the nurse practitioner threat

[F0nzie]

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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? 🙂

I've seen and admitted this many patients in a 12 hour shift covering the ED and CL service. I felt like a raging pheochromocytoma. If I had a psych NP on my team sharing the work I wouldn't complain. Less availability of providers in a community or hospital setting doesn't get us more pay, it just puts a noose around our neck and limits access to care.

 

[heyjack70]

I've seen and admitted this many patients in a 12 hour shift covering the ED and CL service. I felt like a raging pheochromocytoma. If I had a psych NP on my team sharing the work I wouldn't complain. Less availability of providers in a community or hospital setting doesn't get us more pay, it just puts a noose around our neck and limits access to care.

That sucks.

 

[zenman]

I've seen and admitted this many patients in a 12 hour shift covering the ED and CL service. I felt like a raging pheochromocytoma. If I had a psych NP on my team sharing the work I wouldn't complain. Less availability of providers in a community or hospital setting doesn't get us more pay, it just puts a noose around our neck and limits access to care.

...and makes you die early.

 

[InBoston]

...and makes you die early.

Lookie here, a genuine militant NP. They are so rare these days.

 

[ghost dog]

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? 🙂

Please:

1. Go to medical school.
2. Attend a residency.
3. Write the USMLE steps 1,2 and 3 (and pass).

4. Obtain 10,000 hours of clinical experience, as opposed to the minimal experience NPs currently have.

That should do it.

 

[zenman]

Please:

1. Go to medical school.
2. Attend a residency.
3. Write the USMLE steps 1,2 and 3 (and pass).

4. Obtain 10,000 hours of clinical experience, as opposed to the minimal experience NPs currently have.

That should do it.

Sorry, not going to happen. It's a fact of life that people can help another without having to have the credentials you have. I applaud you for what you've done but you don't always have to be a Navy Seal to get the job done. Know what I mean?

 

[nitemagi]

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? 🙂

When you "take call" how many hours do you work, and from when to when?

 

[firedoor]

Sorry, not going to happen. It's a fact of life that people can help another without having to have the credentials you have. I applaud you for what you've done but you don't always have to be a Navy Seal to get the job done. Know what I mean?

If the job you're referring to is psychiatry, then it should be done by a psychiatrist. No exceptions. No retreat. No surrender.

 

[InBoston]

If the job you're referring to is psychiatry, then it should be done by a psychiatrist. No exceptions. No retreat. No surrender.

Spoken like a true Navy Seal 😉

 

[ghost dog]

Spoken like a true Navy Seal 😉

The problem is: it's the patients who get taken down by the friendly fire of NP weekend warriors.

http://www.youtube.com/watch?v=pxFAUsweUas

 

[zenman]

When you "take call" how many hours do you work, and from when to when?

Friday afternoon to Monday morning. Come in on Sat make rounds, do admits or discharges, make consults on the floors. Same for Sunday.

 

[zenman]

If the job you're referring to is psychiatry, then it should be done by a psychiatrist. No exceptions. No retreat. No surrender.

Well as a "Psychiatric" nurse practitioner I don't care what ya call it.

 

[zenman]

The problem is: it's the patients who get taken down by the friendly fire of NP weekend warriors.

http://www.youtube.com/watch?v=pxFAUsweUas

Well, let's see here. My unit med director can see my work daily with the inpatients and ED docs and hospitalists in regards to any consults I do. I'll let you know when there is a complaint.

I'm not a weekend warrior as I work full time...ex Specialist 6th class.

 

[Saluki]

Sorry, not going to happen. It's a fact of life that people can help another without having to have the credentials you have. I applaud you for what you've done but you don't always have to be a Navy Seal to get the job done. Know what I mean?

I don't think anyone is going to argue that one needs an MD to "help another" person... I think all psychiatrists, regardless of their position on mid-level providers, realize that the work provided by the RNs, social workers, and unit secretaries are essential for making an inpatient psychiatric unit run.

