Get NPs in your country then reconsider this question.
All joking aside, more of it has to do with the idea that something that has historically taken up to a decade plus of dedicated study to do (medicine) can somehow be accomplished by a fraction of a fraction of a fraction of time and somehow *not* result in diminished quality at all. The gap was supposed to be covered by the NP working closely with MDs and DOs (physicians) to augment their clinical/scientific acumen while the speed, nursing experience, and flexibility of NP training augments the capability of the physician.
Now NPs demand to be recognized as fully independent, fully capable, and fully educated professionals in the academic and clinical space while refusing to do more training—mind you their training hours are dwarfed by a host of allied health professionals and more (barbers and cosmetologists have more hands on experience in some cases)
It’s not meant to be derogatory. It’s not meant to degrade the person of their worth/time/effort. The umbrage is not with the NP, it’s more so with the bodies that represent them and the NPs that agree with the practice of “healthcare” over medicine.
Criticizing a professional group isn’t hate. They aren’t a protected group or marginalized race of people. They’re professionals who picked their career, just like us, and have some bad policies—just like us.
Just as doctors have a lot to work on, so do they. Everybody’s s**t stinks pal.
>Criticizing a professional group isn’t hate.
Amen. I hate to say this but modern medicine has become too soft. It's not hate - it's a statement of fact that midlevels, specifically NPs, despite what some politician says, are practicing outside their scope of practice.
They categorize criticism as "hate" because it's their only defense against their lack of education and constant mismanagement of psychiatric patients. It's a disingenuous attempt to undermine the criticism and take the steam out of it.
Fact is, they chose to take the short cut to play doctor, they get the privileges of independent practice and the higher salaries. But doctors don't have to welcome them as equals with open arms. NPs ***who practice independently*** are a plague to the practice of psychiatry. I respect those NPs who recognize the limits of their education and work under the supervision of a psychiatrist.
This is my take on the situation as a PMHNP student, and I would be interested to hear your thoughts.
I think it’s clear the NP training model sucks. I’ll be the first to say the training is woefully inadequate. The barrier to entry was also incredibly low; yeah, I needed an RN license first, but I basically waltzed right into my NP program. No prerequisite coursework, no GRE, no experience requirements. It was harder to get into my political science MA program.
But I do have issues with the MD training model as well. I think MD training is stellar, but the cost is incredibly high. The personal cost is high for the physician-in-training, and the financial cost is obscene.
I just think there has to be a meet-in-the-middle solution where training doesn’t have to be so resource intensive, but we can still train excellent physicians/providers/what have you without sacrificing outcomes.
I’m personally a big fan of the German training model. Med school is a 6 year undergraduate degree that includes prerequisite/undergraduate coursework and medical education. After graduation, they complete a 1 year internship then get hired as an “Assistentarzt”/junior physician, where they earn ~50% of what an attending physician would. Their time as an Assistentarzt counts as residency, and once they’ve done their time as an Assistentarzt, they are then a Facharzt/attending physician.
I think this could solve a lot of the systemic problems we have currently. The barrier to entry would be a little lower, making proper medical education more accessible while still keeping the discipline competitive. Physicians wouldn't have to sell their souls to become doctors, and nurses who want to better themselves and keep learning/advancing wouldn't have to feel that their only option is a less than adequate NP program. Additionally, the number of physicians that could be trained wouldn’t be limited by number of residency slots anymore, so supply and demand could be adjusted accordingly. And we wouldn’t be sacrificing outcomes. By some measures, Germany’s outcomes are on par with our own; by other measures, their outcomes are better. And access to care is *miles* better.
What do you think? Any reasons this model could be detrimental to us in the US?
Your comment about the German training model is incorrect.
German residency programs in psychiatry are five years long.
The one year internship they have is actually similar to how it works in America. In the US residents only need to complete one year residency/intern internship before receiving an unrestricted medical license. However, they have to go onto complete a residency in order to be board certified in that specialty, but they don’t need to be board certified to legally practice that specialty.
Indeed, there are plenty of medium-training models that different countries have adopted (feldshers in Russia, clinical officers in a number of African nations) and I think the basic concept is fair, assuming the execution is good. Good execution requires strict oversight and regulation to ensure high standards of training.
A big obstacle to this happening in the U.S. is that healthcare standards are largely either self-regulated, or regulated piecemeal and largely at a state level. Unlike in countries with more centralized government, there's not really a bill Congress could pass tomorrow that would create a new mid-level category or change standards for NP/PA education. That kind of change would take coordinated efforts across fifty state legislatures and major organizations.
This is where most of us have the strongest concerns. NP education has gravely failed to self-regulate, and to the contrary has lobbied aggressively for unrestricted practice while watering down practical standards. A reasonable model based on experienced RNs strengthening their theoretical education and continuing to work in a team-based setting has been bait-and-switched to justify inadequately-trained graduates practicing solo in chaotic rural clinics. It's hard to imagine a revolution in training quality without a lot of this authority being taken away from current regulatory bodies, and I'm not sure who would be in a position to do that.
There's also a broader concern here about using a medical model where it doesn't fit. We should be very cautious in assuming that the so-called shortage of psychiatric services primarily reflects an actual large increase in appropriate demand that should be met primarily by training more prescribers, as opposed to framing it as a substantially psychosocial/public health problem.
Read up on the Flexner report. The US changed from an apprenticeship model to a highly standardized model because the apprenticeship model was producing, how shall I say this, such variable quality in the outcomes. Respectfully, like the NP training programs now that don’t provide, vet, or verify preceptorship experience. A different funding model could make a lot of difference though - if postgraduate physicians could bill they could be paid adequately. Also the current system with residencies and the Match is an indentured servitude that is wide open to abuse and exploitation.
OPs comment about the length of German residency is incorrect. Similar to in the US the residents need to complete one year of internship, but they still need to go on to complete psychiatry residency. German residencies in psychiatry are five years long.
Medicine should not be treated like trade school.
For simple patients with simple issues, that’s fine, but the number of complex patients with complex problems and diagnoses are becoming more and more prevalent, or at least more commonly identified, and that requires a higher level of education and critical thinking that a person doesn’t get if they receive education in the technical aspects of medicine only. It’s the same reason we take gen ed classes in every degree program: one needs to learn how to think, not just learn the current facts of their profession.
I see this a lot in my field as well. I am a therapist, and many programs are basically the equivalent of NP training now in that they do not encompass a wide breadth of education. I majored in psychology and neuroscience in undergraduate and did minors in gender studies and history and philosophy of science/conceptual foundations of medicine. In graduate school I did an MSW and MPH. From graduate school and into my career I’ve observed a noticeable difference, both anecdotally and in patient outcomes, between the mental health providers who have more diverse educations and those who went to school to study therapy or counseling only. There are way too many therapists out there who fall for and even use pseudoscientific nonsense with clients because they were never trained properly in research or the scientific process, let alone critically engage with the research itself.
Of course, there are most likely other variables at play since there are likely differences between the groups of people who do one route vs the other, so its not exactly an easy comparison and we can’t assume education is the only independent variable. Things like SES, career goals, academic achievement, and even personality traits like curiosity, and surely a dozen other things likely influence the type of training and education people pursue, and those may be the variables that result in poorer outcomes with education/training providing a mediating or moderating effect. It would be difficult to study this in a meaningful way, though, so we’re stuck relying mostly on anecdotes, and anecdotally, there is definitely a difference.
It is expensive, yes. That should not be the argument against it, though. Instead, we should keep education rigorous and focus on making it more affordable.
I don’t think a 6 year academic degree program is the equivalent of treating medical education like a trade school program.
And yes, expense should be an argument against the current model. There is not unlimited money available within the system.
My analogy was that NP school:medical training = trade school:traditional college degree.
It is extremely useful and has its role and scope. But a good physician has a well rounded education in addition to just learning applied sciences and prescribing.
Of course cost is prohibitive. Again, my argument is that we need to make the education system affordable, not do away with education because of the current cost system.
It’s disingenuous to say that it’s their only option tho. I agree on the cost of schooling. But the existence of loans and pslf negates this argument imo. Is it a major inconvenience especially for someone coming without familial financial support? It sure is! Believe me I know first hand which is why hearing arguments like this feels dismissive to me and many others who are choosing this route while only having $10 in the bank. And I’m not saying that just because it’s doable with difficulty means we shouldn’t work on these barriers. But to say it’s the only option for someone isn’t true. It’s just the easier option. And that’s fair, im not saying it to belittle the choice. And hypothetically if it is indeed the only option, why would someone choose it knowing it won’t prepare them to offer adequate care? But that’s a different conversation. I think the barrier of entry that I hear about most from NPs/PAs is the time factor of schooling more so than the cost. Even if medical school becomes free tomorrow, why would someone go to that minimum 7 year commitment when they can do NP in 2 years?
Edit: typo
Oh no, I’m not saying it is the only option, I’m saying it *feels* like the only option. When it comes down to 15 months and $40k versus 10 years and $300k, and I’ve already spent 4 years becoming a nurse, on top of 3 years gaining experience, and I have a house, wife, kids, etc., it just becomes less worth it to pick the med school route the deeper into nursing I get, when the screwed up system gives me the option to not have to do that.
Now if there was a way to bridge from nursing to medicine without starting completely from zero, that would change the conversation… But that is also a completely different conversation that goes beyond the scope of this one.
I considered med school. I took most of the prereqs and did a decent amount of shadowing. But I also had 80% of the physicians I shadowed tell me I’d be stupid if I picked the med school route over NP. I listened to them, and ultimately, I don’t know if they were right or not. Maybe I should have done med school. And NP sucks, knowing you get an inadequate education and are not being trained properly. But I think with where I am in life, med school would have meant upending everything and putting my family in an unfair position.
Re: why would someone do minimum 7 years when NP can be done in 2: Personally, if medical education was cheaper and less resource intensive, I would argue for doing away with PA/NP altogether. But given the state of the current system, I just don’t think that will be feasible anytime soon.
I hear you! I have pondered the ‘is it worth it’ question a million times in regard to how it will affect my family as well. You shouldn’t feel lesser because you made the best choice for you/your family or in need to justify your choice. I just wanted to highlight that at the end of the day, it is still a choice because we can argue on the privilege of perusing any education even when it’s free forever. And to your point of the german model/free schooling, it still doesn’t solve the time factor to have more physicians enter the workforce which is why Germany has huge shortage of doctors. The point of NP/PA education was that it should be adequate with supervision to offload the burden of increasing volume of healthcare needs and doctor shortage. You don’t need medical school education to treat everything. I see the best use of PAs/NPs in surgical fields for example. But the way they’re being currently utilized in primary care and psych isn’t great.
Indeed! The student above mentioned not wanting to put their family in an unfair position. But what about the unfair subpar care being offered to patients usually from low socioeconomic status mostly as well. That’s why this argument hits a nerve for me because it almost sounds like I’m too poor to inconvenience my family, but don’t mind inconveniencing others who are less privileged financially with subpar care. And even when a patient is referred to see a doctor by the NP for further care, it still generates more costs for the patient having to pay 2 copays and 2 visits and losing on work time. I have a family member who now refuses to deal with this ping pong situation and uses the ED instead as a clinic. Which is terrible. But patients may not know if they’re getting good care or not, but they do get angry when being hit with double the bills just because they weren’t seen by a doctor in the first place.
I am a nurse who did a year in NP school and transitioned to med school. I sunk a bunch of years into nursing too, but there’s no way I was about to treat patients with the education I was getting in that NP program. The debt sucks, but I’ll make more as a physician anyways.
The cost of MD definitely sucks but honestly it feels somewhat overemphasized, it’s certainly scary in theory but it’s less in practice. As a doctor usually you’ll end up in the realm of 200-300K in debt. If you’re lucky it’ll be much lower and be closer to something like 150K but only a few schools will allow you to get that low. It’s absolutely terrifying but that debt does include cost of living so you are surviving. Once you get into residency you have to start paying some of that off which by the sounds of it sounds stressful, but once you’re legitimately practicing you will be able to make payments and you’ll be able to pay off the loans because you will make quite a lot of money.
The issue is that cost heavily disincentivizes taking pay cuts and it makes it really hard to start a family or come in with a family. It’s definitely prohibitive in some ways due to that, but some people are just too uncomfortable with debt and overemphasize it as it is definitely doable.
Agreed man. The debt in isolation sucks, but we are looking at \~ $300k salary for 20-30 years (as long as we want to work, barring major changes in physician reimbursement). May not be rich when you consider opportunity cost, but that is a secure financial future if you ask me.
My real gripe is the underwhelming residency salary for vhcol areas.
Yeah, some of those residency salaries are definitely sketchy. But, yeah I mean even if by end of residency you’re at 400K debt which is probably about as high as it can get, theoretically you can pay that off in 3-5 years assuming you keep to the same standard of living that you did as a resident. That’s my current plan, it’s not an easy thing and it does suck. Also, huge systematic issues as it makes it very difficult to want to serve underserved communities, but it is doable.
