Questions regarding mid-level providers

[atexpsych]

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Hello everyone,

I am hoping to tap into the collective to gain some information regarding working with mid-level providers. I am currently a solo practitioner with a relatively successful outpatient clinic that I have been building over the last 3 years. At this point it I find myself starting the contemplation stage of working with (contract) or hiring (salary) a mid-level provider (PA/APN) however I realize that I am completely in the dark with all of this. I know that my first step is to register with the state board as a delegating physician however after that I am not certain how to proceed. Does anyone know of any resources I might be able to look into for guidance. None of my fellow psychiatrists are working with mid-levels and so they aren't able to help. I am hoping that there are some people here who have experience with this. I haven't gone the job-posting route because I haven't really decided if I should work with someone on a 1099 basis or as an actual salaried employee; also I'm not certain if I would bring them on board in to my clinic or work with them as they operate their own. Again, any guidance of any kind would be greatly appreciated. I hope others might read this as well and find some helpful information.

 

[MBBSMOM]

Are you in a full practice state for NPs? If not you are in charge of supervising them. This will take a substantial amount of time. If the NP makes a mistake your license is on the line since you’re the supervising physician.

 

[Sushirolls]

If you are looking at this purely as a business venture and nothing more, it could be a good thing.

But if you start thinking about quality of care delivered, there is a reason why your colleagues in the area haven't hired one.

Most states 1099 work, when evaluated more closely, is actually employed work and will get reamed in court. So best to assume if you are bringing some one in to your clinic it'll be as an employee to reduce your legal risks for labor law.

Personally I don't want care by a midlevel for myself nor my family.

 

[Jules A]

I would be certain there are NPs and possibly PAs working psychiatry in your state so find out who is using them and in what settings. The training and abilities of NPs can vary greatly. Scrutinize their RN experience for inpatient psych and requiring psychiatrist references. PsychNPs who are worth their salt should have a fair number of psychiatrist colleagues who know them and can speak to their work.

As for the liability it will depend whether you are in a full practice authority state to a certain extent however as an employer there is the expectation that an individual is practicing competently and within their scope. There are often histrionic warnings regarding the risk of utilizing midlevels but how often are they backed up by actual reports of physicians being sued solely due to their midlevel? A high quality clinician can be difficult to find regardless of if a physician, PA or NP but could possibly be a nice addition to your practice if a good fit.

Pay for quality, insist on RN experience and choose wisely.

 

[PikminOC]

I would be certain there are NPs and possibly PAs working psychiatry in your state so find out who is using them and in what settings. The training and abilities of NPs can vary greatly. Scrutinize their RN experience for inpatient psych and requiring psychiatrist references. PsychNPs who are worth their salt should have a fair number of psychiatrist colleagues who know them and can speak to their work.

As for the liability it will depend whether you are in a full practice authority state to a certain extent however as an employer there is the expectation that an individual is practicing competently and within their scope. There are often histrionic warnings regarding the risk of utilizing midlevels but how often are they backed up by actual reports of physicians being sued solely due to their midlevel? A high quality clinician can be difficult to find regardless of if a physician, PA or NP but could possibly be a nice addition to your practice if a good fit.

Pay for quality, insist on RN experience and choose wisely.

Not histrionics. If it's you sued due to the mid-level, that's terrible.
I think psychiatry is hard enough as as a psychiatrist.
If op hires a physician, he shouldn't be on the hook for outcomes as that physician he hires should be a deep pocket for mp lawyers

 

[sighchiatry]

It seems that a lot of it depends on which type of state you practice in.

State Practice Environment

It’s essential that NPs and policy makers have a clear understanding of how their state laws and regulations impact their practice. AANP’s interactive State Practice Environment map provides an overview of NP licensure for all 50 states, Washington, D.C. and U.S. territories. For details about the…

www.aanp.org

Full practice states - you are most likely good to go.

Restricted practice states - I wouldn't do it, everything falls on you.

Liability/ risk /etc in the reduced practice states is unclear to me though.