I think the tricky piece with mid level providers is that there is no clear consensus on exactly what does and does not fall within their purview. If a psychiatric nurse practitioner is really capable of doing all that a fully trained psychiatrist can do, then perhaps I'm going through a much longer course of training than I should😛 If not, then where do the limits lie and how are those maintained?

All that said, I've seen some wonderful mid level providers on pediatrics services, who worked well as members of a team: taking on the less complicated follow up cases, arranging for the patient's medications, doing the parent/patient teaching on how to give injections, etc. My experience with the psychiatric nurse practitioners has been a little less positive, but I've also met far fewer mid level providers in psychiatry....

I doubt we're going to be able to solve any of these questions on this thread, and I feel that the tone of the thread is becoming progressively more heated (perhaps unsurprisingly given the inauspicious title)

 

[InBoston]

I don't think anyone is going to argue that one needs an MD to "help another" person... I think all psychiatrists, regardless of their position on mid-level providers, realize that the work provided by the RNs, social workers, and unit secretaries are essential for making an inpatient psychiatric unit run.

I think the tricky piece with mid level providers is that there is no clear consensus on exactly what does and does not fall within their purview. If a psychiatric nurse practitioner is really capable of doing all that a fully trained psychiatrist can do, then perhaps I'm going through a much longer course of training than I should😛 If not, then where do the limits lie and how are those maintained?

All that said, I've seen some wonderful mid level providers on pediatrics services, who worked well as members of a team: taking on the less complicated follow up cases, arranging for the patient's medications, doing the parent/patient teaching on how to give injections, etc. My experience with the psychiatric nurse practitioners has been a little less positive, but I've also met far fewer mid level providers in psychiatry....

I doubt we're going to be able to solve any of these questions on this thread, and I feel that the tone of the thread is becoming progressively more heated (perhaps unsurprisingly given the inauspicious title)

I doubt using reason will really make any difference with a militant NP.

 

[zenman]

I don't think anyone is going to argue that one needs an MD to "help another" person... I think all psychiatrists, regardless of their position on mid-level providers, realize that the work provided by the RNs, social workers, and unit secretaries are essential for making an inpatient psychiatric unit run.

I think the tricky piece with mid level providers is that there is no clear consensus on exactly what does and does not fall within their purview. If a psychiatric nurse practitioner is really capable of doing all that a fully trained psychiatrist can do, then perhaps I'm going through a much longer course of training than I should😛 If not, then where do the limits lie and how are those maintained?

All that said, I've seen some wonderful mid level providers on pediatrics services, who worked well as members of a team: taking on the less complicated follow up cases, arranging for the patient's medications, doing the parent/patient teaching on how to give injections, etc. My experience with the psychiatric nurse practitioners has been a little less positive, but I've also met far fewer mid level providers in psychiatry....

I doubt we're going to be able to solve any of these questions on this thread, and I feel that the tone of the thread is becoming progressively more heated (perhaps unsurprisingly given the inauspicious title)

That is a difficult and interesting question probably due in part to each state board of nursing. At some point, and they are working on a consensus, maybe there will be a clearer picture of each role. You can have the complicated cases as I prefer the "walking wounded." I do have a lot of medical experience, and in fact, got my first masters in psych when I was working in ICU. So I am pretty comfortable working with medical patients. Today I was asked to see a dialysis patient to assess his competency. Totally inappropriate consult as the patient just went through dialysis and was confused as usual afterwards as well as having several other problems contributing to delirium.

I don't think the tone here is becoming heated. Just a friendly discussion.

 

[nitemagi]

Today I was asked to see a dialysis patient to assess his competency. Totally inappropriate consult as the patient just went through dialysis and was confused as usual afterwards as well as having several other problems contributing to delirium.

I don't think the tone here is becoming heated. Just a friendly discussion.

How is that inappropriate? You can say they don't have capacity after your evaluation, Because of their delirium.

