Psychiatrist vs. Psych NP?

[futuredocandmom]

Hello, I'm debating between taking a psychiatrist/MD route, and being a psych NP.

I'd really appreciate input on the difference between the two roles in a clinical setting. I'm very interested in therapy, and also want to approach being a clinician from the perspective of natural sciences (as opposed to social science/psychology). I've heard that as a psychiatrist, it can be difficult to have time to do a lot of therapy in some jobs, and so while I can see myself loving medicine, I'm not sure how fulfilled I would ultimately be as a psychiatrist if I weren't able to be hands-on with patients in a sustained, ongoing way.

Thank you in advance for any feedback on this question.

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[medium rare]

Hello, I'm debating between taking a psychiatrist/MD route, and being a psych NP.

I'd really appreciate input on the difference between the two roles in a clinical setting. I'm very interested in therapy, and also want to approach being a clinician from the perspective of natural sciences (as opposed to social science/psychology). I've heard that as a psychiatrist, it can be difficult to have time to do a lot of therapy in some jobs, and so while I can see myself loving medicine, I'm not sure how fulfilled I would ultimately be as a psychiatrist if I weren't able to be hands-on with patients in a sustained, ongoing way.

Thank you in advance for any feedback on this question.

You'll be under the same pressures as a psych NP as a psychiatrist. Therapy training is typically minimal to non-existant in psych NP programs and you'll be in demand because of your ability to prescribe; no one will hire you to do therapy. The only real place you'll be able to do therapy to any extent will be in private practice and you'll likely need to seek out additional therapy training in order to have some competence as a therapist.

On the other side, psych NP training will save you years and thousands of dollars. In my area, psych NPs generally make 2/3 to 3/4 of what psychiatrists are paid. That's very good 'bang for the buck.'

 

[BobA]

Wow, you're in a good location for psych np I guess. Around here a psych np averages about $95,000 while a psychiatrist averages about $180,000.

 

[medium rare]

Wow, you're in a good location for psych np I guess. Around here a psych np averages about $95,000 while a psychiatrist averages about $180,000.

True. I'm in an independent practice state for NP's. Psych NPs around here start at $125K in public mental health.

 

[futuredocandmom]

Thank you. I'd like to research scope of practice by state. Very helpful feedback.

 

[zenman]

Thank you. I'd like to research scope of practice by state. Very helpful feedback.

The states where you'd have totally independent practice are:
Hawaii, New Mexico, Alaska, District of Columbia, Idaho, Arizona, Montana, New Hampshire, Oregon, Rhode Island, Washington, Wyoming.

That's good in the sense that you'll never have to close your practice at a moment's notice if your collaborating physician changes their mind. You can always buddy up to have someone to consult with.

 

[futuredocandmom]

Wow, thanks very much!

This is great information. Though I enjoy working with others/on a team, I'd prefer to work as autonomously as possible with my own patients.

 

[meriwether]

I'm also interested in becoming a psych NP. I'm currently working on the prereqs. I have an MSW and currently do psychotherapy so I'm interested in pursuing an MSN to expand my practice. Good luck with your decision!

 

[Sneezing]

1) From what I have seen of NPs and PAs with regards to their trainging and practice I would never hire a NP. Their training is too superficial and they over emphasize what they learn as an RN as though it is a medical school equivalent.
2) Therapy can be performed by social workers, Psychologists, and psychiatrists. I suppose a NP and PA can, too. It boils down to educational foundations, mentorship, self drive to excell at it. Just because you can doesn't mean you should. Therapy can do just as must damage to a person in ignorant hands as a wrongly prescribed medication.
3) A physician and psychiatrist is and will always be the gold standard. If an opportunity for expert testimony on an NP case comes across a physician, most wouldn't hesitate to pick it up. Conversely no NP will ever be considered expert testimony against a physician.
4) As a psychiatrist you will have been trained to effectively handle almost every practice setting and safe prescribing of all psychotropics. With the experience of medical school and residency you learn what not to do and have a very healthy respect for your limitations.
5) If you are looking for the benefits of a mid level job, do yourself and your future patients a service and become a PA before an NP. Just because the nursing lobby has succesfully got themselves independent practice in various states doesn't mean they should have or are prepared to undertake such a role.
6) Respect, authority, and a prescription pad in the wrong hands is as dangerous as a drunk driver - sooner or later they'll hurt someone.

If not already apparent, my opinion and experience has been heavily biased.

 

[9point75]

pa's np's msw's. If you want to do doctor work, you should go to doctor school. Nobody respects a person who takes the easy route. Nobody.

 

[digitlnoize]

pa's np's msw's. If you want to do doctor work, you should go to doctor school. Nobody respects a person who takes the easy route. Nobody.

