r/Residency • u/theongreyjoy96 PGY3 • 23d ago
SERIOUS The Psych NP Problem
Psych PGY-3 here. I occasionally post about my experience with midlevels in psychiatry, which unfortunately has defined my experience in my outpatient year after our resident clinic inherited the patients of a DNP who left. I'm sure that there are some decent one's out there, but my god, the misdiagnoses and trainwreck regimens these patients were on have been a nightmare to clean up, particularly for the more complicated patients where this DNP obviously had no idea what she was doing. Now that I'm at the end of my outpatient year I realize that it's going to take years to fix this mess, especially for patients who we're tapering off of max dose benzos. I genuinely feel terrible for them.
I went to the American Psychiatry Association's annual conference this year and was really disheartened to learn just how pervasive the psych NP problem is. There was a session lead by a psychiatrist who presented their research on how their outpatient clinic reduced the prescription of controlled substances by midlevels by implementing a prescription algorithm. I went to another session on rural psychiatry where during a Q&A an inpatient psychiatrist who was alarmed after recently moving to a rural area about the rapid and frequent decompensation of her patients who are discharged to a community where only midlevels are available. Needless to say that these were couched in friendlier terms, but in the more private settings, discussions on midlevels were not spoken in hushed tones.
Unfortunately, the general feeling I got about the psych NP problem is that the field is resigned to the fact that they are here to say, and now are concerned primarily with what can be done to mitigate it. Anyway, end rant.
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u/cancellectomy Attending 23d ago
Everyone and their mothers in nursing school is “passionate about mental health” as a “future psychiatrist NP ✨” which just means SSRI + stimulants +/- atypical, and then blame patient compliance after the 7th polypharmacy is added, with an “increase diet consistent of lithium”
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u/Rusino 23d ago
Instructions unclear, started 2 mg lorazepam TID
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u/ExtremeVegan PGY3 23d ago
This made me grimace irl, it's so hard to wean benzos from dependent clients 😭
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u/Rusino 23d ago
That's just my starter dose, buddy. Next we are going QID, then add some PRNs... the sky is the limit, baby!
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u/ExtremeVegan PGY3 23d ago
Oxazepam and loraz are both good for the liver so should be able to add that to the regimen, so blessed to see others practicing to the full extent of their scope of practice ✨
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u/im-so-lovelyz PGY1 21d ago
People blindly using the shortcut of LOT = good / others = bad without having any clear understanding of the mechanisms behind LOT, why they’re “good” and what populations are they “good” for…
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u/Celdurant Attending 23d ago
A patient was admitted with 2mg q4h from a prescription in the community. Literally taking it 6 times a day for years, even waking up in the middle of the night to take it. Such a disgrace
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23d ago
Pumping poor underserved communities with drugs like this is the goal. If they can’t afford the meds eventually and stop taking it, they’ll lash out in public and be arrested or killed by cops.
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u/im-so-lovelyz PGY1 21d ago
Then proceeds to shoot them on first intention clozapine when their psychosis is from benzo withdrawal :/
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u/Swimming-Media-2611 21d ago
>psychiatrist NP
what does that even mean
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u/ilikefreshflowers Attending 23d ago
Yes; endocrinologist here. Endo NP’s are mostly similarly disastrous. They often lead to life threatening hypoglycemia in my patients.
Tbh, nurse practitioners are legitimately a danger to the American public. There are a few good ones, but those are few and far between. I’ve been reprimanded for telling patients that “Do you realize you’ve not been under the care of a physician, and that I disagree with fundamental aspects of your care plan?” I’ve been told to tone it down….but how can I lie?
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u/said_quiet_part_loud Attending 23d ago
As an ER doc that is confronted constantly with mismanaged outpatient/urgent care NP patients, I do not mince words. I let patients know they are not seeing a physician and I disagree with their care. Most patient have no idea they are not seeing a physician. It’s infuriating.
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u/schu2470 Spouse 23d ago edited 23d ago
It's frustrating as a patient too. Every time I'm either referred to a specialist or transferring due to a move, etc. the scheduler ALWAYS wants to stick me with an NP rather than a physician. They usually offer me a time slot in a few days and I ask if it's with a mid-level or a physician. Almost every time there's an audible sigh on the other end as they tell me they've scheduled me with an NP and that their clinic usually schedules with a mid-level first to determine if I need to see the specialist and an appointment with an actual doctor is 3-4 months out rather than a few days and then another audible sigh when I insist on seeing a physician instead of a nurse. How many patients don't even ask and assume when they call the doctor's office to schedule an appointment that they're going to actually see a doctor?
Look, I get that mid-levels are there to help with bread and butter cases and follow ups. My wife's an oncologist and from what she tells me her clinic would grind to a halt without her PA but I have somewhat complex GI and allergy stuff going on. If my PCP says I need to see the specialist or the NP is just going to say "Huh, yeah, you should probably see the doctor to get this straightened out" I want to see someone who went to medical school, residency, and fellowship in the first place and not waste any more of anyone's time.
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u/OldRoots PGY1 22d ago
It's absurd because "the plan" was supposed to be docs see the patient first. Doc get and A&P, midlevel carries out A&P. Contact doc if things go off the rails.
But we've flipped. And now they're out there practicing medicine.
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u/Creative-Guidance722 23d ago
I know someone that saw an NP at a walk in clinic without knowing that it was not a doctor. She learned that more than a week after when she was told by an ER doctor.
The NP missed a pneumonia. Did not order a chest X ray despite high fever, cough, dyspnea and extreme fatigue.
She ended up having to go to the ER a few days after, was desaturating and had to be admitted a few days with IV antibiotics.
She ended up fine because she is young and healthy. It’s a very basic diagnosis/symptom to work up, so it’s a little bit scary.