 

[liquidshadow22]

I wonder if in full practice states the np will command much higher salaries in comparison to restricted

 

[Jules A]

Not histrionics. If it's you sued due to the mid-level, that's terrible.
I think psychiatry is hard enough as as a psychiatrist.
If op hires a physician, he shouldn't be on the hook for outcomes as that physician he hires should be a deep pocket for mp lawyers

If you get sued due to anything its terrible. If not a full practice authority state there is still the expectation and responsibility of the midlevel to practice in a safe and appropriate manner. Can you point us to cases where this has happened? I have seen a few but not an overwhelming number and for what its worth if you have a physician who is negligent working at your practice do you not think the practice will also be sued? I have no interest working with someone incompetent but think the concern tends to be inflated on certain message boards.

The number of midlevels will soon outnumber physicians. I'm not saying it is ideal just that it is the future of health care. Much like telepsych which I loathe but have accepted is here to stay and will only continue to expand. Adaptation is probably a decent strategy especially if there is the option to expand access to care and profit after consideration of the risks vs benefits.

 

[MBBSMOM]

If you get sued due to anything its terrible. If not a full practice authority state there is still the expectation and responsibility of the midlevel to practice in a safe and appropriate manner. Can you point us to cases where this has happened? I have seen a few but not an overwhelming number and for what its worth if you have a physician who is negligent working at your practice do you not think the practice will also be sued? I have no interest working with someone incompetent but think the concern tends to be inflated on certain message boards.

The number of midlevels will soon outnumber physicians. I'm not saying it is ideal just that it is the future of health care. Much like telepsych which I loathe but have accepted is here to stay and will only continue to expand. Adaptation is probably a decent strategy especially if there is the option to expand access to care and profit after consideration of the risks vs benefits.

The thing is midlevels will over saturate themselves. It is already happening FNPs are already being denied jobs even from Walmart. I've looked at many hospital systems in my states. They are hiring physicians of all specialties but only 2-3 NPs in very specialized areas. The thing is also most new NPs don't even value being an RN for a couple of years. Most of the NPs in my area have no RN experience I'm not sure if any of them I would allow to practice under my license. The all online NP schools which require no RN experience are very troubling to me as a physicians. If the standards for the programs were higher I might consider working with an NP. But anyway I work IP and we do not utilize midlevels for IP at all.

 

[splik]

If op hires a physician, he shouldn't be on the hook for outcomes as that physician he hires should be a deep pocket for mp lawyers

This is not true and a common misconception of the risk of NPs. In a lawsuit everyone gets named and then by a process of elimination the named defendants get whittled down. If you employ a physician, then you are responsible for that physician's bad outcomes and can be expected to be named in any lawsuit. Plaintiff's lawyer can argue that you were negligent in hiring, or that you were negligent because you failed to supervise the physician and should have known what they were doing. This also applies to NPs in full practice states (i.e. if the shît hits the fan, you are still expected to be supervising them if you hire them).

The supervision of midlevels is not so much the issues from a lawsuit standpoint. The issue is that NPs have so much less training that we might expect the liability of hiring/supervising them to be much much greater than a physician (who for the most part should be a peer, though there may be more mentorship/supervision if they are a new graduate).

 

[TexasPhysician]

My medical board holds (supervising) physicians accountable for all midlevel decisions. I know a psychiatrist that lost his license forever over a midlevel.

 

[keolu hills]

Instead of hiring NPs and PAs, what if you were to hire social workers (LCSWS) and Master's level licensed mental health counselors to do therapy in your clinic. And just hire another psychiatrist to do mediciation visits. This seems to work really well in the state that I am in. And these midlevels are salaried employees.

 

[liquidshadow22]

My medical board holds (supervising) physicians accountable for all midlevel decisions. I know a psychiatrist that lost his license forever over a midlevel.

What did the midlevel do?

 

[PikminOC]

This is not true and a common misconception of the risk of NPs. In a lawsuit everyone gets named and then by a process of elimination the named defendants get whittled down. If you employ a physician, then you are responsible for that physician's bad outcomes and can be expected to be named in any lawsuit. Plaintiff's lawyer can argue that you were negligent in hiring, or that you were negligent because you failed to supervise the physician and should have known what they were doing. This also applies to NPs in full practice states (i.e. if the shît hits the fan, you are still expected to be supervising them if you hire them).

