotonergic antagonism, in addition to effects on dopamine and you have to understand OTHER medical conditions (neurologic, cardiac, reproductive, neoplastic, ophthalmic, to name some main ones) to minimize serious side effects. You can thrown a 68yo man into renal failure that can lead to urosepsis and risk of death if you don't know how muscarinic receptors affect bladder function in BPH. And I wouldn't trust a nurse to remember this when she prescribes your grandfather Thorazine.

How about patients who have strange presentations? What will a NP or psychologist do when they see a patient who is sitting motionless with echolalia? How will you begin to work up someone like that? Let me guess, you will prescribe an antipsychotic. The patient doesn't improve because you missed a key diagnosis you had no clue about. I could go on and on with various scenarios I've seen just as an intern.

You guys (NPs, PAs, psychologists, and Vistaril) all figure that if you know your psych drugs you can be a psychiatrist. That's idiotic. You have to have an understanding of diseases of the other systems because:

1) our drugs affect other systems of the body usually in negative ways,
2) other diseases cause/contribute to mental illness and both need management, and
3) other diseases first present like a mental illness and you may miss them.

A good psychiatrist can jump on a cancer diagnosis right away, or acidosis, or underlying liver failure that's leading to SBP since each can first look like mental illness (just to give some examples). This is why physicians should oversee each prescribed medication. Period.

 

[zenman]

I love nurses, and don't want to turn this into anything antagonistic.

Maybe you guys do similar work, but for the general population out there Psychiatrists and Psych NPs don't do the same work. One manages things like delirium, psychosis, and depression with 8 years of medical training, and the other manages them with nursing training.

Antipsychotics affect heart function, change seizure thresholds, affect white blood cell counts, have alpha blockade, cholinergic blockade, serotonergic antagonism, in addition to effects on dopamine and you have to understand OTHER medical conditions (neurologic, cardiac, reproductive, neoplastic, ophthalmic, to name some main ones) to minimize serious side effects. You can thrown a 68yo man into renal failure that can lead to urosepsis and risk of death if you don't know how muscarinic receptors affect bladder function in BPH. And I wouldn't trust a nurse to remember this when she prescribes your grandfather Thorazine.

How about patients who have strange presentations? What will a NP or psychologist do when they see a patient who is sitting motionless with echolalia? How will you begin to work up someone like that? Let me guess, you will prescribe an antipsychotic. The patient doesn't improve because you missed a key diagnosis you had no clue about. I could go on and on with various scenarios I've seen just as an intern.

You guys (NPs, PAs, psychologists, and Vistaril) all figure that if you know your psych drugs you can be a psychiatrist. That's idiotic. You have to have an understanding of diseases of the other systems because:

1) our drugs affect other systems of the body usually in negative ways,
2) other diseases cause/contribute to mental illness and both need management, and
3) other diseases first present like a mental illness and you may miss them.

A good psychiatrist can jump on a cancer diagnosis right away, or acidosis, or underlying liver failure that's leading to SBP since each can first look like mental illness (just to give some examples). This is why physicians should oversee each prescribed medication. Period.

Got all that, that's why I only use them when I have to vs some of my psychiatrist buddies handing them out like skittles. I know this because we do peer review on each other's patients. Maybe because of their extensive knowledge they feel comfortable with off-label and non-FDA approved uses.

 

[LIDO]

I think you are missing the bigger picture of Leo's post.

 

[st2205]

One of the things that had me the most curious about specific PNP programs is that general medical training is non-existent (see links below). Some programs can be done completely online. I find it strange that, as a profession, there's a push to shake the non-medical stereotype and most all advocate good training in medicine, but then in the name of professional collaboration these are given a pass. Perhaps I have some ignorance about the psych specific NP programs, but I'm honestly not seeing that much more exposure than the masters in psychopharm for psychologists.

http://nursing.utah.edu/programs/resources/2013 Psych Mental Health MS PoS.pdf
http://www.uta.edu/nursing/msn/pmhnp
http://nursing.osu.edu/sections/aca...hiatric-mental-health-nurse-practitioner.html

 

[zenman]

I think you are missing the bigger picture of Leo's post.

No I got it. I agree physicians have much more extensive medical training available in your head while I have to actually look at Stahl's, for example, to check interactions/precautions with other systems.

One of the things that had me the most curious about specific PNP programs is that general medical training is non-existent (see links below). Some programs can be done completely online. I find it strange that, as a profession, there's a push to shake the non-medical stereotype and most all advocate good training in medicine, but then in the name of professional collaboration these are given a pass. Perhaps I have some ignorance about the psych specific NP programs, but I'm honestly not seeing that much more exposure than the masters in psychopharm for psychologists.

http://nursing.utah.edu/programs/resources/2013 Psych Mental Health MS PoS.pdf
http://www.uta.edu/nursing/msn/pmhnp
http://nursing.osu.edu/sections/aca...hiatric-mental-health-nurse-practitioner.html

When you look at distance education in a negative light you probably haven't looked at the research. Non are completely "online" as clinical is done in person. Granted some people are better suited sitting in the class room while it's a cursed bore to me, as well as a waste of time and expense.

NP programs build off the basic "medical" knowledge in the BSN program. I've had a neuroscience course, pharm course, and psychopharm course. Went all way through Stahl's Essential Psychopharm except for one chapter plus some other general pharm book. I don't know what other courses do but do know some only have one pharm course. I was happy to see that FNPs at my school were also required to take a course in psychopathology and psychoparm. Course it's nowhere near what you guys get.