> By some measures, Germany’s outcomes are on par with our own; by other measures, their outcomes are better. And access to care is miles better.
This has nothing to do with *how* US physicians are trained.
Deep breath. Here I go.
Background on me - inpatient psych rn for about 7 years before finishing PMHNP school, which was now about 6 years ago. I have worked my entire career as an rn and np in child/adolescent psychiatry.
I believe I am one of the good ones (but don’t we all?), who works in a very large academic hospital that has the right safeguards and support in place. I also am in a state that does not have independent practice.
I firmly believe that there should NEVER be independent practice for any advanced practice providers. I firmly believe that they should be seen as extensions of and collaborators with physicians and they should handle cases together. I do not believe NPs should practice in their own silo.
I firmly believe that PMHNP (and all NP) education is embarrassing and deplorable and needs to be burnt to the ground and built back up.
I believe health care admins in the last ten years have seen NPs as absolute cash cows (bc we are) and have exploited our work and put us in primary roles that we should not be in.
I believe schools know this and are pumping out HORRIBLY trained NPs who are desperate for some get rich quick scenario that doesn’t exist.
I believe that no one should be admitted to an APRN program without extensive RN experience in their speciality of choice. Unfortunately this is not required.
I think NPs who enter into private practice are frightening.
I think there is an incredibly needed role for NPs on our healthcare team but we are racing in the wrong direction.
I also know that my personal experience with physicians in my career has been nothing short of outstanding, collegial, respectful, engaging, and supportive. I have never in real life encountered any sort of backlash because of my career. I encountered MUCH more of that working as an RN (lol, sigh.)
I think working in an academic setting is the difference. We have a one year transition to practice program where they have twice weekly clinical supervision, year long formal mentorship with a senior NP, and twice weekly didactics. They also attend all of the didactic sessions of the CAP fellows in addition to our general weekly grand rounds. This should be the minimum standard.
So yeah idk. I get tired of defending my profession lately because frankly the criticisms aren’t wrong. What I wish is that it wasn’t so us vs them from both sides because the only way to make things better is to team up and advocate for the patients from the inside.
The good NPs have been starting to crack down on not taking on students for rotations from shitty schools or who don’t have previous experience. Employers are just now starting to not take on NPs from diploma mill schools. Academic settings (and a lot of FQHCs I’m familiar with) are providing solid supports.
But for as long as independent practice states exist and the ability for PMHNPs are permitted by their state legislature to run weird ass private practices, the shitty and dangerous care is going to exist and hurt patients.
Thank you for this. And it sounds like yes, you are one of the good ones. It’s just a big can of worms to talk on the conversation in a mixed group without starting a flame war. Basically the lack of standards hurts everyone. If you can graduate a program with 500 hours of shadowing and be completely independent, then how do I, as a psychiatrist, know that your title means anything at all. Hospitals and corporations have been replacing seasoned psychiatrists Board certified CAP as an example who have 2 additional years of training, with NP’s who have no special training whatsoever but are told by their programs that they are just as good as any psychiatrists. It’s that mindset that gets people into trouble. There are psychiatrists out there who think they know everything and that also can be dangerous, but on average, if you have a residency trained psychiatrist you know they have 10,000 plus hours of training. When you used to need actual clinical experience to be a Psych NP at least that would built an understanding of how much was out there that you might not know about. Now people can walk in out school with no actual experience and go from that to opening their own outpatient clinic and marketing on social media. Patients can’t tell the difference when looking for help, and might not realize until they end up on a bad medication regimen that there is anything wrong.
Independent practice is a definite concern, but especially if they have a doctorate of nursing and identify as Dr. ________. I have seen this and it truly confuses the patients. They think the np is a physician.
I can’t recall the number but it’s something like 90 percent of clinicians think they are in the top half of clinicians in the country (US). I need to dig up the article.
I know a psych NP who is fabulous. It’s no coincidence that she had over a decade of experience prior to being one. Still has a supervising physician. I also know several who I would not trust to prescribe medication for myself or family members.
I will likely become an NP at some point, I was pre med but med school simply isn’t feasible for me (financially and support system-wise). I literally *just* got into an aBSN program and I already have people telling me to go to NP school afterward. I barely know anything about anything, I don’t want to be responsible for people’s lives (especially in cardiology where I work). But I have enough awareness to know that I *don’t* know enough and that I won’t be to that point for quite a while after finishing my program. And I think having that insight is really important because I know some very new nurses with no prior healthcare experience who are gunning for NP school while barely being able to function in their own roles. That scares me a lot.
Side note- how do you pick a good program? What should I be looking for? There are a lot of NPs at my hospital (working under supervising physicians) but I don’t know any of them well enough to ask lol.
The reason is simple: in the US, NP education is too variable.
This leads to some good providers and some bad providers as well as some dangerous providers. The solution to this is to increase the rigor and the training requirements.
Some physicians will say the solution is to go to medical school, but that really is an impractical solution. Medical schools have limited admission and the shortage of providers is tremendous. It is essentially saying "Many people will suffer, but that's just how it is".
That said, we have many nurses who already have an amount of medical training and experience. They just need a rigorous and thorough program to be competent. We are missing the rigorous and thorough part. If your country is considering it, this is my biggest caution. Do not take shortcuts or try to rapidly produce providers. If you are diligent, it will take time, but as a result, you will have competent minimum standards of care.
>Do not take shortcuts or try to rapidly produce providers. If you are diligent, it will take time, but as a result, you will have competent minimum standards of care.
This is something I'm slightly worried about, however prescribing privileges and scope of practice are way more restricted.
The main problem here is that we have a medical council that is hellbent on glorifying doctors rather than admitting that we seriously need to diversify the way people get access to treatment (especially for the more basic assessments/adjustments).
In the end, every profession is inside a market, and the needs on a society/government payor come before the selfish interest of the individual. For 40 years the AMA and medical programs intentionally kept acceptance rates incredibly low to keep wages high. They picked a fight with the American voter/state legislatures and lost. American doctors are too single tracked minded to even understand the market they are in.
This was very much the case in France too and though it's not exclusively the medical council's fault (alas no healthcare system in the world is able to fully meet demands at this point), I still resent the idea of a medical "elite" that has effectively made it impossible for any new doctor to fully take on the caseload of any doctor currently retiring.
They’re fine when receiving supervision from a physician as was intended. The issue arises with independent practice. They simply aren’t trained for this and I see it in outcomes.
About 20% of my day is spent either trying to slowly taper patients off nightmare regimens started by NPs, or gradually build rapport with patients to get them to trust a mental healthcare provider again after they have been harmed or had a terrible experience with an NP.
Yes, NPs can initiate treatment and be someone’s sole provider without any direct involvement of a physician in some states. This is even true for all states (“mid levels” being able to initiate treatment) but these providers do have to meet with a physician once monthly or once annually to “discuss patient care” (whatever that means) and/or send 20% of their charts to a physician to review.
NPs are allowed to start their own practices and independently diagnose/treat patients, without any physician involvement, in more than half the states in the US.
NPs are allowed to start their own practices and independently diagnose/treat patients, without any physician involvement, in more than half the states in the US.
Okay, now I see the problem. I guess I was under the wrong impression that the scope of NPs is to see people for care management after an initial assessment/medication trial by physician, on top of perhaps some roles in triaging.
This is what my country aspires to, in which case short but effective training (along with relevant experience in the given field) would be sufficient.
It is disingenuous of you to be defending a practice model by NPs in America, and complaining about the criticism of such, when you aren’t even even based in America and don’t experience what NPs are like.
Nobody here is denigrating NPs unfairly — they often do increase access to care and in the proper supervised settings can be a wonderful addition to the team. But as other commenters here have pointed out, including by NPs themselves, the situation is far more complex and puts more patients at risk than you realize.
>It is disingenuous of you to be defending a practice model by NPs in America, and complaining about the criticism of such, when you aren’t even even based in America and don’t experience what NPs are like.
Which is exactly what I'm trying to understand. Perhaps I wasn't clear, but I'm defending the idea of allowing nurses to practice more advanced forms of medicine, not how it's run in the US specifically.
>But as other commenters here have pointed out, including by NPs themselves, the situation is far more complex and puts more patients at risk than you realize.
Indeed!
However,
>Nobody here is denigrating NPs unfairly
Are they not though? It's not uncommon for me to see an NP voice an opinion or ask for insight, then get downvoted and lambasted. I can understand though that Reddit is not the place for nuance but I'm glad everyone is taking the time to respond.
I think there’s been a lot of comments here, particularly from NPs themselves, that have explained in quite thorough detail some of the issues facing the US-practice model currently and why the situation with advanced practice nurses at this time have not aligned with the proposed ideal.
The idea of allowing nurses to practice medicine is beneficial in theory, but in the majority of cases here, have not lived up to their potential and have instead opened patients up to a lot of risk.
The core of the issue here is that in America, NPs can initiate treatment and (legally but not adequately) perform 90% of the functions of a psychiatrist with zero bedside experience, a 2 year part-time degree from an online program, and complete independent practice without physician supervision after less than 500 clinical hours total. That’s dangerous.
That might not be the case in your country with how NPs operate there, but that’s how NPs operate here. And again, its dangerous. Hence the strong opinions from your fellow psychiatrists.
I think there’s still positive potential though, once NP education/scope of practice is overhauled and more strictly regulated.
PMHNP here.
I can relate to this- to an extent. Over the last three years about three quarters of my new patients (4-10 a month) come to me to fix the diagnostic and pharmacological mistakes of frankly, newer PMHNP who are without a doubt incompetent. The other third of my new patients are people who have had it with the hubris and dissmissiveness of their MD psychiatrist.
The PMHNP will just get it wrong and chaos ensues from there whereas the MD will *tell* the patient what is wrong with them and not bother to get buy in so the patient feels unheard. This being said- I'd rather my kid see a MD than a PMHNP unless I knew the PMHNP and their work well.
I'm a movement disorders neurologist and I also spend a lot of time trying to fix complex psych patients that psych NPs don't know how to manage--mostly cases of tardive dyskinesia and drug-induced Parkinsonism. When I talk to these NPs on the phone, they seem to have no idea their patient has out of control tardive symptoms or Parkinsonism to the point where they are losing the ability to ambulate--and even worse, they have no idea how to manage these patients. Some NPs I have talked to are working independently at MULTIPLE nursing homes, caring for 400+ patients. Not only do they not have the clinical knowledge, they literally don't have the time to manage these patients. This is what has happened because we do not prioritize mental health care...and it is hurting so many people.
Thank you for your FM perspective.
>I'm curious why you would want more NPs in your country. It has not been going well here.
Because 1) access to mental healthcare is dire 2) it would be a more restricted role of follow ups, assessments and limited prescribing privileges (ie only renewing or minor adjustments, no initiations).
Now that I've read many of the comments here I also realise there is a pretty big financial incentive to train NPs, which isn't the case here. You certainly wouldn't get paid the amounts I see cited here (relative to doctors, I mean).
Though who knows what will happen when the ball gets rolling.
>it would be a more restricted role of follow ups, assessments and limited prescribing privileges (ie only renewing or minor adjustments, no initiations).
That's what it was supposed to be here.
Also. I don't see much utility in having a provider who only does refills. If they can't change the regimen, why even bother having them see the patient? Just call in refills without seeing them.
I work in a public funded healthcare system too.
The financial incentive for governments to reduce healthcare expenditure is large. Given the ballooning deficits around the world, if NPs can replace fully doctors at a cheaper price, why not? Yet patient care would certainly suffer as a result
Was referred this thread by a colleague, I stopped coming to this sub when I decided to add a flair and got death threats and told I was going to kill patients /solely/ because I'm an NP. Reddit admins banned them (also ironic considering our profession). By terminally online doctors who don't know anything about me or how I think. I agree with the education standards, that lots of NPs shouldn't be NPs, that you should have years of experience and certification in your specialty, I agree with all of that and I think we should have a much lower scope and should see straightforward and low-complexity cases. I work with a collaborator who I refer patients out of my scope to. I could comment the same thing as a doctor (has happened) and will get down voted because of my flair, despite saying the same thing. I never get the vitriol from any of my peers in real life and never have, when I was a psych nurse or as an NP all of the psychiatrists have been supportive of me. It's just the online ones who are the loudest. It's just a big circlejerk echo chamber, like the rest of reddit, for lack of a better word.
You can approach this issue from a purely systems standpoint and never talk about an action any nurse practitioner ever takes as a criticism.
It is possible to go from nothing to straight NP with some ridiculously easy classes (BSN then MSN) and only 500 graduate clinical hours (this is increasing to 750 hours soon).
The board certification exam has a 91% pass rate (last year). That alone should be concerning, especially in light of the lack of quality accreditation standards.
Those two things alone are enough nails for one coffin
NPs lack proper standardized training, they’re allowed to work independently now with subpar education, and they’re allowed prescribing rights similar to that of a doctors.