When I decided to go back to school and go into medicine, I thought long and hard about the various options. Ultimately, I picked medical school because I wanted to have the "final" say, and I wanted to have the most thorough training I could. Sometimes, I tiny part of me wishes I'd skipped all the debt and residency and headache and just gone to PA/NP school, but then I wake up and realize that isn't what I want. I want to be the authority, the last word, the person the NP's turn to when they have a difficult case that they can't manage. And, here I am.

I appreciate mid-levels, and I think they could really help stem the shortage in severe shortage areas, which is where they should be given independent practice rights. Not by state, but by certain areas within states. As it stands now, an NP with independent practice rights in say, Arizona, is just going to move to Phoenix, which already has plenty of docs...comparatively. All that being said, I think the number of professions calling themselves "doctor" is getting out of hand. If you want to be a doctor go to medical school. If you want to be a mid-level, then don't, but let's stop pretending that they're the same thing, because they're not, IMO. Will they have similar outcomes in many (perhaps most) bread and butter cases? Maybe. But, it's the physician's training that prepares us to handle the difficult cases and to catch the subtle diagnoses that sets us apart.

If you were going to send your sick mother to a health care provider, who would it be? A doctor or a mid-level? I know what I would do.

 

[OldPsychDoc]

...If you were going to send your sick mother to a health care provider, who would it be? A doctor or a mid-level? I know what I would do.

That's a crap argument. Know what? I just let an NP start my kid on methylphenidate. He bounces off the walls, won't sit still through a meal, wanders all over the kindergarten classroom, and is on the verge of being the kid none of the others wants to play with. They've been testing him for a month and a half, and I'm not going to wait ANOTHER month and a half just to have that prescription written by someone with "MD" after his/her name. The NP called me, told me how she usually recommends titrating the med, what the alternatives and adjuncts are, etc. Basically, she approached the issue the same way I was taught to, and yes, I trust her.

I supervise a CNS (who is more conscientious than I am 90% of the time), I work side by side with PAs. We all bring something to the table here. This pissing contest fatigues me...

 

[digitlnoize]

That's a crap argument. Know what? I just let an NP start my kid on methylphenidate. He bounces off the walls, won't sit still through a meal, wanders all over the kindergarten classroom, and is on the verge of being the kid none of the others wants to play with. They've been testing him for a month and a half, and I'm not going to wait ANOTHER month and a half just to have that prescription written by someone with "MD" after his/her name. The NP called me, told me how she usually recommends titrating the med, what the alternatives and adjuncts are, etc. Basically, she approached the issue the same way I was taught to, and yes, I trust her.

I supervise a CNS (who is more conscientious than I am 90% of the time), I work side by side with PAs. We all bring something to the table here. This pissing contest fatigues me...

That's fine, and I agree that mid-levels can handle most bread and butter cases. However, would you have still made the same choice if you weren't a psychiatrist, didn't know what was wrong, didn't know the NP, and there were no access problems to the MD?

I've worked with great mid levels. But I've also seen them mismanage complex cases that greatly improved under a doctors care.

My point though wasn't to start a pissing contest. I truly believe that mid levels have a place in medicine and have used them myself when appropriate. I simply wanted to point out my own reasons for choosing med school over mid level.

Would I let my ER PA friend throw a couple sutures in my kids cut? Sure! Would I let my mom, who is as medically and psychologically complex as they come, see an NP that I didn't know? Yes, but I would recommend she see a doctor, and if she did see the NP, at the first sign of suboptimal management, she would be switched to a doc. But, the NP might do a great job.

I should add that by no means do I think docs are infallible. I'd switch docs (or at least discuss the situation) at the first sign of mismanagement too.

 

[zenman]

pa's np's msw's. If you want to do doctor work, you should go to doctor school. Nobody respects a person who takes the easy route. Nobody.

Interesting. I did some clinical on a Marine base in Okinawa. A retired Captain who was now working as a civilian psychiatrist on base sent his daughter over to shadow different psych professionals as she was interested in being a psychologist. Both her dad and my psychiatrist preceptor told her to go the psych NP route.

 

[whopper]

Nobody respects a person who takes the easy route. Nobody.

Many people who became a NP didn't do it to do the easy route. Some were nurses who wanted to further their education.

 

[Manicsleep]

Anecdotal references don't actually mean your point is valid. Usually the opposite is true.

That's a crap argument. Know what? I just let an NP start my kid on methylphenidate. He bounces off the walls, won't sit still through a meal, wanders all over the kindergarten classroom, and is on the verge of being the kid none of the others wants to play with. They've been testing him for a month and a half, and I'm not going to wait ANOTHER month and a half just to have that prescription written by someone with "MD" after his/her name. The NP called me, told me how she usually recommends titrating the med, what the alternatives and adjuncts are, etc. Basically, she approached the issue the same way I was taught to, and yes, I trust her.

