the future of psychiatric practice

[psychnpgirl]

In 2016 17,000 US physicians graduated and 23,000 US nurse practitioners graduated. Moving forward there will be a higher percentage of psych NPs prescribing the nation's psych meds in specialty settings. Our education (that of psych NPs) kinda sucks (actually sucks a lot, is way under-regulated). This is the current reality. However, it seems that perhaps psychiatrist education is not *ideal* either. The main reason I say it's not ideal is because from a purely capitalist macroeconomic standpoint the field has been in a chronic shortage for decades. If there aren't enough of a type of professional to provide a population with a basic needed service then something is wrong with the model.

What am I getting it? Well, I'm a psych NP. I've been practicing *4 months* (almost) (hehe). I'm having fun but intimidated by everything I don't know. I do have awesome supervision and collaboration within an integrative care setting, so I'm learning a lot and I personally will hopefully be okay in terms of not doing dramatic harm for my lack of education.

I am really, really fortunate to be 24 and have no loans thanks to a scholarship. Part of me wants to go to med school now for these reasons. But then I realize: doctors have a tough time! You graduate older and have lots of loans, which binds you into accepting a prescribed role in a system you might spend time changing if you didn't have to play catch-up with your personal finances. SO another part of me just had a slightly hypomanic-sounding idea:

*What if* we could cure the longstanding psychiatry shortage? And spend $ much more efficiently as a society on psych drug development vs. much lower cost but harder to implement psychosocial interventions a la Anatomy of an Epidemic?

I feel like, in order to do this, we would need to either completely revamp the NP educational path to make it not suck and attract on average more and smarter and more passionate-about-psych people--like current psych PhD programs--or create an entirely different, new educational path that did not require the expense of med school but required more than RN + MSN school, with more emphasis on pathophysiology, pharmacy, differential med diagnosis as relates to psychiatry, sociological factors, maybe even more like an LCSW type component, more understanding of the recovery movement, less on bedside acute care nursing ... I dunno exactly what it would entail, but I think I'm onto something with the general idea. With the Internet there has never before been a time where people across the country could easily collaborate to formulate a blueprint for a solution to a public health crisis so longstanding it's now taken for granted by patients and providers alike. I'm rambling now.

Anyway.... I donno.... maybe this makes no sense and you can poke a bunch of holes in the whole idea. I'm really open to any feedback. Thank you!

*Edit*: 40% of psychiatrists are in all cash private practice (I think that's a real statistic I read somewhere). So for CMHCs take all the issues mentioned above and multiply them by at least two. This stuff is so real, and I would love to hear if anyone else has been thinking about ideas like this.

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[TexasPhysician]

I disagree with almost everything you have written.

1. I believe all outpatient medical services should be cash-only. Non-emergent medical services should be paid a fair price. Insurance is a way to force an entire sector to take below-market wages. Insurance costs would also be better controlled if we limited coverage to hospital based care. The care is also better as cash medical care results in more education and 1:1 diagnostic time. I have fewer return visits because quality is better. I specifically seek out cash physicians despite having insurance. All of my personal physicians are cash only. My health is better for it. Everyone listens and follows through more often when you pay for it.

2. The #1 prescriber of psych meds is primary care physicians as it should be. You don’t need a specialist to treat many mental health conditions. When a psychiatrist improves clinical care, the patient should be referred back to primary care to continue management. Patients could return with complications that PCP can’t handle. All specialists could be better at this. Many patients continue seeing a dermatologist when it isn’t needed. A PCP could pick-up care.

3. The cost of cash services is not prohibitive to most Americans. I have many Medicare and Medicaid patients that see the value in my services. The complaint is more that insurance for a family is around $1500+ Per month now. Cash on top of $1500/month is the problem. The insurance industry is out of control and ripe for change.

4. NP’s and PA’s in my opinion are best suited to work with primary care physicians.

5. Specialty training by NP’s and PA’s is incredibly deficient and in my opinion is no better than that of a family physician.

6. Telemedicine laws can be relaxed to improve access to rural populations.

7. CMHC’s should hire more PCP’s with NP’s, and PA’s to handle mental health needs as first line. If anything, this is where extra psych training could be useful for PA’s and NP’s as the focus would be 90% mental health with a PCP. CMHC’s should also hire a lot more counselors and psychologists. Therapy is highly underused at CMHC’s.

With the above changes, I don’t believe there would be a psychiatric shortage. Current laws, insurance demands, and delayed returned referrals create an artificial shortage.

In no way are my opinions meant to be derogatory to anyone. I do believe that NP’s and PA’s are valuable to medical care, but I believe the education provided them is best designed for primary care with supervision.

* Similar topics have not resulted in polite conversation. If we can’t be respectful, this thread won’t last long.

 

[wolfvgang22]

We need more psychiatrists, not more poorly trained NPs or PAs. I used to help train NPs and PAs, and thought it was good, but not anymore. It starts out innocuous, the idea being to help with the large volume of easy, straightforward cases. But the fact is that we are specialists, and most of the easy cases like this are seen in primary care. When a patient needing specialized psychiatric care sees a "psych NP" with their crash course in basic pharmacology, at best they get lucky following a treatment algorithm, but often they waste time with ineffective treatment and sometimes even dangerous prescriptions.

Also, the arrogance of these mostly young, poorly trained clinicians has been increasingly astounding each year. Lots of half baked ideas about how to fix things and demands to be treated equal to a psychiatrist in the clinic while not knowing a fraction of what they don't know. The fact is that the plan of many employers now is to have psychiatrists train these folks because they are cheaper, so they don't have to pay or listen to physicians who have good ideas with experience.

My advice is if you want to be a doctor, go to medical school.

 

[singasongofjoy]

I’m curious to know how much cash outpatient services would cost if insurance were not driving it all up. As a postdoc I don’t have to pay for my health insurance (thank you, university!) but I sure would balk at paying ~$500 every time I go see my OB if that were a true cost. Where could one find research on what the true cost of cash only medical care would likely be for various outpatient services?