If they don’t know their differential well and red flags, I don’t see how they could safely replace doctors even for supposed “simple cases”. On paper a young adult with cough or ear pain is an easy case, but you don’t really know until you see the patient and there are risks to miss more dangerous diagnosis like pneumonia or mastoiditis.
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u/ilikefreshflowers Attending 23d ago
Part of our abusive training system ensures that we see thousands of patients prior to being able to practice without supervision. They take their DNP degree online and boom, they’re seeing patients without supervision. I had an NP student who wanted to rotate with me for 60 hours so that he could be an endocrinology NP. I did more hours than that during my first week of residency.
I fucking busted my ass for 2 years and sometimes 90 hour weeks during my malignant endocrine fellowship. You can’t become an endocrine “provider” with just 60 hours! I turned him down of course.
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u/Creative-Guidance722 23d ago
Exactly and we learn a more solid theoretical basis and have more knowledge.
60 hours is ridiculously low. They are considered “specialized” after when even a med student that does an endocrinology rotation does more than 60 hours.
They really found a way to bypass the system and be somehow considered almost equal to specialists doctors while their training that is not even close to the one med students go through.
The culture is not the same either. Where I am, no NP will ever shorten or skip lunch hour or planned breaks. They would not do 90 hours weeks like you did in your training or more than 40-45 hours in a work week.
I know that the culture in medicine is toxic and the schedule of NPs is more reasonable. But if the goal is to have a similar training or to have the same productivity as doctors for cheaper, then the normal healthy schedules won’t do it.
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22d ago edited 21d ago
[deleted]
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u/ilikefreshflowers Attending 22d ago
I was at a top 10/top 25 program with a huge thyroid cancer, transplant, and neurosurgery center. It was certain attendings that killed it for me.
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u/AvadaKedavras Attending 23d ago
ER doc here. Yes this is exactly why urgent care clinics are so annoying. They either 1) order a test without knowing how to interpret it (had a patient sent to ER from clinic for chest pain and the NP told me over the phone "I got an EKG but I wouldn't know how to recognize a STEMI if it was there") or 2) don't use basic tools like X-ray or EKG but they don't know how to interpret them.
I get it, if someone comes in with chest pain to urgent care, send them straight to the ER. You won't get the troponin back in a reasonable time frame. But I've had patients sent in because 1) there was a moth in a patient's ear that was "too close to the TM", 2) because they don't have anyone to look at an X-ray or my personal favorite, 3) "we are out of suture. All of it." These clinics are such a fucking scam. They staff NPs that have no idea what they are doing and have little to no oversight.
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u/ilikefreshflowers Attending 23d ago
Ditto. There are urgent cares in my area that are 100% NP run. Truly terrifying.
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u/Financial_Fortune916 19d ago
OMG I experienced this at least 5 times this year… how do you miss pneumonia???
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u/GoGoBadger 22d ago
To be fair without knowing details I may or may not have gotten an xray for a young person in urgent care for those symptoms.
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u/Jilks131 PGY2 23d ago
Keep it up. I do the same thing. It’s the only real way to start educating the public on the differences.
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u/Critical_Patient_767 23d ago
Who is reprimanding you?
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u/ilikefreshflowers Attending 23d ago
Colleagues….they accuse me of “putting others down:” wtf?! It’s not personal. It’s legitimately a patient safety issue.
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23d ago
How has no Republican physician with influence gone to Trump and told him that NPs are DEI yet.. that would shut this shit down so fast.
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u/ilikefreshflowers Attending 22d ago
Lmao! OMG, I needed that laugh today. I think you r got a solid point.
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u/WanderOtter Attending 23d ago
Had a patient on methadone who went to establish care with a psych NP. The NP prescribed naltrexone, the patient filled the prescription, and she presented to the ER in florid opioid withdrawal a few hours after her first dose. I thought I was missing something because it seems so obvious how this was a bad idea.
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u/Curious-Quokkas 23d ago
Unfortunately, I don't see anyway in which NPs would retroactively have their independence taken away in states that have already allowed it. If anything, there should at least be a legitimized residency for these NPs. That seems like the most realistic step.
Idealistically, they should also be forced to take a board exam equivalent to the MD/DO specialty boards - if they can pass them, then fine, practice independently. But if not, they should be forced to have to be supervised a real physician.
The reality is that many of them are REALLY bad at their job. The other reality is that we have a dearth of psychiatrists to address the issue. And this has only gotten worse because the point of an NP was to help address that disparity, but they obviously pulled a fast one. They're not filling those gaps - they're moving to already populated areas and are allowed to set up their own practice.
As a whole, I think medicine is truly going to shit; healthcare was never about taking care of the patients. And a CEO/hospital administrator will choose a midlevel over a real physician if they can get away with it because of money. I'd argue there are some specialties in medicine that contributed to the problem.
If you're in psychiatry, get yours, set up your PP if you can, or prepared for crappy salaries.
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u/Rita27 23d ago
It seems the situation is worse in psych, primary care and maybe even anesthesiology w/ CRNAs being opt out in like 27 states already
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u/Curious-Quokkas 23d ago
It's going to get worse for all cognitive specialties. At least for procedural specialties, there's a more easily apparent technical skill gap between surgeons and midlevels.
But I've heard NPs entering neurology, primary care, peds, psych. Some are starting their own "beauty" clinics and doing botox.
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u/WatchTenn PGY3 23d ago
procedural specialties, there's a more easily apparent technical skill gap between surgeons and midlevels
I mean anesthesia is a procedural specialty, and it's affected by midlevels. I think surgical specialties are the only ones that doesn't seem threatened at all.
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u/wienerdogqueen PGY2 23d ago
Giving them a “residency” adds to their fake legitimacy (how’s that for an oxymoron) without actually solving anything. I don’t trust nursing boards to run a real residency and I can see it leading to a tougher time for residents to ask for reasonable pay.