I supervise a CNS (who is more conscientious than I am 90% of the time), I work side by side with PAs. We all bring something to the table here. This pissing contest fatigues me...

Its not a crap argument. Its a very good argument. MDs are trained better than NPs...at least most programs train their residents well.

Please go to a CRNA for your anesthesia and an NP for your MI or stroke. Its easy to have a psychiatric medication started for something you have a lot of knowledge about and can supervise as a physician. But when you are helpless, I would love to see you refuse that tired and fatigued "MD" title with its pointless years of training.

I think you mentioned you were a program director. A person who is responsible for training psychaitrists who feels that NPs are as good as psychiatrists is frightens me on so many levels.

Interesting. I did some clinical on a Marine base in Okinawa. A retired Captain who was now working as a civilian psychiatrist on base sent his daughter over to shadow different psych professionals as she was interested in being a psychologist. Both her dad and my psychiatrist preceptor told her to go the psych NP route.

I have told people to do that as well. That doesn't mean NPs are anywhere close to as well trained as Psychiatrists. Your logic is a bit (okay okay, you completely missed the boat...I love that navy humor) off.

 

[digitlnoize]

Obviously OP, the issue is complicated. You should always do what is right for you. From this much of the discussion, you should be aware that as a psych NP, you would be looked down on by a certain population of physicians (whether that's right or wrong is another story...).

If you don't mind the workload or the debt, and you're interested in the rest of medicine (i.e. learning about other diseases/drugs and how they affect mental health) then go to medical school. I've loved my time in medical school, despite the workload, and am VERY glad that I changed careers (and life) to do it.

As a MD/DO you will have the most autonomy your patients and the most professional respect. Also, although in certain states the NP earning potential is pretty high, the most assured route to a solid income in still medicine. Physicians almost always out-earn their mid-level counterparts by a hefty margin. Not always, but usually.

On the other hand, if you're only interested in psych, are ok with not learning the depth found in medical school, and don't want to spend the money/time on medical school, and don't mind the likely (somewhat) lower salary then consider psych NP.

I do think NP's and PA's have their place. I think they are excellent for dealing with basic problems and complaints (FP office: sore throat in a healthy person), which allow the doctors time to manage more complex cases. I also think that many (or even most) are capable of handling more complex cases, but without the INSANE hours of medical school training, you don't really know what you're missing...which I find dangerous.

Warning! The following is an anecdotal story and is only reflective of one experience I have had with NP's. I have also had many good experiences with my mid-level colleagues.

I have a family member who was seeing an NP and was very undermanaged. The NP's problem list for my family member was 2 or 3 items, all from history. At her next appointment, I sent her to the physician with a list and they diagnosed 10 more. Now that they are treated, she is doing much better. Granted, I had some insight the NP didn't have, but some things were clear from her history (i.e. she is sedentary, agoraphobic, hx depression, very poor diet, etc...and the NP didn't check her CBC or Vit. D). Turns out she was VERY deficient in both D and B12. Not major problems, per se, but things that weren't even discussed in her NP visit, who said she was perfectly healthy despite her obesity, fatigue, depression, HTN, hypothyroidism (didn't check that either), poor nutrition, metabolic syndrome, anxiety disorder, panic attacks, extremely poor dental care (didn't check that or recommend she see a dentist), and I don't remember what else. Multiple unaddressed problems. Plus, she was already on a psych cocktail and seeing a psychiatrist regularly for that. She has still not had a colonoscopy despite being over 50 (although it has finally been recommended once she saw the doc...the NP let is slide), no mammo (same story).

Ultimately, I found that the complexity of her case was not something the NP could manage well in the time provided. The doc did ok. Much of it was managed after the blood work came back with the low Vit D, B12, and thyroid, but at least the doc checked. Another NP might have checked. Another NP might have been more forceful regarding screening tests. Another doc might have been more lax.

However, this was my experience, and as such, I am usually of the opinion that complex medical cases should be managed by the practitioner with the highest level of training. If I know the mid-level personally, and know them to be very good, that's another story. If the prospective patient is healthy that's also another story. If there is a problem with access, this is also another story.

 

[zenman]

I have told people to do that as well. That doesn't mean NPs are anywhere close to as well trained as Psychiatrists. Your logic is a bit (okay okay, you completely missed the boat...I love that navy humor) off.

Yes, you not only missed the boat but you ran aground. Nowhere was there any mention of NPs being as well trained as psychiatrists. Both the above mentioned psychiatrists thought it was the best deal overall. Now you may refloat your boat...and your logic.

You know why Navy guys love to have Marines onboard their ship?
So they will have someone to dance with.

