the nurse practitioner threat

[jiggabot]

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NPs can prescribe more or less independently in 20 states and that number is growing. There were 40,000 NPs in 2000, 80,000 in 2006, and 140,000 in 2011. Psychiatric NPs make up about 3% of the total number of NPs.

There are 40,000 psychiatrists currently practicing. I calculate that in 15 years, the growth of NPs will result in such an increase in supply of drug-prescribing mental health care providers that psychiatrists will be making the same amount as NPs. What do you guys think?

 

[nitemagi]

 

[AnnoyedByFreud]

NPs can prescribe more or less independently in 20 states and that number is growing. There were 40,000 NPs in 2000, 80,000 in 2006, and 140,000 in 2011. Psychiatric NPs make up about 3% of the total number of NPs.

There are 40,000 psychiatrists currently practicing. I calculate that in 15 years, the growth of NPs will result in such an increase in supply of drug-prescribing mental health care providers that psychiatrists will be making the same amount as NPs. What do you guys think?

dang. 3%!? you psychiatrists best take cover!

 

[firedoor]

NPs can prescribe more or less independently in 20 states and that number is growing. There were 40,000 NPs in 2000, 80,000 in 2006, and 140,000 in 2011. Psychiatric NPs make up about 3% of the total number of NPs.

There are 40,000 psychiatrists currently practicing. I calculate that in 15 years, the growth of NPs will result in such an increase in supply of drug-prescribing mental health care providers that psychiatrists will be making the same amount as NPs. What do you guys think?

There are so many variables in play that it's difficult to make reliable predictions. That said, it is clear that physicians are not priviledged from market forces and so a healthy degree of concern is not only appropriate but necessary. Complacency yields defeat.

I doubt the sky will be falling for psychiatrists or other physicians any time soon, but for too long we as physicians have not been effective enough in promoting our group interests IMHO.
This ultimately effects our finances, autonomy and patient care.

Personally, in addition to my own professional and economic self-interests, I philosophically disagree with mid-levels practicing medicine and so will support legislative actions which are in physicians' best interests on these issues. Likewise, I have chosen not to hire, supervise or choose a mid-level practitioner for my own medical care. I would hope that physicians with similiar views would do the same.

 

[digitlnoize]

NPs can prescribe more or less independently in 20 states and that number is growing. There were 40,000 NPs in 2000, 80,000 in 2006, and 140,000 in 2011. Psychiatric NPs make up about 3% of the total number of NPs.

There are 40,000 psychiatrists currently practicing. I calculate that in 15 years, the growth of NPs will result in such an increase in supply of drug-prescribing mental health care providers that psychiatrists will be making the same amount as NPs. What do you guys think?

If we do make the same amount it'll be a crapload. There is already a drastic shortage and an extra 1200 NP's is not going to make a dent.

Also, of those 40,000 psychiatrists: >55% are over 55yo. That means we'll likely be losing 20,000 psychiatrists in the next 10 years. To make matters worse, psych has been one of the slowest growing specialties for the last few years. We have one of the highest average ages. Compare this with EM, which has been growing like crazy, and has one of the lowest average ages. Those specialties who are very dependent on federal money have the most to worry about. Medicare can't afford to continue to pay EM rates for Primary Care problems. Soon, we'll see a prohibition on coverage for PC problems in ER's. A huge percent of ER visits (>50%?) are non-emergent primary care problems. When these stop being covered, you can bet there will be a drastic drop in ER visits, but with the huge growth they've seen and the young population...good luck finding a job guys. Now, if the gov't magically finds money to support the current medicare spending rates, they'll be ok, but I don't think that's likely. These are the guys who should be worrying...ER and Anesthesia. Lots of specialties will see a salary drop, but not too extreme. I expect everyone to equalize out around 200k.

Psych on the other hand, is poorly funded by most insurances, many of us already are cash only or partially cash only. As the shortage gets worse, insurers will either have to raise our rates or we'll bail and take cash only, and people will either have to pony up, or go without (which they may, to the detriment of society).

Either way, I think psych is pretty darn safe comparatively.

 

[whopper]

Given that I don't think psychiatrists as a group are not under any real danger for the next several years, there's a shortage of psychiatrists in most parts of the country, people advocating for non-MD prescribers is due to the shortage, and that the main way to fight for our own interests are through lobbying groups that pseudo-bribe politicians, I'm happy with not doing much about this nurse practitioner issue.

If you're smart, you can actually profit quite nicely by having an NP work for and with you.

 

[jiggabot]

If we do make the same amount it'll be a crapload. There is already a drastic shortage and an extra 1200 NP's is not going to make a dent.