The supervision of midlevels is not so much the issues from a lawsuit standpoint. The issue is that NPs have so much less training that we might expect the liability of hiring/supervising them to be much much greater than a physician (who for the most part should be a peer, though there may be more mentorship/supervision if they are a new graduate).

I work by myself. I cant deal with all the nonsense from having other people. I once had a therapist and it didn't go well.

 

[TexasPhysician]

What did the midlevel do?

Short story: Too many controlled meds to the wrong people. He reviewed more charts than that required by the state, but the state rules that the minimum is there for midlevels after you’ve worked with them for many years. Until then, they expect you to review and catch it all.

 

[clausewitz2]

Short story: Too many controlled meds to the wrong people. He reviewed more charts than that required by the state, but the state rules that the minimum is there for midlevels after you’ve worked with them for many years. Until then, they expect you to review and catch it all.

So basically treat them like junior residents until you are absolutely positive they aren't going to open their own private pill mill. I wonder if the whole situation could have been avoided by requiring the NPs to consult him on all BZD/stimulant prescriptions until he decided otherwise. It seems like controlled substances and the profligate provision thereof motivates medical boards in a way few other things do.

 

[PikminOC]

So basically treat them like junior residents until you are absolutely positive they aren't going to open their own private pill mill. I wonder if the whole situation could have been avoided by requiring the NPs to consult him on all BZD/stimulant prescriptions until he decided otherwise. It seems like controlled substances and the profligate provision thereof motivates medical boards in a way few other things do.

He was benefitting monetarily

 

[Sushirolls]

Home - Physicians for Patient Protection

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www.physiciansforpatientprotection.org

A society for physicians only. Check it out.

 

[Jules A]

So basically treat them like junior residents until you are absolutely positive they aren't going to open their own private pill mill. I wonder if the whole situation could have been avoided by requiring the NPs to consult him on all BZD/stimulant prescriptions until he decided otherwise. It seems like controlled substances and the profligate provision thereof motivates medical boards in a way few other things do.

I see more BZD/Stims from the old psychiatrists and PCPs than from psych midlevels but monitoring diagnosing and prescribing until the midlevel is known to be competent only makes sense and probably not a bad idea with physicians hired also. Probably a waste of time to make them consult for all schedule 2 meds though.

I find it very hard to believe the physician referenced above had no clue his midlevel was prescribing inappropriate meds, that he was monitoring the midlevel as per reasonably expected and that his own prescribing was in fact solid.

 

[Jules A]

A society for physicians only. Check it out.

Ever notice? Mere mention of that special "society" clears the room every time.

 

[Sushirolls]

Ever notice? Mere mention of that special "society" clears the room every time.

This room or rooms in the tangible world?
I'm slowly looking at their website more. Might be something I associate my name to.

 

[Jules A]

This room or rooms in the tangible world?
I'm slowly looking at their website more. Might be something I associate my name to.

All three. Just my opinion but I doubt they will garner significant physician or public support largely due to the mean spirited tone. Regardless of how one feels midlevels are here to stay. How they are educated, trained and utilized is what will have the potential to result in a cohesive working alliance and increased access to safe care.

 

[Sushirolls]

I didn't get the impression it is mean spirited tone. When ARNP or CRNAs claim equivalency or superiority, that dictates Physician Advocacy needs to step up.

We are horrible at letting slide the nuances of their poor care.

Just this past month I had a patient tell me an inpatient ARNP told them their anxiety would be "cured" with propranolol buspar combo. Despite the patient having a past buspar trials with no positive effect, and a more lengthy history that reflects the TCA I started is the most hopeful direction to continue with. Had another ARNP tell my patient they have autistic spectrum disorder on an inpatient unit (adult) because they too had Autism - and over my career I've made ZERO autism diagnoses on an inpatient unit. The list goes on, every month, something new.

Agreed, they are here to stay but labeling and identifying the deficiencies is a first start to optimizing their education, training and utilization as you allude to. Right now our traditional societies, like the APA, aren't doing anything.

 

[clausewitz2]

I didn't get the impression it is mean spirited tone. When ARNP or CRNAs claim equivalency or superiority, that dictates Physician Advocacy needs to step up.

We are horrible at letting slide the nuances of their poor care.