 

[zenman]

Obviously OP, the issue is complicated. You should always do what is right for you. From this much of the discussion, you should be aware that as a psych NP, you would be looked down on by a certain population of physicians (whether that's right or wrong is another story...).

Probably true but as a person in this field you really don't give a rattlesnake's butt about what other people think.

If you don't mind the workload or the debt, and you're interested in the rest of medicine (i.e. learning about other diseases/drugs and how they affect mental health) then go to medical school. I've loved my time in medical school, despite the workload, and am VERY glad that I changed careers (and life) to do it.

In NP school we learned about the diseases that affect mental health, just not in the depth that a physician has. It's an area you best spend some time in, especially when a PCP prescribes meds that interact with yours because he may not know what the heck you are giving the patient. I had a patient today whose speech was so slurred I barely could understand her. Found out her PCP had her on Gabapentin 800 mg tid. That and my Risperidone qhs pretty much did a job on her. And her PCP told her that he could go much higher with the dose. Just get in the habit of requiring your patients to bring in all their meds. And if someone has chronic pain, for ex, and are depressed help them out with an antidepressant that will help their mood and chronic pain.

As a MD/DO you will have the most autonomy your patients and the most professional respect. Also, although in certain states the NP earning potential is pretty high, the most assured route to a solid income in still medicine. Physicians almost always out-earn their mid-level counterparts by a hefty margin. Not always, but usually.

I've never had a problem with professional respect. Most people are so glad to just get help. As an NP you will have a solid income, just not as much as a physician. But you have to also look at the other side...you're cheaper than a physician. Dr. Lawrence Climo, in his book "Psychiatrist on the Road" tells about how he was given a 2 week notice at his job he had held for 18 yrs and was replaced by an NP...due to financial constraints.

On the other hand, if you're only interested in psych, are ok with not learning the depth found in medical school, and don't want to spend the money/time on medical school, and don't mind the likely (somewhat) lower salary then consider psych NP.

I do think NP's and PA's have their place. I think they are excellent for dealing with basic problems and complaints (FP office: sore throat in a healthy person), which allow the doctors time to manage more complex cases. I also think that many (or even most) are capable of handling more complex cases, but without the INSANE hours of medical school training, you don't really know what you're missing...which I find dangerous.

Yep a patient who shows up with FMS, ADHD, Bipolar Disorder, and Borderline Personality Disorder...and a few substance dependences...will make you wish you had an extra shot of caffeine that morning!

 

[Technotronic]

 

[zenman]

Why is this even a question?

If you want to make money become an NP.
If you actually want to learn something and help patients, get an MD.

This is not even Logic 101.

 

[whopper]

Medical doctors certainly do have more training, but the quality of the person treating the patient is highly variable, and I've seen NPs I'd rather have vs. medical doctors.

A medical doctor is certainly capable of more, all things being equal, though I've also seen several (actually a frightening large percentage, around 1/2) of medical doctors flubbing on cases to the degree where if someone with the training of a NP wanted to do a better job on the specific case they could, simply because they cared.

Bottom line, I'd rather judge the medical professional on the quality of their work rather than the title. I would expect more from an M.D. based on the extra training, but so many M.D.s IMHO fail to live up to the expectation.

 

[Technotronic]

 

[Therapist4Chnge]

Medical doctors certainly do have more training, but the quality of the person treating the patient is highly variable, and I've seen NPs I'd rather have vs. medical doctors.

A medical doctor is certainly capable of more, all things being equal, though I've also seen several (actually a frightening large percentage, around 1/2) of medical doctors flubbing on cases to the degree where if someone with the training of a NP wanted to do a better job on the specific case they could, simply because they cared.

Bottom line, I'd rather judge the medical professional on the quality of their work rather than the title. I would expect more from an M.D. based on the extra training, but so many M.D.s IMHO fail to live up to the expectation.

This is the closest thing to a useful post in this thread.

The reason why the NP route is popular is that it is quicker, less barriers to entry, and it provides a solid salary afterwards. The training is not the same, nor is the pay...but they both appear to be "good enough" for most people and situations.

 

[OldPsychDoc]

This is the closest thing to a useful post in this thread.

The reason why the NP route is popular is that it is quicker, less barriers to entry, and it provides a solid salary afterwards. The training is not the same, nor is the pay...but they both appear to be "good enough" for most people and situations.

...and since fewer MDs seem to want to go into primary care, will likely be how physician shortages in those fields will be handled in the years ahead.

 

[BobA]

The insecurity of posters on this thread is amazing.

 

[zenman]

Are you an NP? I sense self esteem issues.
Words on a forum won't make you smarter or more competent but I can try. NPs are the best, they are better than MD's and they should run the world.