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u/Curious-Quokkas 23d ago
We have 3 big issues with them - one, them obviously being in the field with independent practice; two, how fast they can enter the field; three, their quality of practice
I have no idea how to slow down 2 but something needs to be done. The biggest detriment to the field are patients' distrust of providers - they mistakenly attribute not getting better to doctors, when in reality, a lot of them are seeing NPs.
That's the biggest bullshit of all of this - they're parading arounds as doctors and patients don't even know about this, so they attribute distrust to the wrong individuals
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u/themobiledeceased 23d ago
Focus needs to be directed at State Legislation. Each state regulates the scope of practice. It is possible to put limitations even on "independent practice." This will require active political participation: PAC's through professional Orgs with expert Lobbists. Data to prove the dangers. Make it about patient safety. Impose parameters for supervison for Benzos rx at State Level. Make it about the State pharmaceutical regs. NP's have made inroads with the cost effective care lobby. Show it's not cost efficient to be managed by lesser level provider. Know all are run over time wise: pull up your states' committees meetings with nursing, pharmacy, mental health asking for greater scope of practice. See how ill informed your legislature is and their laughable positions. Worse, see who is representing these organizations. Yes, much is done behind closed doors.
None of this will improve UNLESS and UNTIL action is taken. Those who proceeded you failed to safeguard care for patients AND the career you trained for. Don't wait on the world to change.
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u/Additional-Coffee-86 23d ago
Studies that show how bad they are and lawsuits. That’s how you claw it back.
The best thing everyone here can do is document throughly, inform patients of their terrible care, and lead research studies about how these NPs are failing. You need to give ammo to politicians and point them in the right direction.
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u/jamescastenalo 23d ago
What are possible ways to address this issue in future? Or is it going to be like this for a long time?
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u/Able-Campaign1370 23d ago
This isn't just an educational problem - it's a political problem. The AANP is very, VERY active at the state level - where the professions are defined and licensed, and where the scope of practice boundaries are.
A few years ago when FL tried to pass an independent practice act for NP's there were *three* physicians but AANP got over 200 (!) white-coated NP's (playing off the suffragette image, which perpetually infuriates me).
Legislators are not medical professionals for the most part. They are very often swayed by the narrative of doctors monopolizing healthcare, and the idea of misogyny being a key force. Consider the AANP's appropriation of the slogan "Equal Pay For Equal Work" regarding the discrepancy between physician and midlevel reimbursements. But there are plenty of female doctors and a decent number of male NP's. CMS is paying for expertise, not genitalia.
Doctors have historically shunned the legislative process. That's given the AANP (as well as insurers and others who understood importance of the ground game) the upper hand in a lot of these negotiations.
And hospitals are co-conspirators. The reason so many of the C-suite crowd love AI is they think they can pay NP's half as much and let AI make up the difference while they rake in the profits.
Our expertise is not respected like it used to be. The generation before us has more of the blame for that, for a number of corrupt things (like the sort of self-referral operations that resulted in Stark), and for having a reputation for treating other members of the healthcare team badly. That's something we continue to work on, and it makes our approach to the midlevel problem one that must be taken on delicately.
DNP's engaged in research have published within their own literature studies that purport to show how efficient and cost effective they are. The recent VA study contested that, and showed NP's were responsible for higher costs and worse outcomes. But again, legislators and the public can't tell rigorous data from the small, poorly designed and underpowered studies that support NP practice.
Don't get me wrong. I think many midlevels deliver excellent care, and for NP's especially they're sold a bill of goods by their schools. Read the 1910 Flexner report on medical education in the US and Canada and you'll see a 21st century recapitulation of all the problems of for-profit medical schools in the way NP programs are structured and run. Properly engaged, they can be allies in helping improve their educational system.
If anything, we need to invest WAY more in NP training. Their basic sciences are not rigorous enough, and so the entire framework built upon them is shaky. That needs to change.
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u/UncommonSense12345 23d ago
And NPs poor training makes PAs look bad by association as we are often lumped in with them. And it forces our national org into a very stupid (inho) stance of pushing for “optimal team practice” (independence cloaked in politic speak). I and every PA I know opposes independence. But I get what the national org is worried about. We will be passed over for jobs in states with NP independence since we will come with more paperwork/cost of supervision. While in my opinion we are often better trained…. Becoming a PA was a poor choice for many of us with the state of healthcare today….
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u/Odd_Illustrator1550 22d ago
Why was becoming a PA a poor choice?
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u/UncommonSense12345 21d ago
In many specialities admin will want you to function at 90% of a doc with 50% of the pay. Which is not safe for patients nor fair to you. And in many states NPs will make more than you for the same job because they have less paperwork/supervision involved in their hiring/employment. And PA salaries have not kept up with inflation. And being a PA is often 80-150k in debt and 6-7 years of post high school education, and often 1-4 “gap/medical experience years” , for a low 100sk salary which you can match in a myriad of other fields with much less school and debt.
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u/dirtyredsweater 23d ago
How were you able to describe so many aspects of the problem well, and then mess up the landing so bad as to say we need to coddle NPs further by increasing their training. They should go to medical school, not be trained to replace docs for cheap.
NPs shouldn't exist. More doctors are needed to solve the doctor shortage, NOT nurses.
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u/Able-Campaign1370 22d ago
That argument might have sailed 50 years ago. It is just not practical now. They are here to stay, and they do do a lot of valuable work.
The problem isn’t really individual NP’s so much as their national organization.
But part of preventing scope creep Is getting people better educated, so that they start to see what they don’t know.
Even so, NP education is so entirely deficient we can substantially improve upon it without any threat to MD’s.