15 years from now it will not be 1200 NPs, it will be 16,000 psychiatric NPs (550,000 x 0.3. Based on current growth rates, I predict 550,000 NPs in 15 years, but of course you can give or take hundreds of thousands to that number).

Anyway, even if 25,000 psychiatrists leave the field in 15 years, about 18,000 will enter, creating a deficit of only 7,000. Thus, you have a net gain of 9,000 prescribing mental health care providers. The only way psychiatrists nowadays don't all make 150k is that there is a shortage. The 9,000 net gain will eliminate any shortage, reduce the reimbursement per visit, and everyone (NPs and psychs) will make about $100k-$200k. To those psychiatrists who employ several NPs currently, those NPs will say see you later and strike out on their own. Bottom line is that I am not yet convinced that psychiatry is safe from NPs...

Also, guys already in the field like whopper would have had a pretty good run by 15 years. Guys potentially entering the field will have our careers in jeopardy (at least financially) 1/3 of the way through.

 

[digitlnoize]

15 years from now it will not be 1200 NPs, it will be 16,000 psychiatric NPs (550,000 x 0.3. Based on current growth rates, I predict 550,000 NPs in 15 years, but of course you can give or take hundreds of thousands to that number).

Anyway, even if 25,000 psychiatrists leave the field in 15 years, about 18,000 will enter, creating a deficit of only 7,000. Thus, you have a net gain of 9,000 prescribing mental health care providers. The only way psychiatrists nowadays don't all make 150k is that there is a shortage. The 9,000 net gain will eliminate any shortage, reduce the reimbursement per visit, and everyone (NPs and psychs) will make about $100k-$200k. To those psychiatrists who employ several NPs currently, those NPs will say see you later and strike out on their own. Bottom line is that I am not yet convinced that psychiatry is safe from NPs...

Also, guys already in the field like whopper would have had a pretty good run by 15 years. Guys potentially entering the field will have our careers in jeopardy (at least financially) 1/3 of the way through.

You're forgetting population growth. Even if the NP growth rate is sustainable a net gain of only 9000 providers, given the current drastic shortage is not enough to provide care for the increased population.

Still, I doubt the NP growth rate is sustainable, at least while keeping up the standard of graduates. There are only going to be so many "good" healthcare providers, regardless of their initials, and the patients will gravitate to them, if they have a choice. But, I don't think we'll get to that point. The PCP's and Gas have much more to worry about than "we" do. (Can I say "we" yet? )

 

[sunlioness]

The only way psychiatrists nowadays don't all make 150k is that there is a shortage. The 9,000 net gain will eliminate any shortage, reduce the reimbursement per visit, and everyone (NPs and psychs) will make about $100k-$200k.

Even supposing that's true (which I doubt), that's still a lot of money. The percentage of people in the USA living below the poverty line is the highest it's been in years (15.1% in 2010, up from 14.3% the previous year. For African Americans, it's 25.8% below the poverty line. And 25.3% of Latinos --as reported in a BBC article that I just read today). I'm in no way saying that I want to make less or even necessarily that I feel I should make less. Just that all things considered, there are bigger fish to fry than worrying about NPs taking our jobs and lowering our salary when the people who desperately need our services can't access them.

 

[nitemagi]

Plus factor in the rising prevalence of mental illness. Rising on WHO list to #2 or #1 cause of morbidity.

While I don't think we should let our field be eroded, the OP's post comes off as a sensationalized scare tactic.

How many years have I been hearing about how we'll all be absorbed into neuro? Or how prescribing psychologists are taking over the country? Please. I've been in two major metro areas in california and I could count the psychiatric NP's on one hand.

Mid-level providers are exactly that. Plus healthcare reform may shift a much higher reimbursement back towards primary care. So, again, I at your scare tactics.

 

[digitlnoize]

I'd also like to see where they got the #'s for the NP growth and % of NP's in psych. Not sure I believe them.

 

[nitemagi]

I'd also like to see where they got the #'s for the NP growth and % of NP's in psych. Not sure I believe them.

Agreed. Citation, please.

Jiggabot did say "I calculate," meaning based on his/hers estimates, again source data unavailable.

And I want to add that these long term predictions are notoriously faulty, even when made by much more reputable individuals that SDN posters. They used to predict nationally that there'd be a primary care glut, now here we are with a primary care shortage.

 

[whopper]

I'd be interested in hearing what the APA has to say about this since it's lobbying division is usually on top of these things.

 

[F0nzie]

Every medical specialty will experience fluctuations in salary influenced by competitive, economic, and political forces. One thing that never changes: The cream always rises to the top.

 

[medium rare]

15 years from now it will not be 1200 NPs, it will be 16,000 psychiatric NPs (550,000 x 0.3. Based on current growth rates, I predict 550,000 NPs in 15 years, but of course you can give or take hundreds of thousands to that number).