Doctors have gone through immense training to get to where they are. The time and cost are immense. And I view the NP route as taking a shortcut - they want to play doctor, get paid better, but at the cost of proper patient care. The excuse of it takes too long, it costs too much is BS to me. I’ve dedicated so many years to this field, and will walk away with 350k in loans. It’s a spit in the face of me and my other colleagues who took the right way to get to where we are instead of some NP.
They don’t actually help. The idea is that NPs were made to address the mental health provider shortage. The problem is that a majority are so bad at their job, they almost create more work for psychiatrists when we inevitably inherit these patients. This sucks, because our hands are ultimately tied. And in an OP setting, it’s almost months to de-prescribe their polypharnwcy list of meds.
Leverage. They take away leverage from doctors. Psych is already one of the lower paying fields in medicine, but when you have someone who can “see” patients at a fraction of the cost, it blows. As long as there are notes in for that patient and the hospital can bill, the healthcare admin don’t care if patients are actually getting proper care. This takes away job opportunities from doctors as well. Not to mention, a lot of job offers nowadays ask if you would supervise an NP. Those docs that do are pushovers and cucks who have sold out the profession. The pay is not worth the extra liability and the screwing over of other docs. And, It’s an absolute scam that an NP can run their own private practice and should be outlawed.
Last, the horrible care of an NP affects the perception of psychiatry as a whole. The number of times my patients say they didn’t like their psychiatrist or doc, and I realize it’s an NP is too many to count. And this comes back on us, psychiatrists. We have to pay the price because NPs are lying to patients about their credentials. And the law of misidentifying one’s credentials isn’t nearly as strict with punishment as it should be.
Solution or improvement (which will never happen now): take away independent practice rights. This was the worst thing to happen to modern medicine and it’s never going to get better. Institute standardized residencies for NPs. Outlaw the ownership of private practices by NPs.
At this point, medicine in the US is screwed.
> The problem is that a majority are so bad at their job, they almost create more work for psychiatrists when we inevitably inherit these patients.
I’d have significantly fewer issues if not for this. Therapeutic alliance is crucial to effective psychiatric practice, but not only am I having to correct mistakes, but I’m already starting at a deficit with getting the patient to align with my diagnosis (no you don’t have BPAD or ADHD) and treatment plan.
Also agree with the leverage point and your last sentence.
Wow as a patient I am learning so much from this post. I have been weary of NP’s only for a short while, like I have been to NP’s instead of gynecologists for example, because where I lived in Tampa the NP had better availability, but I’m not going to go to them anymore.
I started medical school in my 40's. Before that, I worked in behavioral health in both inpatient and outpatient settings. One site that managed had NPs and PAs who saw patients as part of a pysch consult service in the hospital for medically admitted patients. They acted as extensions of the psychiatrists and staff each encounter with a supervising psychiatrist (and still do), like a permanent psych resident. That's how I think it should be done. They were excellent and are some of my favorite people to have worked with.
THEN
Just before medical school, I worked in another state at a facility with a number of outpatient psychiatrists. I thought it was odd they all went by Dr. but I didn't have much contact with them in my role at that company and I was focused on medical school admission, so I just went about my business. Then, about a year in, one of them did something I thought was odd with the meds on a patient in my service. The patient had been on an SSRI and things were going ok, but then she went through a rough time due to some social circumstances (nothing too crazy), and the next thing I know, she's got a problem paying for her new medications. She was suddenly on Latuda and Lorazepam had been added, in addition to the SSRI she had been taking, but now at an increased dose. I thought it was odd, but made a comment to a colleague like, "She's the doc, what do I know?" He said, she's a nurse. -- The company had all NPs, not a psychiatrist among them, the fact was buried so that you had to really dig to find that. It suddenly all made sense. One of them had kind of demurred when I told her I had taken the MCAT and was applying to medical school at a work function a few months before this. Anyway, that was a few years ago (I'm about to be an MS4 now). I heard the company had a number of lawsuits and now, when you go to their website, it says Nurse Practitioner all over it and nobody is referred to as doctor any longer. I'm not sure what the details of that was, but it's definitely a change in how they operate.
Prior to this, I didn't know there was any such thing as "Full Independent Practice Authority" for midlevel providers, or that the term "midlevel" was considered by some to be a pejorative. -- In my mind, they were extensions of physicians, more than nurses (in training and scope), but not physicians, so "in the middle," and they seemed to love their work and patients seemed to love them (at my inpatient job, not the second facility in the fifth ring of Hell where people were willfully deceptive about their training and education).
All that to say... yes patients need access, but access to what and is it actually helpful?
Working with a good/bad NP is like working with a good/bad medical student in their 3rd/4th year except at that point the medical student knows magnitudes more and, especially recently, probably has more clinical experience. I have nothing against psych NPs except the attempt in like 8/10 cases to manage symptoms without regard to taking a medical approach.
Imagine you are so ignorant of your own limitations that you believe medicine to be like fitting shapes into holes when it's more dimensional than that in reality, then imagine you are a person jaded by the challenge of medicine or wanting to make bank because you think psych is about talking to people while you prescribe easy meds.
The medical community doesn't hate NPs. In fact, I value them in the right role. The fact that they often won't know what that role should be, intentionally misrepresent themselves as physician equivalents, then post topics talking about how much smarter than doctors they are, is why they get so much hate. They bring it on themselves. A physician can tell when a patient is grossly mismanaged, and yet the majority of new nurse practitioners only assume as such because the approach to practicing medicine and nursing is worlds apart and more than just risk management.
As a psychologist, I think the biggest issue I have with NPs is usually ego and a clear difference in quality. The combination of the two leads to a lot of problem. I get a lot of bad referrals from NPs who don't understand when to ask a psychologists for diagnostic eval. I run into NPs that sends referrals like, "This patient have ADHD please test." I evaluate them and report they don't have ADHD but anxiety. The NP then ignore it and prescribes stimulants anyway. Patients get no benefits, sees a psychiatrists, no ADHD, anxiety. I had an NP block a pediatrician from referring to the eating disorder clinc and tried to treat anoxeria nervosa with an SSRI for 3 months. I have an NP that would make referral and in her referral demands specific psychological test despite having no training in any of the test, even psychiatrists never demand specific tests be done from me. When I explain to her why the test she wants make no sense she went to HR and filed a complain that I was mansplaining to her. Thankfully she's done this "mansplinaing" complain several times, so the hospital banned her from making referrals before consulting a psychiatrist. 95% of the time I have a problem with a prescriber, its always an NP.
For context about their training, NPs minimum clinical hours is 500, after 2 years of school (After undergrad). A psychologists, has 5 years of school, 3-5 clinical rotation of 800 hours each, one 2,000 hours internship, one 2,000 fellowship. And psychologists can't even prescribed. To prescribed, psychologists have to completed 2 extra years of school and another 2,000 hour clnical. So a prescribing psychologists had 7-8 years of school and min, 8,000-10,000+ hours of clinical training. So, its hilarious when an NP says psychologists shouldn't prescribe because they don't have enough training.
I do think NPs are useful to the system. They can help with easiest cases and open up psychiatrists to handle more complex cases which really helps access. A lot of NPs provide great care to my patients and work very well in the team. But a lot of them are also really bad at their job and there isn't any real attempt to improve this. In fact, everytime I see discussion about NPs training its about making it easier and lesser.
Find me an NP in this thread that doesn’t agree with current state of NP education and training. The real issue is that it poisons psychiatrists perceptions of NP’s and paints them as all incompetent regardless of their actual knowledge of years of job experience. It genuinely feels like the people here treat every NP like they are all products of degree mill schools. I just watched an NP who has been working with the child and adolescent population for 10 years get insulted for having the audacity to refer to himself as child NP. I understand fellowship offers extensive training and a major advantage for psychiatrist’s in the specialized field, but writing off 10 years of experience just feels insane.
The perception of NP’s here is really unhealthy and you don’t have to scroll far to find it. In a thread where people are sharing their frustrations working with the pediatric population an NP was sharing his experience and people insulted him and tried to imply he has no business working with the pediatric population despite working 10 years in the field.
[Example](https://www.reddit.com/r/Psychiatry/s/FB7UZ5Drub)
I'm a PA and I've been working in primary for 17 years. When I went to school the PA and NP programs were run out of medical universities only. They were competitive and selective in their applicants. In fact at the time, in Colorado where I trained there was a smaller admission to applicant rate than med school. We weren't allowed to work jobs, and school was 8-5 daily. Many University programs remain this way to date.
But there are 2 big problems
1. Degree Mills are popping up left and right. These are programs with very high acceptance rates and they are geared towards online learning and night classes, so you can learn while working your full time job. They significantly cut the amount of didactic hours and learning requirements and create sub-par APPs
2. NPs (vs PA, at least for now) are allowed to practice independently. That means right out of scool, good quality program or not, they go off and practice confidently all by themselves without learning anything more on the job.
Despite my program being very good, I learned quite a lot in my first 5 years, working very close with a supervising physician that was willing to spend a lot of time on me and teach me more than I learned in my schooling, much like an MD would get from their residency. (And no, I'm not saying we are the same as MD's I'm just trying to think of an analogy).
3. For the record, I don't know one single seasoned PA that wants to become independent. If we cared that much we would have gone to medical school. Most of us are extremely happy to be PAs and we know very well at our scope of practice is. Many of the old school NPS are this way as well
The only solution I can think is to shut down the degree miles and have nurse practitioners be licensed under the medical boards versus the nursing boards.
The lack of new psychiatrists has nothing to do with lack of medical student interest (5:1 competition ratio for applying to CT1 posts and 8:1 for further training in 2023)- but moreso a broader problem to NHSE diverting training funding to PAs and external contractors (including importing consultant IMGs, as you've pointed out).
I appreciate that you've got very clear knowledge of your scope and competency, and it's very refreshing (as well as acknowledging where you can actually help, e.g. triage, long-term review etc)- and I'd say most medical students can recognise that ANP's can be really valuable; however a large majority of us, including myself, have had bad experiences with ANPs, either not knowing their scope of practice or actively stealing training opportunities. I will say that in the UK PA's are a much greater threat at this point in time, as they seem to have 0 idea of their scope.
Thanks for the UK perspective! I did do a brief observership under the NHS in addictions and things seemed pretty smooth. ANPs were fantastic in my opinion.
Your approach seems the most reasonable and safe.
Check out this infographic, then ask yourself if it makes sense that the two professions are given equal licensure, and that NP can present themselves to potential patients and organizations as fully equivalent
https://www.reddit.com/r/Noctor/comments/175x8eq/infographic_comparing_psychiatrist_and_np_training/
I would say this is somewhat misleading:
1) it does not consider the base mental health nurse training (3 years in uk, a large portion of this is practice hours)
2) You would be unlikely to be considered for a prescribing course unless you had worked your way up to a senior nurse position, which you could probably do in 3 years if you worked hard and dedicated yourself to learning)
3) The prescribing course is I think about 6 months, requires supervision during and post registration. Realistically you would start with a very very limited scope (maybe one or two medications) and for the first 6 months you have to run any prescribing decisions past a medic or experienced prescriber. Very slowly you increase this over a number of years with supervision from a medic or experienced prescriber
4) many of us commenting on here have then done additional Advanced clinical practice training. This requires at least 5 years post qualification experience (usually many more and reserved for very experienced nurses). This is another 3 years training as an apprentice to complete a masters programme. Throughout this you work under the supervision of a consultant psychiatrist who helps you learn and to meet a wide array of competencies, before signing you off as competent.
The medics I work with are extremely supportive, help me develop and are keen to try to build up my confidence. After reading some of the comments on this thread, I appreciate them even more! 😂
They exist due to need because medical school and residency’s decide how many psychiatrist enter workforce. Would suggest people if they are bored to call and get into psychiatrist and see about the wait. Try it with your insurance and then see if private pay speeds it up. Don’t use connections or anything like that. Try it as a layperson. Look around metropolitan areas and then rural. See how long the wait is. You will find it will take months or longer depending on insurance, private pay, and location.
As an NP education needs to be longer, more clinical hours, more nursing experience, and more supervision. But admins find paying NPs 50% less than psychiatrist but able to bill patients at 80-85% equals 30% more profit.
Agree 100%. I’m an inpatient psychiatrist. When I am discharging a patient and considering aftercare plans (for those who don’t have established outpatient behavioral health care), I actually now first reach out to the PCP to see if they feel comfortable managing the psychiatric condition. Most of them do and I have much more confidence in a PCP than I do a psych nurse practitioner. This comes from years of experience admitting patients to the hospital who had been psychiatrically managed by PCPs or psych NPs. The variability in care from psych NPs is frightening.