Related to CMHC and underutilization of psychosocial therapy- agree 100%. How does one meet the difficulty of getting folks to engage in therapy as frequently as indicated though? I think we need more availability of services outside of regular working hours for one- and in a wider variety of settings. But implementing that would have its own challenges I suppose.

 

[Ironspy]

The problem is that most of the psychiatrists on this board think that what you're describing is medical school and residency. There are no shortcuts. There is no way to condense 4 years of med school + 4 years of residency into a 2-3 year part time program that covers "pathophysiology, pharmacy, differential med diagnosis as relates to psychiatry" bc there is too much information to cover.

I don't see the value of a psych NP over a PCP who is trained in pathophys, pharm and medicine though lacks formal psych training.

 

[TexasPhysician]

I’m curious to know how much cash outpatient services would cost if insurance were not driving it all up. As a postdoc I don’t have to pay for my health insurance (thank you, university!) but I sure would balk at paying ~$500 every time I go see my OB if that were a true cost. Where could one find research on what the true cost of cash only medical care would likely be for various outpatient services?

It varies. My family pays $120/month which includes as many private visits with a double board-certified IM/peds docs as we wish. Monthly fee for all outpatient visits whether we go or not which is VERY reasonable. This includes gyn services.

We pay $75 per dermatology appointment. Reasonable added costs for anything cut off and sent to pathology.

I’m probably the most expensive I know which is about $300 for a 1.5 hour new eval with children. I’m very thorough and provide many recommendations. Time-wise - derm makes more as they fit 5+ visits in 1.5 hours, so I’m not that expensive for the time provided.

Cash costs are quite fair if you look around. There isn’t long waits either.

 

[Bearcat74]

I am a psych NP with 30 years experience. I have been a preceptor for psych NP students, from a large university for several years. It should be required that any psych NP have at least three years of staff RN experience before going in to a psych nurse practitioner program.

The NP students with psych staff nurse experience are greatly superior in knowledge than those who go straight through with no hospital experience, or retrain from family NP careers. The originator of this thread seems very immature, and should not be prescribing medications without serious supervision from experienced psychiatrists.

 

[psychnpgirl]

^ What seems immature about my post? Just curious. I always benefit from increased self-knowledge and sometimes feedback anonymously on the Internet can be helpful for increasing my self-awareness, so maybe you can do me the favor of helping me with that. I am 24 and certainly never claimed the benefits of wisdom. Love your picture, BTW.

TexasPhysician: Thank you for the comment about cash practice. I do wonder if research is being done about if/how that could be implemented on a population scale that could overtake insurance based practice? Do you know of anything like this? I also love the idea that this shortage could be alleviated by loosening certain laws, and would like to learn more about the context of your opinions and how you developed them. Can you recommend sources? Also, how do we change coordination of care so that people who don't need specialist care stop getting it? Where I work, stimulants must be prescribed by psych specialists rather than PCPs, so we get a lot of very simple ADHD cases.

And does the shortage of primary care docs not also play a role when we talk about having them pick up more of our easier cases?

It would be great for all children to be raised by good-enough parents, it would be great for every person to be treated for their mental health problems early in their course of illness by a seasoned, non-pharma funded, top-notch, culturally competent psychiatrist. Realistically, there are limited resources in the world. I see a lot of discussion around who's competent enough to treat patients. I am not arguing that NP education is ever comparable to psychiatrist education. What I am arguing for is a perhaps an alternative, less myopic view, in which we are all sort of inculcated into our own maybe? somewhat? self-interested narrow perspectives. I don't like the ugly debates that only serve to increase each others' propensity for navel-gazing. And I am arguing for a public health stance: There are never enough psychiatrists. Do you really think there is a way to get medical students to go into psychiatry that hasn't already been tried? If you can find a way, or if like Texas said, there are enough PCPs to pick the slack if care coordination improved and laws became more lax, my whole post MIGHT be moot, but still, psych NPs would be cheaper, and therefore the issue might persist even if we could veer society in the direction of cash-only for outpatient care. But what about inpatient? It seems like the issue of psych NPs existing would persist regardless.

Is it better to be a purist/idealist and argue for a future in which many people continue to have no psychiatric provider at all, or open ourselves up to a more productive discussion with each other?

This is a health care economics issue more than anything else. The world continues to go forward in the direction it will. "Close supervision" is a lovely idea but rarely happens even in the states with the strictest laws on NP/PA practice. More psych NPs are graduating and the number of psychiatrists graduating stays the same or decreases. Moral outrage itself doesn't change this economic reality, "the race to the bottom". Online NP programs where people select their own clinicals and don't need any RN experience *exist*--we can't make them not exist by saying how bad they are. There is a massive shortage of psych NPs and psychiatrists. I was recruited SO heavily when I graduated, it was insane. This is not a question of who is competent, but rather, who can be legally paid for services, and how can we raise the standard of that but within a frame that's economically viable for society.

One last thing. Change your perspective to GLOBAL psychiatry and I don't think you can argue that there is anything artificial about the shortage.

 

[TexasPhysician]

All clinicians are heavily recruited. Administrators need to be paid despite pulling in $0. This is in part because physicians, midlevels, therapists, etc are generally not good at developing a private practice or negotiating well. We pay the bills of others and thus are recruited heavily.

There is no shortage of people wanting to become psychiatrists in the US. The current # of spots fills every year.

There are 0 reasons why PCP’s can’t prescribe and treat ADHD. Admin is likely developing such rules to shunt easy patients to NP’s.

There is no $$ in referring patients back to PCP’s, so all specialists get lazy in doing so. Kickbacks are illegal, but I’d argue that kickbacks to PCP’s-only (don’t want this abused) would reduce long-term health costs. It would incentivize specialists to return stable patients and decrease shortages. Abuse of this would need to be monitored.