Just this past month I had a patient tell me an inpatient ARNP told them their anxiety would be "cured" with propranolol buspar combo. Despite the patient having a past buspar trials with no positive effect, and a more lengthy history that reflects the TCA I started is the most hopeful direction to continue with. Had another ARNP tell my patient they have autistic spectrum disorder on an inpatient unit (adult) because they too had Autism - and over my career I've made ZERO autism diagnoses on an inpatient unit. The list goes on, every month, something new.

Agreed, they are here to stay but labeling and identifying the deficiencies is a first start to optimizing their education, training and utilization as you allude to. Right now our traditional societies, like the APA, aren't doing anything.

It wasn't midlevels who told everyone who had ever had a mood swings in the 90s that they were bipolar and needed Depakote.

 

[Sushirolls]

It wasn't midlevels who told everyone who had ever had a mood swings in the 90s that they were bipolar and needed Depakote.

I'm not saying Physicians are perfect, and yes we can critique our own performance quite well. But that's the difference we do critique, we do analyze, we do strive to improve, continually raise our standards, and very important for psychiatry we actively teach about boundaries and aren't hugging our patients in the halls.

ARNP and lesser of PA are more concerned about scope of practice, their labels, and parity with physicians then actually improving the care they deliver.

 

[heartsink]

It wasn't midlevels who told everyone who had ever had a mood swings in the 90s that they were bipolar and needed Depakote.

I think its an unfair comparison to view the general advancement of medicine and psychiatric theory throughout the ages as comparable to the differences in education, training, and standards of midlevel providers to physicians. You could just as easily be saying "well it wasn't midlevels that were bloodletting everyone with a humour imbalance in the 1090's".

 

[clausewitz2]

If we are going to fault all midlevels for the terrible prescribing or diagnostic habits of some of them and thus justify why MD training is necessary, it is relevant to consider an enormous pattern of terrible diagnosis and prescribing largely enacted by people with MD training in very recent memory.

It is not the case that since then we have had some massive discovery undermining the previous paradigm and thus it was only reasonable that they should have practiced that way. It's just no longer faddish and Pharma influence is less grotesquely obvious.

Your degree will not protect you from being gullible or intellectually lazy. Midlevels are here to stay and trying to pretend otherwise is deeply foolish. Better to recognize the need for supervision, mentoring, and thoughtful on the job training.

 

[MBBSMOM]

If we are going to fault all midlevels for the terrible prescribing or diagnostic habits of some of them and thus justify why MD training is necessary, it is relevant to consider an enormous pattern of terrible diagnosis and prescribing largely enacted by people with MD training in very recent memory.

It is not the case that since then we have had some massive discovery undermining the previous paradigm and thus it was only reasonable that they should have practiced that way. It's just no longer faddish and Pharma influence is less grotesquely obvious.

Your degree will not protect you from being gullible or intellectually lazy. Midlevels are here to stay and trying to pretend otherwise is deeply foolish. Better to recognize the need for supervision, mentoring, and thoughtful on the job training.

This I'm not that found of "midlevels" but I hate how every problem in psychiatry and medicine is blamed on mid levels. Pts being misdiagnosed easy just blame the midlevels. Pts being over medicated just blame the midlevels. If we blame midlevels as a whole we can not fix the misdiagnosis that is so rampant in our field. I've seen psychiatrist diagnose bipolar without ever screening for mania just because the pt was on Lamictal for epilepsy not bipolar. I've seen other rampant issues in clinical management from both psychiatrists and NPs.

 

[liquidshadow22]

This is not true and a common misconception of the risk of NPs. In a lawsuit everyone gets named and then by a process of elimination the named defendants get whittled down. If you employ a physician, then you are responsible for that physician's bad outcomes and can be expected to be named in any lawsuit. Plaintiff's lawyer can argue that you were negligent in hiring, or that you were negligent because you failed to supervise the physician and should have known what they were doing. This also applies to NPs in full practice states (i.e. if the shît hits the fan, you are still expected to be supervising them if you hire them).

The supervision of midlevels is not so much the issues from a lawsuit standpoint. The issue is that NPs have so much less training that we might expect the liability of hiring/supervising them to be much much greater than a physician (who for the most part should be a peer, though there may be more mentorship/supervision if they are a new graduate).

