Psychiatry's image taking a hit because of lower standards to practice?

[irondoc]

---

Members do not see this ad.

We've got a severe reduction in standards in what it takes to practice. Psych NP programs are churning out tons of Psych NPs who will be practicing independently in some states, and with loose supervision in others. I think just based on numbers people will be much more likely to see Psych NPs instead of Psychiatrists.

Is anyone else concerned that watered down education standards could very negatively affect the image of psychiatry? There hasn't exactly been a very positive history, but the stigma has significantly improved over the years.

 

[thepoopologist]

You are worried about NPs.
There is also the Scientology/anti-psychiatry movement, some of whom include psychiatrists
There is also psychiatry's history from the beginning of time to the 1950s being repeated as if it is current practice
There is also mass media i.e. Split, Stoneheart Asylum where I believe ECT was used to blow up someones head
Lets not forget there are below average psychiatrists and physicians in general out there that are highlighted all the time in books and in media
Then there is the image of us all being heros while pay is cut and hours increased by the MBAs

I can go on. This is just the reality.
Do you like psychiatry? If you do, the job market can always use another good psychiatrist.
Step 1. Become clinically good
Step 2. Dealing with all the other garbage

 

[birchswing]

I don't think anti-psychiatry is significant.

Look at the recent bizarre thoughts that have taken hold of millions of people with no evidence and no funding (q anon, conspiracies about the election results). That's a significant movement. It may or may not whimper out, but at the moment it's significant. And it doesn't require million dollar superbowl ads like scientology takes out—just tweets.

With psychiatry there is actual evidence—because it's the whole point of psychiatry—that people's behaviors are being changed through external means (mostly medication). It's not a fringe theory. It's what it is. And yet there's nowhere near the same level of passion about it. Even with Scientology's huge stockpiles of cash.

With psychiatry there is 1) Something tangible to actually question and 2) Groups have tried spending a lot of money to question it and go after it, and yet nothing much ever materialized. If it were going to happen it would have by now.

I think the most vulnerable organizations are the pharmaceutical companies, not psychiatrists themselves—as an example, Purdue Pharma (now bankrupt) and even large chain pharmacies were targeted in the opiate epidemic. Individual doctors have been but not as a class.

 

[irondoc]

You are worried about NPs.
There is also the Scientology/anti-psychiatry movement, some of whom include psychiatrists
There is also psychiatry's history from the beginning of time to the 1950s being repeated as if it is current practice
There is also mass media i.e. Split, Stoneheart Asylum where I believe ECT was used to blow up someones head
Lets not forget there are below average psychiatrists and physicians in general out there that are highlighted all the time in books and in media
Then there is the image of us all being heros while pay is cut and hours increased by the MBAs

I can go on. This is just the reality.
Do you like psychiatry? If you do, the job market can always use another good psychiatrist.
Step 1. Become clinically good
Step 2. Dealing with all the other garbage

I'm talking about ways of how the field can hold itself to a high standard and to build upon whatever progress has been made. Other physicians that prescribe psychoactive drugs are not calling themselves as psychiatrists. Sure, there are below average psychiatrists who practice poorly, but they're below the average among psychiatrists. It shouldn't mean that more damage cannot be done by a very large group practicing "psychiatry" with significantly less education.

 

[thepoopologist]

I'm talking about ways of how the field can hold itself to a high standard and to build upon whatever progress has been made. Other physicians that prescribe psychoactive drugs are not calling themselves as psychiatrists. Sure, there are below average psychiatrists who practice poorly, but they're below the average among psychiatrists. It shouldn't mean that more damage cannot be done by a very large group practicing "psychiatry" with significantly less education.

I'm sure someone can give a more nuanced answer than myself.

What you are talking about is branding. Like how there is concern Tesla's brand is diluted because NIO or Xpeng or Li are now competitors. Tesla's brand only holds true in the face of those competitors as long as the engineering and finish continue to be high quality, the advances like autopilot and battery life continue to improve, and the product is appealing enough that a big cross section of the population either buys it or would like to buy it. Tesla's price doesn't have to decrease because of the competitors; although there will definitely be people who prefer Chinese knockoffs to the original thing, it doesn't mean Tesla's still don't have a place on the market. Another approach is that Tesla could pay off some Senators and make the argument that people deserve the highest quality product and that the introduction of lesser products would increase traffic fatalities by 100%, thus adding billions of dollars of liability into the system. Maybe one of those arguments about liability is the Chinese autopilot feature is a total buggy ripoff of the original. Another approach is they could sue the other companies directly of patent infringment, thus blocking their introduction into the US market. If I'm Tesla, all these avenues are worth pursuing, but the basis of each avenue still relies on the idea that Tesla is and remains the highest quality product.

 

[birchswing]

I'm talking about ways of how the field can hold itself to a high standard and to build upon whatever progress has been made. Other physicians that prescribe psychoactive drugs are not calling themselves as psychiatrists. Sure, there are below average psychiatrists who practice poorly, but they're below the average among psychiatrists. It shouldn't mean that more damage cannot be done by a very large group practicing "psychiatry" with significantly less education.

4 years of medical school and 1 year of residency to be a licensed physician in my state (and many others). And I have yet to find where there is a legal definition of psychiatrist—and I have looked.

From what I can tell, a psychiatric nurse practitioner (sometimes listed as psychiatric mental health nurse practitioner) must actually complete a training program (2-3 year graduate program) and then pass an exam and have (in my state) 500 clinical hours training.

So whether it's better education or not, it does seem more regulated for PMHNPs.

From what I can tell, there is no such thing as licensing a psychiatrist. Of course there are board certifications.

Let me know if I am wrong on any of this. This is only from my own research I did a while back when I almost saw a psychiatrist who had not done a residency. Edit: They had done part of a residency, twice, but never finished either—to be more accurate.

 

[Yoyomama88]

4 years of medical school and 1 year of residency to be a licensed physician in my state (and many others). And I have yet to find where there is a legal definition of psychiatrist—and I have looked.

From what I can tell, a psychiatric nurse practitioner (sometimes listed as psychiatric mental health nurse practitioner) must actually complete a training program (2-3 year graduate program) and then pass an exam and have (in my state) 500 clinical hours training.