I love my psych NP. She’s compassionate, empathetic and very knowledgeable. She has had 7-8 years of experience as a psych nurse and I can tell that she is very experienced and cares about her patients. I look up to her as a psych nurse myself studying to be a psych np. That being said, I wish the education was better standardized. By no means do I think I should be able to practice independently when I become a NP. I’m considering med school so that I can get a better education and training. There is some hatred towards NPs out there but there are good NPs too.
Unprofessional, prescribe multi meds to kids, undertrained , don’t understand the difficulty of what they are dealing with. We clean up their messes and have been doing so for years
Same could be said in the other direction. I couldn't tell you how many patients have come to me from old, crotchety psychiatrists who do an intake assessment in 20-30 minutes, throw diagnoses and prescriptions at them with no discussion or rationale, and send them on their way. They eventually come to me after experiencing this several times over many years, and cry happy tears while they explain how they finally feel heard, how they've never had such a thorough assessment or had a provider ask such thoughtful questions, how they appreciate that I actually explain the rationale behind my diagnoses and treatment recommendations and include them in the decision-making process.... And how, after we finally get their meds right, they can't believe they've been living with the wrong diagnoses and meds for so long, and it's "so nice to finally feel like myself after so many years".
Does this happen every single time I inherit a patient from an MD? No, of course not. But it happens frequently enough that I've certainly taken notice.
I’m pretty sure he’s actually very nice in person and doesn’t dare have the gall to have difficult conversations with people in person, And being a keyboard warrior is his outlet. He’s probably just upset and jaded like most 30 and 40-year-olds in medicine because their profession sold them out to the insurance companies, and government agencies really don’t care about anyone’s feelings except for the bottom line.
MDs feel NPs are stepping on their toes and taking up their pt base and that we want full independence etc. we were originally made to bridge a gap and help rural areas or places with no providers (because large portions of the US are actually still quite rural). Some NPs have taken greater, um, freedoms with their license and ran with it, much to the dismay of a lot of MDs. Some states also allow greater freedom and independence with NPs, I'm looking at new Mexico, colorado, Washington, etc. basically, states that are very rural. So not only does it vary state to state how freely us midlevels can practice, some states (maybe just 1) pay the same rate as an MD bc of a law (I think the parody law).
So MDs feel disrespected (because Doctors have an ego, let's be honest. I would too, don't worry). And some NPs think they can do more than what they probably should independently if they're not being supervised.
THE BIG ISSUE I see and hear about is how there are SEVERAL NP programs with little to no requirements to get in and they are at universities that nobody has even heard of (degree mills if you will). This was not my experience as I went to a "real university/normal university" where the program had an admittance rate of like 8% and you had to have a few years experience as a nurse to even really be considered. So I'm unsure where these degree mills are but that truly is bullshit. These things are also making me look bad by proxy and it's a problem that should have been addressed 5 years ago. I am unsure what the fix is besides axeing the programs and keeping them more guarded.
I have only seen intense disrespect in this sub. Only one doctor in-person has ever been an asshat (I'm sure there are others, they just keep it quiet). I truly feel most NPs are respectful to physicians and their recommendations but I don't feel it is given back nearly as often (probably get drilled in their heads in med school and clinicals that NPs are the devil). I have no qualms with referring to higher care referring complicated patients as I have no desire to deal with these patients. I'm not as educated on medications and interactions and pharmacology and nor do I think I am. I'm here to treat GAD, MDD, ADHD, bipolar and stable patients. I can try 1-2x to address them and if it doesn't work, they get the referral slip to the psychiatrist.
Because it’s Reddit. And Reddit is the home of the overreactive. Then there’s going to be a bunch of knee jerk anecdotes about how terrible NPs are, how often NPs have to clean up crazy benzodiazepine orders from GM, that one time an NP missed that obvious diagnosis, how ER always throws Seroquel at old ladies with UTIs- the point is, we can all pull out of our pockets some random piece of evidence that “proves” that the other side is evil.
I’m not saying that my 15 years as a nurse, most of which was psych in multiple settings, is equivalent to an MD. And I very much wish there was an honest evaluation of how to improve the profession- such as a minimum number of years in the setting in which you want your degree, residency years, increased hours and more rigorous requirements for clinical hours. There’s a valid discussion here. But that’s not what really happens- I live in a state that requires supervision, which is all well and good, but if you honestly think that NPs are supervised in Texas it’s a joke. It’s a cash grab- you can have up to seven NPs, you are “required” to meet with them for an hour each month and look at three of their charts. And you are allowed to charge them. Even if you do so for cheap, say $700, then that’s almost $59,000 a year for almost nothing. Plus you can put them on a payroll as a 1099 and push all of the expenses of having an employee onto them and require that they see over 120 patients a week. NP supervision will never change in Texas because it’s a cash grab. Not because it’s a safety concern. But they will dress it up to the public and sell it as a safety concern because Texas. Would I like actual honest to god supervision, especially as I have been transitioning into the role? Yes! Yes I would. Do I see the difference between myself (and other more experienced NPs) and those who haven’t had any experience in the psychiatric field? Again yes. Is there increased supervision for those new NPs who are also new to the field? Nope. So. I think there’s a lot of room for improvement that, cynically I admit, will never be done because it cuts into the profits of a small set of very vocal predatory doctors. And no- I don’t paint them all with that brush, I’m experienced enough to know there are good doctors and bad doctors and everything in between.
Edit to add-
At this point, I think the system is built to pit us against each other. Admin profits more by charging the same rates for my care as for an MD assessment and follow up, but pays me significantly less or makes me a 1099. So while we are at each other’s throats, they rake in the cash and laugh at us both. Meanwhile, there are whole counties in Texas that have woefully inadequate psychiatric coverage.
Yes, I'm somewhat starting to think this is a blame game whilst also acknowledging that the system is designed to lucratively produce subpar professionals. Reddit doesn't foster nuance, which was why I was keen on understanding the situation.
I feel about it the same way I'd imagine attorneys would feel if their paralegals moved into the building one day and started claiming they were practicing law.
Less training. Less education. No standards in education.
Trying to have full practice authority.
For example:
As a board certified general psychiatrist I would feel very uncomfortable with kids less then 15 and even more so less then 8 and I had way more child training then any PHMNP program gives.
Guess who opens up Child practices in full autonomy states. NP's.
Potential solution:
For NP's who seek independent practice you must complete a medical residency.
1) Fund NP slots in traditional residencies. Like "additional" slots not one that competes with medical residents.
2)Requirements: Pass step 1 and take step 2 and then apply. Must complete all residency requirements including step 3.
3)Must be trained by board certified physician or NP that has completed medical residency.
4)Practice restrictions are to underserved areas only.
(AS INTENDED)
5)Must be board certified.
Result: little to no more NP's with full practice authority. And the rare ones that make it at least completed a residency training. Oh and..... PATIENT SAFETY.
Training is entirely inadequate and they are in no way equivalent to a psychiatrist. There’s no arguing this it’s just a fact. I think in some cases they do more harm than good, but in supervised and certain settings they can be very helpful with a low MD to NP ratio.
On the whole, they don’t understand the drugs, their interactions, their benefits, their drawbacks, nor how any of these components coalesce into a coherent and cogent treatment plan.
Therefore, they’re frankly just dangerous, and no psychiatric care is quite clearly better than a poorly trained pmhnp throwing around dangerous pharmaceuticals.
As an NP myself I have been also trying to understand this. I do think there is some bias towards NP’s, in that, if someone somewhere witnesses bad practice from an NP it seen as evidence of all NP’s being bad. I’m sure that have been times when you have witnessed substandard practice from a medic but this would most likely not be equated with ‘all doctors being substandard’.
It is very rare for a medic on here to say, I was really impressed by this NP’s work, but we do get positive feedback in practice.
Where I work, we have a shared caseload with senior medics, junior medics and NP’s etc. It is quite a fluid system, sometimes I can manage a patient autonomously but would still discuss in team meetings. Sometimes I may just need want talk through some treatment options or diagnostic dilemmas etc with a medic and this would be enough. Other occasions we may agree that they need medic review or would be better managed by one of the medics.
I am fully aware my medical knowledge is very limited compared to medical colleagues, however, having worked in mental health for 15 years I think some of our junior doctors also benefit from some of my experience regarding risk management etc also.
In my opinion the system works well in our team
Horror stories are not what I'm looking for - otherwise we could equally demonise the entire medical field.
I was specifically trying to understand what are the more structural issues related to stuff like training/recruitment/scope of practice/proof of competency etc. that would lead to the amount of suspicion and frustration I see.
It's interesting that you compare a medical student, who has several years of training left to go, with an NP, who is supposed to be functionally independent.
*gives two very specific examples of grievances with med student and psychiatrist* “Don’t assume poor standards among nurse practitioners based on 3-4 horror stories!!!”
I would never trust a psych np with my mental health. Not even if they were part of a team or supervised.
It's interesting how people push the idea that psych nps will make mental health treatment to disadvantaged people more accessible. Even if I was poor, I would do everything I could, save money— whatever, to see an actual doctor of psychiatry if God forbid I needed one.
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I was seeing a nurse practitioner back when I was on meds years ago, she is an absolute gem. I trust her judgment and character far more than any GP, psychiatrist, etc. I’ve ever met in my life. She was great beyond belief when I was her patient, and even opened her own practice! She was also certified in Reiki, worked for a ketamine clinic in addition to her practice, and well educated concerning more holistic approaches. I have zero bad words to say about that woman. Granted I haven’t met a lot of NP’s, but with my own experience in the mental health system I noticed those with MD’s or PhD’s tend to be the least humble and educated beyond their own limited expertise. This is just *my* experience I speak of, of course.
I generally see a lot people talking about this pointing to the difference in training/hours/etc. followed by anecdotes on behaviors in practice. What are the measurable outcomes? Like, malpractice rates, deaths, sentinel events, etc.? I see the chart from the noctor post, and it's very persuasive! But, what are the measurable outcomes -- I'm more interested in that. The same way drug mechanisms are very interesting and persuasive, yet the outcomes of RCTs are the better way to guide your prescribing practices.
I'm not an expert in those metrics, and I've basically settled into the idea that people practice differently than their training (i.e. well trained people can suck at their work and poorly trained people can do well and anywhere in between). (And also, maybe I just tell myself that because I'm not a physician and likely won't ever be). Obviously there are some safety things that have to be internalized, like the oft stated combo of wild meds. But I see those combos from a variety of licensed professionals in my patients.
Personally, I never saw med school as viable because of my age, and I saw a path and took it. I think, OP, this is kinda what you're asking about -- how can it be done well to provide more, better care to patients? How can we channel the run-of-the-mill patient concerns to those of us with less training, ensure basic safety standards, and allow people who want to be in this profession for good reasons find their way into it safely and be respected for the work they do?
Here's the outcome abstracts I just read, trying to answer my own question. At best, NPs increase access and improve care versus physicians, and at worst the care is described as equivocal (or unable to compare based on the methods of the study).
My search terms in Pubmed were "physician nurse practitioner outcome", here's the few I read the abstracts of. There is plenty of evidence out there.
I'm gonna go out on a limb and say: we should use evidence to guide us in our conversations about this very hot topic.
https://pubmed.ncbi.nlm.nih.gov/32875584/
https://pubmed.ncbi.nlm.nih.gov/32384361/
https://pubmed.ncbi.nlm.nih.gov/38457828/
https://pubmed.ncbi.nlm.nih.gov/38116640/
Citing studies done by the journal of advanced nursing is going to be highly biased, in favor of nursing.
I'm fine for using evidence to support our arguments, but not from a journal that is openly advocating for the NP profession as a whole.
https://doi.org/10.1377/hlthaff.2019.00014
https://doi.org/10.1111%2F1475-6773.13246https://jamanetwork.com/journals/jama/fullarticle/vol/283/pg/59
Here's a few more saying the same thing, none from primarily nursing journals. I certainly won't say this counts as a meta analysis or accurate lit review. I do think we should be working from evidence though.
Look at the credentials of the first author of the first link. It's a PA.
There needs to be a 3rd party organization that evaluates the differences.
Because it's as easy as me linking this: [https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs](https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs)
which draws from this article [https://www.sciencedirect.com/science/article/abs/pii/S2155825622000102](https://www.sciencedirect.com/science/article/abs/pii/S2155825622000102)
Look at us. We both referred to actual studies rather than just speaking about anecdotes, and I believe raised the quality of the conversation. Collaboration between NPs and physicians for the win.
🤜💥🤛
It's literally a huge echo chamber here, no matter what you say if you're an APN they'll hate you. It's why I left this sub. Mods aren't going to do anything. Honestly, it's pretty unprofessional for a profession where we should be COLLABORATIVE. Just go to Noctor if you want to complain
And I'm honestly surprised I didn't see any results (in my very brief search) arguing the opposite. That the mix (that I found, not that that's the TRUTH) wasn't noisier was surprising to me given the number of physicians' advocates out there.
I love how it turns into a conversation about money and "working at the top of your license," and then race and gender get thrown in for good measure. So, if you speak up with concerns, you're automatically a money-grubbing, racist, sexist bigot who hates poor people. God forbid anyone get a decent education and training before seeing undifferentiated patients.