 

[zenman]

I doubt using reason will really make any difference with a militant NP.

So now you realize cognitive intervention is not all it's cracked up to be? 😀

I'm not militant. Here's my method of a warrior. Once two guys I knew were drunk and arguing about which one was the last soldier to actually board a helicopter and leave Vietnam. Their girlfriends got mad and left with me.

 

[zenman]

How is that inappropriate? You can say they don't have capacity after your evaluation, Because of their delirium.

The patient didn't have the capacity and the hospitalist should know that. You're not going to get his baseline now. Personally if he wanted more I'd have gone with a neuro consult.

 

[nitemagi]

The patient didn't have the capacity and the hospitalist should know that. You're not going to get his baseline now. Personally if he wanted more I'd have gone with a neuro consult.

Capacity is a time dependent state. One needs to document someone's lack of capacity for a particular decision at that time. You're right, though, that they should have been able to assess and document that themselves. No state including renal failure means someone has lost a global capacity. Including psychosis, delirium, etc. Hence the need for clinical examinations, serially.

 

[zenman]

I've also received consults and go up to ICU/CCU and the patient is still on the vent. I call now before I go up.

 

[F0nzie]

The patient didn't have the capacity and the hospitalist should know that.

Whether the hospitalist should know if a patient has capacity is irrelevant. Capacity determinations are the bread and butter consult-liaison psychiatry aka psychosomatic medicine which is a 1 year fellowship after general psychiatry residency. Capacity determinations can only be made by physicians (M.D. or D.O.) and psychiatrists in particular are deemed specialists in this area. I do not believe that Psychiatric NPs, regardless of their priveleges to practice and prescribe independently can legally make capacity determinations. I know for a fact Psychiatric NPs cannot run involuntary psych units in my state because they do not meet the qualifications to testify in court.

 

[nitemagi]

I've also received consults and go up to ICU/CCU and the patient is still on the vent. I call now before I go up.

Being unable to speak does not preempt having capacity or doing a capacity evaluation. Anyone doing consults should know that frankly. Look up alphabet and word boards.

 

[F0nzie]

Look up alphabet and word boards.

Found the link! Alphabet and Word Boards

 

[digitlnoize]

Being unable to speak does not preempt having capacity or doing a capacity evaluation. Anyone doing consults should know that frankly. Look up alphabet and word boards.

Exactly what I was going to say! There are many ways to communicate besides speech.

Come on, even the med student knows that! NP Fail.

Oh, and because it is awesome and helpful, below is a link illustrating how the alphabet board can be used. From Breaking Bad. Fast Forward to 1:45 and start from there:

[YOUTUBE]http://www.youtube.com/watch?v=jBrhI8au3N4[/YOUTUBE]

 

[nitemagi]

Found the link! Alphabet and Word Boards

Damnit! I fall for that Every time!

 

[deleted432032]

Found the link! Alphabet and Word Boards

Damn it

 

[Therapist4Chnge]

Being unable to speak does not preempt having capacity or doing a capacity evaluation.

It depends...what if they have a global aphasia? How about if they can't consistently answer yes or no? I guess you could try, but it'd be a pretty straight-forward case. The overall point is fair though.

 

[firedoor]

Well as a "Psychiatric" nurse practitioner I don't care what ya call it.

And as a psychiatrist I do very much care about "what ya call it". Definitions matter, and I have no qualms about defining what psychiatry is--beginning with the first principle that it is a branch of medicine and should therefore be practiced exclusively by physicians.

 

[InBoston]

And as a psychiatrist I do very much care about "what ya call it". Definitions matter, and I have no qualms about defining what psychiatry is--beginning with the first principle that it is a branch of medicine and should therefore be practiced exclusively by physicians.

Well, there are psych PhDs running for prescribing priviledges too, and getting psychopharm degrees online.

 

[firedoor]

Well, there are psych PhDs running for prescribing priviledges too, and getting psychopharm degrees online.