So whether it's better education or not, it does seem more regulated for PMHNPs.

From what I can tell, there is no such thing as licensing a psychiatrist. Of course there are board certifications.

Let me know if I am wrong on any of this. This is only from my own research I did a while back when I almost saw a psychiatrist who had not done a residency. Edit: They had done part of a residency, twice, but never finished either—to be more accurate.

Of course there are board certifications

No insurance is gonna pay for your care from a physician unless the above is present. No hospital will hire either as it will be difficult to get malpractice coverage for practicing psychiatry

 

[NickNaylor]

I'm not sure what you're advocating to change? Yes, there are bad PMHNPs, and I am no supporter of midlevel independent practice, but there are also terrible psychiatrists, too, just as there are terrible physicians in all specialties. I'm not sure there's much you can do on that front beyond keeping the barriers to entry high, because once you're a licensed physician you generally are afforded a LOT of autonomy to do whatever it is that you want to do. Should practice standards be higher? Sure, I guess, but the question is how to do that in a way that is administratively feasible.

All that you can really do as an individual is make sure that you are providing the best quality of care that you can. I'm not sure that railing about a small number of random yahoos doing a bunch of crazy stuff is a useful expense of time and energy.

 

[irondoc]

I'm not sure what you're advocating to change? Yes, there are bad PMHNPs, and I am no supporter of midlevel independent practice, but there are also terrible psychiatrists, too, just as there are terrible physicians in all specialties. I'm not sure there's much you can do on that front beyond keeping the barriers to entry high, because once you're a licensed physician you generally are afforded a LOT of autonomy to do whatever it is that you want to do. Should practice standards be higher? Sure, I guess, but the question is how to do that in a way that is administratively feasible.

All that you can really do as an individual is make sure that you are providing the best quality of care that you can. I'm not sure that railing about a small number of random yahoos doing a bunch of crazy stuff is a useful expense of time and energy.

Bad physicians and bad psychiatrists exist even though they have years of training. This analogy does not compare to PMHNP practicing with full authority with what is essentially a 2-3 month clinical experience requirement. Imagine the significantly higher likelihood that someone will be harmed or mismanaged by someone with that level of training. These people with minimal experience won't just be a small number. They will be the vast majority of psychiatric providers.

At the very least, it is important to not be passive and let laypeople know the major differences in training and be clear about who is a psychiatrist. But I agree, there is not much that can be done about the proliferation of PMHNPs.

 

[splik]

We've got a severe reduction in standards in what it takes to practice. Psych NP programs are churning out tons of Psych NPs who will be practicing independently in some states, and with loose supervision in others. I think just based on numbers people will be much more likely to see Psych NPs instead of Psychiatrists.

Is anyone else concerned that watered down education standards could very negatively affect the image of psychiatry? There hasn't exactly been a very positive history, but the stigma has significantly improved over the years.

Patients love their NPs. Many patients dont know the difference. They are quite happy receiving unfettered access to benzos and stimulants. As mentioned above, the standard of care in psychiatry is embarassingly low and that has nothing to do with NPs. There are many reasons to be concerned about the proliferation of online only NPs with no nursing experience, but this is not one of them.

 

[Stagg737]

We've got a severe reduction in standards in what it takes to practice. Psych NP programs are churning out tons of Psych NPs who will be practicing independently in some states, and with loose supervision in others. I think just based on numbers people will be much more likely to see Psych NPs instead of Psychiatrists.

Is anyone else concerned that watered down education standards could very negatively affect the image of psychiatry? There hasn't exactly been a very positive history, but the stigma has significantly improved over the years.

This is not a problem unique to psychiatry. I’ve seen similar problems in FM, peds, EM, etc. Yes, I do have significant concerns regarding the educational and professional standards of those without MD or DO degrees, but the image of psychiatry in particular is not one of those concerns.

 

[Sushirolls]

Medicine with each passing day is less and less a profession. NDs and DCs and DNPs and ARNPs and PAs as the continue to expand the scope of practice and numbers, will continue to lower the standard of what it takes to practice medicine. Suits, health systems, politicians, administrators, and even some physicians are furthering this collapse.

Positively, I can tell patients seeking continuance of benzos or inappropriate stimulants or affirmation that marijuana is their cure all; other people in community exist to do this for them as I will not. One less headache to manage.

If you wish to cling to the standards that medicine is and was progressing towards, I encourage you to open your own practice or find the rare pockets where there is still value to physician practice. But these pockets are becoming less and less each day.

Negatively, at some point in the next 20-40 years we will be the 'last physicians' in the US and after that mere technicians in a service industry with the right certificates to get a specific job.

Society doesn't care, nor will it. The only question is the rate of change that precipitates this 'lights out' moment.

 

[PikminOC]

Bad physicians and bad psychiatrists exist even though they have years of training. This analogy does not compare to PMHNP practicing with full authority with what is essentially a 2-3 month clinical experience requirement. Imagine the significantly higher likelihood that someone will be harmed or mismanaged by someone with that level of training. These people with minimal experience won't just be a small number. They will be the vast majority of psychiatric providers.

At the very least, it is important to not be passive and let laypeople know the major differences in training and be clear about who is a psychiatrist. But I agree, there is not much that can be done about the proliferation of PMHNPs.

Yes exactly right, and the odds of a bad psychiatrist are much less due to the rigorous training requirements. To get into medical school is a feat, then thru, then residency, then board certs. CME for physicians is much more than CE and more rigorous. And then recerts!

 

[Mad Jack]

Medicine with each passing day is less and less a profession. NDs and DCs and DNPs and ARNPs and PAs as the continue to expand the scope of practice and numbers, will continue to lower the standard of what it takes to practice medicine. Suits, health systems, politicians, administrators, and even some physicians are furthering this collapse.

Positively, I can tell patients seeking continuance of benzos or inappropriate stimulants or affirmation that marijuana is their cure all; other people in community exist to do this for them as I will not. One less headache to manage.

If you wish to cling to the standards that medicine is and was progressing towards, I encourage you to open your own practice or find the rare pockets where there is still value to physician practice. But these pockets are becoming less and less each day.