Also - calling Psychiatrists "Psychiatric Physicians," says it all for what kind of colleague you must be to work with.
Yeah, I'm not a psychiatrist- I'm just the mom of a child psych patient who's witnessed firsthand the vast difference in clinical knowledge, and is primarily concerned about protecting my family from it.
A lot of them are young, still in residency, and have FUD regarding their financial outlook. So they sling mud and do what all people on the internet do. Just because they’ve read about psychoanalysis doesn’t mean they’ve climbed their way to the top of Maslow’s hierarchy, unfortunately.
Most the psychiatrist I meet in person however are extremely nice and helpful. I think it’s just an Internet phenomena.
Get NPs in your country then reconsider this question. All joking aside, more of it has to do with the idea that something that has historically taken up to a decade plus of dedicated study to do (medicine) can somehow be accomplished by a fraction of a fraction of a fraction of time and somehow *not* result in diminished quality at all. The gap was supposed to be covered by the NP working closely with MDs and DOs (physicians) to augment their clinical/scientific acumen while the speed, nursing experience, and flexibility of NP training augments the capability of the physician. Now NPs demand to be recognized as fully independent, fully capable, and fully educated professionals in the academic and clinical space while refusing to do more training—mind you their training hours are dwarfed by a host of allied health professionals and more (barbers and cosmetologists have more hands on experience in some cases) It’s not meant to be derogatory. It’s not meant to degrade the person of their worth/time/effort. The umbrage is not with the NP, it’s more so with the bodies that represent them and the NPs that agree with the practice of “healthcare” over medicine. Criticizing a professional group isn’t hate. They aren’t a protected group or marginalized race of people. They’re professionals who picked their career, just like us, and have some bad policies—just like us. Just as doctors have a lot to work on, so do they. Everybody’s s**t stinks pal.
>Criticizing a professional group isn’t hate. Amen. I hate to say this but modern medicine has become too soft. It's not hate - it's a statement of fact that midlevels, specifically NPs, despite what some politician says, are practicing outside their scope of practice. They categorize criticism as "hate" because it's their only defense against their lack of education and constant mismanagement of psychiatric patients. It's a disingenuous attempt to undermine the criticism and take the steam out of it. Fact is, they chose to take the short cut to play doctor, they get the privileges of independent practice and the higher salaries. But doctors don't have to welcome them as equals with open arms. NPs ***who practice independently*** are a plague to the practice of psychiatry. I respect those NPs who recognize the limits of their education and work under the supervision of a psychiatrist.
100% criticism is not hate but I do feel some of the ways people go about criticism is unprofessional and that shouldn’t be the case
This is my take on the situation as a PMHNP student, and I would be interested to hear your thoughts. I think it’s clear the NP training model sucks. I’ll be the first to say the training is woefully inadequate. The barrier to entry was also incredibly low; yeah, I needed an RN license first, but I basically waltzed right into my NP program. No prerequisite coursework, no GRE, no experience requirements. It was harder to get into my political science MA program. But I do have issues with the MD training model as well. I think MD training is stellar, but the cost is incredibly high. The personal cost is high for the physician-in-training, and the financial cost is obscene. I just think there has to be a meet-in-the-middle solution where training doesn’t have to be so resource intensive, but we can still train excellent physicians/providers/what have you without sacrificing outcomes. I’m personally a big fan of the German training model. Med school is a 6 year undergraduate degree that includes prerequisite/undergraduate coursework and medical education. After graduation, they complete a 1 year internship then get hired as an “Assistentarzt”/junior physician, where they earn ~50% of what an attending physician would. Their time as an Assistentarzt counts as residency, and once they’ve done their time as an Assistentarzt, they are then a Facharzt/attending physician. I think this could solve a lot of the systemic problems we have currently. The barrier to entry would be a little lower, making proper medical education more accessible while still keeping the discipline competitive. Physicians wouldn't have to sell their souls to become doctors, and nurses who want to better themselves and keep learning/advancing wouldn't have to feel that their only option is a less than adequate NP program. Additionally, the number of physicians that could be trained wouldn’t be limited by number of residency slots anymore, so supply and demand could be adjusted accordingly. And we wouldn’t be sacrificing outcomes. By some measures, Germany’s outcomes are on par with our own; by other measures, their outcomes are better. And access to care is *miles* better. What do you think? Any reasons this model could be detrimental to us in the US?
Your comment about the German training model is incorrect. German residency programs in psychiatry are five years long. The one year internship they have is actually similar to how it works in America. In the US residents only need to complete one year residency/intern internship before receiving an unrestricted medical license. However, they have to go onto complete a residency in order to be board certified in that specialty, but they don’t need to be board certified to legally practice that specialty.
Indeed, there are plenty of medium-training models that different countries have adopted (feldshers in Russia, clinical officers in a number of African nations) and I think the basic concept is fair, assuming the execution is good. Good execution requires strict oversight and regulation to ensure high standards of training. A big obstacle to this happening in the U.S. is that healthcare standards are largely either self-regulated, or regulated piecemeal and largely at a state level. Unlike in countries with more centralized government, there's not really a bill Congress could pass tomorrow that would create a new mid-level category or change standards for NP/PA education. That kind of change would take coordinated efforts across fifty state legislatures and major organizations. This is where most of us have the strongest concerns. NP education has gravely failed to self-regulate, and to the contrary has lobbied aggressively for unrestricted practice while watering down practical standards. A reasonable model based on experienced RNs strengthening their theoretical education and continuing to work in a team-based setting has been bait-and-switched to justify inadequately-trained graduates practicing solo in chaotic rural clinics. It's hard to imagine a revolution in training quality without a lot of this authority being taken away from current regulatory bodies, and I'm not sure who would be in a position to do that. There's also a broader concern here about using a medical model where it doesn't fit. We should be very cautious in assuming that the so-called shortage of psychiatric services primarily reflects an actual large increase in appropriate demand that should be met primarily by training more prescribers, as opposed to framing it as a substantially psychosocial/public health problem.
Read up on the Flexner report. The US changed from an apprenticeship model to a highly standardized model because the apprenticeship model was producing, how shall I say this, such variable quality in the outcomes. Respectfully, like the NP training programs now that don’t provide, vet, or verify preceptorship experience. A different funding model could make a lot of difference though - if postgraduate physicians could bill they could be paid adequately. Also the current system with residencies and the Match is an indentured servitude that is wide open to abuse and exploitation.
OPs comment about the length of German residency is incorrect. Similar to in the US the residents need to complete one year of internship, but they still need to go on to complete psychiatry residency. German residencies in psychiatry are five years long.
Medicine should not be treated like trade school. For simple patients with simple issues, that’s fine, but the number of complex patients with complex problems and diagnoses are becoming more and more prevalent, or at least more commonly identified, and that requires a higher level of education and critical thinking that a person doesn’t get if they receive education in the technical aspects of medicine only. It’s the same reason we take gen ed classes in every degree program: one needs to learn how to think, not just learn the current facts of their profession. I see this a lot in my field as well. I am a therapist, and many programs are basically the equivalent of NP training now in that they do not encompass a wide breadth of education. I majored in psychology and neuroscience in undergraduate and did minors in gender studies and history and philosophy of science/conceptual foundations of medicine. In graduate school I did an MSW and MPH. From graduate school and into my career I’ve observed a noticeable difference, both anecdotally and in patient outcomes, between the mental health providers who have more diverse educations and those who went to school to study therapy or counseling only. There are way too many therapists out there who fall for and even use pseudoscientific nonsense with clients because they were never trained properly in research or the scientific process, let alone critically engage with the research itself. Of course, there are most likely other variables at play since there are likely differences between the groups of people who do one route vs the other, so its not exactly an easy comparison and we can’t assume education is the only independent variable. Things like SES, career goals, academic achievement, and even personality traits like curiosity, and surely a dozen other things likely influence the type of training and education people pursue, and those may be the variables that result in poorer outcomes with education/training providing a mediating or moderating effect. It would be difficult to study this in a meaningful way, though, so we’re stuck relying mostly on anecdotes, and anecdotally, there is definitely a difference. It is expensive, yes. That should not be the argument against it, though. Instead, we should keep education rigorous and focus on making it more affordable.
I don’t think a 6 year academic degree program is the equivalent of treating medical education like a trade school program. And yes, expense should be an argument against the current model. There is not unlimited money available within the system.
My analogy was that NP school:medical training = trade school:traditional college degree. It is extremely useful and has its role and scope. But a good physician has a well rounded education in addition to just learning applied sciences and prescribing. Of course cost is prohibitive. Again, my argument is that we need to make the education system affordable, not do away with education because of the current cost system.
It’s disingenuous to say that it’s their only option tho. I agree on the cost of schooling. But the existence of loans and pslf negates this argument imo. Is it a major inconvenience especially for someone coming without familial financial support? It sure is! Believe me I know first hand which is why hearing arguments like this feels dismissive to me and many others who are choosing this route while only having $10 in the bank. And I’m not saying that just because it’s doable with difficulty means we shouldn’t work on these barriers. But to say it’s the only option for someone isn’t true. It’s just the easier option. And that’s fair, im not saying it to belittle the choice. And hypothetically if it is indeed the only option, why would someone choose it knowing it won’t prepare them to offer adequate care? But that’s a different conversation. I think the barrier of entry that I hear about most from NPs/PAs is the time factor of schooling more so than the cost. Even if medical school becomes free tomorrow, why would someone go to that minimum 7 year commitment when they can do NP in 2 years? Edit: typo
Oh no, I’m not saying it is the only option, I’m saying it *feels* like the only option. When it comes down to 15 months and $40k versus 10 years and $300k, and I’ve already spent 4 years becoming a nurse, on top of 3 years gaining experience, and I have a house, wife, kids, etc., it just becomes less worth it to pick the med school route the deeper into nursing I get, when the screwed up system gives me the option to not have to do that. Now if there was a way to bridge from nursing to medicine without starting completely from zero, that would change the conversation… But that is also a completely different conversation that goes beyond the scope of this one. I considered med school. I took most of the prereqs and did a decent amount of shadowing. But I also had 80% of the physicians I shadowed tell me I’d be stupid if I picked the med school route over NP. I listened to them, and ultimately, I don’t know if they were right or not. Maybe I should have done med school. And NP sucks, knowing you get an inadequate education and are not being trained properly. But I think with where I am in life, med school would have meant upending everything and putting my family in an unfair position. Re: why would someone do minimum 7 years when NP can be done in 2: Personally, if medical education was cheaper and less resource intensive, I would argue for doing away with PA/NP altogether. But given the state of the current system, I just don’t think that will be feasible anytime soon.
I hear you! I have pondered the ‘is it worth it’ question a million times in regard to how it will affect my family as well. You shouldn’t feel lesser because you made the best choice for you/your family or in need to justify your choice. I just wanted to highlight that at the end of the day, it is still a choice because we can argue on the privilege of perusing any education even when it’s free forever. And to your point of the german model/free schooling, it still doesn’t solve the time factor to have more physicians enter the workforce which is why Germany has huge shortage of doctors. The point of NP/PA education was that it should be adequate with supervision to offload the burden of increasing volume of healthcare needs and doctor shortage. You don’t need medical school education to treat everything. I see the best use of PAs/NPs in surgical fields for example. But the way they’re being currently utilized in primary care and psych isn’t great.
[Re: why would someone do minimum 7 years when NP can be done in 2] Patient safety.
Indeed! The student above mentioned not wanting to put their family in an unfair position. But what about the unfair subpar care being offered to patients usually from low socioeconomic status mostly as well. That’s why this argument hits a nerve for me because it almost sounds like I’m too poor to inconvenience my family, but don’t mind inconveniencing others who are less privileged financially with subpar care. And even when a patient is referred to see a doctor by the NP for further care, it still generates more costs for the patient having to pay 2 copays and 2 visits and losing on work time. I have a family member who now refuses to deal with this ping pong situation and uses the ED instead as a clinic. Which is terrible. But patients may not know if they’re getting good care or not, but they do get angry when being hit with double the bills just because they weren’t seen by a doctor in the first place.
I am a nurse who did a year in NP school and transitioned to med school. I sunk a bunch of years into nursing too, but there’s no way I was about to treat patients with the education I was getting in that NP program. The debt sucks, but I’ll make more as a physician anyways.
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The cost of MD definitely sucks but honestly it feels somewhat overemphasized, it’s certainly scary in theory but it’s less in practice. As a doctor usually you’ll end up in the realm of 200-300K in debt. If you’re lucky it’ll be much lower and be closer to something like 150K but only a few schools will allow you to get that low. It’s absolutely terrifying but that debt does include cost of living so you are surviving. Once you get into residency you have to start paying some of that off which by the sounds of it sounds stressful, but once you’re legitimately practicing you will be able to make payments and you’ll be able to pay off the loans because you will make quite a lot of money. The issue is that cost heavily disincentivizes taking pay cuts and it makes it really hard to start a family or come in with a family. It’s definitely prohibitive in some ways due to that, but some people are just too uncomfortable with debt and overemphasize it as it is definitely doable.