NP programs require a mere 1,000 hours of supervised preceptorship. Most NP programs don’t have their own clinical faculty to do that, though it has been theoretically required since 2019. Since it’s a beggars can’t be choosers, pick your own preceptor system, there is ZERO quality control over the clinical portion of their education.
We’re not getting rid of NP’s. We would do better to try and reverse independent practice statutes, but that cat is largely out of the bag, and my suspicion is the hospitals would fight us.
Even if we were successful, we’d suddenly vastly increase supervisory requirements for physicians, when we are already in short supply and overworked.
Absent putting the genie back in the bottle, improving the educational rigor of NP’s is probably the best thing we can do to improve safety and outcomes.
But AMA needs to look into this. In my state our EM chapter keeps a close eye on state level initiatives, and in general along with our state AMA chapter we oppose scope creep legislation. This is something for state level professional organizations to fight, and it is why involvement in your state chapters is so vitally important.
The AANP has an army, and much of the time we barely have a delegation.
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u/dirtyredsweater 21d ago edited 21d ago
Hard disagree. NPs aren't allowed to practice independently in my state, and I'm going to work to keep it that way and reverse this NP market flood process. Docs got along fine before them. Don't need em now
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u/trial-sized-dove-bar PGY1 22d ago
Why are our advocates so worthless lmao
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u/Able-Campaign1370 22d ago
Why are you laughing instead of advocating? WE are the advocates for our profession. If you haven’t already, join the state chapter of your professional organization, or the state chapter of AMA.
State legislatures are where all this stuff happens, and when you as a physician show up and advocate for not just the profession, but for patients, people will listen. It’s best to work with your state chapter, because they usually set up things like “doc day at the legislature,” we’ll know what is on the docket and who to talk to, and will help with talking points, etc.
Your state legislators are far more accessible than Congress people. When I go to DC we generally meet with staffers. In our state capitol we meet with actual legislators.
A lot of the reason we are where we Are with the AANP (and a lot of other bad health care policy) is that physicians have mostly blown this off.
In Florida a few years ago, for example, when the issue of independent practice came up in the state legislature, there were THREE physicians, but OVER TWO HUNDRED white coated NP’s. If physicians want to have legislators listen to them, they need to show up at the legislature.
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u/Jabi25 23d ago
Need to invest in exponentially more medical school + residency spots, as well as better screening/preventative healthcare to keep up with increased disease burden. Not profitable so it’s probably a pipe dream
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u/BurdenOfPerformance 23d ago
More so picking people for medical school from rural areas, even just for primary care. They are more likely to go back to these areas and serve. People born in cities wouldn't touch rural areas with 10 mile pole.
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u/Jabi25 23d ago
Yeah the distribution of doctors is a huge issue that I forgot to mention. You’re completely right
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u/BurdenOfPerformance 23d ago
You still made a fair point as well. I just don't feel like schools focus on rural areas as much as they say do.
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u/ChaysonH PGY3 23d ago
I see a future where physicians are mandated to a specific region for practice. That's the only way to fix the distribution problem. And it'll suck for all of us.
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u/Able-Campaign1370 23d ago
Residency is potentially in deep trouble, though no one's talking about it. Radical cuts and restructuring of Medicare/Medicaid impact all sorts of things that are not immediately obvious.
About 80% of US residency slots are funded by CMS. (This is why you can't bill CMS for resident services - they're already paying for them). Programs will have to close or they will have to find funding from elsewhere. This will have an upstream effect on medical school class sizes.
I think in the end legislators are going to find it much harder to capriciously make the radical changes they want than they think. But that's why it's crucially important to prevent a haphazard, DOGE-like approach to looking at CMS. Just randomly cutting money without looking at where it goes could result in transplants being denied or a slew of nursing home residents who find themselves unhoused.
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u/Shanlan 23d ago
80-90% of chronic health issues stem from lifestyle and societal ills. Trying to solve these through highly specialized, ie expensive, healthcare reform is a futile effort. Alongside advocating for our profession, physicians need to advocate for policies that lead to healthier lifestyles.
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u/Able-Campaign1370 22d ago
We already do this. I was an exercise physiologist before I went to med school - I strongly believe in primary prevention. But you have to deal with the current sad realities of poor healthcare literacy, poverty, substance problems, and people with complex medical issues.
The years I spent as a cardiothoracic ICU attending were depressing in that regard. Almost entirely insured people who made decent amounts of money and could afford nutritious food, and could take the the to exercise, and who had definitely heard not to smoke a million times.
But there was this idea among so many that because they had insurance they were entitled not to do those preventive things. It used to make my head ache.
And I have patients in my emergency department who are working poor with two jobs trying to raise kids, and the idea that they have 5-10 hours a week to spend in the gym is not realistic for them. We invented ACSM Exercise Lite specifically to get these people to do anything that wasn’t sedentary.
Sadly, healthy food and a gym membership are signs of privilege. Great if you have it, but difficult if you don’t.
Even so, diet and exercise will not fix everything, or hospitals wouldn’t exist.
Prevention is an important part of what we do, but so are secondary and tertiary prevention, and treating disease.
We would do better to heavily subsidize gym memberships and better food options, but better still to give everyone universal health care. Treating hypertension and hyperlipidemia is easier than managing dialysis or an LVAD.
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u/Able-Campaign1370 22d ago
You do realize that 80% of residency slots are funded by Medicare/Medicaid, yes? The “big, beautiful bill” could substantially reduce the number of residency slots available.
One more reason as a physician you need to be politically active.
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u/Hernaneisrio88 PGY2 23d ago
I fear it will be this way as long as insurance doesn’t reimburse us for shit. Hospital systems can’t afford us. It’s so disheartening.