 

[Armadillos]

fwiw I think the bashing distance learning aspect is a little misplaced, if you stop by almost any med-school today less than 15% of first and second years go to class, they all listen to the recordings online or just read the syllabus/robbins/first aid themselves. I know my medschool has had a hard time getting a couple lecturers to still lecture because giving a lecture to an empty room sucks.

Not saying that DNPs are recieving the same education, just that bashing it solely based on the fact its online is a bit shortsighted seeing as thats the way pretty much all education is trending.

 

[billypilgrim37]

An online course and lectures being online are vastly different things.

 

[zenman]

An online course and lectures being online are vastly different things.

Man, that's deep, lol!

 

[billypilgrim37]

Man, that's deep, lol!

For any halfway decent medical school, the lectures are only one part of even the pre-clinical curriculum. You may listen to the lectures online (lectures are lectures), but there are still plenty of hours of small group didactics and other experiences that require a person to be in person and participating. We probably had 15 hours of week of lectures, most of which we probably all watched in our underwear at 2x speed, and then another 6-15 hours each week of other things that you couldn't watch online because they weren't lectures. Much of the learning in medical school, even pre-clinical, is not through lectures and is also based on being surrounded by a lot of very talented classmates and dedicated teaching faculty.

So, yeah, an online course and lectures being online are vastly different things. And I shouldn't have to explain that.

 

[zenman]

So, yeah, an online course and lectures being online are vastly different things. And I shouldn't have to explain that.

You do to me cause I get to the bottom line and make sure we're all clear, lol!

 

[vistaril]

A good psychiatrist can jump on a cancer diagnosis right away, or acidosis, or underlying liver failure that's leading to SBP since each can first look like mental illness (just to give some examples). This is why physicians should oversee each prescribed medication. Period.

this is great I guess, but in most of community psychiatry(and including settings like the VA) this knowledge base(for the psychiatrists who actually have the skills to use it) is going to be hard to put it into use.

If you wanted to work with things like SBP, liver failure, acidosis, etc....you should have gone into a medical or surgical field. I'm assuming because you went into mental health you wanted to work with depression and anxiety and whatnot instead.

And if you for a second that the rest of medicine in the future is going to come rushing to the aid of psychiatrists in our battle with psych NP's, that is delusional. Most of the rest of medicine just considers 'behavioral health' one entity....they don't much care the difference between different behavioral health providers.

 

[st2205]

Perhaps I shouldn't have brought up online courses as it's really neither here nor there and much less pertinent than other issues. Now perhaps I'm missing somewhere in looking at the curricula of several programs, but there's absolutely no medicine/primary care exposure (I'm not talking coursework), which I find scary. Relying on the leftovers of a BSN is no substitute, though I could imagine without such exposure some may question its necessity. It makes me wonder, with no hyperbole intended, why we wouldn't be able to create an intensive 6 month course for psych techs or any others with some mental health experience and turn them into prescribers.

Vistaril has advocated removing psychiatry from medicine by making it its own independent pathway where you skip much of the supposed irrelevant medical training to fast track into psychiatry. Oddly, the PMHNP is precisely what vistaril is describing, from what I can tell.

 

[vistaril]

Perhaps I shouldn't have brought up online courses as it's really neither here nor there and much less pertinent than other issues. Now perhaps I'm missing somewhere in looking at the curricula of several programs, but there's absolutely no medicine/primary care exposure (I'm not talking coursework), which I find scary. Relying on the leftovers of a BSN is no substitute, though I could imagine without such exposure some may question its necessity. It makes me wonder, with no hyperbole intended, why we wouldn't be able to create an intensive 6 month course for psych techs or any others with some mental health experience and turn them into prescribers.
.

because psych techs don't have any real relevant background/training....psych NP's do.

 

[AnnoyedByFreud]

Perhaps I shouldn't have brought up online courses as it's really neither here nor there and much less pertinent than other issues. Now perhaps I'm missing somewhere in looking at the curricula of several programs, but there's absolutely no medicine/primary care exposure (I'm not talking coursework), which I find scary.

Vistaril has advocated removing psychiatry from medicine by making it its own independent pathway where you skip much of the supposed irrelevant medical training to fast track into psychiatry. Oddly, the PMHNP is precisely what vistaril is describing, from what I can tell.

My program is 3 quarters primary care/physical health assessment and 4 quarters pure psych, just so you know. That curriculum that was posted didn't include any clinical rotations listed, just the coursework. All NPs must take advanced physical health assessment which has a clinical rotation that goes with it.

 

[st2205]

My program is 3 quarters primary care/physical health assessment and 4 quarters pure psych, just so you know. That curriculum that was posted didn't include any clinical rotations listed, just the coursework. All NPs must take advanced physical health assessment which has a clinical rotation that goes with it.

But what does all of this equate to, exactly? What is the clinical rotation? How many?

 

[LIDO]

I feel awful for patients that are assigned rogue ancillary staff playing doctor. We all have a role in the system. NPs are physician extenders. Go back and forth all you want, but that is the truth.

 

[AnnoyedByFreud]

But what does all of this equate to, exactly? What is the clinical rotation? How many?

I think that's what makes it hard... it isn't mean to equate to what you're familiar with (physician training). If anyone claims that, they're crazy. All my rotations are in psychiatric settings and with psych patients, even when I'm there to do physical health assessment. I know I will be in outpatient and inpatient settings, including one quarter in a psychiatric emergency room. I was just posting to address your original point and explain that psych NPs do get advanced physical health/internal medicine/primary care (however you want to put it) training. It is not just what they learn at the RN level.