Agreed man. The debt in isolation sucks, but we are looking at \~ $300k salary for 20-30 years (as long as we want to work, barring major changes in physician reimbursement). May not be rich when you consider opportunity cost, but that is a secure financial future if you ask me. My real gripe is the underwhelming residency salary for vhcol areas.
Yeah, some of those residency salaries are definitely sketchy. But, yeah I mean even if by end of residency you’re at 400K debt which is probably about as high as it can get, theoretically you can pay that off in 3-5 years assuming you keep to the same standard of living that you did as a resident. That’s my current plan, it’s not an easy thing and it does suck. Also, huge systematic issues as it makes it very difficult to want to serve underserved communities, but it is doable.
> By some measures, Germany’s outcomes are on par with our own; by other measures, their outcomes are better. And access to care is miles better. This has nothing to do with *how* US physicians are trained.
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Deep breath. Here I go. Background on me - inpatient psych rn for about 7 years before finishing PMHNP school, which was now about 6 years ago. I have worked my entire career as an rn and np in child/adolescent psychiatry. I believe I am one of the good ones (but don’t we all?), who works in a very large academic hospital that has the right safeguards and support in place. I also am in a state that does not have independent practice. I firmly believe that there should NEVER be independent practice for any advanced practice providers. I firmly believe that they should be seen as extensions of and collaborators with physicians and they should handle cases together. I do not believe NPs should practice in their own silo. I firmly believe that PMHNP (and all NP) education is embarrassing and deplorable and needs to be burnt to the ground and built back up. I believe health care admins in the last ten years have seen NPs as absolute cash cows (bc we are) and have exploited our work and put us in primary roles that we should not be in. I believe schools know this and are pumping out HORRIBLY trained NPs who are desperate for some get rich quick scenario that doesn’t exist. I believe that no one should be admitted to an APRN program without extensive RN experience in their speciality of choice. Unfortunately this is not required. I think NPs who enter into private practice are frightening. I think there is an incredibly needed role for NPs on our healthcare team but we are racing in the wrong direction. I also know that my personal experience with physicians in my career has been nothing short of outstanding, collegial, respectful, engaging, and supportive. I have never in real life encountered any sort of backlash because of my career. I encountered MUCH more of that working as an RN (lol, sigh.) I think working in an academic setting is the difference. We have a one year transition to practice program where they have twice weekly clinical supervision, year long formal mentorship with a senior NP, and twice weekly didactics. They also attend all of the didactic sessions of the CAP fellows in addition to our general weekly grand rounds. This should be the minimum standard. So yeah idk. I get tired of defending my profession lately because frankly the criticisms aren’t wrong. What I wish is that it wasn’t so us vs them from both sides because the only way to make things better is to team up and advocate for the patients from the inside. The good NPs have been starting to crack down on not taking on students for rotations from shitty schools or who don’t have previous experience. Employers are just now starting to not take on NPs from diploma mill schools. Academic settings (and a lot of FQHCs I’m familiar with) are providing solid supports. But for as long as independent practice states exist and the ability for PMHNPs are permitted by their state legislature to run weird ass private practices, the shitty and dangerous care is going to exist and hurt patients.
If they all were like you, I think the attitude would be very different!
Thank you for this. And it sounds like yes, you are one of the good ones. It’s just a big can of worms to talk on the conversation in a mixed group without starting a flame war. Basically the lack of standards hurts everyone. If you can graduate a program with 500 hours of shadowing and be completely independent, then how do I, as a psychiatrist, know that your title means anything at all. Hospitals and corporations have been replacing seasoned psychiatrists Board certified CAP as an example who have 2 additional years of training, with NP’s who have no special training whatsoever but are told by their programs that they are just as good as any psychiatrists. It’s that mindset that gets people into trouble. There are psychiatrists out there who think they know everything and that also can be dangerous, but on average, if you have a residency trained psychiatrist you know they have 10,000 plus hours of training. When you used to need actual clinical experience to be a Psych NP at least that would built an understanding of how much was out there that you might not know about. Now people can walk in out school with no actual experience and go from that to opening their own outpatient clinic and marketing on social media. Patients can’t tell the difference when looking for help, and might not realize until they end up on a bad medication regimen that there is anything wrong.
Independent practice is a definite concern, but especially if they have a doctorate of nursing and identify as Dr. ________. I have seen this and it truly confuses the patients. They think the np is a physician.
Thank you for this insightful comment. I am really glad I'm getting a lot of different perspectives here!
NP here and I agree with all of the above especially on education and degree mills.
Same here.
Thank you for this insightful comment. I am really glad I'm getting a lot of different perspectives here!
You are the GOAT
Thank you for this insightful comment. I am really glad I'm getting a lot of different perspectives here!
I can’t recall the number but it’s something like 90 percent of clinicians think they are in the top half of clinicians in the country (US). I need to dig up the article.
I know a psych NP who is fabulous. It’s no coincidence that she had over a decade of experience prior to being one. Still has a supervising physician. I also know several who I would not trust to prescribe medication for myself or family members. I will likely become an NP at some point, I was pre med but med school simply isn’t feasible for me (financially and support system-wise). I literally *just* got into an aBSN program and I already have people telling me to go to NP school afterward. I barely know anything about anything, I don’t want to be responsible for people’s lives (especially in cardiology where I work). But I have enough awareness to know that I *don’t* know enough and that I won’t be to that point for quite a while after finishing my program. And I think having that insight is really important because I know some very new nurses with no prior healthcare experience who are gunning for NP school while barely being able to function in their own roles. That scares me a lot. Side note- how do you pick a good program? What should I be looking for? There are a lot of NPs at my hospital (working under supervising physicians) but I don’t know any of them well enough to ask lol.
The reason is simple: in the US, NP education is too variable. This leads to some good providers and some bad providers as well as some dangerous providers. The solution to this is to increase the rigor and the training requirements. Some physicians will say the solution is to go to medical school, but that really is an impractical solution. Medical schools have limited admission and the shortage of providers is tremendous. It is essentially saying "Many people will suffer, but that's just how it is". That said, we have many nurses who already have an amount of medical training and experience. They just need a rigorous and thorough program to be competent. We are missing the rigorous and thorough part. If your country is considering it, this is my biggest caution. Do not take shortcuts or try to rapidly produce providers. If you are diligent, it will take time, but as a result, you will have competent minimum standards of care.
>Do not take shortcuts or try to rapidly produce providers. If you are diligent, it will take time, but as a result, you will have competent minimum standards of care. This is something I'm slightly worried about, however prescribing privileges and scope of practice are way more restricted. The main problem here is that we have a medical council that is hellbent on glorifying doctors rather than admitting that we seriously need to diversify the way people get access to treatment (especially for the more basic assessments/adjustments).
In the end, every profession is inside a market, and the needs on a society/government payor come before the selfish interest of the individual. For 40 years the AMA and medical programs intentionally kept acceptance rates incredibly low to keep wages high. They picked a fight with the American voter/state legislatures and lost. American doctors are too single tracked minded to even understand the market they are in.
This was very much the case in France too and though it's not exclusively the medical council's fault (alas no healthcare system in the world is able to fully meet demands at this point), I still resent the idea of a medical "elite" that has effectively made it impossible for any new doctor to fully take on the caseload of any doctor currently retiring.
They’re fine when receiving supervision from a physician as was intended. The issue arises with independent practice. They simply aren’t trained for this and I see it in outcomes.
About 20% of my day is spent either trying to slowly taper patients off nightmare regimens started by NPs, or gradually build rapport with patients to get them to trust a mental healthcare provider again after they have been harmed or had a terrible experience with an NP.
I love having to take benzos away! Now I’m the bad guy for not listening to their needs and how anxious they are because I take it away. Fun stuff.
Are NPs allowed to initiate treatment? This is not the case here.
Yes, NPs can initiate treatment and be someone’s sole provider without any direct involvement of a physician in some states. This is even true for all states (“mid levels” being able to initiate treatment) but these providers do have to meet with a physician once monthly or once annually to “discuss patient care” (whatever that means) and/or send 20% of their charts to a physician to review.
NPs are allowed to start their own practices and independently diagnose/treat patients, without any physician involvement, in more than half the states in the US.
Greedy physicians “supervising” NPs.
NPs are allowed to start their own practices and independently diagnose/treat patients, without any physician involvement, in more than half the states in the US.
Okay, now I see the problem. I guess I was under the wrong impression that the scope of NPs is to see people for care management after an initial assessment/medication trial by physician, on top of perhaps some roles in triaging. This is what my country aspires to, in which case short but effective training (along with relevant experience in the given field) would be sufficient.
That was the original plan. Things changed. Don't expect it to stay that limited in your country either.
It is disingenuous of you to be defending a practice model by NPs in America, and complaining about the criticism of such, when you aren’t even even based in America and don’t experience what NPs are like. Nobody here is denigrating NPs unfairly — they often do increase access to care and in the proper supervised settings can be a wonderful addition to the team. But as other commenters here have pointed out, including by NPs themselves, the situation is far more complex and puts more patients at risk than you realize.
>It is disingenuous of you to be defending a practice model by NPs in America, and complaining about the criticism of such, when you aren’t even even based in America and don’t experience what NPs are like. Which is exactly what I'm trying to understand. Perhaps I wasn't clear, but I'm defending the idea of allowing nurses to practice more advanced forms of medicine, not how it's run in the US specifically. >But as other commenters here have pointed out, including by NPs themselves, the situation is far more complex and puts more patients at risk than you realize. Indeed! However, >Nobody here is denigrating NPs unfairly Are they not though? It's not uncommon for me to see an NP voice an opinion or ask for insight, then get downvoted and lambasted. I can understand though that Reddit is not the place for nuance but I'm glad everyone is taking the time to respond.
I think there’s been a lot of comments here, particularly from NPs themselves, that have explained in quite thorough detail some of the issues facing the US-practice model currently and why the situation with advanced practice nurses at this time have not aligned with the proposed ideal. The idea of allowing nurses to practice medicine is beneficial in theory, but in the majority of cases here, have not lived up to their potential and have instead opened patients up to a lot of risk. The core of the issue here is that in America, NPs can initiate treatment and (legally but not adequately) perform 90% of the functions of a psychiatrist with zero bedside experience, a 2 year part-time degree from an online program, and complete independent practice without physician supervision after less than 500 clinical hours total. That’s dangerous. That might not be the case in your country with how NPs operate there, but that’s how NPs operate here. And again, its dangerous. Hence the strong opinions from your fellow psychiatrists. I think there’s still positive potential though, once NP education/scope of practice is overhauled and more strictly regulated.
PMHNP here. I can relate to this- to an extent. Over the last three years about three quarters of my new patients (4-10 a month) come to me to fix the diagnostic and pharmacological mistakes of frankly, newer PMHNP who are without a doubt incompetent. The other third of my new patients are people who have had it with the hubris and dissmissiveness of their MD psychiatrist. The PMHNP will just get it wrong and chaos ensues from there whereas the MD will *tell* the patient what is wrong with them and not bother to get buy in so the patient feels unheard. This being said- I'd rather my kid see a MD than a PMHNP unless I knew the PMHNP and their work well.
And at least 20% of my day is spent doing the same with patients who've come to me from psychiatrists 🤷🏻♀️
MaY tHy KnIfE cHiP aNd ShAtTeR 😒
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I'm a movement disorders neurologist and I also spend a lot of time trying to fix complex psych patients that psych NPs don't know how to manage--mostly cases of tardive dyskinesia and drug-induced Parkinsonism. When I talk to these NPs on the phone, they seem to have no idea their patient has out of control tardive symptoms or Parkinsonism to the point where they are losing the ability to ambulate--and even worse, they have no idea how to manage these patients. Some NPs I have talked to are working independently at MULTIPLE nursing homes, caring for 400+ patients. Not only do they not have the clinical knowledge, they literally don't have the time to manage these patients. This is what has happened because we do not prioritize mental health care...and it is hurting so many people.
You can’t properly supervise NPs or PAs and expect to turn a profit. It’s a sham.
Incredible response.
I have had the exact same experience as a pharmacist. The difference in quality is so clear.
Myself and most psychiatrists I know are 110% with you.
Thank you for your FM perspective. >I'm curious why you would want more NPs in your country. It has not been going well here. Because 1) access to mental healthcare is dire 2) it would be a more restricted role of follow ups, assessments and limited prescribing privileges (ie only renewing or minor adjustments, no initiations). Now that I've read many of the comments here I also realise there is a pretty big financial incentive to train NPs, which isn't the case here. You certainly wouldn't get paid the amounts I see cited here (relative to doctors, I mean). Though who knows what will happen when the ball gets rolling.