Again your logic is way off track...and I have such ego integrity that I don't mind confronting you at all, nor will I let your lack of knowledge on the subject take precedent over my grasp of the subject.

 

[zenman]

The insecurity of posters on this thread is amazing.

Where are you infants coming up with all this insecurity crap?

OP, I hope you are getting what you need here.

 

[BobA]

Where are you infants coming up with all this insecurity crap?

OP, I hope you are getting what you need here.

I was referring to the need for both sides to have a pissing contest. It's all about insecurities on both sides.

 

[futuredocandmom]

I appreciate the feedback and debate a great deal. In part, my original question was about the roles of psychiatrists versus psych nps, mainly in terms of administering psychotherapy. The scope of practice question is also clearly an important one.

Many of the considerations I'm making as I formulate my clinical plans are personal (my age and the phase of life I'm in, the cost and feasibility of further education, etc.), but in a more objective sense, I'm interested in the contrasting roles of a psychiatrist vs. a psych np. I'm a meticulous student and worker and know that I would seek to excel either way, and so I'm trying to gain a sense of how my opportunities might differ by choosing one path over the other.

Thank you again for all of the input.

 

[digitlnoize]

I appreciate the feedback and debate a great deal. In part, my original question was about the roles of psychiatrists versus psych nps, mainly in terms of administering psychotherapy. The scope of practice question is also clearly an important one.

Many of the considerations I'm making as I formulate my clinical plans are personal (my age and the phase of life I'm in, the cost and feasibility of further education, etc.), but in a more objective sense, I'm interested in the contrasting roles of a psychiatrist vs. a psych np. I'm a meticulous student and worker and know that I would seek to excel either way, and so I'm trying to gain a sense of how my opportunities might differ by choosing one path over the other.

Thank you again for all of the input.

There are also logistic factors, as long as you're being practical. I'm a non-trad student myself, and decided to do medicine at 26, after spending some time trying to be a musician/teacher/producer/etc. You don't have to answer these, but they're things to think about. If you know all this already, just ignore me...

1. Do you have a college degree already? If so, what's your GPA like? Med school admissions likes them as high as possible definitely over 3.5. Over 3.75 is even better.

2. Along the same lines, have you done any science classes? Med school requires 1 year of: Biology, Physics, Chemistry, and Organic Chemistry. These also get calculated into their own BCPM or "Science" GPA. Also good to be >3.75, but is typically lower than your overall GPA.

3. Age. I will be 34 when I finish medical school, and 38-39 when I finish residency/fellowship. It's not so bad, really. I obviously have a lot of catch up to do retirement wise, but I'm also going to be in a much better position than I was at my old 30k/year music-teaching job(s).

4. Kids. I have a 10 year old daughter. My wife and I are going to have another one (or two) at some point during residency after I have a (meager) income. It really hasn't been that difficult during med school, but I have a very supportive spouse.

For me, if I was 50 with 2 kids and a stay at home spouse, there is no way I would do medical school. I'm not sure where my cut off is though. Starting from scratch, with no coursework to general psych is at least a 4+4+4=12 year process, so starting at 40 and ending at 52 doesn't sound so hot either. However, if you're 30, I'd definitely go for it. I guess 30-40 would be a toss up for me.

Maybe you're not starting from scratch. Maybe you already have some coursework and a great GPA. Even better. Nursing school is also quite competitive. I have many friends who spent longer trying to get into nursing school than I did getting in to medical school.

The pre-med forums are actually pretty helpful, especially the non-trad forum. I'd look for more advice along these lines there for either route.

 

[MDyoucantseeme]

Therapy can do just as must damage to a person in ignorant hands as a wrongly prescribed medication.

Eloquently put and I agree with you on this.

 

[zenman]

I was referring to the need for both sides to have a pissing contest. It's all about insecurities on both sides.

Ok, I see your point.

 

[whopper]

about the roles of psychiatrists versus psych nps, mainly in terms of administering psychotherapy.

Psychiatrists: in general, my opinion is that psychiatrists are undertrained in psychotherapy, but there are specific residency programs with excellent psychotherapy training. A further problem is there are few outlets where psychiatrists can really focus on doing good psychotherapy. Most of the emergency and short-term facility psychiatric programs don't utilize psychotherapy much, if at all, other than brief supportive therapy. Even in PP, where psychiatrists have more power to mold the practice into what they want, I've seen few actually give out in-depth psychotherapy.

As for NPs, it's even less.

I have seen, however, a type of NP and/or psychiatrist that chooses to further their psychotherapy training on their own and become quite adept at it, though they are exceptions.

Again, it's up to the individual IMHO, and I'd expect more from a psychiatrist, but I'm often underwhelmed with what I see. Out of about 25 psychiatrists I can name off the top of my head less than 5 of them actually had an interest in doing good psychotherapy.

