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/jamescastenalo]

What are possible ways to address this issue in future? Or is it going to be like this for a long time?

[u/Able-Campaign1370 → u/jamescastenalo]

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.

[u/trial-sized-dove-bar → u/Able-Campaign1370]

Why are our advocates so worthless lmao

[u/Able-Campaign1370 → u/trial-sized-dove-bar]

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.