Negatively, at some point in the next 20-40 years we will be the 'last physicians' in the US and after that mere technicians in a service industry with the right certificates to get a specific job.

Society doesn't care, nor will it. The only question is the rate of change that precipitates this 'lights out' moment.

Eventually the system will likely collapse as it has in many developing countries where physicians are paid so little and work so hard that anyone with any sense goes to nursing school instead. The Philippines is one such country, and we'll likely see a similar fate here, where the number of actual physicians becomes scant due to the reward on investment being too small. Let's just hold on for as long as we can, and captain this ship as it goes down

 

[heartsink]

Society doesn't care, nor will it. The only question is the rate of change that precipitates this 'lights out' moment.

Let's just hold on for as long as we can, and captain this ship as it goes down

uh... merry christmas everyone...

 

[clausewitz2]

Eventually the system will likely collapse as it has in many developing countries where physicians are paid so little and work so hard that anyone with any sense goes to nursing school instead. The Philippines is one such country, and we'll likely see a similar fate here, where the number of actual physicians becomes scant due to the reward on investment being too small. Let's just hold on for as long as we can, and captain this ship as it goes down

Surely the popularity of nursing in the Philippines is more about the ability to find nursing jobs overseas in richer countries than about the domestic labor market. The abundance of Pinoy nurses staffing many hospital departments around the US would tend to suggest the former is a major factor...

 

[Mad Jack]

Surely the popularity of nursing in the Philippines is more about the ability to find nursing jobs overseas in richer countries than about the domestic labor market. The abundance of Pinoy nurses staffing many hospital departments around the US would tend to suggest the former is a major factor...

Oh, absolutely. But if salaries for physicians trend low enough that there isn't much of a premium when compared to nursing, the incentive will switch significantly. I wouldn't have invested 8 years of my life into this field if it didn't give me some decent ROI, I could already pull 100k as a respiratory therapist working fewer hours than I work as a resident. Eventually the incentive structure may shift to the point that the best and brightest go elsewhere, and only those that are drawn to fancy titles or that are absurdly altruistic but not necessarily the most talented end up in the field

 

[Mad Jack]

In this scenario, wouldn't the fewer physicians and their expertise become even more valuable? Which theoretically should lead to higher prestige and compensation?

Possibly. Though I bet there will always be someone stupid enough to fill the shoes, even it pays almost nothing

 

[Sushirolls]

In this scenario, wouldn't the fewer physicians and their expertise become even more valuable? Which theoretically should lead to higher prestige and compensation?

Doubtful. This assumes there aren't forces from insurance companies, CMS, politicians [with good intentions, but bad implementation like we are currently seeing with balanced billing legislation]. With this vain of thought we should already be seeing it for physicians against the back drop of these mid-levels fields - but we aren't - only the same rate of descent into the cold icy Atlantic waters as the Titanic creaks downward.

1) fellow citizens don't even know the difference of the alphabet soup. Continually people say, "My doctor..." but when you google them, its an ARNP or PA.
2) Hospitals and health systems have been laying off physicians during covid to extract more work out of them, while prepping the job adds to replace the fired physicians with a midlevel.

 

[FrontierPsychiatry]

Eventually the system will likely collapse as it has in many developing countries where physicians are paid so little and work so hard that anyone with any sense goes to nursing school instead. The Philippines is one such country, and we'll likely see a similar fate here, where the number of actual physicians becomes scant due to the reward on investment being too small. Let's just hold on for as long as we can, and captain this ship as it goes down

 

[thepoopologist]

If anything my motivation to stay healthy and well funded has increased after reading this thread.

 

[michaelrack]

I don't think anti-psychiatry is significant.

Look at the recent bizarre thoughts that have taken hold of millions of people with no evidence and no funding (q anon, conspiracies about the election results).

And don't forget all the Russian collusion nonsense

 

[dl2dp2]

NP is a major issue. I have physician friends who run NP-focused practices: NPs have lower quality but better profit margin and are slated to expand. MDs need to innovate and have a pitch, as well as collectively bargain hard. His opinion is facilities-based publicly funded MD jobs will die out. This will affect a lot of lower-tier trained MDs. Higher tier MDs will still get hired/be partnered to do medical director oriented jobs to manage multiple NP case loads.

Commercial insurance and cash practices will still favor MDs--as a patient, if I can find and afford an MD I wouldn't go to an NP, though there is downward pressure--commercial insurance-driven practices are increasingly unable to find in-network MD providers. So most MDs will be chasing after 30-40% of the market that's cash-based.

Currently this is not affecting job market because the demand has grown astronomically, but I think in the next 20 years if you are a lower tier/DO/FMG trained at community programs, you'll be either offered a job that's not very desirable or be prepared to start your own practice. Cush state/non-profit community jobs will be very rare and tend to be reserved for prestige residency grads and will have a large admin component. Current med students who are interested in a long term sustainable career in psychiatry should plan to work hard and match into as good a residency program as possible to hedge against this. The current state where anyone with a pulse can waltz into a community job that pays 250k for 35 hours a week will end sooner than you think.

 

[AD04]

Change is inevitable. People have been predicting doom since the 80's (or maybe even earlier) and yet for decades physicians have no trouble finding jobs and making more money every year. Predicting doom sounds smart and attracts attention.

So I'm going to sound stupid. Change will continue. But things will be ok and physicians will continue to have no trouble finding jobs and will continue to make more money every year.

But this is how you prepare in case I am wrong. I would encourage you to learn how private practice works and how to document and how to bill. Because at the very least, if the doomsday scenario does occur, you can always start your own practice and take Medicare and by being a physician, you have a huge marketing advantage over NPs. (And when you have enough work, then you may expand by overseeing NPs.) And it will benefit you now because in many scenarios, the knowledge will help you maximize income so you can put away more money today in preparation for the future.

 

[dl2dp2]

You mentioned low tier/DO/FMG.

What about DO/FMG that train at university programs? As a follow-up question, are DOs at a disadvantage for cash practice even if they train at strong programs?

1. pursuing prestige every step of your career will always be an investment. All investments are risky, and you may not see a return.