 

[zenman]

Psychiatrists: in general, my opinion is that psychiatrists are undertrained in psychotherapy, but there are specific residency programs with excellent psychotherapy training. A further problem is there are few outlets where psychiatrists can really focus on doing good psychotherapy. Most of the emergency and short-term facility psychiatric programs don't utilize psychotherapy much, if at all, other than brief supportive therapy. Even in PP, where psychiatrists have more power to mold the practice into what they want, I've seen few actually give out in-depth psychotherapy.

As for NPs, it's even less.

I have seen, however, a type of NP and/or psychiatrist that chooses to further their psychotherapy training on their own and become quite adept at it, though they are exceptions.

Again, it's up to the individual IMHO, and I'd expect more from a psychiatrist, but I'm often underwhelmed with what I see. Out of about 25 psychiatrists I can name off the top of my head less than 5 of them actually had an interest in doing good psychotherapy.

Even though meds are challenging and interesting I think it's even more interesting, and more challenging, to help someone just by listening and using words.

 

[Flymm]

Psychiatrists: in general, my opinion is that psychiatrists are undertrained in psychotherapy, but there are specific residency programs with excellent psychotherapy training. A further problem is there are few outlets where psychiatrists can really focus on doing good psychotherapy. Most of the emergency and short-term facility psychiatric programs don't utilize psychotherapy much, if at all, other than brief supportive therapy. Even in PP, where psychiatrists have more power to mold the practice into what they want, I've seen few actually give out in-depth psychotherapy.

As for NPs, it's even less.

I have seen, however, a type of NP and/or psychiatrist that chooses to further their psychotherapy training on their own and become quite adept at it, though they are exceptions.

Again, it's up to the individual IMHO, and I'd expect more from a psychiatrist, but I'm often underwhelmed with what I see. Out of about 25 psychiatrists I can name off the top of my head less than 5 of them actually had an interest in doing good psychotherapy.

I am currently looking at residencies and you bring up an excellent point about the limited programs that provide a solid foundation in psychotherapy. Would you mind naming some programs that do so and feel free to name some that are well balanced psychotherapy and psychopharmacology. Thanks!

 

[whopper]

I can't think of any off the top of my head. My own program did try to improve the training in psychotherapy, but a problem was that with residents deprived of sleep, fearing USMLE 3, and seeking moonlighting opportunities, they were not paying attention to the finer aspects of psychotherapy, that is highly theoretical and not as quick acting as a medication. It really takes someone truly interested in it (IMHO) to truly appreciate it. I hate saying it but if it came down to reading Linehan or studying for Step 3, I completely understand a resident choosing Step 3. Academic survival, is after all, not overrated.

Another problem I've noticed is several residencies are focused on treating patients in a setting where long-term psychotherapy cannot be done. E.g. working in an ER, or a short-term inpatient unit. I felt I really didn't get into some deep sessions with psychotherapy until I saw them at least several times.

What I'd shoot for is look for programs where you can have access to long-term patients, where you can actually focus on getting step 3 out of the way quickly so you can focus on the psychiatry boards where psychotherapy is something you have to know to some degree, some actual structure to psychotherapy, and actively seeking CMEs in psychotherapy. I've also noticed that doing an H&P starting from prenatal development to the present can lead to some big discoveries and most psychiatrists do not opt for this approach.

IMHO, it's really in a long-term facility, or outpatient, where the patient sees you several times over the course of months, possibly even years where psychotherapy really starts to get to levels where one is passing the levels of that of something anyone could do, with or without training, if they simply just listened and tried to show that they cared.

When one has a borderline patient that self-mutilates, one cannot simply see this patient as a type that needs to be shot up with a needle of Thorazine every time they get the urge to do something dangerous. Unfortunately, it's not out of the ordinary to see a psychiatrist and all they know about dealing with this is this type of approach.

I just saw a patient for the Court who has severe borderline PD and she did not get DBT, despite having it for several years. She was never even referred to it. Pathetic. Utterly pathetic. Someone mentioned in another thread that other psychotherapies may possible be just as effective as DBT. Fine, but the psychiatrist only offered meds, and did not address any of the underlying psychological theories as to deal with the real issue---she was cutting herself because of feelings of emptiness. IMHO, the psychiatrist's treatment was on the order of a sin, but I'll curb my rant.

Oddly, something that really helped my psychotherapy skills was watching Ramsay's Kitchen Nightmares, the British, not the American version. Unfortunately, most of the youtube videos of the British show were removed. You can catch them on BBC-America, but remember I only recommend the British version.