 

[xlithiumx]

I think that's what makes it hard... it isn't mean to equate to what you're familiar with (physician training). If anyone claims that, they're crazy. All my rotations are in psychiatric settings and with psych patients, even when I'm there to do physical health assessment. I know I will be in outpatient and inpatient settings, including one quarter in a psychiatric emergency room. I was just posting to address your original point and explain that psych NPs do get advanced physical health/internal medicine/primary care (however you want to put it) training. It is not just what they learn at the RN level.

So, the program you have is 7 quarters, some of which includes clinical work. The coursework is provided by nurses who have not learned medicine.

A physician who is a psychiatrist spends 2 years in extremely intense classroom study of basic medical science which essentially exceeds that of any other professional school in difficulty and intensity. She then spends 6 years getting supervised clinical training which tends to range from 40-80 hours per week. Over the course of this training, the psychiatrist learns not only all of the general medicine required to earn an MD degree but then has 4 full years to focus specifically on psychiatric theory and practice. A psychiatrist at the end of residency training will, almost certainly, know more than any psychiatric nurse practitioner will ever know about psychiatry. At the end of training, a psychiatrist will have over 10000 hours of supervised clinical care experience. A figure that is greater than 10 times that of even people who complete a DNP degree.

To have one quarter of "advanced physical health" means essentially that you know barely any more medicine than a lay person. The gulf between the level of understanding of human physiology and pathophysiology between a nurse practitioner and a physician is almost unimaginable.

To complete medical training means that one has passed a series of very rigorous challenges to be admitted to the medical profession. Nurses are not professionals and neither are nurse practitioners. Nurses are technical employees and nurse practitioners are technical employees who are pretending to be professionals without going through the rigors of the process of initiation and qualification required of the profession. This is something nurses cannot understand.

Nurses have a union. Zenman in the other NP thread announces that he works 40 hours per week and "not a minute more." This is characteristic of nurses as technical employees. Professionals fulfill obligations to their patients, their profession, society, and to themselves in that order. Professionals stay until the work is done, even when that means making personal sacrifices. Professionals to not participate in labor unions. Professionals self-govern and have standards of conduct that exceed those of the lay person. Professionals are granted the privilege of the public trust as a reward for this behavior.

If a psychiatrist wants to employ an NP to increase their revenue, then by all means go ahead and do it. The patients will be receiving substandard care.

There is no case too simple for the care of a psychiatrist and if we're going to declare with certainty that mental disorders are medical illnesses, then patients deserve the care of a physician who has dedicated the greater part of a decade learning his craft. They deserve the care of someone who is willing to make the personal sacrifices associated with becoming a physician. They deserve a professional. I don't refer to NPs and I won't in the future. My patients and family deserve better.
.

 

[xlithiumx]

Got all that, that's why I only use them when I have to vs some of my psychiatrist buddies handing them out like skittles. I know this because we do peer review on each other's patients. Maybe because of their extensive knowledge they feel comfortable with off-label and non-FDA approved uses.

You're being really cute there, but the reality is that you'll never understand the human body in a way that a physician does. So, you can be coy and hide behind that, but it's totally true that physicians use medications off-label because they have a vastly superior understanding of human physiology to you. They actually understand with some degree of competence what happens when you put the substance in the body. To rely on FDA indications and dosing guidelines is to essentially tie your hands behind your back and fail your patients. I get that because of your lack of training, you have to practice that way, but your physician colleagues don't.

 

[zenman]

Just wait till I get home. I'm going to have some fun with you!

 

[vistaril]

You're being really cute there, but the reality is that you'll never understand the human body in a way that a physician does. So, you can be coy and hide behind that, but it's totally true that physicians use medications off-label because they have a vastly superior understanding of human physiology to you. They actually understand with some degree of competence what happens when you put the substance in the body. To rely on FDA indications and dosing guidelines is to essentially tie your hands behind your back and fail your patients. I get that because of your lack of training, you have to practice that way, but your physician colleagues don't.

lol....it's this type of attitude why psychiatrists are seen by so many(physicians, nurses, and professionals in other fields) as not the best and brightest. Eliminating this kind of thinking from the field would give us better reps.

 

[xlithiumx]

lol....it's this type of attitude why psychiatrists are seen by so many(physicians, nurses, and professionals in other fields) as not the best and brightest. Eliminating this kind of thinking from the field would give us better reps.

Just because you didn't learn anything in medical school doesn't mean there wasn't anything to learn. Just because you don't like medicine doesn't mean it's not critically important to the practice of psychiatry.

Psychiatrists lose the respect of their physician colleagues when they refuse to maintain their body of medical knowledge. Seems like you're on that track. Good luck.

 

[vistaril]

Just because you didn't learn anything in medical school doesn't mean there wasn't anything to learn. Just because you don't like medicine doesn't mean it's not critically important to the practice of psychiatry.

Psychiatrists lose the respect of their physician colleagues when they refuse to maintain their body of medical knowledge. Seems like you're on that track. Good luck.

nonsense....psychiatrists(well behavioral health workers in general) lose the respect of internists, surgeons, family physicians, etc when they can't offer real expertise on an issue that greatly helps the patient. Either because they don't have the skill set, or because the model in which they treat that particular patient doesn't allow them to implement that skill set(for example med check appts when the pt would most benefit from a course of cbt). The idea that a nephrologist will somehow respect us more because we know 35% as much medicine instead of 25% as much medicine as them is absurd. They'll respect us if we are really good at doing the stuff they can't do well....not the stuff they just don't care to do(ie throw ADs at a sad patient).....