These numbers are wholly inaccurate. While the math may add up for these projections based on recent trends, nursing programs of all kinds (RN and NP) are at their saturation point with regard to the number of new students they can admit and train due to a severe shortage of nurse educators. RN programs routinely have wait lists of 2 years or more just to start a program once being admitted.

There isn't a nursing college in the country that isn't begging for nurse educators due to a variety of factors - namely a limited supply and very poor reimbursement. Who's going to take a full-time faculty position for ~40K when one can easily make 2 - 4 times that much in a direct-service NP position?

Psychiatry isn't going anywhere.

 

[roroy]

15 years from now it will not be 1200 NPs, it will be 16,000 psychiatric NPs (550,000 x 0.3. Based on current growth rates, I predict 550,000 NPs in 15 years...

550,000 x 0.03 = 1,650

 

[Omppu27]

550,000 x 0.03 = 1,650

He multiplied it by .3, not .03

 

[nitemagi]

He multiplied it by .3, not .03

Again, evidence for a 30% growth rate for 15 years?

 

[notdeadyet]

Again, evidence for a 30% growth rate for 15 years?

Agreed. I'm curious if anyone can provide evidence of a growth rate of 30% over 15 years for any other segment in healthcare.

medium rare is dead right about the limiting factors being Nurse Educators. There is a much bigger shortage of RNs than NPs and nursing schools are nowhere near able to keep up, with waiting lists of 3 years in some places. This is due to lack of nurse educators and no one's come up with a solution to that one.

There is a segment of docs (though it's actually usually med students or residnets) screaming about the sky falling by this group or that group encroaching, and it's been happening for decades, yet still every doc seems to have a job and no one's average salary has dropped below $150K or so.

Except for pediatricians. And no one's encroaching on their turf. So go figure.

 

[jiggabot]

550,000 x 0.03 = 1,650

I meant to use 0.03, not 0.3. 550,000 x 0.03 = 16,500. We both failed, me on a typo, you on not checking your math.

As for citation, the number of NPs isn't a number based on some intricate study. Just google any article about NPs and their numbers. As for not enough NP educators, that may be so, but the trends in numbers are as thus regardless.

 

[billypilgrim37]

Sometime in the next 15 years I'm sure an NP will give a rich guy's daughter a dose of demerol while she's on an MAOI and NPs will be forever limited to working 80 minutes a week. Don't worry.

 

[Sneezing]

Personally, in addition to my own professional and economic self-interests, I philosophically disagree with mid-levels practicing medicine and so will support legislative actions which are in physicians' best interests on these issues. Likewise, I have chosen not to hire, supervise or choose a mid-level practitioner for my own medical care. I would hope that physicians with similiar views would do the same.

I share the same sentiments.


Psychiatry or any physician doesn't need to worry that has the ability to open their own office based practice. Advertising that you are a physician and don't employ mid-levels providing a guarantee of that will be a niche in itself. Nurse practitioners need to realize that they really aren't needed. They aren't the gold standard and are merely tolerated. As metaphorical "parasites" on the system they are rocking the boat by increasing their numbers. An ideal parasite isn't noticed by its host (like 10 years ago), but a bad parsite sickens and weakens its host (the future). In anesthesia for instance they will saturate the market, and reduce their salary. As a whole there will eventually be collective advertising by physicians of multidisciplines coming together as one voice stating "our practice doesn't use mid levels come to us for the best care." By increasing their numbers they are laying the foundations of a two tiered system not just based on insurance/money but also on degree/experience.

If you have good insurance, cash, or well off flexible spending account and choice of providers is in your realm of feasibility for non-emergent care, why wouldn't you chose the better trained 'provider'?

Physicians are the Gold standard for a reason. This won't change.

 

[digitlnoize]

Physicians are the Gold standard for a reason. This won't change.

I, personally, agree...but I know a number of patients who don't.

The anti-doctor sentiment among the public does exist. I know a good number of people who have told me, "I prefer to see NP's because they spend more time with me."

Physicians have been hurting our image through the 10-15min appointment that is the current standard. Patients really, really hate it and feel (rightly or wrongly) that NPs spend more time and/or are more attentive.

This is more of a problem in FM than psych obviously, but it still applies, I think. And, it bothers me. The psych metaphor would be the guys doing wham-bam 10-15min med checks without listening to the patient...

 

[Sneezing]

NPs don't spend more time with patients that's a fallacy. Second people who have anti-doctor sentiments is fine by me. Its been my experience they also believe in CAM more than medicine. That's a headache worse than some axis II disorders. A problem I have is when that sentiment isn't our fault. Many midlevels are percieved by the public as physicians and when they anger patients or treat them poorly the patient blames it on a physician. Too many times I've called up this poor providers to get the scoop and collateral only to learn I'm talking with a midlevel and not Dr. John Smith like the patient believed.