And there are chiropractors practicing quackery, nurses and PA's practicing medicine and people refer to Enrique Iglesias as a "musician"...that doesn't make it right.

 

[zenman]

Whether the hospitalist should know if a patient has capacity is irrelevant. Capacity determinations are the bread and butter consult-liaison psychiatry aka psychosomatic medicine which is a 1 year fellowship after general psychiatry residency. Capacity determinations can only be made by physicians (M.D. or D.O.) and psychiatrists in particular are deemed specialists in this area. I do not believe that Psychiatric NPs, regardless of their priveleges to practice and prescribe independently can legally make capacity determinations. I know for a fact Psychiatric NPs cannot run involuntary psych units in my state because they do not meet the qualifications to testify in court.

True and I discussed it with my shrink boss this morning and she's going to wait till his delirium is cleared. I may be wrong but I see no reason to do a capacity determination with delirium. Seems like pissing in the wind to me.

 

[zenman]

Exactly what I was going to say! There are many ways to communicate besides speech.

Come on, even the med student knows that! NP Fail.

Oh, and because it is awesome and helpful, below is a link illustrating how the alphabet board can be used. From Breaking Bad. Fast Forward to 1:45 and start from there:

[YOUTUBE]http://www.youtube.com/watch?v=jBrhI8au3N4[/YOUTUBE]

Perhaps you can spell "propofol." Put the name boards away please.

 

[zenman]

And as a psychiatrist I do very much care about "what ya call it". Definitions matter, and I have no qualms about defining what psychiatry is--beginning with the first principle that it is a branch of medicine and should therefore be practiced exclusively by physicians.

I feel your anguish...

 

[zenman]

Whether the hospitalist should know if a patient has capacity is irrelevant. Capacity determinations are the bread and butter consult-liaison psychiatry aka psychosomatic medicine which is a 1 year fellowship after general psychiatry residency. Capacity determinations can only be made by physicians (M.D. or D.O.) and psychiatrists in particular are deemed specialists in this area. I do not believe that Psychiatric NPs, regardless of their priveleges to practice and prescribe independently can legally make capacity determinations. I know for a fact Psychiatric NPs cannot run involuntary psych units in my state because they do not meet the qualifications to testify in court.

True and I discussed it with my shrink boss this morning and she's going to wait till his delirium is cleared. I may be wrong but I see no reason to do a capacity determination with delirium. Seems like pissing in the wind to me.

 

[firedoor]

I feel your anguish...

No anguish, just a genuine respect for the practice of medicine.

 

[InBoston]

Everyone wants the money. Nps want the money.

 

[splik]

I may be wrong but I see no reason to do a capacity determination with delirium. Seems like pissing in the wind to me.

You are wrong. The presence of delirium or dementia does not preclude capacity. Capacity is specific to time, and it is specific to a decision. The surgical team could have a patient with perforated obstruction necessitating emergent treatment who is delirious and refusing surgery. Or the medical team could have a patient with delirium secondary to UTI who wishes to go home but the medical team feel she needs IV antibiotics and are unsure whether she has capacity to make the decision. From both a medical and legal point of view, it is important to make a determination of capacity at the time, and document it. It would NOT be appropriate to say in these situations 'patient delirious so does not have capacity' without doing a capacity assessment' or 'patient currently delirious, treat underlying condition and will reassess'.

 

[surftheiop]

From the standpoint of a medstudent I think this blanket Pysch NP bashing is absurd, given how little we actually care about the competency of psychiatrists (ie, you could call yourself a psycho-pharmacologist and have 10 minute appointments where you indiscriminately write someone a script for an SSRI and make an easy 250k/yr for your whole career). I would much rather see competency accessed on a provider by provider basis. If someone is providing good care, then why should we care if they have more or less training?

And if someone is providing bad care, I dont care if they are a NP, PhD, MD or DO, then they should be held accountable. Seems like so many of the people fighting against NP's are willing to give all docs a free pass just because they have an MD behind their name.