I have plenty of ideas on a population level, but the government doesn’t care. It is simpler to allow midlevel training centers to mass graduate poorly trained staff with minimal clinical experience. If I were a NP, I would be pushing for strict reform. Higher quality is the way to advance the field.

 

[singasongofjoy]

There are 0 reasons why PCP’s can’t prescribe and treat ADHD. Admin is likely developing such rules to shunt easy patients to NP’s.

Prescribe, sure, and treat as far as that is concerned. But I remain pretty skeptical on the diagnosing of many (not all) PCPs, except in the most obvious of cases. Around here, it seems far too easy for folks to do googling, give PCP list of sx, and come out with an ADHD dx and Rx in a brief visit - and be unwilling to entertain the idea that anxiety, or just unreasonable expectations of themselves, are the true dx. I'd also like PCPs treating ADHD to be generally versed in the importance of behavioral approaches to treating ADHD to address the skill deficits that lead to greater problems with mood/anxiety/social problems down the road for kids with ADHD. Not trying to take this thread on a tangent, but seemed like an opportune time to make a plug for that. Consistent behavioral strategies can make a huge difference with ADHD but a lot of parents who come see me don't seem to have ever heard how important that is (whether they've actually been told or not, I dunno, sure it's selective memory/processing in some cases).

I'm all for letting PCPs manage stable patients who are generally physically healthy. Would decrease the wait of the more complex patients I refer who def need a psychiatrist and imagine this would be true in other specialities as well. The idea of incentivizing that aspect is intriguing.

 

[psychnpgirl]

Kickback idea is intriguing but doesn't answer the question of -- what about the shortage of primary care docs?

And if there's enough interest in psychiatry, then there's a decades-long shortage of residency spots, isn't there?
Why medical students choose psychiatry - a 20 country cross-sectional survey

• Kitty Farooq,
• Gregory J Lydall,
• Amit Malik,
• David M Ndetei,
• ISOSCCIP Group and
• Dinesh Bhugra

- this review (searchable on Google, it won't let me make a link) contradicts your statement that there is sufficient interest of medical school students in psychiatry. Hence my argument for an entirely new educational path. And if your statement is correct that there is sufficient interest, then nothing that has been tried so far has enabled the field to create enough psych residency spots? If there were enough psychiatrists, why would there be more psych NPs than psychiatrists be graduating each year, with so many psych NPs being hired out of the school gate?

Maybe we do just need to come together as NPs to make standards more rigorous. Pharmacists clearly did that over the years.

 

[psychnpgirl]

no. would not be helpful for patients and complete waste of my time.

Fine. My point is, the best outcomes would stem from all people receiving the most high quality treatment all the time, but that's not the direction health care economics drives us in.

Meh. I dunno. The elephant in this thread is that there are going to be more psych NPs than psychiatrists in the upcoming decades if trends continue, and the pocketbooks of taxpayers, govt, insurance companies, organizations, will all support this trend. Practice laws are on a trend to keep loosening. This is what *is happening.* So you went to medical school and residency, I can empathize with the intense rational and emotional standpoint that medical school and residency are the only way, I can't imagine what a sacrifice you made to do that, and I can imagine we have very different intrinsic biases as a result.

Just saying, I think we have an obligation to check our beliefs about how things ought to be against the pragmatic, practical world of how things really are. This is where I bring up the idea of a brand new educational path that would be somewhere in between psych NP, LCSW and psychiatrist, to attract more of the folks who would gravitate toward PhD/LCSW but are willing to learn pathophys and prescribe. Talk about true integrative care.

 

[Stagg737]

Also, the arrogance of these mostly young, poorly trained clinicians has been increasingly astounding each year. Lots of half baked ideas about how to fix things and demands to be treated equal to a psychiatrist in the clinic while not knowing a fraction of what they don't know.

I agree, and think the OP touched on the reasoning for this in her OP. NP used to be a degree to pursue after you'd gained 5-10 years of clinical experience and wanted a higher level of knowledge to increase your clinical acumen. People knew where their knowledge was lacking, and the NP degree served as a chance to fill in that gap. Now it's often a direct path and NP's can start working with minimal clinical experience. I think many I've known who took this route were initially scared to death when they started working and didn't get cocky until 6 months to a year later when they picked up what they considered "adequate" clinical experience. Once they get an understanding for how to handle the basic stuff, Dunnig-Kruger kicks in and they think they've become masters of the field. I give kudos to the OP for recognizing that her knowledge from her NP education is lacking and wanting to fix that. Hopefully that doesn't change after getting a taste of foundational mastery.

I think there could be a legit, more independent role for NPs who have significant experience in the field, then go and complete a program which allows them to gain more focused knowledge about pharm and path after they have that experience. Unfortunately, there is very poor regulation of their education by the nursing community (some NP programs can be completed almost completely online) and NPs are cheaper, so financially there is little motivation to implement the proper regulations and education needed to produce high quality NPs.

I’m curious to know how much cash outpatient services would cost if insurance were not driving it all up. As a postdoc I don’t have to pay for my health insurance (thank you, university!) but I sure would balk at paying ~$500 every time I go see my OB if that were a true cost. Where could one find research on what the true cost of cash only medical care would likely be for various outpatient services?

For primary care, look into direct primary care (DPC) models. They're basically offices where you pay a monthly fee and get a whole list of services that are covered free or at discount. Here's a website for one such group that came and spoke at my medical school at one point: Wichita's Leading Direct Primary Care Practice . If you look under the benefits section there's a page you can download with their prices compared to market retail prices of various labs, tests, and treatments. I know of another group that includes imaging as well where an X-ray is around $50, CT is $200, and MRI is somewhere between $400-800.

For psych, I did an outpatient rotation that was cash only and the prices were $100 for 25 minutes or $200 for 50. For someone needing weekly therapy, it would get expensive fast. However for those patients who just need to be seen once a month or who just need a prescription refill for a controlled substance every 2-3 months, they could have everything covered for under $1,000/year easily.