I'm glad the gov and institutions are pushing for greater transparency in credentials, even prohibting nurse practitioners from identifying themselves as doctors in some states.

Here at the AMA http://www.ama-assn.org/amednews/2011/09/12/bisb0912.htm is a recent article detailing their expansion.

"The Centers for Disease Control and Prevention's National Center for Health Statistics reported in an Aug. 17 data brief that 49% of physicians working in office settings have the practitioners on board. The most likely to work with them: doctors age 54 and younger, those in large groups and those serving a large Medicaid population."

Reading into that statement about group practices that accept a large medicaid population having more mid-levels sounds like tiering of practitioners to me. I'm curious to see if the younger generation demographic holds up. There are plenty of young pissed off physicians, residents, and students out there right now that might shift the trend in the other direction over time.

"The number of allied practitioners expanded at a much faster rate. There were 70,993 nurse practitioners in 1996 compared with 158,348 in 2008, a growth of 123%, according to the Health Resources and Services Administration. The number of physician assistants went up from 29,161 in 1996 to 73,893 in 2008, an increase of 153%, according to the American Academy of Physician Assistants."


Here is another AMA news article that shows public opinion supports the view of physicians as the gold standard. http://www.ama-assn.org/amednews/2010/08/30/prsb0830.htm

"But a new survey said 80% of patients expect to see a physician when they come to the ED. Fewer than half would be willing to see an NP or PA for an ankle injury -- they would rather wait two more hours to be cared for by a physician."

Another excerpt:
"Patients also preferred to see a fully trained physician compared with a medical resident, but not by as wide a margin as their desire to avoid nonphysicians.

Given their strong preferences for care from physicians, patients deserve greater disclosure about who is providing care and what the level of training is, said study lead author Gregory L. Larkin, MD, professor of emergency medicine at Yale University School of Medicine in Connecticut."

 

[whopper]

In other news, NPs will grow to the point where there's more of them than actual human beings. This will be made possible through the mass-production of android NPs.

I have no source to back up this statement.

What I find interesting in trend reports trying to predict the future is in general, there's such things as negative feedback loops, and fluctuations. Let's assume NPs are going up. That doesn't mean they will in the future indefinitely. Something could happen to change all of this. If this trend was so damn predictable, you could literally make millions in future stock investments based on this assumption. Just pump money into stock companies that will profit off this trend.

Now if someone were to actually show me good reason why this trend (if it actually does exist) would continue, then maybe I'd give more thought. Until then....

 

[jiggabot]

In other news, NPs will grow to the point where there's more of them than actual human beings. This will be made possible through the mass-production of android NPs.

I have no source to back up this statement.

What I find interesting in trend reports trying to predict the future is in general, there's such things as negative feedback loops, and fluctuations. Let's assume NPs are going up. That doesn't mean they will in the future indefinitely. Something could happen to change all of this. If this trend was so damn predictable, you could literally make millions in future stock investments based on this assumption. Just pump money into stock companies that will profit off this trend.

Now if someone were to actually show me good reason why this trend (if it actually does exist) would continue, then maybe I'd give more thought. Until then....

Well, while I cannot predict the future, I would say that economic forces will indeed promote the expansion of NPs. Our current healthcare system and its expensiveness is unsustainable...NPs filling in for relatively cheaper fees is gonna be favored. Think about the winners and losers of NPs taking over:

Winners:
politicians as they get to reduce healthcare costs
insurance companies and private companies as coverage is cheaper

Losers:
doctors as they lose their holy status as the only ones who can prescribe and treat
patients as they get care by less qualified practitioners (but they likely won't be aware of this and they will not be lobbying to prevent NPs from prescribing)

pharma won't really care as long as the NPs prescribe

I feel like politicians + insurance companies >> doctors in lobbying power. The numbers I predict, while not predetermined, certainly make sense and would not surprise me. Anyway, I'm not trying to paint a gloomy picture, just my true predictions.

 

[whopper]

Our current healthcare system and its expensiveness is unsustainable.

Well that certainly is a valid point that brings up a can of worms about paying for healthcare (not blaming you, the problem of course is not your fault!)

A lot of other things, however, can happen. E.g. gov mandated costs of meds, a lower standard of care, deals for doctors to get less money if their tuition is paid for.....

Not that I like any of them, just saying it doesn't automatically mean NPs will go up.