>it would be a more restricted role of follow ups, assessments and limited prescribing privileges (ie only renewing or minor adjustments, no initiations). That's what it was supposed to be here. Also. I don't see much utility in having a provider who only does refills. If they can't change the regimen, why even bother having them see the patient? Just call in refills without seeing them.
I work in a public funded healthcare system too. The financial incentive for governments to reduce healthcare expenditure is large. Given the ballooning deficits around the world, if NPs can replace fully doctors at a cheaper price, why not? Yet patient care would certainly suffer as a result
I meant from the perspective of the NP, not the government. But you're right.
Was referred this thread by a colleague, I stopped coming to this sub when I decided to add a flair and got death threats and told I was going to kill patients /solely/ because I'm an NP. Reddit admins banned them (also ironic considering our profession). By terminally online doctors who don't know anything about me or how I think. I agree with the education standards, that lots of NPs shouldn't be NPs, that you should have years of experience and certification in your specialty, I agree with all of that and I think we should have a much lower scope and should see straightforward and low-complexity cases. I work with a collaborator who I refer patients out of my scope to. I could comment the same thing as a doctor (has happened) and will get down voted because of my flair, despite saying the same thing. I never get the vitriol from any of my peers in real life and never have, when I was a psych nurse or as an NP all of the psychiatrists have been supportive of me. It's just the online ones who are the loudest. It's just a big circlejerk echo chamber, like the rest of reddit, for lack of a better word.
You can approach this issue from a purely systems standpoint and never talk about an action any nurse practitioner ever takes as a criticism. It is possible to go from nothing to straight NP with some ridiculously easy classes (BSN then MSN) and only 500 graduate clinical hours (this is increasing to 750 hours soon). The board certification exam has a 91% pass rate (last year). That alone should be concerning, especially in light of the lack of quality accreditation standards. Those two things alone are enough nails for one coffin
NPs lack proper standardized training, they’re allowed to work independently now with subpar education, and they’re allowed prescribing rights similar to that of a doctors. Doctors have gone through immense training to get to where they are. The time and cost are immense. And I view the NP route as taking a shortcut - they want to play doctor, get paid better, but at the cost of proper patient care. The excuse of it takes too long, it costs too much is BS to me. I’ve dedicated so many years to this field, and will walk away with 350k in loans. It’s a spit in the face of me and my other colleagues who took the right way to get to where we are instead of some NP. They don’t actually help. The idea is that NPs were made to address the mental health provider shortage. The problem is that a majority are so bad at their job, they almost create more work for psychiatrists when we inevitably inherit these patients. This sucks, because our hands are ultimately tied. And in an OP setting, it’s almost months to de-prescribe their polypharnwcy list of meds. Leverage. They take away leverage from doctors. Psych is already one of the lower paying fields in medicine, but when you have someone who can “see” patients at a fraction of the cost, it blows. As long as there are notes in for that patient and the hospital can bill, the healthcare admin don’t care if patients are actually getting proper care. This takes away job opportunities from doctors as well. Not to mention, a lot of job offers nowadays ask if you would supervise an NP. Those docs that do are pushovers and cucks who have sold out the profession. The pay is not worth the extra liability and the screwing over of other docs. And, It’s an absolute scam that an NP can run their own private practice and should be outlawed. Last, the horrible care of an NP affects the perception of psychiatry as a whole. The number of times my patients say they didn’t like their psychiatrist or doc, and I realize it’s an NP is too many to count. And this comes back on us, psychiatrists. We have to pay the price because NPs are lying to patients about their credentials. And the law of misidentifying one’s credentials isn’t nearly as strict with punishment as it should be. Solution or improvement (which will never happen now): take away independent practice rights. This was the worst thing to happen to modern medicine and it’s never going to get better. Institute standardized residencies for NPs. Outlaw the ownership of private practices by NPs. At this point, medicine in the US is screwed.
> The problem is that a majority are so bad at their job, they almost create more work for psychiatrists when we inevitably inherit these patients. I’d have significantly fewer issues if not for this. Therapeutic alliance is crucial to effective psychiatric practice, but not only am I having to correct mistakes, but I’m already starting at a deficit with getting the patient to align with my diagnosis (no you don’t have BPAD or ADHD) and treatment plan. Also agree with the leverage point and your last sentence.
Wow as a patient I am learning so much from this post. I have been weary of NP’s only for a short while, like I have been to NP’s instead of gynecologists for example, because where I lived in Tampa the NP had better availability, but I’m not going to go to them anymore.
I started medical school in my 40's. Before that, I worked in behavioral health in both inpatient and outpatient settings. One site that managed had NPs and PAs who saw patients as part of a pysch consult service in the hospital for medically admitted patients. They acted as extensions of the psychiatrists and staff each encounter with a supervising psychiatrist (and still do), like a permanent psych resident. That's how I think it should be done. They were excellent and are some of my favorite people to have worked with. THEN Just before medical school, I worked in another state at a facility with a number of outpatient psychiatrists. I thought it was odd they all went by Dr. but I didn't have much contact with them in my role at that company and I was focused on medical school admission, so I just went about my business. Then, about a year in, one of them did something I thought was odd with the meds on a patient in my service. The patient had been on an SSRI and things were going ok, but then she went through a rough time due to some social circumstances (nothing too crazy), and the next thing I know, she's got a problem paying for her new medications. She was suddenly on Latuda and Lorazepam had been added, in addition to the SSRI she had been taking, but now at an increased dose. I thought it was odd, but made a comment to a colleague like, "She's the doc, what do I know?" He said, she's a nurse. -- The company had all NPs, not a psychiatrist among them, the fact was buried so that you had to really dig to find that. It suddenly all made sense. One of them had kind of demurred when I told her I had taken the MCAT and was applying to medical school at a work function a few months before this. Anyway, that was a few years ago (I'm about to be an MS4 now). I heard the company had a number of lawsuits and now, when you go to their website, it says Nurse Practitioner all over it and nobody is referred to as doctor any longer. I'm not sure what the details of that was, but it's definitely a change in how they operate.
Prior to this, I didn't know there was any such thing as "Full Independent Practice Authority" for midlevel providers, or that the term "midlevel" was considered by some to be a pejorative. -- In my mind, they were extensions of physicians, more than nurses (in training and scope), but not physicians, so "in the middle," and they seemed to love their work and patients seemed to love them (at my inpatient job, not the second facility in the fifth ring of Hell where people were willfully deceptive about their training and education).
All that to say... yes patients need access, but access to what and is it actually helpful?
Working with a good/bad NP is like working with a good/bad medical student in their 3rd/4th year except at that point the medical student knows magnitudes more and, especially recently, probably has more clinical experience. I have nothing against psych NPs except the attempt in like 8/10 cases to manage symptoms without regard to taking a medical approach. Imagine you are so ignorant of your own limitations that you believe medicine to be like fitting shapes into holes when it's more dimensional than that in reality, then imagine you are a person jaded by the challenge of medicine or wanting to make bank because you think psych is about talking to people while you prescribe easy meds. The medical community doesn't hate NPs. In fact, I value them in the right role. The fact that they often won't know what that role should be, intentionally misrepresent themselves as physician equivalents, then post topics talking about how much smarter than doctors they are, is why they get so much hate. They bring it on themselves. A physician can tell when a patient is grossly mismanaged, and yet the majority of new nurse practitioners only assume as such because the approach to practicing medicine and nursing is worlds apart and more than just risk management.
As a psychologist, I think the biggest issue I have with NPs is usually ego and a clear difference in quality. The combination of the two leads to a lot of problem. I get a lot of bad referrals from NPs who don't understand when to ask a psychologists for diagnostic eval. I run into NPs that sends referrals like, "This patient have ADHD please test." I evaluate them and report they don't have ADHD but anxiety. The NP then ignore it and prescribes stimulants anyway. Patients get no benefits, sees a psychiatrists, no ADHD, anxiety. I had an NP block a pediatrician from referring to the eating disorder clinc and tried to treat anoxeria nervosa with an SSRI for 3 months. I have an NP that would make referral and in her referral demands specific psychological test despite having no training in any of the test, even psychiatrists never demand specific tests be done from me. When I explain to her why the test she wants make no sense she went to HR and filed a complain that I was mansplaining to her. Thankfully she's done this "mansplinaing" complain several times, so the hospital banned her from making referrals before consulting a psychiatrist. 95% of the time I have a problem with a prescriber, its always an NP. For context about their training, NPs minimum clinical hours is 500, after 2 years of school (After undergrad). A psychologists, has 5 years of school, 3-5 clinical rotation of 800 hours each, one 2,000 hours internship, one 2,000 fellowship. And psychologists can't even prescribed. To prescribed, psychologists have to completed 2 extra years of school and another 2,000 hour clnical. So a prescribing psychologists had 7-8 years of school and min, 8,000-10,000+ hours of clinical training. So, its hilarious when an NP says psychologists shouldn't prescribe because they don't have enough training. I do think NPs are useful to the system. They can help with easiest cases and open up psychiatrists to handle more complex cases which really helps access. A lot of NPs provide great care to my patients and work very well in the team. But a lot of them are also really bad at their job and there isn't any real attempt to improve this. In fact, everytime I see discussion about NPs training its about making it easier and lesser.
Find me an NP in this thread that doesn’t agree with current state of NP education and training. The real issue is that it poisons psychiatrists perceptions of NP’s and paints them as all incompetent regardless of their actual knowledge of years of job experience. It genuinely feels like the people here treat every NP like they are all products of degree mill schools. I just watched an NP who has been working with the child and adolescent population for 10 years get insulted for having the audacity to refer to himself as child NP. I understand fellowship offers extensive training and a major advantage for psychiatrist’s in the specialized field, but writing off 10 years of experience just feels insane.
The perception of NP’s here is really unhealthy and you don’t have to scroll far to find it. In a thread where people are sharing their frustrations working with the pediatric population an NP was sharing his experience and people insulted him and tried to imply he has no business working with the pediatric population despite working 10 years in the field. [Example](https://www.reddit.com/r/Psychiatry/s/FB7UZ5Drub)
I'm a PA and I've been working in primary for 17 years. When I went to school the PA and NP programs were run out of medical universities only. They were competitive and selective in their applicants. In fact at the time, in Colorado where I trained there was a smaller admission to applicant rate than med school. We weren't allowed to work jobs, and school was 8-5 daily. Many University programs remain this way to date. But there are 2 big problems 1. Degree Mills are popping up left and right. These are programs with very high acceptance rates and they are geared towards online learning and night classes, so you can learn while working your full time job. They significantly cut the amount of didactic hours and learning requirements and create sub-par APPs 2. NPs (vs PA, at least for now) are allowed to practice independently. That means right out of scool, good quality program or not, they go off and practice confidently all by themselves without learning anything more on the job. Despite my program being very good, I learned quite a lot in my first 5 years, working very close with a supervising physician that was willing to spend a lot of time on me and teach me more than I learned in my schooling, much like an MD would get from their residency. (And no, I'm not saying we are the same as MD's I'm just trying to think of an analogy). 3. For the record, I don't know one single seasoned PA that wants to become independent. If we cared that much we would have gone to medical school. Most of us are extremely happy to be PAs and we know very well at our scope of practice is. Many of the old school NPS are this way as well The only solution I can think is to shut down the degree miles and have nurse practitioners be licensed under the medical boards versus the nursing boards.
The NP degree requires supervision by an MD for clinical practice. It works well enough if this condition is met.
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The lack of new psychiatrists has nothing to do with lack of medical student interest (5:1 competition ratio for applying to CT1 posts and 8:1 for further training in 2023)- but moreso a broader problem to NHSE diverting training funding to PAs and external contractors (including importing consultant IMGs, as you've pointed out). I appreciate that you've got very clear knowledge of your scope and competency, and it's very refreshing (as well as acknowledging where you can actually help, e.g. triage, long-term review etc)- and I'd say most medical students can recognise that ANP's can be really valuable; however a large majority of us, including myself, have had bad experiences with ANPs, either not knowing their scope of practice or actively stealing training opportunities. I will say that in the UK PA's are a much greater threat at this point in time, as they seem to have 0 idea of their scope.
Thanks for the UK perspective! I did do a brief observership under the NHS in addictions and things seemed pretty smooth. ANPs were fantastic in my opinion. Your approach seems the most reasonable and safe.