2. Yes. But this is irrelevant. People who are drawn to cash practices will be drawn to Harvard BA Yale MD Stanford residency. You can't fix what you have no power over. Work as hard as you can to get into as good a residency program as you can and that's really all there is to it, right?

Change is inevitable. People have been predicting doom since the 80's (or maybe even earlier) and yet for decades physicians have no trouble finding jobs and making more money every year. Predicting doom sounds smart and attracts attention.

So I'm going to sound stupid. Change will continue. But things will be ok and physicians will continue to have no trouble finding jobs and will continue to make more money every year.

But this is how you prepare in case I am wrong. I would encourage you to learn how private practice works and how to document and how to bill. Because at the very least, if the doomsday scenario does occur, you can always start your own practice and take Medicare and by being a physician, you have a huge marketing advantage over NPs. (And when you have enough work, then you may expand by overseeing NPs.) And it will benefit you now because in many scenarios, the knowledge will help you maximize income so you can put away more money today in preparation for the future.

Sure, but certain specialties seriously F-ed up. Pathology and rad onc are two good examples. Peds is another one. We should aim to avoid this as a group. So far leadership lucked into an upswing in the last 20 years without much aggressive strategizing--in particular, this emphasis on the "biological" part which was not originally designed with money in mind ended up being a huge leg up inadvertently. Can you imagine if we are competing for our core business against LCSWs? This lack of foresight may not work again in the next 20 years.

 

[dl2dp2]

I get what you are saying. You can only compare your own opportunities and more prestige will be better than less for almost any scenario.

The hard part is when choosing a speciality though. If the future of psychiatry will be so dependent on prestige of training, would DO/FMG students just be better off going for specialities where the work is more of a cut and dry commodity e.g radiology or a procedural field?

I c. It's generally not a good idea to pick a specialty based on factors outside of your control and very far out in the long run. Do you enjoy daily work in psych or rads. Do you enjoy the OR. That's it. In fact, people who regret stuff later on often pick specialty for money, lifestyle, etc. very good example is rad onc--lots went into it not because they like the daily work but because it had for a long time the best money to lifestyle ratio. I actually don't know if it's better (in what metric?) to be a DO going into a rads vs. DO going into psych. Rads job market was quite literally ****ty a few years ago, so your prestige record would definitely matter, possibly a lot in that field also. Nobody can answer these questions for you.

 

[Sushirolls]

Change is inevitable. People have been predicting doom since the 80's (or maybe even earlier) and yet for decades physicians have no trouble finding jobs and making more money every year. Predicting doom sounds smart and attracts attention.

So I'm going to sound stupid. Change will continue. But things will be ok and physicians will continue to have no trouble finding jobs and will continue to make more money every year.

But this is how you prepare in case I am wrong. I would encourage you to learn how private practice works and how to document and how to bill. Because at the very least, if the doomsday scenario does occur, you can always start your own practice and take Medicare and by being a physician, you have a huge marketing advantage over NPs. (And when you have enough work, then you may expand by overseeing NPs.) And it will benefit you now because in many scenarios, the knowledge will help you maximize income so you can put away more money today in preparation for the future.

The marketing advantage of MD/DO over NPs isn't huge.

I'm in a saturated ARNP market right now and only a few people trickle in expressing frustration of ARNP care or new discovering what ARNP is and that their "doctor" was an ARNP. The vast majority of patients don't know, don't care, and never will and this is the crux when people have a baseline assumption that the person before them is a MD. I continually get people who don't know their "doctor" PCP is a really a PA or ARNP.

 

[Merovinge]

The marketing advantage of MD/DO over NPs isn't huge.

I'm in a saturated ARNP market right now and only a few people trickle in expressing frustration of ARNP care or new discovering what ARNP is and that their "doctor" was an ARNP. The vast majority of patients don't know, don't care, and never will and this is the crux when people have a baseline assumption that the person before them is a MD. I continually get people who don't know their "doctor" PCP is a really a PA or ARNP.

I'm surprised you have this experience. In my current location, I frequently hear how happy patients and parents are to talk to someone who actually understands the job of being a child psychiatrist. I cannot count the number of times people mention how nice it is to hear scientific discussion of mechanisms of action, how medications work, underlying pathophysiology, meta-analysis, longitudinal research for several countries, etc compared to their PA/NP experience prior. I'm in a lower health literacy area presently and actually have partially increased my discussion of these topics as it became clear that families and patients feel better knowing their doctor actual knows... things.

 

[sloh]

. So far leadership lucked into an upswing in the last 20 years without much aggressive strategizing--in particular, this emphasis on the "biological" part which was not originally designed with money in mind ended up being a huge leg up inadvertently. Can you imagine if we are competing for our core business against LCSWs? This lack of foresight may not work again in the next 20 years.

Are you suggesting that the current financial boon psychiatrists are experiencing is largely due to practices that capitalize and focus just/largely on meds? Thanks!

 

[Sushirolls]

I'm surprised you have this experience. In my current location, I frequently hear how happy patients and parents are to talk to someone who actually understands the job of being a child psychiatrist. I cannot count the number of times people mention how nice it is to hear scientific discussion of mechanisms of action, how medications work, underlying pathophysiology, meta-analysis, longitudinal research for several countries, etc compared to their PA/NP experience prior. I'm in a lower health literacy area presently and actually have partially increased my discussion of these topics as it became clear that families and patients feel better knowing their doctor actual knows... things.

C&A is different I believe. Parents will put in more concern for their kids than themselves. My assistant and I get calls for C&A every so often and there is definitely a greater awareness of the MD/DO superiority over midlevels with these help seeking parents.

 

[Yoyomama88]

The marketing advantage of MD/DO over NPs isn't huge.

I'm in a saturated ARNP market right now and only a few people trickle in expressing frustration of ARNP care or new discovering what ARNP is and that their "doctor" was an ARNP. The vast majority of patients don't know, don't care, and never will and this is the crux when people have a baseline assumption that the person before them is a MD. I continually get people who don't know their "doctor" PCP is a really a PA or ARNP.

Trust me the adhd pts do not care who is writing their Adderall haha

 

[dl2dp2]

Are you suggesting that the current financial boon psychiatrists are experiencing is largely due to practices that capitalize and focus just/largely on meds? Thanks!