 

[E Dubble]

Well, while I cannot predict the future, I would say that economic forces will indeed promote the expansion of NPs. Our current healthcare system and its expensiveness is unsustainable...NPs filling in for relatively cheaper fees is gonna be favored. Think about the winners and losers of NPs taking over:

Winners:
politicians as they get to reduce healthcare costs
insurance companies and private companies as coverage is cheaper

Losers:
doctors as they lose their holy status as the only ones who can prescribe and treat
patients as they get care by less qualified practitioners (but they likely won't be aware of this and they will not be lobbying to prevent NPs from prescribing)

pharma won't really care as long as the NPs prescribe

I feel like politicians + insurance companies >> doctors in lobbying power. The numbers I predict, while not predetermined, certainly make sense and would not surprise me. Anyway, I'm not trying to paint a gloomy picture, just my true predictions.

Costs will actually go up as utilization increases. The number of consults will likely increase and probably morbidity as well. Also, I believe that independent NPs bill the same as physicians.

 

[InBoston]

In other news, NPs will grow to the point where there's more of them than actual human beings. This will be made possible through the mass-production of android NPs.

I have no source to back up this statement.

What I find interesting in trend reports trying to predict the future is in general, there's such things as negative feedback loops, and fluctuations. Let's assume NPs are going up. That doesn't mean they will in the future indefinitely. Something could happen to change all of this. If this trend was so damn predictable, you could literally make millions in future stock investments based on this assumption. Just pump money into stock companies that will profit off this trend.

Now if someone were to actually show me good reason why this trend (if it actually does exist) would continue, then maybe I'd give more thought. Until then....

android nps? sounds like a better deal than medical school.

 

[whopper]

I'm actually in need of a NP because I'm leaving my current jobs and taking an academic and clinical position with the local university hospital. The private practice I'm in can't find a psychiatrist to replace me, and I an NP could handle the load I'm leaving.

I have no problem with protecting our turf but it has to be done in an ethical manner. Just as psychologists often push for med prescription power without realistically addressing the lack of research (they keep citing the military study as proof it's safe when that same study even said it was not applicable to the public), we can't simply base this off of our ability to profit without addresssing the lack of services available to those in need.

In my opinion, if the lack of services continue, that only increases the risk of the alleged problem with increasing NPs.

I'm not even sure I see it as a problem. I've yet to see any psychiatrists mention it is in regards to their ability to work. When you got communities such as in Iowa where there's literally no psychiatrist whatsoever for several counties, communities have little choice but to give psychiatric responsibilities to others. I can't argue in good faith to deny NPs to have psychiatric prescription power if nothing else is being done by people in our own profession to help fix that. One cannot simply argue that capitalistic market forces will fix this when it hasn't for several years.

 

[AnnoyedByFreud]

What an interesting post. It's refreshing to read an opinion other than "NPs are evil!" on this forum. In my area, if your goal is to see a psychiatrist, you need to be prepared to wait for weeks/months... and all the "good ones" with great reputations aren't even taking patients. Even the psych NPs are turning patients away, they are so overburdened.

 

[Ibid]

One cannot simply argue that capitalistic market forces will fix this

 

[Leo Aquarius]

Wait what? All the reputable psychiatrists aren't seeing patients, and good NPs are turning away people? Are you located in some terribly desolate region of the country or something?

What, then, are the psychiatrists doing if they aren't seeing patients... that's what a psychiatrist does, treat patients.

 

[nitemagi]

Wait what? All the reputable psychiatrists aren't seeing patients, and good NPs are turning away people? Are you located in some terribly desolate region of the country or something?

What, then, are the psychiatrists doing if they aren't seeing patients... that's what a psychiatrist does, treat patients.

The poster is implying everyone is busy and their practices are full. You turn people away if you're too full to see new patients.

 

[sunlioness]

Wait what? All the reputable psychiatrists aren't seeing patients, and good NPs are turning away people? Are you located in some terribly desolate region of the country or something?

What, then, are the psychiatrists doing if they aren't seeing patients... that's what a psychiatrist does, treat patients.

Psychiatrists are seeing lots and lots of patients. But there are too many patients for all the psychiatrists. There's a horrible access problem nationwide. At the hospital I just worked at in a decent sized city, it would often take us 3 months to get people who were being discharged from the hospital in with a psychiatrist. It's a problem here too where just after starting my new job I am already completely booked 3-4 months in advance. It's not a good situation for patients and if NPs can help fix it, I'm all for it.

 

[F0nzie]

Shortage or no shortage of Psychiatrists... demand can go up and down all it wants and it's not necessarily going to change how a profession in medicine gets paid. Insurance companies and Medicare provide for our salary and they set the rates based on economic and political factors.

