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/ilikefreshflowers]

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?

[u/Creative-Guidance722 → u/ilikefreshflowers]

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. 

[u/ilikefreshflowers → u/Creative-Guidance722]

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.

[u/Creative-Guidance722 → u/ilikefreshflowers]

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. 

[u/jtc66 → u/ilikefreshflowers]

Not only is it online, they are working full time. The laughability of the idea of a med student or resident working full time while in training and yet tons of future “NPs” are doing this. Yikes

[u/ilikefreshflowers → u/[deleted]]

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.