The current financial boon has to do with:
1. mental health stigma decreasing
2. some meds actually work very well: suboxone, newer formulation stimulants, clozapine, lithium, etc.
3. these meds that work well also are not that simple to manage
4. in a subset of people common meds make a big difference

These facts lead to a large number of people wanting to get the service/evaluation to maximize the potential benefits of meds, which actually only benefits a small number of people, but we can't tell who these people are until we try them on meds. Hence psychiatrists benefit from the sale from the larger community that we are experts in psych meds. This also leads to vastly increased utilization. Therapy utilization has increased as well, but therapy alone is VERY cheap due to oversupply. My patients are consistently quoting me $50 or below per session from mid-levels.

Secondarily, more relevant for cash psychiatrist:
1. large cadre of underqualified therapists.
2. patients prefer meds + therapy.
3. 10% of top earners captured lots of salary growth.
4. mental health issues are big for work effectiveness and other high-cost issues during the peak earning/investment years (young adults).

These facts lead to a fairly robust private cash sector. Quality of therapy typically delivered by a cash psychiatrist is equivalent to or insubstantially higher than average non-MD, but the variance is much lower. People who have the money don't have the time to trial-and-error different therapists until they find a good one. THIS is the MAIN reason IMO of the value of an MD doing therapy. However, the marketing generally focuses on the med aspects (i.e. I dominate the "biological"). Given NPs can't deliver therapy, it's pretty obvious why APA focusing on biological stuff is a winning formula.

 

[AD04]

Pathology and rad onc are two good examples. Peds is another one.

For pathology and radiation oncology, it seems to be over-training of physicians rather than letting NPs take over the field. But even in pathology and radiation oncology, physicians can find work. They may not be in metropolitan areas but they still make physician salaries.

I'm not aware of the problem with pediatrics so you'll have to educate me on that one.

Maybe it is better to look at anesthesia to predict the future course psychiatry may take.

What should psychiatrists do to tackle the abundance of NPs?

The marketing advantage of MD/DO over NPs isn't huge.

I'm in a saturated ARNP market right now and only a few people trickle in expressing frustration of ARNP care or new discovering what ARNP is and that their "doctor" was an ARNP. The vast majority of patients don't know, don't care, and never will and this is the crux when people have a baseline assumption that the person before them is a MD. I continually get people who don't know their "doctor" PCP is a really a PA or ARNP.

I was in private practice too and was in a wealthy area -- the type of place most people want to be -- extremely saturated with psychiatrists (lots of them from prestigious institutions) and ARNPs. People with money certainly care about qualifications and fund of knowledge to explain diagnosis and medications. And most well-to-do (and educated) people are fearful of getting addicted. The people that only care about getting controlled medications aren't the type of patients you want anyways. (I also asked people about their former psychiatrists and looked them up and if they were seeing an ARNP, I will let them know that they were not seeing a physician.)

I'm not sure why your growth has been lackluster. Since you take insurance, insurance companies should be sending lots of people your way. Volume shouldn't be the issue. My peers in private practices are full after 1 year.

 

[clausewitz2]

For pathology and radiation oncology, it seems to be over-training of physicians rather than letting NPs take over the field. But even in pathology and radiation oncology, physicians can find work. They may not be in metropolitan areas but they still make physician salaries.

I'm not aware of the problem with pediatrics so you'll have to educate me on that one.

Maybe it is better to look at anesthesia to predict the future course psychiatry may take.

What should psychiatrists do to tackle the abundance of NPs?



I was in private practice too and was in a wealthy area -- the type of place most people want to be -- extremely saturated with psychiatrists (lots of them from prestigious institutions) and ARNPs. People with money certainly care about qualifications and fund of knowledge to explain diagnosis and medications. And most well-to-do (and educated) people are fearful of getting addicted. The people that only care about getting controlled medications aren't the type of patients you want anyways. (I also asked people about their former psychiatrists and looked them up and if they were seeing an ARNP, I will let them know that they were not seeing a physician.)

I'm not sure why your growth has been lackluster. Since you take insurance, insurance companies should be sending lots of people your way. Volume shouldn't be the issue. My peers in private practices are full after 1 year.

I dropped one of the two insurance plans I took after three months and briefly lost a good chunk of my panel but it's two weeks in and I am back to not having room for any intakes for at least the next 4 weeks.

That said, I have a handful of people coming for weekly hour-long therapy+meds so I might have fewer openings than some.

 

[Candidate2017]

You mentioned low tier/DO/FMG.

What about DO/FMG that train at university programs? As a follow-up question, are DOs at a disadvantage for cash practice even if they train at strong programs?

Regions that have lots of cash practice psychiatrists also have long waitlists. Only the most narcissistic of the narcissists can hold out long enough to see someone from a name brand school and residency. Though you may have to pursue therapy training independently if you come from a mediocre residency, as higher functioning patients appreciate therapy.

 

[Mass Effect]

4 years of medical school and 1 year of residency to be a licensed physician in my state (and many others). And I have yet to find where there is a legal definition of psychiatrist—and I have looked.

From what I can tell, a psychiatric nurse practitioner (sometimes listed as psychiatric mental health nurse practitioner) must actually complete a training program (2-3 year graduate program) and then pass an exam and have (in my state) 500 clinical hours training.

So whether it's better education or not, it does seem more regulated for PMHNPs.

From what I can tell, there is no such thing as licensing a psychiatrist. Of course there are board certifications.

Let me know if I am wrong on any of this. This is only from my own research I did a while back when I almost saw a psychiatrist who had not done a residency. Edit: They had done part of a residency, twice, but never finished either—to be more accurate.

Yes, you are wrong. Anyone who has not completed a psychiatry RESIDENCY should not be called a psychiatrist and if you know of someone who is, you should turn them in to the medical board as they are not a psychiatrist. They are a physician. Also, you're comparing an NP's 500 clinical hours with an MD's several thousand clinical hours before graduating med school? And even with one year of residency (the internship), they're going to kick the clinical experience NPs get in the ass.