I was able to find one of the episodes from a Chinese website.
http://www.tudou.com/programs/view/8FyznG0v85k/

 

[peppy]

I am currently looking at residencies and you bring up an excellent point about the limited programs that provide a solid foundation in psychotherapy. Would you mind naming some programs that do so and feel free to name some that are well balanced psychotherapy and psychopharmacology. Thanks!

If you think you might be interested in psychotherapy, I would suggest
taking a look at SUNY Upstate Medical University (the program in Syracuse NY), Medical College of Wisconsin, and Baylor. I think you'd get a really good foundation in psychotherapy at any of those programs.

 

[JaggerPlate]

In NP school we learned about the diseases that affect mental health, just not in the depth that a physician has.

Well I'm sold (as if your "one time I ..."; "I know a person who ..."; "One time I saw a patient who ...", n=1, anecdotal stories weren't enough concrete evidence )

 

[digitlnoize]

In NP school we learned about the diseases that affect mental health, just not in the depth that a physician has.

I'm not asking this to be antagonistic, but I'm wondering...what diseases do you learn about? Can you give us some examples, and the depth.

For example, does the depth extend to include Lyme encephalitis or other infectious diseases? Do you learn about the physiology of pregnancy and its effect on thyroid hormones, drug levels, and rx choice? Temporal lobe epilepsy? HIV and toxoplasmosis? Hemochromatosis as it relates to psychiatric disease?

These are just a few things off the top of my head that I diagnosed or had to deal with this past year as a 3rd year medical student

Would you have put 2 and 2 together and realized that your patient with depression, joint aches, fatigue, and heart arrhythmias (no obvious "bronze skin") had hemochromatosis?

 

[Flymm]

If you think you might be interested in psychotherapy, I would suggest
taking a look at SUNY Upstate Medical University (the program in Syracuse NY), Medical College of Wisconsin, and Baylor. I think you'd get a really good foundation in psychotherapy at any of those programs.

Thanks for the recommendations, I will definitely check them out!

 

[Manicsleep]

I appreciate the feedback and debate a great deal. In part, my original question was about the roles of psychiatrists versus psych nps, mainly in terms of administering psychotherapy. The scope of practice question is also clearly an important one.

Many of the considerations I'm making as I formulate my clinical plans are personal (my age and the phase of life I'm in, the cost and feasibility of further education, etc.), but in a more objective sense, I'm interested in the contrasting roles of a psychiatrist vs. a psych np. I'm a meticulous student and worker and know that I would seek to excel either way, and so I'm trying to gain a sense of how my opportunities might differ by choosing one path over the other.

Thank you again for all of the input.

If you want to do full spectrum mental health care, psychiatry will serve you best. If psychotherapy is your passion but you have limitations in age, time etc you may want to consider a therapy profession such as social work, psychology or MFT.

I can tell you that it is hard to go straight into doing therapy out of residency. you will have to supplement your income with moonlighting until you build up your base. Even then your pay will not be great unless you do cash only or you can negotiate with the insurance companies to give you a higher rate for 90805/90807s.

 

[Therapist4Chnge]

If you want to do full spectrum mental health care, psychiatry will serve you best. If psychotherapy is your passion but you have limitations in age, time etc you may want to consider a therapy profession such as social work, psychology or MFT.

If you want to strictly be a therapist, pursue an MA/MS level degree (Social Work, Mental Health Counseling, etc), as therapy training is only one component of a psychologist's training. Trudging through years of other requirements and training will most likely be a miserable experience if you don't enjoy that work too (research, stats, assessment, teaching, etc).

 

[2012PhD]

If you want to do full spectrum mental health care, psychiatry will serve you best. If psychotherapy is your passion but you have limitations in age, time etc you may want to consider a therapy profession such as social work, psychology or MFT.
90805/90807s.

Manicsleep, you seem to harbor many misconceptions about psychology as a field. I think many people have these misconceptions so I wanted to chime in here and clarify our training. Being a psychologist is not only a "therapy profession." Our training is as long and intensive as medical school training and takes 8-9 years post-college. Clinical psychology PhD programs tend to have 1-5% acceptance rates and are considered the most competitive graduate programs overall.

clinical psychologist PhD/PsyD: 5-7 years of graduate school, clinical placements for several years (4 years is not uncommon) Intensive training with clinical placements that emphasize psychotherapy, assessment, case conceptualization, diagnosis. Coursework in several different therapeutic modalities, biology, psychopharmacology etc.
Internship (2,000 hours of training): By the time we get to internship, we have had 4-5 years of intensive training in mental health treatment, diagnosis, and assessment.
post-doc/fellowship training: additional 1-2 years after graduating. Psychologists need 3,000 hours to attain licensure. In total, we are getting about 6,000 hours by the time we are licensed.

social workers go to graduate school for a 2 year master's degree. This is a very different model and similar to comparing nurses to physicians.