 

[F0nzie]

(ie, you could call yourself a psycho-pharmacologist and have 10 minute appointments where you indiscriminately write someone a script for an SSRI and make an easy 250k/yr for your whole career).

Writing scripts indiscriminately is what happens when you don't get proper training. For example, if we eliminated the 4 year psychiatry residency and turned it into a weekend workshop to supplement our clinical hours from medical school we would get a lot of indiscriminate prescribing from sheer lack of experience. There are instances in which 10 minute med checks are appropriate and times when they are not, however, the most significant limiting factor to expert psychopharmacology is your level of training. Any medical professional can look up a medication on Epocrates and prescribe it, however, it doesn't mean they know what the hell they're doing with it.

(ie, you could call yourself a psycho-pharmacologist and have 10 minute appointments where you indiscriminately write someone a script for an SSRI and make an easy 250k/yr for your whole career).

Making 250k/yr is not easy.

 

[nitemagi]

Writing scripts indiscriminately is what happens when you don't get proper training. For example, if we eliminated the 4 year psychiatry residency and turned it into a weekend workshop to supplement our clinical hours from medical school we would get a lot of indiscriminate prescribing from sheer lack of experience. There are instances in which 10 minute med checks are appropriate and times when they are not, however, the most significant limiting factor to expert psychopharmacology is your level of training. Any medical professional can look up a medication on Epocrates and prescribe it, however, it doesn't mean they know what the hell they're doing with it.

Being on the other side of things, there are people with decent training who still fall into doing brief med visits because they've taken a job that requires them to do it that way. Either due to necessity (too many patients) or greed (by the clinic or by the provider). Sometimes it's a conscious choice, sometimes it's bad training, and sometimes it's falling into the role of letting others dictate how we practice. Just as many let insurance providers dictate the rules, rather than finding a workaround.

 

[surftheiop]

Writing scripts indiscriminately is what happens when you don't get proper training. For example, if we eliminated the 4 year psychiatry residency and turned it into a weekend workshop to supplement our clinical hours from medical school we would get a lot of indiscriminate prescribing from sheer lack of experience. There are instances in which 10 minute med checks are appropriate and times when they are not, however, the most significant limiting factor to expert psychopharmacology is your level of training. Any medical professional can look up a medication on Epocrates and prescribe it, however, it doesn't mean they know what the hell they're doing with it.



Making 250k/yr is not easy.

If you don't think plenty of MD's out in the community prescribe badly then your delusional. Given that all psychiatrists went through essentially the same length of training and passed the same standardized exams its obvious thats not the only thing that determines quality of practice.

Thats why I'm saying each provider should be measured by their current practices at any given time, regardless of what training they went through in the past. If it turns out that NPs aren't meeting good practice guidelines, then they shouldn't practice, but the same should be true of MD's and its obvious this isn't currently the case b/c there are tons of terrible docs making great livings while not actually doing much of anything to improve their patient's situations.

 

[loveoforganic]

I think you're making a pretty big strawman. What I think you're neglecting to factor in is that if training model A produces a much higher frequency of poor care providers than training model B, it would be much more efficient to attempt to change how training model A is done (if it is done at all) than to individually weed out all of the poor practitioners trained under that model.

That said, I'm not saying that psych NPs produce a much higher frequency of practitioners. I do think, however, that opening up practice freedom all at once rather than incrementally with monitoring of efficacy and safety was a poor decision.

 

[surftheiop]

I think you're making a pretty big strawman. What I think you're neglecting to factor in is that if training model A produces a much higher frequency of poor care providers than training model B, it would be much more efficient to attempt to change how training model A is done (if it is done at all) than to individually weed out all of the poor practitioners trained under that model.

That said, I'm not saying that psych NPs produce a much higher frequency of practitioners. I do think, however, that opening up practice freedom all at once rather than incrementally with monitoring of efficacy and safety was a poor decision.