Despite the unprecedented shortage of PCPs and Psychiatrists, wages are not adjusted to meet the public demand like normal market forces. If reimbursement rates matched demand we'd be making a heck of a lot more than 170k per year, specialists in lesser demand would not be earning 2X our salary, and more people would be drawn to our speciality as a counterbalance (although likely not to suffice given our trajectory). I'll compare increasing mental illness to increasing hailstorms. Let's say over the next 10 years due to global climate change, hailstorms will be plaguing the United States and damaging cars more than ever. Is an auto insurance company going to pay the mechanics of the body repair shops more because all the shops are booked for 3-6 months?

Also, I believe that independent NPs bill the same as physicians.

Psych NPs can probably bill for the same codes as Psychiatrists but insurance companies likely adjust their rates 25-50% lower to account for the difference in educational background and credentials. It would explain why their reported salaries are less than ours. At a Psych ER where I moonlight, one of my Attendings informed me that Psych NPs get paid less by the hour to do the same emergent evaluations- filling out the exact same forms, admission orders, and meds.

The only way I see a physician viably participating in the free market of medicine is to cater to the wealthy and start a cash private practice. Unfortunately this limits the scope of the population that can be seen. There are already independent Psych NPs charging $200 cash per hour in several states, particularly in the wealthier suburbs- they however, have a lesser credential advantage competing in the free market when compared to an MD or a DO.

The only threat I see with psychiatric nurse practitioners to the profession of Psychiatry is future job availability at an institution or State agency. ie. if employers decide to hire Psych NPs to Psychiatrists in a 6:1 ratio due to their cost effectiveness. I don't think more NPs will affect our salary, due to reasons described above, but we may not have the current luxury to work anywhere we want.

 

[InBoston]

I'm actually in need of a NP because I'm leaving my current jobs and taking an academic and clinical position with the local university hospital. The private practice I'm in can't find a psychiatrist to replace me, and I an NP could handle the load I'm leaving.

I have no problem with protecting our turf but it has to be done in an ethical manner. Just as psychologists often push for med prescription power without realistically addressing the lack of research (they keep citing the military study as proof it's safe when that same study even said it was not applicable to the public), we can't simply base this off of our ability to profit without addresssing the lack of services available to those in need.

In my opinion, if the lack of services continue, that only increases the risk of the alleged problem with increasing NPs.

I'm not even sure I see it as a problem. I've yet to see any psychiatrists mention it is in regards to their ability to work. When you got communities such as in Iowa where there's literally no psychiatrist whatsoever for several counties, communities have little choice but to give psychiatric responsibilities to others. I can't argue in good faith to deny NPs to have psychiatric prescription power if nothing else is being done by people in our own profession to help fix that. One cannot simply argue that capitalistic market forces will fix this when it hasn't for several years.

Does the android np have one patient-care program...."Xanax, go away. Xanax, go away".?

 

[Therapist4Chnge]

If you have good insurance, cash, or well off flexible spending account and choice of providers is in your realm of feasibility for non-emergent care, why wouldn't you chose the better trained 'provider'?

Those are some very big"Ifs"....most people (particularly in today's economy) don't have those.

 

[zenman]

The only threat I see with psychiatric nurse practitioners to the profession of Psychiatry is future job availability at an institution or State agency. ie. if employers decide to hire Psych NPs to Psychiatrists in a 6:1 ratio due to their cost effectiveness. I don't think more NPs will affect our salary, due to reasons described above, but we may not have the current luxury to work anywhere we want.

That's probably the only threat you have from us NPs. I'm on call this weekend and today made rounds, admitted 4 patients, and made 8 consults on the floors. I don't think there's going to be a shortage of patients anytime soon.

 

[OldPsychDoc]

Those are some very big"Ifs"....most people (particularly in today's economy) don't have those.

Even those that do are waiting 6-8 weeks for intakes in our area (major midwestern metro, not rural, either).

 

[AnnoyedByFreud]

Wait what? All the reputable psychiatrists aren't seeing patients, and good NPs are turning away people? Are you located in some terribly desolate region of the country or something?

What, then, are the psychiatrists doing if they aren't seeing patients... that's what a psychiatrist does, treat patients.

I think you need to re-read my post. And no, I live in a metro area on the west coast.

 

[Leo Aquarius]

My goodness. I had heard about a general shortage of psychiatrists but had not realized the true extent of it - I feel for patients who are forced to wait 3 months to see a psychiatrist and must suffer in the meantime. What can we do to improve the situation?

 

[Fastball32]

I love nurses. My mom is a nurse. However nurses aren't trained in physiology, pharmacology, or psychology to the extent of psychiatrists. Personally, I am not threatened by RNP's because the difficult cases need to be supervised by Psychiatrists anyways. Even Psychologists that can prescribe (New Mexico & Louisiana) need us when things get tough. Neurologists have wanted to combine psychiatry with neurology for quite some time, but to explain human behaviors through bio, psycho, social, and spiritual means is the most difficult aspect in medicine and which is why I chose Psychiatry. Psychiatry is the last frontier in medicine for a reason, it'll never be completely objective. I always thought that it is easy to be an average Psychiatrist, but it is extrememly challenging to be a great one. There is room for us all.