 

[xlithiumx]

nonsense....psychiatrists(well behavioral health workers in general) lose the respect of internists, surgeons, family physicians, etc when they can't offer real expertise on an issue that greatly helps the patient. Either because they don't have the skill set, or because the model in which they treat that particular patient doesn't allow them to implement that skill set(for example med check appts when the pt would most benefit from a course of cbt). The idea that a nephrologist will somehow respect us more because we know 35% as much medicine instead of 25% as much medicine as them is absurd. They'll respect us if we are really good at doing the stuff they can't do well....not the stuff they just don't care to do(ie throw ADs at a sad patient).....

Just to clarify, then: what was it about my insistence that physician psychiatric training is vastly superior to that of a nurse provider precisely because of its length and intensity would lead me to lack the respect of other physician colleagues?

From my perspective (and I believe the perspective of several others on this forum including Splik, who seems to know a hell of a lot about almost everything), psychiatry is tremendously complex and to do it well requires broad and deep knowledge of general medicine, psychology, culture, basic neuroscience, and philosophy. Psychiatry is more integrative than any other medical specialty and therefore requires long and intense study.

If you don't do that, or don't share that paradigm, then maybe you are worthy of whatever lack of respect you receive/perceive.

I have not had that experience with my primary medicine colleagues. I have had the experience of my primary medical colleagues being deeply appreciative of my capacity to help them manage very ill patients and provide them education on how to do it better themselves. We share a reciprocal respect based on acknowledgement of the inherent difficulty and complexity of our specialties.

 

[vistaril]

Just to clarify, then: what was it about my insistence that physician psychiatric training is vastly superior to that of a nurse provider precisely because of its length and intensity would lead me to lack the respect of other physician colleagues?

From my perspective (and I believe the perspective of several others on this forum including Splik, who seems to know a hell of a lot about almost everything), psychiatry is tremendously complex and to do it well requires broad and deep knowledge of general medicine, psychology, culture, basic neuroscience, and philosophy. Psychiatry is more integrative than any other medical specialty and therefore requires long and intense study.

If you don't do that, or don't share that paradigm, then maybe you are worthy of whatever lack of respect you receive/perceive.

I have not had that experience with my primary medicine colleagues. I have had the experience of my primary medical colleagues being deeply appreciative of my capacity to help them manage very ill patients and provide them education on how to do it better themselves. We share a reciprocal respect based on acknowledgement of the inherent difficulty and complexity of our specialties.

to answer the first question- your arrogance associated with it. I recognize that there are certain patients I am probably better equipped to treat than psych nps. But I also recognize that this isn't needed for most patients, and I also recognize that my practice model in some settings doesn't allow this training to really stand out over an np.

 

[JourneyAgent]

Just to clarify, then: what was it about my insistence that physician psychiatric training is vastly superior to that of a nurse provider precisely because of its length and intensity would lead me to lack the respect of other physician colleagues?

From my perspective (and I believe the perspective of several others on this forum including Splik, who seems to know a hell of a lot about almost everything), psychiatry is tremendously complex and to do it well requires broad and deep knowledge of general medicine, psychology, culture, basic neuroscience, and philosophy. Psychiatry is more integrative than any other medical specialty and therefore requires long and intense study.

If you don't do that, or don't share that paradigm, then maybe you are worthy of whatever lack of respect you receive/perceive.

I have not had that experience with my primary medicine colleagues. I have had the experience of my primary medical colleagues being deeply appreciative of my capacity to help them manage very ill patients and provide them education on how to do it better themselves. We share a reciprocal respect based on acknowledgement of the inherent difficulty and complexity of our specialties.

I've heard this as well from my instructors that I most respect. They all seem to have arrived at some perpetual struggle to learn and know more. The short cutting of training being unthinkable from that viewpoint. I recently worked with a British trained neonatologist of first rank pedigree who remarked on the absurdly short training of American pediatricians expected to treat complex patients.

I think if you couldn't find that nuance in psychiatry, then you shouldn't have gone to medical school and trained in the field in the first place. It's a lazy, shoddy practice to criticize without organizing your own efforts towards mastery of the art. Critics who are masterful at their work are probably among the best we have. Critics who are mediocre are not worth the conversation.

I would never have been satisfied with NP training. And so the obstacles of practicing a higher form of the art presented by market forces are to be navigated,and struggled against and most certainly not resigned to.

I would feel ashamed of myself to have failed to honor my teachers' continual path of learning to accept and internalize equivalence with NP training.

 

[zenman]

You're being really cute there, but the reality is that you'll never understand the human body in a way that a physician does. So, you can be coy and hide behind that, but it's totally true that physicians use medications off-label because they have a vastly superior understanding of human physiology to you. They actually understand with some degree of competence what happens when you put the substance in the body. To rely on FDA indications and dosing guidelines is to essentially tie your hands behind your back and fail your patients. I get that because of your lack of training, you have to practice that way, but your physician colleagues don't.

I understand that as well as understanding many physicians will never understand the human body in a way that I do...with training outside mainstream medicine. I see the same population here that everyone does so if a psychiatrist feels good, with their vastly superior knowledge, pumping antipsychotics into young soldiers go to it. I did peer-review on just one psychiatrist and there were 16 charts with antipsychotics. I maybe have 2-3 patients on them. Their use is rampant, which is now why the Gods on high are making us review charts. So basically it looks looks like my practice might be beneficial...at least I hope so.

I studied cell function and structure. I didn't have an electron microscope like you probably did. Heck, I can't even remember what the Henderson-Hasselbach equation is about. Probably can't even explain the Kreb's cycle either.