 

[2012PhD]

Many professionals don't know what our training is like and how LONG and intensive it really is. We have done a really poor job of educating other professionals about our areas of expertise and what differentiates us from m.a. level providers.

 

[billypilgrim37]

Our training is as long and intensive as medical school training and takes 8-9 years post-college.

There are plenty of us on this board who sing the praises of psychology, respect our colleagues, and find these -ology vs -iatry debates really silly. But you will piss us off really quickly if you try to say your training is as intensive as ours. You never worked an 80 hour week, never did CPR on somebody at 3AM who died right in front of you, and you never had to work a 30 hour shift q4. You worked plenty hard compared to the average human being, and you worked hard enough to deserve our respect in a myriad of ways, but your training is not that intensive compared to what we go through.

There is no good way of comparing competitiveness for medicine compared to psychology, because a completely different set of human beings apply for both of these things with only a tiny bit of overlap. The average psychology grad student's undergrad GPA is much less than the average medical school. The prereqs for someone to apply to psychology grad school (not to get in, but to apply) are minimal compared to medical school, so your denominator is inflated. A med school applicant had to pass organic chemistry and physics. A psychology applicant had to pass an experimental psych and stats class. No comparison.

The reason why we respect psychologists is because we work with them, see their value, trust their judgment, and enjoy their different perspectives. But we're never going to think you worked as hard as we did, because you didn't. That's okay. Nobody should have to work as hard as we do.

 

[digitlnoize]

A med school applicant had to pass organic chemistry and physics. A psychology applicant had to pass an experimental psych and stats class. No comparison.

It's funny. I actually found my undergrad Psychology classes MUCH harder than Organic Chemistry or Physics because the grading was so subjective.

At least in O-Chem and Physics there's a clear cut right answer. In psych, I had a lot of essay tests, and if you didn't agree with the professor it was a bad grade for you.

 

[2012PhD]

There are plenty of us on this board who sing the praises of psychology, respect our colleagues, and find these -ology vs -iatry debates really silly. But you will piss us off really quickly if you try to say your training is as intensive as ours. You never worked an 80 hour week, never did CPR on somebody at 3AM who died right in front of you, and you never had to work a 30 hour shift q4. You worked plenty hard compared to the average human being, and you worked hard enough to deserve our respect in a myriad of ways, but your training is not that intensive compared to what we go through.
/QUOTE]

I was not suggesting that we work harder than you. I was referring to the fact that clinical psychology is not a "quick therapy route" as manic sleep was suggesting. It is an 8 year plus training program after the BA degree. Many people don't know this and assume that psychology is a quicker route. This is why some clinical psychology students switch to medical school or want to go into medicine once they realize that getting the degree and getting licensed takes just as long (since our income is lower).

The average GPA for getting into clinical psychology PhD is usually 3.6 across programs. I have no idea what it is for medical school and i'm not interested in comparing this.

Clinical psychology PhD's also pull in 60-80 hour weeks pretty frequently in graduate school. We take a full-load of courses, TA classes, do research, and work in a hospital/clinic about 2 days per week, often all in one semester. We don't have 30 hours shifts and we don't do CPR. Our training is different. It is less intense in the sense that we are not required to do 24 hour shifts at a hospital, but we frequently take suicide calls from patients and do crisis intervention as well.

 

[whopper]

At least in O-Chem and Physics there's a clear cut right answer. In psych, I had a lot of essay tests, and if you didn't agree with the professor it was a bad grade for you.

Sounds more like a philosophy class than psychology to me. Psychology is a science.

IMHO medical school is more intense than graduate psychology though graduate psychology certainly is competitive in it's own right. I've never seen psychology grad students pull all-nighters, several times a week for years, while having to study half-asleep. The entire medical education curriculum is not like this all the time in every field, but is for at least a few years in almost all fields including psychiatry. Psychology grad students could also slow down their curriculums and hold off on things (though some medstudents could do this too but usually not in residency.) Most psychology grad students I see still have something of a life. E.g. they actually have the time to visit a friend on weekend and hang out, even raise a family.

In fact, IMHO medical training is too intense for it's own good and would benefit from being at a pace like a psychology grad course. I've known residents crash their cars while falling asleep due doing a 36 hr. shift, and have shifts like that more than once a week. I've never seen one psychology grad student have to go through something like that.

That's not written with any disdain for psychology, and psychology grad students certainly do work harder than most people. If anything it's a criticism of our own field's training. Thankfully things are a bit better now.

 

[billypilgrim37]

That's not written with any disdain for psychology, and psychology grad students certainly do work harder than most people. If anything it's a criticism of our own field's training. Thankfully things are a bit better now.

That's pretty much a perfect sum up.