Does this apply if another psychiatrist, midlevel, or therapist is working as a 1099 contractor in your clinic? Technically, they are not employees at that point.

 

[splik]

Does this apply if another psychiatrist, midlevel, or therapist is working as a 1099 contractor in your clinic? Technically, they are not employees at that point.

Of course. It’s no different since you still hired them and are responsible for vetting them.

In addition, for NPs if you are working in a state that does not allow independent practice for them it is probably not allowed for them to be 1099 since if they need supervision they are not a contractor. In my state it is expressly illegal for NPs to be 1099

 

[WisNeuro]

Of course. It’s no different since you still hired them and are responsible for vetting them.

In addition, for NPs if you are working in a state that does not allow independent practice for them it is probably not allowed for them to be 1099 since if they need supervision they are not a contractor. In my state it is expressly illegal for NPs to be 1099

Keep an eye out, there's some chatter in my private practice listservs about some changes and tightening of rules as it comes to 1099 classification that would make it harder to be legally classified as such heading forward. AFAIK nothing concrete yet, but could be coming down the pipeline in the next year or so. If you have 1099 employees, or are one, will definitely be worth a meeting with your own lawyer.

 

[trophyhusband]

Keep an eye out, there's some chatter in my private practice listservs about some changes and tightening of rules as it comes to 1099 classification that would make it harder to be legally classified as such heading forward. AFAIK nothing concrete yet, but could be coming down the pipeline in the next year or so. If you have 1099 employees, or are one, will definitely be worth a meeting with your own lawyer.

Guessing this is some of the stuff the 87,000 new IRS agents will start looking into. It's about time frankly a lot of these 1099 positions are abuses of the IC designation.

 

[WisNeuro]

Guessing this is some of the stuff the 87,000 new IRS agents will start looking into. It's about time frankly a lot of these 1099 positions are abuses of the IC designation.

Just to be clear, the 87k will not be all audit agents, many of those positions are supposed to be IT and admin positions, The infrastructure of that agency needs a major update. But yeah, there are definitely some abuses. But hopefully we don't overcorrect.

 

[trophyhusband]

Just to be clear, the 87k will not be all audit agents, many of those positions are supposed to be IT and admin positions, The infrastructure of that agency needs a major update. But yeah, there are definitely some abuses. But hopefully we don't overcorrect.

Fair enough, I didn't pay much attention to what the 87k were going to be doing. Guessing a lot of those folks will be reviewing tax returns if not "agents" meaning the people who go out and investigate. But updated infrastructure should help in identifying the abuses as well. I can't say I understand the fear of overcorrecting. The criteria are fairly clear so it's fairly easy to tell if someone is or isn't an IC.

 

[WisNeuro]

Fair enough, I didn't pay much attention to what the 87k were going to be doing. Guessing a lot of those folks will be reviewing tax returns if not "agents" meaning the people who go out and investigate. But updated infrastructure should help in identifying the abuses as well. I can't say I understand the fear of overcorrecting. The criteria are fairly clear so it's fairly easy to tell if someone is or isn't an IC.

Not as easy as one would think. Many places get caught on minutiae. Also a lot of people who would like to be an IC instead of W2 are opposed to this. We are getting a lot in our state association who are ICs who are worried that they won't be able to stay that way.

 

[TexasPhysician]

Keep an eye out, there's some chatter in my private practice listservs about some changes and tightening of rules as it comes to 1099 classification that would make it harder to be legally classified as such heading forward. AFAIK nothing concrete yet, but could be coming down the pipeline in the next year or so. If you have 1099 employees, or are one, will definitely be worth a meeting with your own lawyer.

I’ll believe it when I see it as it’s political suicide at the federal level. The rules are fairly clear, but I recognize my bias as I’ve defended this in court. Currently being a contractor is beneficial to the contractor and the other business. Further restrictions upset everyone involved.

 

[WisNeuro]

I’ll believe it when I see it as it’s political suicide at the federal level. The rules are fairly clear, but I recognize my bias as I’ve defended this in court. Currently being a contractor is beneficial to the contractor and the other business. Further restrictions upset everyone involved.