 

[vistaril]

I understand that as well as understanding many physicians will never understand the human body in a way that I do...with training outside mainstream medicine. I see the same population here that everyone does so if a psychiatrist feels good, with their vastly superior knowledge, pumping antipsychotics into young soldiers go to it..

preach on bro...

 

[zenman]

So, the program you have is 7 quarters, some of which includes clinical work. The coursework is provided by nurses who have not learned medicine.

A physician who is a psychiatrist spends 2 years in extremely intense classroom study of basic medical science which essentially exceeds that of any other professional school in difficulty and intensity. She then spends 6 years getting supervised clinical training which tends to range from 40-80 hours per week. Over the course of this training, the psychiatrist learns not only all of the general medicine required to earn an MD degree but then has 4 full years to focus specifically on psychiatric theory and practice. A psychiatrist at the end of residency training will, almost certainly, know more than any psychiatric nurse practitioner will ever know about psychiatry. At the end of training, a psychiatrist will have over 10000 hours of supervised clinical care experience. A figure that is greater than 10 times that of even people who complete a DNP degree.

I read once where a physician said her BS in physics was more difficult in anything she learned in medical school. I've heard anthropology and astrophysics made medical school look like kindergarden also. Yes, your school was difficult but don't think just because you earned a Ranger tab means you're cream of the crop.

To have one quarter of "advanced physical health" means essentially that you know barely any more medicine than a lay person. The gulf between the level of understanding of human physiology and pathophysiology between a nurse practitioner and a physician is almost unimaginable.

To complete medical training means that one has passed a series of very rigorous challenges to be admitted to the medical profession. Nurses are not professionals and neither are nurse practitioners. Nurses are technical employees and nurse practitioners are technical employees who are pretending to be professionals without going through the rigors of the process of initiation and qualification required of the profession. This is something nurses cannot understand.

This basically shows you're an idiot, probably cause you spent so much time memorizing stuff instead of learning what was actually happening in the real world. "Technical" employees graduate from trade schools, not universities.

Nurses have a union. Zenman in the other NP thread announces that he works 40 hours per week and "not a minute more." This is characteristic of nurses as technical employees. Professionals fulfill obligations to their patients, their profession, society, and to themselves in that order. Professionals stay until the work is done, even when that means making personal sacrifices. Professionals to not participate in labor unions. Professionals self-govern and have standards of conduct that exceed those of the lay person. Professionals are granted the privilege of the public trust as a reward for this behavior.

I only have to work 40 hours a week because I'm efficient. Actually I'm lazy which has led to me being very efficient. I don't whine and complain about how much charting I have to do nor do I have to come in on weekends to catch up. I have my system and it works. That is the way of a true professional. I balance the rest of my life in other pursuits. Many docs are burnt out after 10 years and have one of the highest suicide rates around. I've been around over 40 years and have no intention of stopping till I keel over dead. I would be careful about saying anything about how much the public trusts you, lol!

If a psychiatrist wants to employ an NP to increase their revenue, then by all means go ahead and do it. The patients will be receiving substandard care.

Got the research behind that or is that just a personal opinion?

There is no case too simple for the care of a psychiatrist and if we're going to declare with certainty that mental disorders are medical illnesses, then patients deserve the care of a physician who has dedicated the greater part of a decade learning his craft. They deserve the care of someone who is willing to make the personal sacrifices associated with becoming a physician. They deserve a professional. I don't refer to NPs and I won't in the future. My patients and family deserve better.
.

Send them to someone who loves to pump meds in them and make them fat.

 

[xlithiumx]

I understand that as well as understanding many physicians will never understand the human body in a way that I do...with training outside mainstream medicine. I see the same population here that everyone does so if a psychiatrist feels good, with their vastly superior knowledge, pumping antipsychotics into young soldiers go to it. I did peer-review on just one psychiatrist and there were 16 charts with antipsychotics. I maybe have 2-3 patients on them. Their use is rampant, which is now why the Gods on high are making us review charts. So basically it looks looks like my practice might be beneficial...at least I hope so.

It's not entirely clear to me why you bring up antipsychotic use. I think yours and my views about that are entirely in line. I use antipsychotics in schizophrenia and for psychotic mood episodes, and that's pretty much it. Of course those agents have indications in major depressive disorder as well as bipolar disorder, but I have trouble with the idea that they should be used, given the manifest risks of metabolic syndrome, EPSE, and of course TD.

That said, Zenman, you cannot effectively treat severe psychiatric illness in an evidence based fashion if you limit yourself to FDA label indications and dose ranges. Fluoxetine upward of 60 mg is off-label, but is a mainstay of the treatment of both bulimia and OCD. Low-dose lithium is a well-supported adjunct in treatment-resistant depression. Buspirone is as effective as bupropion as an adjunct for depression, but has no indication.

Are you suggesting that you'd never use sertraline above 200 mg in a patient with severe OCD? Are you saying that you'd never use topiramate for affective lability in borderline personality disorder? Do you fail to use prazosin for nightmares in your soldiers with PTSD?

Evidence based treatments for severe psychiatric illness fall outside of FDA label indications and dose ranges. If you can't stomach that, then you can't effectively treat an SPMI population. There is so much more to psychiatry than you and Vistaril make it out to be. Just because you choose not to use the tools available to help your patients doesn't mean they don't exist.

You also get a major side-eye from me regarding your "special knowledge" of human physiology based in non-medical understandings. Human physiology is a science. Eastern medicine is a religion. You can believe it, you can refer your patients for it, but you cannot ethically practice Eastern medicine in a psychiatric practice. You fail to meet the community standard of practice and sell your patients a non-medical bill of goods from a position of authority. If you do that, you represent your religious or spiritual belief as a fact of medical science. That is wrong.