It would be great for all children to be raised by good-enough parents, it would be great for every person to be treated for their mental health problems early in their course of illness by a seasoned, non-pharma funded, top-notch, culturally competent psychiatrist. Realistically, there are limited resources in the world. I see a lot of discussion around who's competent enough to treat patients. I am not arguing that NP education is ever comparable to psychiatrist education. What I am arguing for is a perhaps an alternative, less myopic view, in which we are all sort of inculcated into our own maybe? somewhat? self-interested narrow perspectives. I don't like the ugly debates that only serve to increase each others' propensity for navel-gazing. And I am arguing for a public health stance: There are never enough psychiatrists. Do you really think there is a way to get medical students to go into psychiatry that hasn't already been tried? If you can find a way, or if like Texas said, there are enough PCPs to pick the slack if care coordination improved and laws became more lax, my whole post MIGHT be moot, but still, psych NPs would be cheaper, and therefore the issue might persist even if we could veer society in the direction of cash-only for outpatient care. But what about inpatient? It seems like the issue of psych NPs existing would persist regardless.

To the first bolded point, the entire reason for a broad medical education is so physicians understand the intricacies of care between various fields. How do antibiotics affect psychiatric medications and vice versa? What medical conditions do we need to rule out before making psychiatric diagnoses? How would these potential diagnoses change our treatment plans? When our inpatients develop a medical problem, is it something we can manage on the psych unit or do they need to be transferred? These are all things which come with having a broader medical education which would be lost or un-mastered through a more focused, consolidated education.

To the second bolded point, it's not necessary. If you look at other threads in this forum many people have said psych is becoming more competitive. I think this is because our generation has a greater focus on lifestyle outside of work, and a field like psychiatry in which a 40-45 hour work week is the norm is very attractive. Additionally, it's less competitive (for now), meaning there's a better chance for decent applicants and stronger to end up where they want instead of having to bust their butts and be superstars just to have a shot. Those things make it an attractive field, and there has been no struggle to fill residency seats even with increasing availability.

More psych NPs are graduating and the number of psychiatrists graduating stays the same or decreases.

If you look at the data the number of medical students entering psychiatry and psychiatry residents entering practice each year is increasing. There are also over 100 positions being added each year in recent years according to NRMP data, so the shortage is being addressed.

 

[psychnpgirl]

^ I appreciate that it is being addressed - but still - if there were truly enough psychiatrists, there would be no need for psych NPs. Is that an overly simplistic interpretation? We see essentially the same population of patients. I see as many simple ADHD follow-ups as my MD supervisor.

Specifically I'm thinking, if I could have spent my 2 years of RN school learning all about cross referrals and medical rule outs for psych, and then spent my 2 years in my master's programs focused entirely on medical/psychiatry, then had a 1 yr residency in psych med management and 1 year in therapy and 1 year combined, that would have been amazing. And a path like that probably would attract more people who otherwise would have simply become therapists because they didn't want to go through all of RN or MD school. Also, lots of people don't want to be "nurses" because it lacks the same prestige as even MSW at least in some circles.

U.S. Psychiatrist Shortage Intensifies - per Forbes article July 2017. not sure of validity.

 

[Stagg737]

^ I appreciate that it is being addressed - but still - if there were truly enough psychiatrists, there would be no need for psych NPs. Is that an overly simplistic interpretation? We see essentially the same population of patients. I see as many simple ADHD follow-ups as my MD supervisor.

Specifically I'm thinking, if I could have spent my 2 years of RN school learning all about cross referrals and medical rule outs for psych, and then spent my 2 years in my master's programs focused entirely on medical/psychiatry, then had a 1 yr residency in psych med management and 1 year in therapy and 1 year combined, that would have been amazing. And a path like that probably would attract more people who otherwise would have simply become therapists because they didn't want to go through all of RN or MD school.

I think it is an overly simplistic interpretation as it doesn't address distribution at all. Some medical fields have no shortage of physicians, the problem is most people want to work in/near major metros, not Nowhere, KS or some other middle-of-nowhere rural location.

I think the path you're describing would likely be a better path for mid-levels in psych than a general NP education, but we would still need fully trained Psychiatrists imo. There's too much to know to not have people with a full medical education involved in at least a supervisory role. Note, I'm not yet a psychiatrist or an expert by any means and the attendings on here may have very different (and more knowledgeable) opinions than me. I've just had a variety of experience and family in the general field that I've discussed with with previously, so I feel I do have some insight.

 

[hamstergang]

And if there's enough interest in psychiatry, then there's a decades-long shortage of residency spots, isn't there?

Residency spots are funded partially by the government (though not all are, hospitals can just paid the full price themselves). Congress sets how much money get allocated for this, and unless something changed very recently, this amount hasn't changed in a very long time. Residency spots can't just pop out of nowhere. Besides needing money, there needs to be appropriate clinical experience and training for each spot.

So the number of psychiatry residency spots isn't so much determined by the interest of medical students but by other factors.

 

[psychnpgirl]

^ My point was just that there aren't enough psychiatrists to serve the population.

 

[TexasPhysician]

^ My point was just that there aren't enough psychiatrists to serve the population.

It is impossible to determine exactly what is “enough” psychiatrists. You keep quoting poor articles as evidence. It isn’t true. Enough is subjective.

The current health care system is flawed. The flaws create gaps in care.

The government is not bright enough to fix the system, so they create patches.

In most major cities, patients can see a psychiatrist within 2 weeks at a reasonable price. Reasonable is not free.

 

[singasongofjoy]

^ My point was just that there aren't enough psychiatrists to serve the population.

I would like to again reiterate what another poster said above- the problem is not necessarily with total number but rather with distribution. There are many rural and relatively poor areas in my state where you simply can’t attract psychiatrists (or psychologists for that matter) which affects care provision and wait lists. Even more true if you are talking about specialists within psychiatry- there are a couple psychiatrists around here (a metropolitan area) who specialize in ASD/Developmental disability and there will never be a short wait because there aren’t that many specialists and they have a good reputation. I’d be afraid to send these complex patients to an NP for Rx.