 

[psychacad]

If patients hate you, they will not come, regardless of the 'prestigious' UG/Med/residency you went to. It's also not so hard to latch your name onto a 'prestigious' name for fellowship, and patients would hardly know the difference between a competitive residency and fellowship (and I doubt it is game changing anyhow). Your reputation in the community and among doctors and the quality of care you can provide will override every other factor. Only a few years ago, some were touting the benefits of undergoing prestigious analytic training to capture 'high paying' patients, but analytic institutions really are struggling, cause no one has time for that.

I would focus on being an excellent psychiatrist regardless where you land and ignore the doomsaying. For now, the market is great. You can have a very well paying job anywhere you want with unmatched flexibility with hours and setting.

 

[birchswing]

Yes, you are wrong. Anyone who has not completed a psychiatry RESIDENCY should not be called a psychiatrist and if you know of someone who is, you should turn them in to the medical board as they are not a psychiatrist. They are a physician. Also, you're comparing an NP's 500 clinical hours with an MD's several thousand clinical hours before graduating med school? And even with one year of residency (the internship), they're going to kick the clinical experience NPs get in the ass.

I do know of someone. The medical board said it's not a legally defined term when I inquired. He describes himself as a residency-trained psychiatrist on his web-site. He has a cash-only practice. The reason I picked up on it was that I found it peculiar that he described himself residency-trained. Residency-trained as opposed to what, I thought. So I did some digging and the board of medicine has two public pieces of information from two different residencies he was kicked out of. He was technically trained at the residencies but did not finish either of them.

I just tried again doing a web search to see if there are legal definitions, and it circles back to studentdoctor where someone wrote that residents can call themselves psychiatrists.

If you can point me to a statute, I would be curious.

I do understand that this is an outlying case.

 

[hallowmann]

Medicine with each passing day is less and less a profession. NDs and DCs and DNPs and ARNPs and PAs as the continue to expand the scope of practice and numbers, will continue to lower the standard of what it takes to practice medicine. Suits, health systems, politicians, administrators, and even some physicians are furthering this collapse.

Positively, I can tell patients seeking continuance of benzos or inappropriate stimulants or affirmation that marijuana is their cure all; other people in community exist to do this for them as I will not. One less headache to manage.

Can I just say that I'm so sick of patients telling me that their marijuana is their 100% safe cure all, and then the utter denial they express when I even mention potential adverse effects. I get that legalization is spreading, but its not like I get that type of pushback from talking about adverse effects of alcohol.

Oh, absolutely. But if salaries for physicians trend low enough that there isn't much of a premium when compared to nursing, the incentive will switch significantly. I wouldn't have invested 8 years of my life into this field if it didn't give me some decent ROI, I could already pull 100k as a respiratory therapist working fewer hours than I work as a resident. Eventually the incentive structure may shift to the point that the best and brightest go elsewhere, and only those that are drawn to fancy titles or that are absurdly altruistic but not necessarily the most talented end up in the field

I could see less people going into medicine due to increasing training requirements in the face of increased independent practice rights of midlevels more than for decreased salaries. The NPs/PAs have to get paid less or else their would be no benefit to healthcare systems to having them around as opposed to physicians.

 

[Central_SOULcus]

Eventually the incentive structure may shift to the point that the best and brightest go elsewhere, and only those that are drawn to fancy titles or that are absurdly altruistic but not necessarily the most talented end up in the field

I see what you're trying to say, but why the assumption that someone who is "absurdly altruistic" is "not necessarily the most talented?" One of my favorite mentors is a gifted clinician who is not only "absurdly altruistic" but also happens to be Ivy League-trained (for both med school and residency). Obviously that's an n of 1, but we all know there are many physicians who also fit the same description.

 

[MisterKitty]

I’m not sure about psychiatry’s image taking a hit since we have arguably the least prestige associated with our field compared to every other one.
But I do think our pay will take a hit due to mid levels. We can’t even find moonlighting in our program’s city because the inpatient units have moved to hiring mid levels for weekend coverage.
As someone with little interest in outpatient psychiatry I feel that I’ve made a massive mistake choosing the field. I feel that mid levels will soon replace inpatient psychiatrists as a cheaper alternative

 

[Mad Jack]

I see what you're trying to say, but why the assumption that someone who is "absurdly altruistic" is "not necessarily the most talented?" One of my favorite mentors is a gifted clinician who is not only "absurdly altruistic" but also happens to be Ivy League-trained (for both med school and residency). Obviously that's an n of 1, but we all know there are many physicians who also fit the same description.

I said not necessarily as in it is possible but not necessary. There's nothing saying a person can't have both, but right now you can't make it into medicine with hopes and dreams to help others alone when you're only pulling 490s on the MCAT. I worry that minimum standards of technical and scientific competence will fall should the field become highly uncompetitive, leading to talented and even highly competent physicians becoming more the exception than the norm

 

[Stagg737]

4 years of medical school and 1 year of residency to be a licensed physician in my state (and many others). And I have yet to find where there is a legal definition of psychiatrist—and I have looked.

From what I can tell, a psychiatric nurse practitioner (sometimes listed as psychiatric mental health nurse practitioner) must actually complete a training program (2-3 year graduate program) and then pass an exam and have (in my state) 500 clinical hours training.

So whether it's better education or not, it does seem more regulated for PMHNPs.

From what I can tell, there is no such thing as licensing a psychiatrist. Of course there are board certifications.

Let me know if I am wrong on any of this. This is only from my own research I did a while back when I almost saw a psychiatrist who had not done a residency. Edit: They had done part of a residency, twice, but never finished either—to be more accurate.

A lot is incorrect here. 4 years of med school + intern year is what is what is required to be a licensed physician/general practitioner. Claiming one is any form of specialist with such credentials is essentially fraud. Those individuals can prescribe many psych meds, but I'd be surprised if a state allowed them to prescribe controlled substances or label themselves as a psychiatrist with 1 year of psych residency.

It is far LESS regulated for PMHNP. Their "certifications" are often completion of programs which focus more on research and administrative courses than clinical education. Some NP certs do not even have exams and many "clinical hours" are bogus (show up for 4 hours, sit around, don't actually see patients). To give an idea of requirements for psychiatrists, we must complete med school, complete 48 months of residency (minimum), pass Step 1-3 or Level 1-3 (DOs), and often need to become board certified with recertification every 10 years.