 

[Saluki]

I have heard of graduates of anesthesiology residencies having trouble getting jobs in the city they wanted due to many hospitals going to a model of several nurse anesthetists to one or two anesthesiologists.

I'm not sure that I see this happening as much in other areas of medicine. I think the main reason this occurs in anesthesia is because patients aren't really aware. If my grandparents meet the nurse anesthetist while they're being put to sleep, they assume that the "real doc" is nearby and closely supervising. And if you asked a parent in the children's hospital directly "Would you rather have a physician or a nurse providing the anesthesia while we correct your child's complex congenital heart defect?", I doubt you're going to get many choosing the nurse option.

In several pediatric subspecialty clinics, I've seen the nurse practitioner take care of minor complaints, paperwork related to pre-authorizations, and routine visits for children that have been stable for some time. This allows the physicians to see new patients and those with more complex issues. In some clinics, everyone seems to fill their own roles and live happily together. In others, there's tension as the physicians feel that the nurse practitioners are trying to take primary ownership for patients including not sending the patient over to the main physician for more serious symptoms.

I doubt nurse practitioners are going to result in all of us being unemployed and homeless. I think the bigger issue is that there seems to be a trend of trying to deal with a maldistribution of health care providers by increasing numbers (psychologists providing medication, mid level providers, more medical schools, larger class sizes). So far this hasn't seemed to result in much better access for the people in rural North Dakota or a huge upsweep in people choosing family practice. Instead, it seems to have merely increased the competition for already competitive residencies and desirable jobs in desirable locations.

I don't know what the proper solution is, but I think it would help if the news sources, government, etc. started speaking of it as a maldistribution issue. Because if you're wealthy or live in a desirable area, there are probably openings tomorrow......

 

[AnnoyedByFreud]

I love nurses. My mom is a nurse. However nurses aren't trained in physiology, pharmacology, or psychology to the extent of psychiatrists. Personally, I am not threatened by RNP's because the difficult cases need to be supervised by Psychiatrists anyways. Even Psychologists that can prescribe (New Mexico & Louisiana) need us when things get tough. Neurologists have wanted to combine psychiatry with neurology for quite some time, but to explain human behaviors through bio, psycho, social, and spiritual means is the most difficult aspect in medicine and which is why I chose Psychiatry. Psychiatry is the last frontier in medicine for a reason, it'll never be completely objective. I always thought that it is easy to be an average Psychiatrist, but it is extrememly challenging to be a great one. There is room for us all.

To clarify, this is not necessarily true. It depends on whether or not the NP is practicing in an independent practice state.

 

[zenman]

I went back and read the rest of this thread and will make some comments from my role as a psych NP.

Personally, in addition to my own professional and economic self-interests, I philosophically disagree with mid-levels practicing medicine and so will support legislative actions which are in physicians' best interests on these issues. Likewise, I have chosen not to hire, supervise or choose a mid-level practitioner for my own medical care. I would hope that physicians with similiar views would do the same.

Maybe you could best spend your energy elsewhere. The enemy is corporate takeover of healthcare. I remember in the 80's when DRG's came into being and I knew exactly where in s#it creek we were heading. Sure enough we did. Many physicians are now employed rather than in private practice.

Given that I don't think psychiatrists as a group are not under any real danger for the next several years, there's a shortage of psychiatrists in most parts of the country, people advocating for non-MD prescribers is due to the shortage, and that the main way to fight for our own interests are through lobbying groups that pseudo-bribe politicians, I'm happy with not doing much about this nurse practitioner issue.

If you're smart, you can actually profit quite nicely by having an NP work for and with you.

That's exactly what you do as a smart person. Work the system.

Sometime in the next 15 years I'm sure an NP will give a rich guy's daughter a dose of demerol while she's on an MAOI and NPs will be forever limited to working 80 minutes a week. Don't worry.

This NP would give an MAOI only as a last resort and certainly wouldn't give any opiates on top of it.

I share the same sentiments.


Psychiatry or any physician doesn't need to worry that has the ability to open their own office based practice. Advertising that you are a physician and don't employ mid-levels providing a guarantee of that will be a niche in itself. Nurse practitioners need to realize that they really aren't needed. They aren't the gold standard and are merely tolerated. As metaphorical "parasites" on the system they are rocking the boat by increasing their numbers. An ideal parasite isn't noticed by its host (like 10 years ago), but a bad parsite sickens and weakens its host (the future). In anesthesia for instance they will saturate the market, and reduce their salary. As a whole there will eventually be collective advertising by physicians of multidisciplines coming together as one voice stating "our practice doesn't use mid levels come to us for the best care." By increasing their numbers they are laying the foundations of a two tiered system not just based on insurance/money but also on degree/experience.