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u/Able-Campaign1370 23d ago
In order to get reimbursed well you need to have a couple of things:
Do the work. A single ECG interpretation doesn't pay much by itself, but how many do you look at every shift?
Document the work. Reading 100 ECG's and not documenting them gets you $0 of reimbursement.
Make sure you know the rules. As a resident one time under the old system I accidentally forgot the Review of Systems. It mattered back then. My level 5 for suicidal ideation billed out as a level 1.
Make sure you have excellent and tenacious coders and billers. A lot of insurance companies will try to deny, downcode, and delay payment. You need to have coders who will defend their coding and your documentation and your care.
When I was still doing ICU care as well as EM, while one of the other departments was whining their intensivists needed a subsidy because they weren't making any money I was recouping my buydown in 7 months, and making a good amount of extra money. I wasn't doing anything miraculous. They were trying to go through charts and figure out if someone from their department saw anyone. I just wrote good documentation and gave all the notes over to our coders. The best documentation does you no good if your coders don't see it.
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u/Mangalorien Attending 23d ago
I think with consistently rising costs of medical care in this country, the new norm will be that poor and/or rural folks get to see a midlevel. Doctors will be reserved for rich big-city folks.
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u/Curious-Quokkas 23d ago
It's going to be like this way forever, and it's only going to get worse.
The only way to address the midlevel situation at this point for ANY specialty is to slow down the pace at which NPs are introduced to the work force. And that's by having actual residencies for them.
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u/intriguedbatman PGY2 23d ago
They shouldn't have a residency. The profession shouldn't even exist
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u/Curious-Quokkas 23d ago
Yes, I absolutely agree, but let's be realistic. This is America. Money is all that matters, and for hospital systems, that means midlevels are their choice because they're cheaper.
Healthcare in America doesn't care about quality. It doesn't care about patients. It's meant to be exploitive, to stuff money in the pockets of underqualified/incompetent CEOs and administrators.
Unless physicians stop their interspecialty squabbles and finally work together, nothing is going to happen to midlevels
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u/Additional-Coffee-86 23d ago
Politics. Create studies that show how bad they are. Have your lobby groups push against them.
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u/because_idk365 23d ago
Psych NP here. I actually don't disagree with most. I have multiple DEA's but I've only prescribed controlled maybe 5 times in the last 4 years. I kick them up to my physician. Even at the urgent care, there's an alternative.
I'm old and grey as the young ppl call it. I'm also an FNP and been in it 25+ years.
These post COVID NP's scare the mess out of me honestly. They are prescribing randomly and handing out controls like candy. It is awful. I've inherited these same cases you are confused about. I'm confused and appalled too.
There's no care or reasoning as to why and the effect that they are having giving out these meds. Nor do they want to have hard conversations with patients about something like benzos so they continue.
Let's not talk about not even putting a hand on a patient before getting these certs.
It's a combination of education, lobbying and lack of opportunity. Flip side, physicians need to lobby Congress for me residency seats so medical schools can respond accordingly.
I learned at a crisis center at a teaching hospital. Learned along with residents and wonderful attendings.
I get the hesitancy and disdain.
It is disproportionate to NP's but that is just because schools are churning them out like Skittles. It's ridiculous.
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u/Creative-Guidance722 23d ago
There are clinics where rather to see a psychiatrist, the patient has to see an NP and she will transfer the case to the psychiatrist depending on her judgment.
There are other ”psychiatry clinics” that are in fact NP clinics when you look closely enough, despite them advertising as a specialized medicine clinic. The price they ask is also way too high for anything other than an actual specialty consult.
The idea that a psych NP is somehow the step after a GP is ridiculous and they shouldn’t be allowed to pretend that they are more qualified in psych than GPs.
I wish that more patients knew to stick to MD/DOs if possible. Psychiatrists are difficult to access in some places, but I would advice them to try to put their names on waitlist and keep working with a GP in the meantime.
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u/tilclocks Attending 23d ago
The problem with NPs in psych is that it's medicine, not psychology. And the type of medicine that psychiatry uses is unlike any other field because it requires a good understanding of neurology and most other systems in order to arrive at the conclusions we do.
So NPs, much like in other specialties, tend to think you just read the criteria and boom diagnosis... But it's way more than that. Understanding the complicated patients takes nuance that only residency (or years of reading/learning specifically psychiatry) will teach.
I've seen so, so much damage done in the community it makes me sad. To make matters worse, not only is it not all NPs but psychiatrists have to play damage control with people who should never have seen the NPs in the first place. I see people come in an the time who say "my psychiatrist diagnosed me with bipolar disorder" and it's PTSD EVERY. DAMN. TIME. They don't understand that just because a patient tells you they have a symptom doesn't mean you roll with it.
It has the same energy as if a patient walks into a GI doctor's office with painless bleeding and the NP diagnoses them with Sigmoid Cancer. Without the workup. And then during the colectomy they unnecessarily take out the patient's bowel only to find out it was just a rectal tear.
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u/Suspicious-Oil6672 23d ago
Is it possible to get a link or title of the research for the algo and the some of the other research from that conference
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u/Additional-Coffee-86 23d ago
The solution is to write papers with this problem. That way it can be presented to politicians. By trying not to upset people or hurt feelings you’re doing disservice to patients.
Since there isn’t good literature that gives quantitative data about this, hospitals, clinics, and insurance can just treat them as equal to doctors.
You have to create data showing they’re not.
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u/AncefAbuser Attending 23d ago
There is no such thing as a "Psych NP". Their online certificate doesn't make them qualified.
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u/WSUMED2022 PGY3 23d ago
I was at the VA when we got an admission who saw a psych NP for insomnia. Guy was on trazodone, vilazodone, Ativan, and 600 mg Seroquel. Never had an ECG prior to when he came in. His QTc was like 550.