 

[xlithiumx]

I read once where a physician said her BS in physics was more difficult in anything she learned in medical school. I've heard anthropology and astrophysics made medical school look like kindergarden also. Yes, your school was difficult but don't think just because you earned a Ranger tab means you're cream of the crop. ...

You're wrong and you will never be able to see it. I'm sorry. You offer straw men in response to very valid criticisms of your training. At least fight fire with fire. Your response to the argument that NPs don't have rigorous enough training to competently practice medicine is to say "you all make people fat." That's really weak sauce.

 

[vistaril]

It's not entirely clear to me why you bring up antipsychotic use. I think yours and my views about that are entirely in line. I use antipsychotics in schizophrenia and for psychotic mood episodes, and that's pretty much it. Of course those agents have indications in major depressive disorder as well as bipolar disorder, but I have trouble with the idea that they should be used, given the manifest risks of metabolic syndrome, EPSE, and of course TD.

That said, Zenman, you cannot effectively treat severe psychiatric illness in an evidence based fashion if you limit yourself to FDA label indications and dose ranges. Fluoxetine upward of 60 mg is off-label, but is a mainstay of the treatment of both bulimia and OCD. Low-dose lithium is a well-supported adjunct in treatment-resistant depression. Buspirone is as effective as bupropion as an adjunct for depression, but has no indication.

Are you suggesting that you'd never use sertraline above 200 mg in a patient with severe OCD? Are you saying that you'd never use topiramate for affective lability in borderline personality disorder? Do you fail to use prazosin for nightmares in your soldiers with PTSD?

Evidence based treatments for severe psychiatric illness fall outside of FDA label indications and dose ranges. If you can't stomach that, then you can't effectively treat an SPMI population. There is so much more to psychiatry than you and Vistaril make it out to be. .

whoa there cowboy.....while I do agree with zenman in that I think psych nps do a fine job and are more than capable to treat most psych patients(and we know that see the same patients in many settings independently as psychs do), don't include me just after that ranting you did on FDA indications and dosages and stuff. I don't give a flip what the fda says or approves.....I am wondering why you think it takes some massive scholarly knowledge to prescribe zoloft 250 or lexapro 30-40 or whatever...knowing that higher doses of these meds are sometimes more effective in ocd and some anxiety disorders is not exactly high level knowledge. Every psych np I know who has been practicing at least a year is aware of this.

 

[vistaril]

You're wrong and you will never be able to see it. I'm sorry. You offer straw men in response to very valid criticisms of your training. At least fight fire with fire. Your response to the argument that NPs don't have rigorous enough training to competently practice medicine is to say "you all make people fat." That's really weak sauce.

unfortunately, I see a ton of psych np's prescribe the same polypharmacy nonsense that so many psychs prescribe.

Honestly, I can't tell much of a difference between the prescribing patterns of psychs and psych nps. And thats not a compliment to either group.

The biggest advantage good psychiatrists have on psych nps is that psych nps don't have therapy training(or really any decent training) and usually arent skilled in it. Now a lot of psychs dont either. And most of the ones that do don't actually practice in a setting where they can use it. But still, that is a big difference...

 

[vistaril]

I only have to work 40 hours a week because I'm efficient. QUOTE]

I dont understand this discussion on either side about hours. Some psychiatrists work 25 hrs. Some 40. Some 55. Some psych nps work 25 hours. Some 40. Some 55. Some psychiatrists have positions that may require them to sometimes stay after hours. Some psych nps have positions that may require them to stay after hours. Same with weekends.

That's all dependent on the work setting, who you're working for(yourself, a hospital system, agency, etc), and what sort of contract you signed. It has nothing to do with being a psych np or a psych.

 

[Leo Aquarius]

Vistaril has advocated removing psychiatry from medicine by making it its own independent pathway where you skip much of the supposed irrelevant medical training to fast track into psychiatry. Oddly, the PMHNP is precisely what vistaril is describing, from what I can tell.

What if Vistaril is actually a midlevel, a psych NP perhaps, who is pretending to be a psych resident to give more credibility to his arguments and anti-psychiatry bias.


Has anyone considered this possibility?

 

[billypilgrim37]

What if Vistaril is actually a midlevel, a psych NP perhaps, who is pretending to be a psych resident to give more credibility to his arguments and anti-psychiatry bias.


Has anyone considered this possibility?

He's not. He's a resident. I know people at his program.

 

[JourneyAgent]

He's not. He's a resident. I know people at his program.

Nevertheless. His depiction of psychiatry as a maze of mediocrity that predestines those who wander into it lost therein. Accompanied by a confident air of judgement on the poor practices of his colleagues and attendings...is perplexing. He seems to enjoy playing 3 card monty with his ostensible motivations, turning on a dime, the minute his proclamations of the limitations of the field comes close to landing on his own shoulders for it's lack of imagination, resolve, and self-respect.

It is understandable that this confusion arises. One he seems to thrive on. For what gain I have no earthly idea.

 

[priorities2]

Psych NP programs vary, but all have at least some therapy education. If you look at Yale's program for example, it's mostly therapy focused.

 

[vistaril]

What if Vistaril is actually a midlevel, a psych NP perhaps, who is pretending to be a psych resident to give more credibility to his arguments and anti-psychiatry bias.


Has anyone considered this possibility?

I am a huge supporter of psychiatry.....my support just takes a somewhat different form than yours.

 

[JourneyAgent]

Psych NP programs vary, but all have at least some therapy education. If you look at Yale's program for example, it's mostly therapy focused.

