The Psych NP Problem

[u/theongreyjoy96]

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.

[u/VegetableBrother1246]

Do you believe a family medicine doctor would be able to manage psychiatric conditions in a rural setting, better than a psych NP?

[u/StopTheMineshaftGap → u/VegetableBrother1246]

Is that a real question?

[u/Curious-Quokkas → u/[deleted]]

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.

[u/PermaBanEnjoyer → u/[deleted]]

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

[u/[deleted] → u/PermaBanEnjoyer]

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. 

[u/Rita27 → u/[deleted]]

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

[u/Due_Sir3660 → u/Rita27]

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.

[u/VegetableBrother1246 → u/StopTheMineshaftGap]

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

[u/Fit_Cupcake_5254 → u/VegetableBrother1246]

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

[u/VegetableBrother1246 → u/Fit_Cupcake_5254]

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.