500 clinical hours is nothing. That is less than 3 months of residency. Average physicians in a 4 year program will have 10,000+ hours of training. To give you an idea of how little 500 hours is, many states require hair stylists and dog groomers to have more hours than that to be licensed. So someone needs more hours to cut your dog's hair than practice medicine on a human. Let that sink in for a moment.

I do know of someone. The medical board said it's not a legally defined term when I inquired. He describes himself as a residency-trained psychiatrist on his web-site. He has a cash-only practice. The reason I picked up on it was that I found it peculiar that he described himself residency-trained. Residency-trained as opposed to what, I thought. So I did some digging and the board of medicine has two public pieces of information from two different residencies he was kicked out of. He was technically trained at the residencies but did not finish either of them.

I just tried again doing a web search to see if there are legal definitions, and it circles back to studentdoctor where someone wrote that residents can call themselves psychiatrists.

If you can point me to a statute, I would be curious.

I do understand that this is an outlying case.

Psychiatrists by definition are physicians, Here is the Medicare and APA's definitions for psychiatrist:

https://www.cms.gov/files/document/medicare-mental-health.pdf

What is Psychiatry?

Learn more about psychiatry, psychiatric training, and more at psychiatry.org

www.psychiatry.org

Note, psychiatrists are MDs or DOs per these definitions. However, I do believe many states allow for equivalent foreign degrees to MD or DO such as MBBS to be called psychiatrists as well.

It sounds like the individual you're referring to can legally call themselves a psychiatrist, though I would guess they are probably not thought of too highly in the community.

I'm in a saturated ARNP market right now and only a few people trickle in expressing frustration of ARNP care or new discovering what ARNP is and that their "doctor" was an ARNP.

This is very odd to me. I see a lot of patients who are frustrated that previous treatment was not helpful, oftentimes by a mid-level. Sometimes the patient doesn't know they were a midlevel, sometimes they do. Most of the time, those are the patients who have an actual axis 1 problem that hasn't been appropriately treated or severe personality for whom meds just don't do anything. I'm guessing this will vary significantly based on geography and saturation.

My patients are consistently quoting me $50 or below per session from mid-levels.

Wut? I'm in a fairly low COL area, and even here I don't think I know any mid-levels or have I seen any on psychologytoday who charge less than $80-100/hr unless they do sliding scale fees. How saturated with therapists is your area?

What should psychiatrists do to tackle the abundance of NPs?

Not much any individual field can do other than protect specific treatment modalities. Physicians as a whole need to realized the significance of mid-level encroachment and lack of training/pre-requisites for certain levels of practice. There are now ICUs completely run by NPs and NPs doing cardiac catheterizations. Imo psych is safer because of the relative ease of setting up private practices, especially cash-only practices. However, the dominoes have already started falling, who knows where things will be in 20 years.

 

[VA Hopeful Dr]

A lot is incorrect here. 4 years of med school + intern year is what is what is required to be a licensed physician/general practitioner. Claiming one is any form of specialist with such credentials is essentially fraud. Those individuals can prescribe many psych meds, but I'd be surprised if a state allowed them to prescribe controlled substances or label themselves as a psychiatrist with 1 year of psych residency.

You'd be wrong. Somewhere around half of states allow an unrestricted license about 1 year of post-graduate training. If you have a full license in a state, you can get a normal DEA number.

 

[Stagg737]

In this scenario, wouldn't the fewer physicians and their expertise become even more valuable? Which theoretically should lead to higher prestige and compensation?

Not necessarily, but I do think this provides some job security in our field given the ability to run a cash-only practice. There will always be people willing to pay for quality, which is something to consider in terms of job path/security.

Doubtful. This assumes there aren't forces from insurance companies, CMS, politicians [with good intentions, but bad implementation like we are currently seeing with balanced billing legislation]. With this vain of thought we should already be seeing it for physicians against the back drop of these mid-levels fields - but we aren't - only the same rate of descent into the cold icy Atlantic waters as the Titanic creaks downward.

1) fellow citizens don't even know the difference of the alphabet soup. Continually people say, "My doctor..." but when you google them, its an ARNP or PA.
2) Hospitals and health systems have been laying off physicians during covid to extract more work out of them, while prepping the job adds to replace the fired physicians with a midlevel.

Again, I don't doubt this is the general path, but I do think psychiatry is a bit more insulated than some other fields (see FM, peds, even derm) in terms resilience to non-cash market factors (insurance, CMS). The only major fear imo would be if we moved to a single-payer system which did not allow cash-only practices, but this would essentially mark the complete destruction of the US healthcare system.

NP is a major issue. I have physician friends who run NP-focused practices: NPs have lower quality but better profit margin and are slated to expand. MDs need to innovate and have a pitch, as well as collectively bargain hard. His opinion is facilities-based publicly funded MD jobs will die out. This will affect a lot of lower-tier trained MDs. Higher tier MDs will still get hired/be partnered to do medical director oriented jobs to manage multiple NP case loads.

Commercial insurance and cash practices will still favor MDs--as a patient, if I can find and afford an MD I wouldn't go to an NP, though there is downward pressure--commercial insurance-driven practices are increasingly unable to find in-network MD providers. So most MDs will be chasing after 30-40% of the market that's cash-based.

Currently this is not affecting job market because the demand has grown astronomically, but I think in the next 20 years if you are a lower tier/DO/FMG trained at community programs, you'll be either offered a job that's not very desirable or be prepared to start your own practice. Cush state/non-profit community jobs will be very rare and tend to be reserved for prestige residency grads and will have a large admin component. Current med students who are interested in a long term sustainable career in psychiatry should plan to work hard and match into as good a residency program as possible to hedge against this. The current state where anyone with a pulse can waltz into a community job that pays 250k for 35 hours a week will end sooner than you think.