If you have good insurance, cash, or well off flexible spending account and choice of providers is in your realm of feasibility for non-emergent care, why wouldn't you chose the better trained 'provider'?

Physicians are the Gold standard for a reason. This won't change.

I was just hired by a hospital who had looked for someone in my position for over a year. Tell my psychiatrist director that I'm really not needed and she would probably rip you a new one! I was hired to do mostly outpatient and consults for ED and hospitalists. One ED doc called me today but had an issue that needed a psychiatrist. I was on call and just gave him my director's number. No problem. Another ED doc, also today, called me and asked me to take care of a psych patient that was medically cleared and somehow got dumped on him. The patient had been placed on a hold by another ED doc. I had the patient on his way home so fast the ED doc was shocked. He shook my hand, thanking me, and then came back over and shook my hand again.

Several of the hospitalists who have worked with me over the last three weeks have already told me to give their patients what they need and just dictate a consult without calling them back. I've changed several psych meds because they weren't the best option for a patient with cardiac problems.

I know I don't know everything but I certainly know how to look it up. And you'll notice I post topics here when I want the opinions of others. The learning never stops.

By the way, what's the best consultative-liaison book out there?

NPs don't spend more time with patients that's a fallacy. Second people who have anti-doctor sentiments is fine by me. Its been my experience they also believe in CAM more than medicine. That's a headache worse than some axis II disorders. A problem I have is when that sentiment isn't our fault. Many midlevels are percieved by the public as physicians and when they anger patients or treat them poorly the patient blames it on a physician. Too many times I've called up this poor providers to get the scoop and collateral only to learn I'm talking with a midlevel and not Dr. John Smith like the patient believed.

I'm glad the gov and institutions are pushing for greater transparency in credentials, even prohibting nurse practitioners from identifying themselves as doctors in some states.

I always tell patients who I am and half the time they will say, "Hello doc" right after I introduce myself. I just give up after that.

In regards to CAM, you might want to include all mental health professions in that group. It's no secret I've studied shamanism with a guy who is a psychologist and medical anthropologist. You would be shocked at the number of mental health people studying complementary modalities. The only disadvantage I see with using CAM is that patients actually get better much faster and you'll have to be dragging in new patients all the time! I recently worked locums and ran into a psychiatrist who had studied shamanism with the anthropologist Michael Harner. Another locums shrink started ordering all the same shamanism books I had. The clinic I was in had asked me not to use any CAM, which I wasn't going to do anyway. I never did tell them that they had a painting in their building by a well-known artist who had also been one of my shamanic teachers. And don't forget about those nutty guys over in Integrative Psychiatry.

And when over 60% of patients use CAM you can bet my MBA that I won't be ignoring that market niche!

I love nurses. My mom is a nurse. However nurses aren't trained in physiology, pharmacology, or psychology to the extent of psychiatrists. Personally, I am not threatened by RNP's because the difficult cases need to be supervised by Psychiatrists anyways. Even Psychologists that can prescribe (New Mexico & Louisiana) need us when things get tough. Neurologists have wanted to combine psychiatry with neurology for quite some time, but to explain human behaviors through bio, psycho, social, and spiritual means is the most difficult aspect in medicine and which is why I chose Psychiatry. Psychiatry is the last frontier in medicine for a reason, it'll never be completely objective. I always thought that it is easy to be an average Psychiatrist, but it is extrememly challenging to be a great one. There is room for us all.

No we're not trained to the extent that you are and I realize that. I'm also in a state where I can practice totally independently. However, I'm now in the hospital setting and have a boss psychiatrist. I have no problem with that especially since she is one funny person. And like you say there is room for all of us.

 

[OldPsychDoc]

I went back and read the rest of this thread and will make some comments from my role as a psych NP.
....
No we’re not trained to the extent that you are and I realize that. I’m also in a state where I can practice totally independently. However, I’m now in the hospital setting and have a boss psychiatrist. I have no problem with that especially since she is one funny person. And like you say there is room for all of us.

I feel...threatened...
😉

 

[zenman]

I feel...threatened...
😉

I doubt you do at this point in your life. 😀 If you do I hope you get some therapy...which is beneficial for everyone in our field.

 

[InBoston]

We should let NPs get sued like everyone else then. And make them take call.

 

[zenman]

We should let NPs get sued like everyone else then. And make them take call.

The hospital carries malpractice on me and I have my own policy, plus I was on call this last Friday, Sat and Sunday. I admitted 6 patients and saw 14 consults on the floors. Anything else you want us to do? 🙂