I mean this is the whole crux of this question. What is the pervasive "at least some" clause. Go get some therapy from that guy, he has at least some shadowing experience. Don't worry, he can also refer or work up your overlapping medical problems, he has at least a course in clinical medicine.

Asking where do you draw the line is an important question. This variance you speak of. Why do we even allow that? You let people near your loved ones with heavy pharmaceuticals that "have at least some" training? I sure as hell don't.

Lately I'm getting hip to the notion proposed by splik and others on here. That it's time we went the other way with it. And studied like her majesty's psychiatry consultants. The comprehensive expert model is what we should emulate. More medicine. More therapy. Long rigorous residency training.

"At least some" is perfect for stocking shelves at walmart. At least some high school. At least some decent smarts up der. At least a course in this. And that. Good to go.

And it's all good. Cause I'm a shaman on the side. We have a different non-physician model that allows alternative framework. For writing the same scripts. At least some irony in that.

 

[AnnoyedByFreud]

Psych NP programs vary, but all have at least some therapy education. If you look at Yale's program for example, it's mostly therapy focused.

So is Penn's program. It used to be a CNS program (which was entirely therapy focused, as psych CNSs work as therapists). When it switched to NP it kept the therapy portion of its program and added in the rest of the NP education. It's a very good program, but I didn't want to move to Philly. 👎

 

[vistaril]

Lately I'm getting hip to the notion proposed by splik and others on here. That it's time we went the other way with it. And studied like her majesty's psychiatry consultants. The comprehensive expert model is what we should emulate. More medicine. More therapy. Long rigorous residency training.
QUOTE]

This would only make us less competitive(relative to psych nps in the future) to the people who hire us(cmhcs, hospitals, VAs, agencies) and pay us(mostly insurers).......

 

[JourneyAgent]

This would only make us less competitive(relative to psych nps in the future) to the people who hire us(cmhcs, hospitals, VAs, agencies) and pay us(mostly insurers).......

Then this is every bit the existential threat some of us, including myself, believe it to be. All the more reason to double down and fight it. Even if we have to become educators and leaders of midlevel teams.

We can't all be hacks. We cant all go the midlevel route and come out ready to nurse the from the clinical tit. Some of us have to know wtf we're doing from go.

If that has to fewer of us to be sustainable, so be it. But I intend to keep trying to perfect the art because the short-cutting alternatives are just not satisfying options for the next 4 decades of my life.

We didn't get into med school and put in all this effort, above and beyond these newcomers so that we could sit back rest on our previous work, let them use us as a crutch for a couple of years and then eat our lunch.

You can insist on that. But if there's a political fight and a struggle for competition in the work place, to see who's model holds the field, expect me on the other side from you. And, I suspect, most of us here, when it comes to that.

At least we agree on one thing. It really is an active hot conflict going on right now. And set to intensify. To see whether we will sustain a model that accommodates the huge effort and expense of medical training.

 

[vistaril]

Then this is every bit the existential threat some of us, including myself, believe it to be. All the more reason to double down and fight it. Even if we have to become educators and leaders of midlevel teams.

We can't all be hacks. We cant all go the midlevel route and come out ready to nurse the from the clinical tit. Some of us have to know wtf we're doing from go.

If that has to fewer of us to be sustainable, so be it. But I intend to keep trying to perfect the art because the short-cutting alternatives are just not satisfying options for the next 4 decades of my life.

We didn't get into med school and put in all this effort, above and beyond these newcomers so that we could sit back rest on our previous work, let them use us as a crutch for a couple of years and then eat our lunch.

You can insist on that. But if there's a political fight and a struggle for competition in the work place, to see who's model holds the field, expect me on the other side from you. And, I suspect, most of us here, when it comes to that.

At least we agree on one thing. It really is an active hot conflict going on right now. And set to intensify. To see whether we will sustain a model that accommodates the huge effort and expense of medical training.

this is great and all, but what exactly(and how) are you going to fight? There is nothing to be done.....you're going to tell these upcoming healthgroups in obamacare/aca not to cover psych np care? they dont care. you're going to tell hospital execs not to hire psych nps at 60% of your salary? they don't care. you're going to tell state boards not to give rx priv to psych nps? They don't care.

This is bigger than us and what we 'want' or 'deserve'. There are a lot of different arguments related to these issues.....for example the model of psychiatry(medical vs nonmedical) and midlevel involvement are very different. One can even argue that increasing midlevel involvement goes more with maintaining the medical model. If the medical model continues to be chipped away at, then that's going to decrease midlevel involvement and incorporate more involvement from psychologists rather than psych nps imo.

 

[JourneyAgent]

this is great and all, but what exactly(and how) are you going to fight? There is nothing to be done.....you're going to tell these upcoming healthgroups in obamacare/aca not to cover psych np care? they dont care. you're going to tell hospital execs not to hire psych nps at 60% of your salary? they don't care. you're going to tell state boards not to give rx priv to psych nps? They don't care.

This is bigger than us and what we 'want' or 'deserve'. There are a lot of different arguments related to these issues.....for example the model of psychiatry(medical vs nonmedical) and midlevel involvement are very different. One can even argue that increasing midlevel involvement goes more with maintaining the medical model. If the medical model continues to be chipped away at, then that's going to decrease midlevel involvement and incorporate more involvement from psychologists rather than psych nps imo.

Nah. Nursing political strategy is tight. Their unions have bowling ball sized nuts. They run health care. They take ground and hold it. F@ck around, they do not. Psychologists are a sidebar to a footnote in healthcare politics. Social workers who can do therapy are much better positioned to do more of our scope or theirs.