Let's hope so. While I'm sure a tightening of rules will be beneficial to workers in some industries, in healthcare, particularly at the doctoral/professional level, there are obviously many people who want to be ICs and not W2s. And, there are some people who are technically both, when you consider LLCs/S-corps. If anything changes, the biggest hassle will be having to meet with and pay your healthcare attorney to make sure things are structured in a sound way and documented correctly.

 

[splik]

Keep an eye out, there's some chatter in my private practice listservs about some changes and tightening of rules as it comes to 1099 classification that would make it harder to be legally classified as such heading forward. AFAIK nothing concrete yet, but could be coming down the pipeline in the next year or so. If you have 1099 employees, or are one, will definitely be worth a meeting with your own lawyer.

This does not apply to physicians. The goal of the laws is to protect employees and it is widely accepted that physicians often prefer being contractors and do not need to protection from many labor laws. But it will apply to many non physician providers.I’m not sure if it would apply to doctoral psychologists but it would apply to masters level therapists, and to NPs, PAs etc

 

[WisNeuro]

This does not apply to physicians. The goal of the laws is to protect employees and it is widely accepted that physicians often prefer being contractors and do not need to protection from many labor laws. But it will apply to many non physician providers.I’m not sure if it would apply to doctoral psychologists but it would apply to masters level therapists, and to NPs, PAs etc

We would be in the boat of many physicians I would assume. Particularly those of us who do legal consulting work.

 

[trophyhusband]

Not as easy as one would think. Many places get caught on minutiae. Also a lot of people who would like to be an IC instead of W2 are opposed to this. We are getting a lot in our state association who are ICs who are worried that they won't be able to stay that way.

What someone prefers doesn't matter at all. Again you're either an IC or you're not.

 

[WisNeuro]

What someone prefers doesn't matter at all. Again you're either an IC or you're not.

What someone prefers definitely does matter as there is not a one size fits all approach to all business. What works for a large, multunational corporation, can cripple small businesses. Stricter laws would vastly change the healthcare landscape, and not for the better. There is a reason that it's making the rounds across professional healthcare groups, and many people are contacting their legislators making their opposition known. Also, I still think you are vastly underestimating the complexity of these rules and how they are applied and seen by different entities. The wording of the actual statutes is vague in many instances and open to interpretation, and has been interpreted differently in different settings.

 

[trophyhusband]

What someone prefers definitely does matter as there is not a one size fits all approach to all business. What works for a large, multunational corporation, can cripple small businesses. Stricter laws would vastly change the healthcare landscape, and not for the better. There is a reason that it's making the rounds across professional healthcare groups, and many people are contacting their legislators making their opposition known. Also, I still think you are vastly underestimating the complexity of these rules and how they are applied and seen by different entities. The wording of the actual statutes is vague in many instances and open to interpretation, and has been interpreted differently in different settings.

The IRS's sole reason for existing is to enforce the rules on the books. They don't, nor should they, care about anyone's personal preference.

Legislators can change those laws/rules if they so choose but it's not up to the IRS to take what anyone wants to be classified as into account.

 

[WisNeuro]

The IRS's sole reason for existing is to enforce the rules on the books. They don't, nor should they, care about anyone's personal preference.

Legislators can change those laws/rules if they so choose but it's not up to the IRS to take what anyone wants to be classified as into account.

That would be great if enforcement was uniform and clear. But, that is unfortunately not the case given the grey areas that exist within the wording of the statutes.

 

[Jules A]

I've heard these rumblings for years and haven't seen any broad enforcement. Likely as others pointed out it probably isn't wouldn't be worth the hassle to enforce. I imagine a fair number of IC technically don't meet the requirements but IRS will continue to look the other way.

 

[WisNeuro]

I've heard these rumblings for years and haven't seen any broad enforcement. Likely as others pointed out it probably isn't wouldn't be worth the hassle to enforce. I imagine a fair number of IC technically don't meet the requirements but IRS will continue to look the other way.

We've had two decent sized practices get tangled up in this in the past decade here. They're well known, and most of us were surprised at the details, as we would have considered the employees ICs as well. Though, I believe one also had an issue with the state DoR as it related to workman's comp, whicg ties into the IC determination.