I can see the first two paragraphs occurring, but partially disagree with the third. I don't think lower-tier MD/DO is going to see a huge hit anytime soon. The demand for psychiatrists is still high enough that true saturation will take a while and given the poor treatment quality of many mid-levels, true saturation may never occur. Good psychiatrists will always be needed, and I think there will be a place for almost all (at least in the outpatient setting) well past 20 years. That being said, I do agree with the last sentence that pay may take a fair hit and that you'll need more than a pulse to get a common clinical job.

You mentioned low tier/DO/FMG.

What about DO/FMG that train at university programs? As a follow-up question, are DOs at a disadvantage for cash practice even if they train at strong programs?

Depends. Prestige and image certainly matter to some demographics. If you're known in the community as a good physician though, you'll get referrals. There are a couple cash-only DOs in my area who don't even take new patients. For now, I think our field still has some insulation (at least in the geographic areas I'm familiar with).

Change is inevitable. People have been predicting doom since the 80's (or maybe even earlier) and yet for decades physicians have no trouble finding jobs and making more money every year. Predicting doom sounds smart and attracts attention.

So I'm going to sound stupid. Change will continue. But things will be ok and physicians will continue to have no trouble finding jobs and will continue to make more money every year.

But this is how you prepare in case I am wrong. I would encourage you to learn how private practice works and how to document and how to bill. Because at the very least, if the doomsday scenario does occur, you can always start your own practice and take Medicare and by being a physician, you have a huge marketing advantage over NPs. (And when you have enough work, then you may expand by overseeing NPs.) And it will benefit you now because in many scenarios, the knowledge will help you maximize income so you can put away more money today in preparation for the future.

I don't think it's stupid. Things aren't as good now in many areas as they were in the 80's and there may still be doom, it just is unlikely to come in the form of an explosive crash and more likely to be a slow descent into hell. The making more money aspect is all relative to inflation as well. Salaries may continue going up, but what is the actual value of those dollars?

I do agree with your last paragraph. I think that anyone currently in residency will have plenty of time to safely set themselves up for financial security as long as they're being responsible in the first 10 years out of residency. The other protective factor to mention is specialization. Find a niche that others can't do or that makes you high demand (forensics, addiction, ASD/ID) and you'll hold onto job security and financial freedom longer.

I’m not sure about psychiatry’s image taking a hit since we have arguably the least prestige associated with our field compared to every other one.
But I do think our pay will take a hit due to mid levels. We can’t even find moonlighting in our program’s city because the inpatient units have moved to hiring mid levels for weekend coverage.
As someone with little interest in outpatient psychiatry I feel that I’ve made a massive mistake choosing the field. I feel that mid levels will soon replace inpatient psychiatrists as a cheaper alternative

Until NPs gain FPA in all states, inpatient jobs will remain secure (at least as supervisory positions). Academic positions will remain open and quality will still matter in a lot of places. Even in the VA system where NPs have had FPA for quite a while, I don't know any inpatient psych units that aren't staffed by physicians (I've worked in or with 5 separate VA inpatient units). That being said, as someone who also loves inpatient psych I am making contingency plans for myself should inpatient become an invalid option in the future.

You'd be wrong. Somewhere around half of states allow an unrestricted license about 1 year of post-graduate training. If you have a full license in a state, you can get a normal DEA number.

I should addend that. I'm not surprised that they can technically call themselves psychiatrists. I am surprised that there are that many states that allow an unrestricted DEA license with only 1 year of residency.

 

[VA Hopeful Dr]

I should addend that. I'm not surprised that they can technically call themselves psychiatrists. I am surprised that there are that many states that allow an unrestricted DEA license with only 1 year of residency.

Its because the states don't control DEA licenses, the DEA (Federal) does.

 

[Sushirolls]

I suspect those inpatient units that only hiring midlevels for inpatient are the for profit companies.

States need to drop the step/level 3 and provide licensure for MD/DO grads post graduation without residency/internship year requirements. As one poster above noted, ARNPs have less hourly requirements then a dog groomer. We should be letting these fresh med grads practice, too.

 

[clausewitz2]

I suspect those inpatient units that only hiring midlevels for inpatient are the for profit companies.

States need to drop the step/level 3 and provide licensure for MD/DO grads post graduation without residency/internship year requirements. As one poster above noted, ARNPs have less hourly requirements then a dog groomer. We should be letting these fresh med grads practice, too.

I don't think we win the fight to justify why we should be preferred over ARNPs by making our training model more like theirs. That just makes us more interchangeable and the minute we can't cite at least some objective reason why we might be better it is game over.

 

[Sushirolls]

I don't think we win the fight to justify why we should be preferred over ARNPs by making our training model more like theirs. That just makes us more interchangeable and the minute we can't cite at least some objective reason why we might be better it is game over.

This is where I have been wavering lately and feeling some sense of demoralization. I have been privy to your point and toted that line. But the more I witness in my deep Blue area the health care utilization of patients dumping cash on ND, DC, ARNPs, etc and all the other issues with politicians, health systems, etc I'm summarily left with the impression too few people care about objective clinical difference or training difference and is an ultimate exercise in futility.

Then seeing the professional societies openly welcome midlevels in the policies and publications. An MD medical school in my area has dropped their psych rotation and integrated it with their Primary care saying they get depression/bipolar there and onsite MSWs provide therapy exposure in the clinic.

The best solutions I've been able to conjure up is this post of replicated a few times:
1) Don't supervise or train ARNP
2) End CMS funding for GME - this reliance on funds is choking our GME system with the concept of 'golden handcuffs'
3) petition states to reduce licensure requirements from PGY 1 (or 2), to that of Medical school graduates, and to drop step/level III
4) Ramp up MD/DO schools and/or class sizes, flood the market with MD/DO grads who will then become the new mid levels and push out the PA/ARNP
5) Join the only organization that actually gives a darn: Home - Physicians for Patient Protection
6) Create medical groups that advertise they are physician only

7) Possibly try to address the swing in medical schools to slap down any student that speaks out against midlevels because it is "anti team player" and the physician is not the captain of the ship but a part of the team - despite the entire medical legal system stating the exact opposite once heads need to roll.

 

[Stagg737]

Its because the states don't control DEA licenses, the DEA (Federal) does.

That doesn't mean that states can't have individual laws governing who can prescribe what. States can certainly have laws that are more restrictive than federal laws.