 

[erg923]

I actually convinced that the last thing most people need for their life/emotional problems is steady stream of psychotropic drugs. SMI is a different story, but this isn't the vast majority of an OP psychiatrist or Psych NP caseload, most likely.

 

[barryggg]

I actually convinced that the last thing most people need for their life/emotional problems is steady stream of psychotropic drugs. SMI is a different story, but this isn't the vast majority of an OP psychiatrist or Psych NP caseload, most likely.

I disagree. I think EVERYONE should be on at least one drug.

 

[calvnandhobbs68]

Fine. My point is, the best outcomes would stem from all people receiving the most high quality treatment all the time, but that's not the direction health care economics drives us in.

Meh. I dunno. The elephant in this thread is that there are going to be more psych NPs than psychiatrists in the upcoming decades if trends continue, and the pocketbooks of taxpayers, govt, insurance companies, organizations, will all support this trend. Practice laws are on a trend to keep loosening. This is what *is happening.* So you went to medical school and residency, I can empathize with the intense rational and emotional standpoint that medical school and residency are the only way, I can't imagine what a sacrifice you made to do that, and I can imagine we have very different intrinsic biases as a result.

Just saying, I think we have an obligation to check our beliefs about how things ought to be against the pragmatic, practical world of how things really are. This is where I bring up the idea of a brand new educational path that would be somewhere in between psych NP, LCSW and psychiatrist, to attract more of the folks who would gravitate toward PhD/LCSW but are willing to learn pathophys and prescribe. Talk about true integrative care.

The “there are going to be a lot more NPs” thing is interesting. People have been saying this for years and it’s probably becoming true for a lot of fields. However, what’s interesting is that where you see job markets in most areas still strong for physicians in most specialities, at least in my region we’re starting to see an oversaturation of NPs. There’s more than one nurse at my hospital who has finished an NP degree and can’t find a job right now or the jobs they’re looking at aren’t exactly the ones they want.

It’s like the CRNA and anesthesia thing....there’s been doom and gloom for a long time now over there and yet anesthesiologists are still coming out of residency with good job offers left and right.

 

[psychnpgirl]

So you're really arguing there's enough psychiatrists so that you could limit NPs and PAs to "appropriate roles alongside PCPs"?

search The National Council, Psychiatric Shortage....


a quote from their report:
Workforce Trends and Projections to Meet Demand

The most recent study of psychiatrists practicing in the U.S. was completed by Tara Bishop, et al. and published in Health A airs in 20167. The population of practicing psychiatrists declined by 10 percent between 2003–2013 when measured by the number of psychiatrists per 100,000 of population. The ndings also showed that neurology, a related specialty, increased by 15.3 percent during the same period and primary care physicians increased by 1.3 percent.

In a study commissioned by the U.S. Department of Health and Human Services8, the authors used a 2013 baseline for their projections. Working from this model, they identi ed that the current workforce of 45,580 psychiatrists would need to increase by 2,800 to meet current demand for mental health
and substance use disorder conditions. In other words, there is currently a 6.4 percent shortage in

the psychiatry workforce. Based on estimates of retirement and new entries into the workforce, they projected that in 2025, unmet need will increase to 6,090 psychiatrists or a de cit of 12 percent of
the workforce. Under a di erent methodology based on survey data on the population identifying a treatment need, the demand for psychiatry will outstrip supply by 15,600 psychiatrists, or 25 percent, in 2025. The study considers the expanded access under health care reform as one of the factors driving demand for behavioral health care.

Geographic Populations with Inadequate Access to Psychiatry

In addition to the number of practitioners in the workforce, access is also commonly measured geographically to ensure that there are enough practitioners to serve the population in the state, county or other service area designated by a government or insurance entity. National estimates are usually tallied based on the availability of professionals by county. In the study by Bishop cited earlier, the number of adult psychiatrists per capita in a speci c cross-section of the population were calculated versus the need9. Her study revealed that 55 percent of counties in the continental U.S. do not have
any psychiatrists. Another study concluded that 77 percent of U.S. counties had “severe shortages” of psychiatrists and other behavioral health providers.

These ndings on the preponderance of counties with little or no psychiatric care available in geographically isolated areas are most severe for child and adolescent psychiatry, a psychiatric sub- specialty. Another study concluded that 43 of 50 states report a “severe shortage10.”

Populations Served by the Existing Workforce

The reduced supply of psychiatrists and the unbalanced concentration in di erent regions have
resulted in a limited workforce in many geographic areas, as documented earlier. However, access to psychiatrists for some of the population, even in areas with su cient professionals in the workforce, is further diminished by the type of reimbursement accepted by private practice psychiatrists. As stated earlier, it is not unusual for psychiatrists to practice in more than one setting, spending some time in a publicly-funded clinic, teaching at a medical school and having a small private practice. Yet, there is also a concentration of the workforce exclusively in private practice who accept only cash for reimbursement. Forty percent of all practicing psychiatrists are in this category11 and it is the highest percentage of any medical specialty except dermatology.

 

[psychnpgirl]

I guess I'm trying to say, yes, going to cash only (assuming that is possible) and increasing tele psych would help because I agree it is a distribution problem, but it's also a numbers problem. and this does not change the economic reality that psych NPs lead care in many many settings. Even if there is no shortage now as you say (which at least in my part of the country couldn't possibly be true based on how many psych NP openings have been open for years), this is partly because there are 14,000 US psych NPs, many of whom practicing completely independently or servings as medical directors of clinics. I'm not saying it's *right*.

to the poster who said not everyone should be on drugs, my comment was meant simply that they should be "treated by the person with the best education". being treated by a psychiatrist in a completely ideal world doesn't mean necessarily being on drugs.