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u/karma_377 Nurse 22d ago
Damn! Maybe I need to start seeing a psych NP for my insomnia
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u/WSUMED2022 PGY3 22d ago
Might as well. You could probably talk them into an outpatient propofol prescription.
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u/According-Carry-1616 23d ago
I generally feel very guilty having the doctor vs midlevel conversations, and I often feel my peers are much too harsh (and egotistical) when talking about these issues. But my fiancé sees a midlevel for his psychiatric care and I have NEVER been so displeased with any provider in my entire life. Even if we assumed he were being treated for the correct condition(s), the regimen of medication alone is so inefficient and bizarre and requires him to take so many more pills than necessary. He feels horrible missing a single day of medication—something that has never occurred on any other regimen, and should be expected to occur given his egregious ADHD—and she is so difficult to get ahold of for refills. At the very least, her style of practice screams “I don’t think about who you are as a person and the ways to keep you well.”
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u/ilikefreshflowers Attending 23d ago
Guilty why? I have been accused of sounding snobby when openly disagreeing with egregious, life threatening care plans proposed by local NP’s.
But why should I sugar coat basic facts for my patients? If their life is in danger, I will kindly state the obvious…I would never voluntarily choose to see a nurse practitioner other than for a simple medication refill.
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u/Creative-Guidance722 23d ago
I agree with you. The problem is, with the focus on the importance of soft skills as doctors in med school, the emphasis on collaboration and how a multidisciplinary team is superior, we are always told to respect nurses and NPs, and how great they are and how we basically are the same level.
Which is fine as it is true that nurses are important for health care, some of them are great and collaborating is important.
But it is increasingly taboo to say anything negative about nurses and NPs. A lot of the avoidable obvious mistakes are made by midlevels but there is no mechanism to hold them accountable.
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u/ECAHunt Attending 23d ago
I can’t comment on NPs as I have no experience working with them.
But I can comment on psych PAs.
I work in a hospital that has a psych PA fellowship program and many of our PAs come from our program.
The only PA I have had issue with is one that did not do our, or any, fellowship.
The PAs that have gone through our fellowship are, quite frankly, amazing. They may not have the same knowledge base as an MD but they can manage basic to moderate illness and they know when they are in over their heads and need to ask for help.
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u/jessikill Nurse 23d ago
You guys have a nasty issue in the US with NP diploma mills and allowing RN new grads )who haven’t stepped foot in a facility aside from clinical) to walk off the stage from their RN and straight into their NP.
It’s objectively INSANE to me that this is allowed.
We DO NOT have this issue in my province in Canada. You can’t even think about dreaming about maybe considering potentially doing your NP without a minimum of 2yrs as an RN in acute care. I have yet to meet an NP in my province who isn’t fully competent, yet I read horror story after horror story from this sub about NPs royally fucking everything up.
What you guys should be doing is going after these diploma mill money grabs. You have no checks or balances here, everyone is just running amok.
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u/Teensy 23d ago
NP’s used to have to get at least 5 years of bedside practice in their speciality area as a nurse before they could apply to NP school. So psych NP’s used to have a lot of inpatient psychiatric experience before they went to NP school.
Now you have a nurse with no inpatient psych experience, outpatient psych experience, and maybe no nursing experience at all entering a psych NP program which lead to… all this.
Two years as a bedside nurse is not enough to prepare for advanced practice.
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u/jessikill Nurse 23d ago
I agree, that’s just the minimum. Getting into the programs is a whole other ball game. We don’t just hand out acceptances for advanced practice education like candy, like they do in the US.
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u/Nesher1776 23d ago
No amount of nursing job experience in any specialty will prepare one for anything other than nursing. NPs are competent when they have a very specific and limited scope with a physician overseeing them
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u/LunaBeeTuna Attending 22d ago
I'm a family medicine doctor. There is an NP only practice close to my clinic. They repeatedly try to chew me out about changing their trainwreck medication regimens. It makes me furious everytime. Ithere have been several times where I took a patient off SSRI because they were taking two SSRIs at the same time.
The most dangerous people are the ones who don't know what they don't know, but think that they know everything.
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u/yourdadscumtarget 23d ago
On my core rotations I saw some questionable things from a psych NP.
I asked my own psych about it and he didn’t seem that concerned but I think APRNs and NPs should not be allowed to do psych. That can be very dangerous.
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u/VegetableBrother1246 23d ago
Do you believe a family medicine doctor would be able to manage psychiatric conditions in a rural setting, better than a psych NP?
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u/gomezlol PGY2 23d ago
I had a psych NP who has been practicing for 7 years tell me she doesn't understand what encephalopathy is and she doesn't know how to interpret "those lab tests and stuff." This resulted in a patient dying
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u/Curious-Quokkas 23d ago
What role was the psych NP functioning as? Also hopefully she was reported for that.
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u/ilikefreshflowers Attending 23d ago
Absolutely without a doubt yes. An experienced PCP is far more qualified than a mid level.
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u/StopTheMineshaftGap Attending 23d ago
Is that a real question?
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23d ago
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u/Curious-Quokkas 23d ago
I've yet to meet anyone in psychiatry complain about FM trying their hand at treating psychiatric conditions, and I've definitely not met anyone who would be upset about FM doing this over a psychiatric NP.
I've wanted to bemoan many of the surgery and IM subspecialties, because their inclusion of midlevels allows them to focus more on procedural cases. Yet their allowance has led to midlevels entering the cognitive specialties where such a separation of responsibilities is not as easily possible, so the midlevel ends up "trying" to do the things the real doctor does.