And I think you're non-medical argument for psychiatry is weak and unattractive to most of them or us.

Our salaries will be sizzling pork fat to hungry ax men with mba's no doubt. But I think making the training even more lopsided and allowing them to proliferate is a fine strategy for engineering our own scarcity and maintaining the level of game I want to strive for. The sort of practice I am only satisfied striving for.

I have some guarded optimism about the public pendulum swinging back the other way. To help that momentum I like the notion of doing what we do and doing it better.

 

[vistaril]

Nah. Nursing political strategy is tight. Their unions have bowling ball sized nuts. They run health care. They take ground and hold it. F@ck around, they do not. Psychologists are a sidebar to a footnote in healthcare politics. Social workers who can do therapy are much better positioned to do more of our scope or theirs.

And I think you're non-medical argument for psychiatry is weak and unattractive to most of them or us.

Our salaries will be sizzling pork fat to hungry ax men with mba's no doubt. But I think making the training even more lopsided and allowing them to proliferate is a fine strategy for engineering our own scarcity and maintaining the level of game I want to strive for. The sort of practice I am only satisfied striving for.

I have some guarded optimism about the public pendulum swinging back the other way. To help that momentum I like the notion of doing what we do and doing it better.

you are still in medical school.....of course you think any model except the medical model is highly flawed. But when you actually start treating your own patients and the middle aged divorced woman with two kids with unstable affect, volatile relationships with family, and parapsychotic thinking fails to respond to Seroquel and Abilify, did 'a little better' with Lamictal initially but it wore off after awhile, didn't respond to Tegetrol or Risperdal, and is currently on Effexor and Klonopin and not getting better and having another breakdown in your office.........well, then you may start to be more openminded about other models.

You're argument about making the training even more lopsided is ridiculous.....do you honestly think excecutives with Blue cross(or the people who wrote the ACA) are sitting around saying "you know if only the difference between psychiatrists and psych nps was 15% greater than it is now we would take psych nps out of the mix"......of course not.

guarded optimism about the public pendulum swinging the other way? huh? Based on what? The question is how much can we preserve what we have with all the changes in healthcare coming......how much LSD have you been taking if you believe the changes that are going to be coming to health care are going to result in MORE expenditures, MORE costly providers, etc......read the writing on the wall- except for cash pay patients, we're entering a period where COST SAVINGS and COST EFFICIENCY is going to be numero uno. It doesn't take a rocket scientist to see that such a push is going to favor psych nps for the noncash pay population relative to psychiatrists.

I do think it's good you want to develop unique and high level clinical skills....but when you do, just stop worrying about this stuff and PUT THEM TO USE. if your skills are so solid and you do provide so much more value than a psych NP or a psychologist or an lcsw(depending on what the pt needs), then let those skills shine on the free market. If you really have skills, open up your own shop and do your cash pay thing and charge a rate in accordance with those superduper skills. Because that mindset is very different than a lot of the rhetoric I hear about wanting to squash psych nps and midlevels and such......someone who is providing such a useful and valuable product shouldn't care what psych nps are doing. After all, in a free market pt's will pick the provider that gives them the most bang for their buck....that's what it all should be about.

 

[zenman]

It's not entirely clear to me why you bring up antipsychotic use. I think yours and my views about that are entirely in line. I use antipsychotics in schizophrenia and for psychotic mood episodes, and that's pretty much it. Of course those agents have indications in major depressive disorder as well as bipolar disorder, but I have trouble with the idea that they should be used, given the manifest risks of metabolic syndrome, EPSE, and of course TD.

Because I've only just been talking about them.

That said, Zenman, you cannot effectively treat severe psychiatric illness in an evidence based fashion if you limit yourself to FDA label indications and dose ranges. Fluoxetine upward of 60 mg is off-label, but is a mainstay of the treatment of both bulimia and OCD. Low-dose lithium is a well-supported adjunct in treatment-resistant depression. Buspirone is as effective as bupropion as an adjunct for depression, but has no indication.

Are you suggesting that you'd never use sertraline above 200 mg in a patient with severe OCD? Are you saying that you'd never use topiramate for affective lability in borderline personality disorder? Do you fail to use prazosin for nightmares in your soldiers with PTSD?

Sure I go off label but like I say I was talking about handing out antipsychotics like skittles to young people off label. I always go to max dose, unless side effects, and especially higher in OCD with antidepressants. I rarely see much positive results with Buspirone. I use a lot of Prazosin.

Evidence based treatments for severe psychiatric illness fall outside of FDA label indications and dose ranges. If you can't stomach that, then you can't effectively treat an SPMI population. There is so much more to psychiatry than you and Vistaril make it out to be. Just because you choose not to use the tools available to help your patients doesn't mean they don't exist.

There's not a lot of severe psychiatric illness in my population, which I prefer. True, some of these young kids will have their first break, but I don't see as many as when I was working inpatient.

You also get a major side-eye from me regarding your "special knowledge" of human physiology based in non-medical understandings. Human physiology is a science. Eastern medicine is a religion. You can believe it, you can refer your patients for it, but you cannot ethically practice Eastern medicine in a psychiatric practice. You fail to meet the community standard of practice and sell your patients a non-medical bill of goods from a position of authority. If you do that, you represent your religious or spiritual belief as a fact of medical science. That is wrong.

Eastern medicine is not a religion. Much of it is plant-based. "Viagra", for example was already present prior to being developed here.I practice EBM in my work setting, otherwise I can do as I wish with full disclosure. My training in other fields just gives me more than one way to look at a patient.