 

[Candidate2017]

Regardless of how one feels midlevels are here to stay. How they are educated, trained and utilized is what will have the potential to result in a cohesive working alliance and increased access to safe care.

Midlevels are not here to stay. They are here to takeover.

But I don't have problems with psych midlevels because I decline to deal with them. I do have problems with primary care midlevels. Whenever I find a medical issue with my patients and refer them to their PCP, things get screwed up if the PCP ends up being a midlevel. I just had a patient hospitalized for a week due to their primary care midlevel adding a medication that every med student knows not to add to certain psych meds.

I loathe calls from primary care midlevels. Every interaction ends up requiring me to take time to educate them on basic medicine. For free. How bad are these primary care midlevels? Once, one of them called to notify me she diagnosed our mutual patient with serotonin syndrome and asked the patient to have me address it at our next appointment, which was in a month.

 

[forchinet121]

Midlevels are not here to stay. They are here to takeover.

But I don't have problems with psych midlevels because I decline to deal with them. I do have problems with primary care midlevels. Whenever I find a medical issue with my patients and refer them to their PCP, things get screwed up if the PCP ends up being a midlevel. I just had a patient hospitalized for a week due to their primary care midlevel adding a medication that every med student knows not to add to certain psych meds.

I loathe calls from primary care midlevels. Every interaction ends up requiring me to take time to educate them on basic medicine. For free. How bad are these primary care midlevels? Once, one of them called to notify me she diagnosed our mutual patient with serotonin syndrome and asked the patient to have me address it at our next appointment, which was in a month.

What was the medication?

 

[ObsequiousAplomb]

What was the medication?

my guess is patient was already taking Lexapro 20, trazodone 150 qhs, and buspar 10 TID because that's already something that should have tipped anyone off to not add another serotonergic medication but could also be an entirely reasonable combination. Or maybe Cymbalta 60 and Buspar or Elavil and Buspar.

Then, because this is a midlevel, sounds like outpatient, and was enough for Candidate2017 to post something absurd like linezolid was added for a mild pneumonia or skin infection.

 

[forchinet121]

my guess is patient was already taking Lexapro 20, trazodone 150 qhs, and buspar 10 TID because that's already something that should have tipped anyone off to not add another serotonergic medication but could also be an entirely reasonable combination. Or maybe Cymbalta 60 and Buspar or Elavil and Buspar.

Then, because this is a midlevel, sounds like outpatient, and was enough for Candidate2017 to post something absurd like linezolid was added for a mild pneumonia or skin infection.

Linezolid being serotenergic is definetly not something every med student knows let’s not exaggerate things

 

[deleted456421]

Midlevels are not here to stay. They are here to takeover.

But I don't have problems with psych midlevels because I decline to deal with them. I do have problems with primary care midlevels. Whenever I find a medical issue with my patients and refer them to their PCP, things get screwed up if the PCP ends up being a midlevel. I just had a patient hospitalized for a week due to their primary care midlevel adding a medication that every med student knows not to add to certain psych meds.

I loathe calls from primary care midlevels. Every interaction ends up requiring me to take time to educate them on basic medicine. For free. How bad are these primary care midlevels? Once, one of them called to notify me she diagnosed our mutual patient with serotonin syndrome and asked the patient to have me address it at our next appointment, which was in a month.

I'm considering a concierge primary care/psychiatry service. Many patients need the latter more than the former but end up on crazy anti-HTN/DM/pain regimens without the care coordination that defined old-school primary care. I often get sarcastic replies (if any at all) when reaching out to midlevels in the community.

In fact, I recently encouraged someone to keep a BP log at home since they suffer horrible white coat HTN. Their PA started a 4th antihypertensive because their BP was >120/80 in the office. Like, I listen to the Curbsider podcast and keep up with JNC guidelines. I know that home values are incredibly important. Why can't a PA do the same?

Have another person receiving both morphine and buprenorphine (the Subutex formulation) with serious side effects. Their NP-only pain management group won't return my calls.

Sure, I worry about my employability years from now because of midlevel encroachment. But the shear quantity of mismanagement worries me more than anything else. I literally feel sick at times.