I agree completely about efficiency, I was just kind of saying from a moral standpoint if the physician community is so bad at guaranteeing a certain level of care from its own providers, its kind of hard for us to credibly tell other folks that their practitioners are inherently inferior.

 

[F0nzie]

If you don't think plenty of MD's out in the community prescribe badly then your delusional.

I'm not delusional about this. I'm very well aware of the fact that there is a rotten apple in every barrel that didn't learn anything from their training; this is not unique to Psychiatry. Comparing myself to idiots out in the community you speak so profoundly of, is not a benchmark I use to evaluate the training I'm receiving in residency. Social workers practice psychotherapy, why not give social workers prescribing privileges? Psych techs know a thing or two about depression, why not let them ask for SIGECAPS and indiscriminately prescribe SSRIs like the village idiot psychiatrist in the community? Same outcome right? When you don't know anything about psychiatry it's easy to say anybody can practice psychiatry.

 

[nitemagi]

I agree completely about efficiency, I was just kind of saying from a moral standpoint if the physician community is so bad at guaranteeing a certain level of care from its own providers, its kind of hard for us to credibly tell other folks that their practitioners are inherently inferior.

That may be true, but as has come up in the prescribing psychology thread over and over again -- psychiatry training may not be the best, and everyone can see that there are bad providers out there. However, no one can make an argument that LESS training (as in psychology prescribers or NP's) would lead to BETTER clinical practice.

 

[surftheiop]

That may be true, but as has come up in the prescribing psychology thread over and over again -- psychiatry training may not be the best, and everyone can see that there are bad providers out there. However, no one can make an argument that LESS training (as in psychology prescribers or NP's) would lead to BETTER clinical practice.

I agree completely, although it would be possible to argue that the type of persons drawn to certain other mental healths fields could in fact make better clinicians due to their personalities/motivations/etc. It is somewhat weird that essentially the main qualifying characteristic for being a physician is that at age 20 you were good at taking a multiple choice test and could say the phrase "Care for sick people" while smiling during a 5 minute interview.

That being said, I obviously think medicine provides the best training or else I wouldn't be in medschool. I am less certain however that medicine attracts (on average) the personalities best suited to be compassionate healers.

 

[Leo Aquarius]

Excellent point.

On NAMI's website:
"Nursing professionals authorized to prescribe medications include psychiatric nurse practitioners, clinical nurse specialists (psychiatric), certified nurse anesthetists and certified nurse midwives. Most laws authorizing advanced nursing professionals to prescribe medications contain limits in terms of practitioners authorized to prescribe, drug schedules under which they may prescribe, or supervisory/collaboration requirements..."

I've watched my psychiatry attending wean numerous people off terrible benzo prescriptions. We often wonder who put them on long-term benzo treatment - nurses, psychologists in New Mexico, general practitioners? Don't forget that these three groups have prescribing privileges.

You can't have it both ways - complain people are getting inappropriate prescriptions, AND complain that not enough nurses, psychologists, and GPs should have crash courses to write prescriptions.

 

[nitemagi]

That being said, I obviously think medicine provides the best training or else I wouldn't be in medschool. I am less certain however that medicine attracts (on average) the personalities best suited to be compassionate healers.

They're independent factors, but not mutually exclusive.

The skills necessary to get into medical school involves being able ot be good at standardized tests, a baseline minimal aptitude for science, and a masochistic ability to delay gratification until the point that you forgot why you started the process. 😀

 

[nitemagi]

I agree completely, although it would be possible to argue that the type of persons drawn to certain other mental healths fields could in fact make better clinicians due to their personalities/motivations/etc.

That depends on how you choose to quantify "better clinician." Compassion? Less medical errors? More knowledgable? Better integration of information. I know of no connection that shows one personality type is more drawn to nursing vs. medical school. Both draw theoretically compassionate people, but I've seen plenty of greedy self-serving people go into both because they knew they'd have a steady job in it and they could do the minimal amount of work.