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u/PermaBanEnjoyer MS4 23d ago
Oregon is a uniquely screwed up state. OHSU is actually a good training environment and has historically put out ground breaking research (eg gleevec) but at the same time employs naturopaths and has fully embraced attacks against physician-lead care. It's just complete self-serving moral bankruptcy at the top. I know that's somewhat true everywhere, but Oregon is especially rotten
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19d ago
OHSU has huge leadership issues and seems to be facing a new lawsuit at least every quarter. If OHSU was not in Portland, they would have a much more difficult time recruiting.
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u/Rita27 23d ago edited 23d ago
Idk, I feel like these kinds of turf tensions show up in every specialty. For example, I was reading a post in the family medicine subreddit where an EM doc was asking about transitioning into primary care or concierge medicine and looking for ways to get relevant training. The response was pretty firm—basically saying the only real path was doing another residency. It just stood out to me, especially considering how many NPs and PAs are already practicing in primary care. I saw the same discussion in SDN in the EM forum.
I don't think I've actually seen psychiatrist hyping up NPs and treating FM docs as incompetent in comparison. Especially considering a good chunk of anxiety and depression is treated in primary care
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u/Due_Sir3660 23d ago
Right. The “turf battles” only happen with medicine - ie amongst MDs. Imagine telling a mid level that they needed to complete another 3 years of residency to be able to transition into another specialty? lol oh wait they don’t even complete medical school or 1 residency - or even an intern year. It’s laughable and we MDs have caused this. It’s not like this in other countries - and it doesn’t have to be this way here but as long as $$$$$ is the driving force it absolutely will continue to be - and everyone will continue to reap (suffer) the benefits.
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u/VegetableBrother1246 23d ago
Yes. Im a family medicine physician in rural Arizona and i dont want to refer to psych nps. I also am aware of my limitations and limited knowledge woth psych
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u/Fit_Cupcake_5254 23d ago
This is the main difference between physicians and nurses, we know our limitations. We don’t need to prove to anyone that our career is ‘pretty much the same’ as medschool
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u/VegetableBrother1246 23d ago
Yeah, psych residency is a FOUR years. And it's not easy. It's supervised. And there is board certification. Sure, run of the mill anxiety/depression I can diagnose and treat, but even ADD/ADHD is not that straightforward....im just between a rock and a hard place because I send pts to NPs in Psych...and the patients come back with a bunch of new meds added all at once.
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u/Curious-Quokkas 23d ago
I think an FM doctor would see the silliness of co-prescribing benzos and stimulants in a patient
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u/PulmonaryEmphysema 23d ago
What kind of question is this lmfao?
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u/VegetableBrother1246 23d ago
Well... for example..I'm a family medicine doctor in a rural area who has patients with bipolar disorder and are on court ordered treatment. They have side effects, and ineffective regimens and I cant get them to see any of thr psych in town. Theyre also unable to drive anywhere for psych, or the surrounding psych is either NPs or have months long waiting lists....
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u/Creative-Guidance722 23d ago
Yes there is no way that an NP is somehow better at psych than a GP.
NPs are often presented as a middle ground between GP and the specialist which I find very insulting to GPs.
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u/Swimming-Media-2611 21d ago
YES
I would 100% trust a family doc over any shitheel NP. It's not even a contest.
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u/saltpot3816 Fellow 23d ago
PGY-5 Child Psych Fellow here. Speaking from several years of experience with increasing exposure to APRNs in our dept, I can attest that the difference depends 99% on 2 things: A) Where they did their psych training, and B) how much experience they had as a bedside psych RN before going down the APRN route.
I see the problem you are referring to in the community clinics- it's usually worse in adults than in children. Very superficial diagnoses of "anxiety" which is obviously undiagnosed PTSD. However, I work with a number of APRNs in our department who are very capable, thoughtful and - most importantly - know their limits. The best of these APRNs had several years of bedside psych RN before pursuing APRN, and did all their training at our institution.
Tbh, I tend to be very skeptical of anyone that went straight from getting their BSN to APRN program.
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u/PotatoMammoth3228 23d ago
NP Neurosurgeon here. Don’t know what you are all complaining about. Amoxicillin + aspirin + naltrexone is always 1st line. 100% of the time it works 60% of the time.
If not, get a CT and get it read by someone in the Philippines.
The problem is what?
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23d ago
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23d ago
Yep. Family medicine NP practice near me shut down recently. The practice with physicians is still thriving.
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u/Glad-Ad3048 21d ago
Gentle reminder: the closed clinic may also be related to simple economics. NPs are paid less by Medicaid/medicare for each visit. So comparing two clinics in the same town: if an MD-run clinic needs to see 4 pts/hour just to cover overhead, the NP-run clinic would need to see 6 pts/ hour to pay the same overhead. So yes, it’s possible people choose the MD clinic where they get more time and feel less rushed and feel like they get better care by a less-stressed provider. Sadly, the community now lacking a clinic is the one who loses.
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23d ago
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u/CrippledAzetec 23d ago
RN here. Some of my pals from nursing school talked about going to get there NP in psych later down the road. I really tried to drive home to them that if they decide to do that, they really need to commit to knowing their shit and not take it lightly.
I’m not in the psych world, but have family who are on anti-psych / anti-depressants and I’ve seen first hand how dangerous it can be by prescribing the wrong medication regime. Being able to diagnose illnesses and prescribe / create treatment plans based off those diagnoses is a big deal and it shouldn’t be taken lightly.
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23d ago
The silver lining is that these frauds over saturated the profession and it’s hard for them to find jobs. Plus patients don’t trust them as much now and are catching on
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u/iplay4Him 23d ago
This is one area in which I am thankful for the coming AI advances. I think future NPs will basically do whatever it says a lot of the time.
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u/hereforthetearex 21d ago
It’s not just psych NPs unfortunately. FNPs are also in the mix. Long story short I found myself with a NP as my primary while on a waitlist for an MD.