 

[Attending1985]

I actually convinced that the last thing most people need for their life/emotional problems is steady stream of psychotropic drugs. SMI is a different story, but this isn't the vast majority of an OP psychiatrist or Psych NP caseload, most likely.

Yes less “prescribers” and more psychosocial support. In this consumer model of healthcare anything goes. Patients can decline the most effective and safe therapy and demand a less effective, less safe therapy and we give it to them. Now they’re, no surprise, not getting better and will be requiring “treatment” long term. Who does this serve? We need serious reform. People with emotional distress and mild to moderate symptoms need to be referred to therapy initially and whatever other support services they would benefit from. No SSRI, no benzos. If you actually attend and don’t improve we can look at things again. I spend more time taking people off of meds than starting them because there isn’t a pill for every kind of suffering and avoidance just doesn’t work long term.

 

[erg923]

to the poster who said not everyone should be on drugs, my comment was meant simply that they should be "treated by the person with the best education". being treated by a psychiatrist in a completely ideal world doesn't mean necessarily being on drugs.

That was me...and was meant to counter the popular argument that there needs to be more prescribers of psychiatric drugs in this country.

Lest's not delude ourselves. That's largely what we are referring to here, right? The fact that you think more people need access to psychotropic medications prescriptions?

You haven't argued that there needs to be more "therapists" (not really true either....but the geographic dispersion argument stands here), more morality, more psychoeducation, more early intervention, or more social safety nets, or more psychological resilience. All of these are what's needed. Not more people prescribing medications to supposedly "ill" peoples.

 

[psychnpgirl]

Erg and Resident, I feel you are both making points that line up well with my original idea that we could improve mental health care by forming a new educational path that enabled learners to function as knowledgeable enough about pathophys and pharm to prescribe (as psych NPs *do* in spite of awfully poor regulation of programs) with more elements of the LCSW and relevant components of med school and psych PhD like evaluating research for bias. Like a psych specific PA program, and similar to PA in that it would maybe require a set number of hours in the field first, thus lowering the burden/cost of residency.

I am 100% on board with all you’re saying, except it’s not low quality evidence that shows there’s a psychiatry shortage. Check the article I linked above- it’s really a consensus and TexasPhysician’s ideas strike me as important and intriguing but at least according to the consensus article I linked above, not sufficient to alleviate the shortages Also not sufficient based on the fact that the market is bearing so many independently practicing psych NPs at present. If we could educate ppl to be experts in pharm AND therapy/psychosocial and do so in a more economically efficient and attractive way for people interested in mental health care but don’t care so much initially for RN/MD school, we could possibly change the whole landscape.

 

[psychnpgirl]

And as myself and others refuting me here here have said, it’s not just about being a “prescriber” but also about having the requisite knowledge to rule out physical causes of mental health symptoms.

 

[finalpsychyear]

if you want to play doctor go to medical school. Everyone wants shortcuts in this country it is simply sad. At the very least have the "NP shortcuts" take the same step 1- step 3 and board exams that all practicing docs do for the specialty they want. You'll never be treated equal because you simply didn't go through the same rigors and at the minimum the same exams and just don't understand medicine as a whole. You feel inferior because your foundation is vastly inferior in its foundation.The NPs i saw in residency were laughable.

 

[Attending1985]

if you want to play doctor go to medical school. Everyone wants shortcuts in this country it is simply sad. At the very least have the "NP shortcuts" take the same step 1- step 3 and board exams that all practicing docs do for the specialty they want. You'll never be treated equal because you simply didn't go through the same rigors and at the minimum the same exams and just don't understand medicine as a whole. You feel inferior because your foundation is vastly inferior in its foundation.The NPs i saw in residency were laughable.

I’ve met plenty of laughable psychiatrists as well. She makes a good point that you probably need less medical knowledge and and more training in psychological principles to be a good psychiatrist.

 

[psychnpgirl]

if you want to play doctor go to medical school. Everyone wants shortcuts in this country it is simply sad. At the very least have the "NP shortcuts" take the same step 1- step 3 and board exams that all practicing docs do for the specialty they want. You'll never be treated equal because you simply didn't go through the same rigors and at the minimum the same exams and just don't understand medicine as a whole. You feel inferior because your foundation is vastly inferior in its foundation.The NPs i saw in residency were laughable.

I truly don't find this offensive, in fact if I were in your shoes and had your life experiences I wouldn't be surprised if I felt the same way. The dynamic between you and I is not dissimilar to the ideological divide in our country today, and the result is *little to no productive across-the-aisle conversation*. I think your remark is a useful one for identifying barriers to conversation because a good percentage of psychiatrists feel the same way. Yet the market is not baring out the way their ideology would have it. Again, this is not a question of what's best, but what's real and what's a realistic step forward for a better future.

Anyway, I've developed a list of health care economics books and will get back to you all after I mature my opinions a bit more. I am also very open to PMs on the subject.

also, conversation on here from 2 yrs ago about the psychiatry shortage... Further Shortage of Psychiatrists in Future

and two posts from a path thread on here on this subject,

1. 
   
2. Relatively speaking I would say its not hard.
   
   The hrs are good, the pay is good, the cases aren't to the point where you'll be kept up all night.
   
   Personally I find it very very interesting stuff.
   
   Only theory I can think of is most people who want to go into medicine think the physical stuff. Most people who want to go into mental health think psychology.
   
   And the 2 schools aren't exactly compatible for all people. Most psyche majors I knew hated physical sciences and same of those who liked physical sciences not liking psyche.
   
   These of course are generalities, and I'm only theorizing.
   
   whopper, Jun 6, 2007
   Report Post to Moderator
   #2Like− QuoteReply
   
   
3. 
   PsychMD2100Psychiatrist in Training2+ Year Member
   210
   0
   Nov 25, 2006
   Near the Danger
   This has come up in other threads but there are 2 prevailing attitudes that deter many undecided med students:
   
   1) Psych isn't "medical" enough and it's not what "real" doctors do
   
   2) There continues to be an intense stigma attached to mental illness both inside and outside the profession of medicine
   
   Clearly, with a name like PsychMD2100, I don't buy into either of them. From a lifestyle standpoint, it's great. However, you really have to like the material; otherwise, you won't be happy.
   
   

 

[psychnpgirl]

Okay, I can’t stop myself from saying one last thing. We direct behavioral health care in most settings in the US- psychiatrists and psych NPs. We have a responsibility to the public, and with 35000 psychiatrists and 14000 psych NPs (plus a few thousand psych PAs, prescribing psychologists, and psych pharmacists), there really aren’t that many of us- we are in total the size of a mid-size suburb. I recently went to a conference and most people were pretty old (no offense, like 55 and up). Those of us who are younger and/or in training are taking on the future of leading mental health care. We can take a dose of our own medicine and use some perspective taking and emotion regulation or we can behave like everyone else and have this turf war play out in the typical capitalistic way. It’s up to us. That’s all.

 

[MacDonaldTriad]

Most psychotropics are being written by primary care doctors. I don't think NPs are doing this much worse than they are. There is data showing that GPs under dose, switch to fast and too slow. At least NPs have someone reviewing their work at least in theory.

 

[psychnpgirl]

Most psychotropics are being written by primary care doctors. I don't think NPs are doing this much worse than they are. There is data showing that GPs under dose, switch to fast and too slow. At least NPs have someone reviewing their work at least in theory.

In 22/50 states there is no required supervision. Some for over 20 years, like Oregon. Enough time to analyze outcomes for sure. Plus, you and I both know, if you’ve been practicing while, MDs don’t usually supervise in a terribly meaningful way.. maybe once a month conversation or reviewing 1 in 50 charts, you making 10,000-15,000 a year if the NP is paying you to sign off on her private practice notes. Mad cash if you could get a few of them. Lawsuit outcomes have found physicians not liable when their NP is sued. Again, I’m not saying it’s right or good for patient care. I’m just advocating for a real view of the present landscape over idealism.

 

[SeniorWrangler]

Mental health care is persistently underfunded, NPs work for less than physicians, the system makes little distinction between kinds of providers, ergo NPs will gradually replace psychiatrists in most settings. Why get upset about it? If society didn't like this outcome, it would change it. As erg923 said above, the system needs a lot more than just more prescribers, anyway. Good case managers and therapists who can reliably provide evidence based treatment and support systems to prevent readmission... might as well ask for universal access to ponies, too.

 

[psychnpgirl]

Mental health care is persistently underfunded, NPs work for less than physicians, the system makes little distinction between kinds of providers, ergo NPs will gradually replace psychiatrists in most settings. Why get upset about it? If society didn't like this outcome, it would change it. As erg923 said above, the system needs a lot more than just more prescribers, anyway. Good case managers and therapists who can reliably provide evidence based treatment and support systems to prevent readmission... might as well ask for universal access to ponies, too.

Why get upset about it? Because we are talking about the future of mental health care in the nation, and we hold responsibility to try our best to make the system as ethical and effective as possible. We do not have to stand by and observe. Someone used the word reform and I agree. Our whole health care system is undergoing reform and psychiatry needs us to help with reform of our field.

 

[TexasPhysician]

. Plus, you and I both know, if you’ve been practicing while, MDs don’t usually supervise in a terribly meaningful way.. maybe once a month conversation or reviewing 1 in 50 charts. Lawsuit outcomes have found physicians not liable when their NP is sued.

If that is the supervision you have gotten, you have had poor training. Find someone that will help you grow educationally.

Your claim that lawsuits have found physicians not liable is false. Even state boards hold physicians liable in the absence of a lawsuit. Reviewing your state laws may be helpful.

The nursing board is quite strong politically. Creating a better level of psychiatric training for NP’s should start there. You are getting push-back here because you want to simplify training that is quite complex.

 

[Mass Effect]

Specifically I'm thinking, if I could have spent my 2 years of RN school learning all about cross referrals and medical rule outs for psych, and then spent my 2 years in my master's programs focused entirely on medical/psychiatry, then had a 1 yr residency in psych med management and 1 year in therapy and 1 year combined

You can't learn medical rule outs until you learn medicine. It's really as simple as that. What you're proposing takes out the undergraduate experience. I'm of the mindset that undergraduate is an important experience for well-roundedness and maturity. Two years of RN school about cross-referrals and medical rule-outs is, honestly, useless without understanding the medicine, learning how to read labs, understanding the physiology of medical correlates. If you want to learn all that, then you have to go to medical school. One year in psych med management is what gets us algorithm kings and queens. You don't learn the true nuances of prescribing. I look back on the end of intern year (one year of prescribing) and I was still clueless. What you're proposing will only lengthen the training of psych NPs, but will really not be any different and will not be the least bit equivalent to the training and knowledge a psychiatrist has, not just when it comes to psychiatry, but when it comes to medicine (ask any inpatient psychiatrist about that).

 

[psychnpgirl]

I don't wanna get caught up in the weeds of state laws in states without independent practice, ppl who have interest can search for outcomes of lawsuits and specific minimal supervision requirements on the Google.

I have one more thought I want to add though. I think I accidentally presented this topic in too incendiary a fashion. I don't think my topic here necessarily presents any threat at all to the income or need for psychiatrists. The same way there are people who go through five-year or six-year residencies that combine IM and psych -- the existence of these specialists isn't not needed because there are psychiatrists who have less years of education and are in theory cheaper to educate. IM/psych combined physicians still find special positions that find use for their special skillsets, right? The same way, we could make mental health care better by making the minimal standards as high as they can be, and ppl with more or more specialized education (psychiatrists) would still find high-paid roles that take advantage of their unique skillsets.

Random article but I feel like it underscores the need for overhaul on the silo'd way that "therapists"/psychologists and "prescribers"/physicians/NPs are educated in totally different wheelhouses,
The Psychoactive Effects of Psychiatric Medication: The Elephant in the Room - available for free when searched
-- rather than teaching everyone to have meds and therapy in their toolbox.