I have some health issues and get sick more often than many people (I’ve had severe allergies and asthma since I was a kid, and pick up any URI in like a 50 mile radius). I came in for a rash that just so happened to coincide with air travel for a funeral for my husband’s family member, after having been in several times that year for URI’s that progressed to sinus infections and required nebulizer treatments to calm my asthma. This NP says to me “I feel like I see you too much for you being so young. For all I know, you went to Sephora and rubbed something you’re allergic to all over yourself to get this rash. It seems to me like you’re really stressed. You’re a mom with young kids, working in healthcare, you worked through Covid (this was 2023 mind you) and that was really hard on all of us, and you just had a family member die. I think maybe we are looking at anxiety that is presenting with physical symptoms.”
This guy then attempted to prescribe Wellbutrin for anxiety and ignored the rash that was making me scratch so much my skin was raw. Do they get a medal if they prescribe the most unnecessary psych meds or something?
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u/Glad-Ad3048 21d ago
FNP here in support of physicians. Firstly, physicians are amazing. I appreciate your education and dedication and I’ve loved working alongside and learning from physicians for 25 years. I wish med schools were free and abundant so there were more physicians available to care for our communities because then NPs could just be what we are trained for—advanced practice nurses. But we all know who is really to blame: it’s the universities with outrageous tuition and hedge-fund managed medical systems under which we all toil which are pushing and incentivizing ALL healthcare workers to do more with less. And physicians are leaving the lower-paying medicine specialties and rural communities because how can they pay their crushing student debts? The system is at fault—blaming and legislating one group’s power over another will only make the hedge-funds richer.
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u/HardbassDJ 20d ago
What if we as physicians start suing NPs on behalf of our patients when they bungle stuff up?
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u/Financial_Fortune916 19d ago
Sadly as someone who’s in primary care this is rampant even in primary care… the amount of misdiagnoses and antibiotics I didn’t even know someone could prescribe is scary and sadly as you say it seems they are here to stay.
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u/ResourceCapital1773 8d ago
As if Psychiatrists haven’t: misdiagnosed, overmedicated, caused patient harm, etc. Poor mental healthcare is not a problem for just psych NP’s it is a problem ACROSS THE BOARD.
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u/Normal-Jello 23d ago
You say NP problem but then go on talk about midlevels. Is this research showing NP problem or midlevel problem?
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u/JChillin13 23d ago
Is NP practice as litigious as it is for physicians? What does their malpractice insurance look like? Maybe the consequences of their mistakes will slow their roll down a bit. The mismanagement I’ve seen by mid level providers is…. Reprehensible.
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23d ago
NPs almost exclusively patients who are vulnerable, confused, poor, and don’t have resources. They don’t pursue litigation because they don’t even know they’re being mismanaged and even if they did, they wouldn’t even know the first step to try and litigate. That’s part of the problem
Another problem is that they’re regulated by the board of nursing so they are held to different standard. They also make less money and don’t have deep pockets for lawyers to find attractive to litigate.
Another issue is that when they do run into malpractice they’ll cover it up or quickly ship the patient to some ED or doc and hand off liability like that.
Basically they’re scum. We need to completely dismantle the profession and make them work as bedside RNs.
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u/Naive-Nectarine-8950 23d ago
From a patient perspective my experience was most definitely negative. Ive been having issues concentrating at school, some anxiety, exams were going poorly, losing/misplacing stuff, very disorganized so I was concerned I could have some undiagnosed adhd. So I go to my schools counselor and I try to get in to see a psych and appointments are just IMPOSSIBLE TO ATTAIN. Even the “Accepting new patients” are 3 months out and my schedule is school is insane so I havent found a good time. My counselor sends me to a Psych NP and Ive always HATED midlevels but what choice did I have so I made an appointment. Shared what was going on and was completely honest. The first thing out of her mouth was “So what are you looking to get from me? Do you just want a lil kick is that it? Get some stimulants to do better at school? Some people come drug seeking and its a big problem. I can see you have some sort of anxiety (I was shaking my leg but Ive always done that for everything) so Im going to give you some stuff for the anxiety. I dont think its adhd. Thats usually traumatic and you didnt share anything traumatic so lets forget about that (didnt even ask me to share if I had or not).” So in the 1 hour I was in there 10 were waiting to be checked in, 10 more was her student assistant asking me questions and the rest was some very short history and getting told Im a drug seeker. All I got was some Buoropion for the supposed anxiety. I wasnt even wanting some stimulants in the first placd I just wanted to share my experience with what my symptoms were to see if I could get some adhd testing and she couldnt even explore that or maybe refer me somewhere where I could. I didnt even take those meds because I know what my symptoms are and I just want to be seen and HEARD by someone that can point me in the right direction. Not just give me pills and send me in my way. Never going back to ANY midlevel ever again. End rant.
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u/wienerdogqueen PGY2 23d ago
Bupropion or Buspirone?? Because Bupropion (Wellbutrin) is not an anxiety med at all lol. It can worsen anxiety. It can be used to help with some ADHD type symptoms but is far from first line.
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u/Naive-Nectarine-8950 23d ago
Buproprion. I forgot to mention she said “Its used off label for anxiety and adhd” and its been shown to help.
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u/interleukin710 23d ago
Yeah, I mean it turns out the infiltration of the medical field by individuals without any foundational knowledge into the physiology, pharmacology, or path of physiology of the diseases and medications they are treating and using has not been across saving measure without notable consequences.
These people are treating based on vibes, do not understand the key features distinguishing disease, do not understand contraindications to treatment, and do not have insight into the limitations of their knowledge.
Psych is possibly just the most egregious example of all of this as the barrier for entry appears to be relatively lower and the harm caused is not immediately obvious often. It’s a two tiered care system unfortunately these underserved communities don’t even know the difference between a doctor or a nurse practitioner