 

[Attending1985]

I don't wanna get caught up in the weeds of state laws in states without independent practice, ppl who have interest can search for outcomes of lawsuits and specific minimal supervision requirements on the Google.

I have one more thought I want to add though. I think I accidentally presented this topic in too incendiary a fashion. I don't think my topic here necessarily presents any threat at all to the income or need for psychiatrists. The same way there are people who go through five-year or six-year residencies that combine IM and psych -- the existence of these specialists isn't not needed because there are psychiatrists who have less years of education and are in theory cheaper to educate. IM/psych combined physicians still find special positions that find use for their special skillsets, right? The same way, we could make mental health care better by making the minimal standards as high as they can be, and ppl with more or more specialized education (psychiatrists) would still find high-paid roles that take advantage of their unique skillsets.

Random article but I feel like it underscores the need for overhaul on the silo'd way that "therapists"/psychologists and "prescribers"/physicians/NPs are educated in totally different wheelhouses,
The Psychoactive Effects of Psychiatric Medication: The Elephant in the Room - available for free when searched
-- rather than teaching everyone to have meds and therapy in their toolbox.

Thanks for sharing this article. I would recommend joining the critical psychiatry network for more of this type of discussion.

 

[michaelrack]

I don't wanna get caught up in the weeds of state laws in states without independent practice, ppl who have interest can search for outcomes of lawsuits and specific minimal supervision requirements on the Google.

I have one more thought I want to add though. I think I accidentally presented this topic in too incendiary a fashion. I don't think my topic here necessarily presents any threat at all to the income or need for psychiatrists. The same way there are people who go through five-year or six-year residencies that combine IM and psych -- the existence of these specialists isn't not needed because there are psychiatrists who have less years of education and are in theory cheaper to educate. IM/psych combined physicians still find special positions that find use for their special skillsets, right? The same way, we could make mental health care better by making the minimal standards as high as they can be, and ppl with more or more specialized education (psychiatrists) would still find high-paid roles that take advantage of their unique skillsets.
.

IM/Psych is a 5 year residency (IM alone is 3 and psych alone is 4). There are few combined positions available in the doc want ads, but some (like myself) gradually create positions that combine both specialties. Among other things, I run an inpatient psych ward, and took over supervising the medical NP for the ward. I think doing med/psych combined residency is more useful than doing a 4 year psych residency followed by 1 of the 1 year fluff subspecialties such as psychosomatics (which I grandfathered into without doing a fellowship, by the way)

of course, for the individual doc, doing an IM/psych residency and then keeping current in both specialties is much harder than doing psych followed by something like psychosomatics

 

[taare]

I am against any NP or Psychologist or pharmacist prescribing altogether. If you want to be a doctor, go to medical school. This occurs only in 'Merica. Our hospital can't recruit a nurse because most of them want to pursue online DNPs and be called Doctors causing tons of confusion ultimately. We had a PA introducing himself as a doctor on the inpatient unit. As MDs and DOs, we rarely cross boundaries and usually refer to a specialist or consult one and like suggested above and don't willy nilly prescribe medications related to other specialties despite being legally authorized to do so so it is beyond me that a psychologist prescribing with a couple of psychopharmacology course is the solution. Might as well get a janitor to do so. In essence, its thinking like you are going to an endocrinologist for your diabetes management but have the nutritionist manage your medications. Come on!

 

[psychnpgirl]

Thanks for sharing this article. I would recommend joining the critical psychiatry network for more of this type of discussion.

amazing tip, thanks!

Taare, my point is market forces. The market is bearing what it is presently bearing, and that includes many thousand currently practicing psych NPs. In other words, it is what it is. Or to paraphrase Lil Wayne, h**z be h**z. Or in other words... Sorry I'll stop. Have you ever read America's Bitter Pill? So much is wrong, and in the beginning of health care reform some amazing physicians had some brilliant ideas (that other very smart people pretty much already had 30 years before). What the market can bear is another story. We can either start where we are or not start at all and just keep espousing idealistic, angry views, cuz that can be fun I guess. Go team. The Vikings won yesterday. Minnesota was happy for the day. Alas.

 

[Liquid8]

I am against any NP or Psychologist or pharmacist prescribing altogether. If you want to be a doctor, go to medical school. This occurs only in 'Merica. Our hospital can't recruit a nurse because most of them want to pursue online DNPs and be called Doctors causing tons of confusion ultimately. We had a PA introducing himself as a doctor on the inpatient unit. As MDs and DOs, we rarely cross boundaries and usually refer to a specialist or consult one and like suggested above and don't willy nilly prescribe medications related to other specialties despite being legally authorized to do so so it is beyond me that a psychologist prescribing with a couple of psychopharmacology course is the solution. Might as well get a janitor to do so. In essence, its thinking like you are going to an endocrinologist for your diabetes management but have the nutritionist manage your medications. Come on!

I have found these NP threads quite interesting, as it’s not something I haven’t given it much thought. NPs are not prominent in the Australian healthcare, let alone the psychiatric landscape and I think this comes down to lengthier training requirements.

Here nurse practitioners have to have completed a minimum of 5 years of nursing in a leadership role – i.e. Clinical Nurse Consultant before being able to apply for the 2 year Masters. Getting to that leadership role in the first place is difficult, takes quite a few more years after graduating with their initial nursing qualification and it’s not a guaranteed or automatic progression.

With a bachelor in Nursing being 3 years, plus a grad year (1), and after a few years working on the ward (2-3), advanced placement (5) plus the NP masters (2) we’re looking at least 13-14 years.

It took me 13 years before I was recognised and allowed to practice independently as a psychiatrist. That included 6 years of medical school, a general internship covering general medicine, general surgery and emergency medicine, another general residency year followed by 5 years of formal psychiatry training and a Masters in Psychiatry.