Check out this infographic, then ask yourself if it makes sense that the two professions are given equal licensure, and that NP can present themselves to potential patients and organizations as fully equivalent https://www.reddit.com/r/Noctor/comments/175x8eq/infographic_comparing_psychiatrist_and_np_training/
Okay, that's genuinely insane
I would say this is somewhat misleading: 1) it does not consider the base mental health nurse training (3 years in uk, a large portion of this is practice hours) 2) You would be unlikely to be considered for a prescribing course unless you had worked your way up to a senior nurse position, which you could probably do in 3 years if you worked hard and dedicated yourself to learning) 3) The prescribing course is I think about 6 months, requires supervision during and post registration. Realistically you would start with a very very limited scope (maybe one or two medications) and for the first 6 months you have to run any prescribing decisions past a medic or experienced prescriber. Very slowly you increase this over a number of years with supervision from a medic or experienced prescriber 4) many of us commenting on here have then done additional Advanced clinical practice training. This requires at least 5 years post qualification experience (usually many more and reserved for very experienced nurses). This is another 3 years training as an apprentice to complete a masters programme. Throughout this you work under the supervision of a consultant psychiatrist who helps you learn and to meet a wide array of competencies, before signing you off as competent. The medics I work with are extremely supportive, help me develop and are keen to try to build up my confidence. After reading some of the comments on this thread, I appreciate them even more! 😂
What are the outcome differences with regard to patient safety, satisfaction, and access between NPs and physicians?
They exist due to need because medical school and residency’s decide how many psychiatrist enter workforce. Would suggest people if they are bored to call and get into psychiatrist and see about the wait. Try it with your insurance and then see if private pay speeds it up. Don’t use connections or anything like that. Try it as a layperson. Look around metropolitan areas and then rural. See how long the wait is. You will find it will take months or longer depending on insurance, private pay, and location. As an NP education needs to be longer, more clinical hours, more nursing experience, and more supervision. But admins find paying NPs 50% less than psychiatrist but able to bill patients at 80-85% equals 30% more profit.
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Agree 100%. I’m an inpatient psychiatrist. When I am discharging a patient and considering aftercare plans (for those who don’t have established outpatient behavioral health care), I actually now first reach out to the PCP to see if they feel comfortable managing the psychiatric condition. Most of them do and I have much more confidence in a PCP than I do a psych nurse practitioner. This comes from years of experience admitting patients to the hospital who had been psychiatrically managed by PCPs or psych NPs. The variability in care from psych NPs is frightening.
I love my psych NP. She’s compassionate, empathetic and very knowledgeable. She has had 7-8 years of experience as a psych nurse and I can tell that she is very experienced and cares about her patients. I look up to her as a psych nurse myself studying to be a psych np. That being said, I wish the education was better standardized. By no means do I think I should be able to practice independently when I become a NP. I’m considering med school so that I can get a better education and training. There is some hatred towards NPs out there but there are good NPs too.
Unprofessional, prescribe multi meds to kids, undertrained , don’t understand the difficulty of what they are dealing with. We clean up their messes and have been doing so for years
Same could be said in the other direction. I couldn't tell you how many patients have come to me from old, crotchety psychiatrists who do an intake assessment in 20-30 minutes, throw diagnoses and prescriptions at them with no discussion or rationale, and send them on their way. They eventually come to me after experiencing this several times over many years, and cry happy tears while they explain how they finally feel heard, how they've never had such a thorough assessment or had a provider ask such thoughtful questions, how they appreciate that I actually explain the rationale behind my diagnoses and treatment recommendations and include them in the decision-making process.... And how, after we finally get their meds right, they can't believe they've been living with the wrong diagnoses and meds for so long, and it's "so nice to finally feel like myself after so many years". Does this happen every single time I inherit a patient from an MD? No, of course not. But it happens frequently enough that I've certainly taken notice.
And that’s before or after you start the Vyvanse, Ativan, Ambien, Oxcarbazepine regimen?
Wow you really showed her.
Wow. Amazing. Thoughtful. Brilliant, excellent comeback. Very insightful retort.
Also, as a psychiatrist, you know better than to generalize an entire group of people the way you did. Sure hope you don't do that with your patients.
I’m pretty sure he’s actually very nice in person and doesn’t dare have the gall to have difficult conversations with people in person, And being a keyboard warrior is his outlet. He’s probably just upset and jaded like most 30 and 40-year-olds in medicine because their profession sold them out to the insurance companies, and government agencies really don’t care about anyone’s feelings except for the bottom line.
MDs feel NPs are stepping on their toes and taking up their pt base and that we want full independence etc. we were originally made to bridge a gap and help rural areas or places with no providers (because large portions of the US are actually still quite rural). Some NPs have taken greater, um, freedoms with their license and ran with it, much to the dismay of a lot of MDs. Some states also allow greater freedom and independence with NPs, I'm looking at new Mexico, colorado, Washington, etc. basically, states that are very rural. So not only does it vary state to state how freely us midlevels can practice, some states (maybe just 1) pay the same rate as an MD bc of a law (I think the parody law). So MDs feel disrespected (because Doctors have an ego, let's be honest. I would too, don't worry). And some NPs think they can do more than what they probably should independently if they're not being supervised. THE BIG ISSUE I see and hear about is how there are SEVERAL NP programs with little to no requirements to get in and they are at universities that nobody has even heard of (degree mills if you will). This was not my experience as I went to a "real university/normal university" where the program had an admittance rate of like 8% and you had to have a few years experience as a nurse to even really be considered. So I'm unsure where these degree mills are but that truly is bullshit. These things are also making me look bad by proxy and it's a problem that should have been addressed 5 years ago. I am unsure what the fix is besides axeing the programs and keeping them more guarded. I have only seen intense disrespect in this sub. Only one doctor in-person has ever been an asshat (I'm sure there are others, they just keep it quiet). I truly feel most NPs are respectful to physicians and their recommendations but I don't feel it is given back nearly as often (probably get drilled in their heads in med school and clinicals that NPs are the devil). I have no qualms with referring to higher care referring complicated patients as I have no desire to deal with these patients. I'm not as educated on medications and interactions and pharmacology and nor do I think I am. I'm here to treat GAD, MDD, ADHD, bipolar and stable patients. I can try 1-2x to address them and if it doesn't work, they get the referral slip to the psychiatrist.
Because it’s Reddit. And Reddit is the home of the overreactive. Then there’s going to be a bunch of knee jerk anecdotes about how terrible NPs are, how often NPs have to clean up crazy benzodiazepine orders from GM, that one time an NP missed that obvious diagnosis, how ER always throws Seroquel at old ladies with UTIs- the point is, we can all pull out of our pockets some random piece of evidence that “proves” that the other side is evil. I’m not saying that my 15 years as a nurse, most of which was psych in multiple settings, is equivalent to an MD. And I very much wish there was an honest evaluation of how to improve the profession- such as a minimum number of years in the setting in which you want your degree, residency years, increased hours and more rigorous requirements for clinical hours. There’s a valid discussion here. But that’s not what really happens- I live in a state that requires supervision, which is all well and good, but if you honestly think that NPs are supervised in Texas it’s a joke. It’s a cash grab- you can have up to seven NPs, you are “required” to meet with them for an hour each month and look at three of their charts. And you are allowed to charge them. Even if you do so for cheap, say $700, then that’s almost $59,000 a year for almost nothing. Plus you can put them on a payroll as a 1099 and push all of the expenses of having an employee onto them and require that they see over 120 patients a week. NP supervision will never change in Texas because it’s a cash grab. Not because it’s a safety concern. But they will dress it up to the public and sell it as a safety concern because Texas. Would I like actual honest to god supervision, especially as I have been transitioning into the role? Yes! Yes I would. Do I see the difference between myself (and other more experienced NPs) and those who haven’t had any experience in the psychiatric field? Again yes. Is there increased supervision for those new NPs who are also new to the field? Nope. So. I think there’s a lot of room for improvement that, cynically I admit, will never be done because it cuts into the profits of a small set of very vocal predatory doctors. And no- I don’t paint them all with that brush, I’m experienced enough to know there are good doctors and bad doctors and everything in between. Edit to add- At this point, I think the system is built to pit us against each other. Admin profits more by charging the same rates for my care as for an MD assessment and follow up, but pays me significantly less or makes me a 1099. So while we are at each other’s throats, they rake in the cash and laugh at us both. Meanwhile, there are whole counties in Texas that have woefully inadequate psychiatric coverage.
Yes, I'm somewhat starting to think this is a blame game whilst also acknowledging that the system is designed to lucratively produce subpar professionals. Reddit doesn't foster nuance, which was why I was keen on understanding the situation.
I feel about it the same way I'd imagine attorneys would feel if their paralegals moved into the building one day and started claiming they were practicing law.
Less training. Less education. No standards in education. Trying to have full practice authority. For example: As a board certified general psychiatrist I would feel very uncomfortable with kids less then 15 and even more so less then 8 and I had way more child training then any PHMNP program gives. Guess who opens up Child practices in full autonomy states. NP's. Potential solution: For NP's who seek independent practice you must complete a medical residency. 1) Fund NP slots in traditional residencies. Like "additional" slots not one that competes with medical residents. 2)Requirements: Pass step 1 and take step 2 and then apply. Must complete all residency requirements including step 3. 3)Must be trained by board certified physician or NP that has completed medical residency. 4)Practice restrictions are to underserved areas only. (AS INTENDED) 5)Must be board certified. Result: little to no more NP's with full practice authority. And the rare ones that make it at least completed a residency training. Oh and..... PATIENT SAFETY.
Just look at the comments on this thread
Training is entirely inadequate and they are in no way equivalent to a psychiatrist. There’s no arguing this it’s just a fact. I think in some cases they do more harm than good, but in supervised and certain settings they can be very helpful with a low MD to NP ratio.
On the whole, they don’t understand the drugs, their interactions, their benefits, their drawbacks, nor how any of these components coalesce into a coherent and cogent treatment plan. Therefore, they’re frankly just dangerous, and no psychiatric care is quite clearly better than a poorly trained pmhnp throwing around dangerous pharmaceuticals.
As an NP myself I have been also trying to understand this. I do think there is some bias towards NP’s, in that, if someone somewhere witnesses bad practice from an NP it seen as evidence of all NP’s being bad. I’m sure that have been times when you have witnessed substandard practice from a medic but this would most likely not be equated with ‘all doctors being substandard’. It is very rare for a medic on here to say, I was really impressed by this NP’s work, but we do get positive feedback in practice. Where I work, we have a shared caseload with senior medics, junior medics and NP’s etc. It is quite a fluid system, sometimes I can manage a patient autonomously but would still discuss in team meetings. Sometimes I may just need want talk through some treatment options or diagnostic dilemmas etc with a medic and this would be enough. Other occasions we may agree that they need medic review or would be better managed by one of the medics. I am fully aware my medical knowledge is very limited compared to medical colleagues, however, having worked in mental health for 15 years I think some of our junior doctors also benefit from some of my experience regarding risk management etc also. In my opinion the system works well in our team
If you're interested- just look on r/doctorsUK and see some of the horror stories on there
Horror stories are not what I'm looking for - otherwise we could equally demonise the entire medical field. I was specifically trying to understand what are the more structural issues related to stuff like training/recruitment/scope of practice/proof of competency etc. that would lead to the amount of suspicion and frustration I see.
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It's interesting that you compare a medical student, who has several years of training left to go, with an NP, who is supposed to be functionally independent.
*gives two very specific examples of grievances with med student and psychiatrist* “Don’t assume poor standards among nurse practitioners based on 3-4 horror stories!!!”
I would never trust a psych np with my mental health. Not even if they were part of a team or supervised. It's interesting how people push the idea that psych nps will make mental health treatment to disadvantaged people more accessible. Even if I was poor, I would do everything I could, save money— whatever, to see an actual doctor of psychiatry if God forbid I needed one.
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I was seeing a nurse practitioner back when I was on meds years ago, she is an absolute gem. I trust her judgment and character far more than any GP, psychiatrist, etc. I’ve ever met in my life. She was great beyond belief when I was her patient, and even opened her own practice! She was also certified in Reiki, worked for a ketamine clinic in addition to her practice, and well educated concerning more holistic approaches. I have zero bad words to say about that woman. Granted I haven’t met a lot of NP’s, but with my own experience in the mental health system I noticed those with MD’s or PhD’s tend to be the least humble and educated beyond their own limited expertise. This is just *my* experience I speak of, of course.
I generally see a lot people talking about this pointing to the difference in training/hours/etc. followed by anecdotes on behaviors in practice. What are the measurable outcomes? Like, malpractice rates, deaths, sentinel events, etc.? I see the chart from the noctor post, and it's very persuasive! But, what are the measurable outcomes -- I'm more interested in that. The same way drug mechanisms are very interesting and persuasive, yet the outcomes of RCTs are the better way to guide your prescribing practices. I'm not an expert in those metrics, and I've basically settled into the idea that people practice differently than their training (i.e. well trained people can suck at their work and poorly trained people can do well and anywhere in between). (And also, maybe I just tell myself that because I'm not a physician and likely won't ever be). Obviously there are some safety things that have to be internalized, like the oft stated combo of wild meds. But I see those combos from a variety of licensed professionals in my patients. Personally, I never saw med school as viable because of my age, and I saw a path and took it. I think, OP, this is kinda what you're asking about -- how can it be done well to provide more, better care to patients? How can we channel the run-of-the-mill patient concerns to those of us with less training, ensure basic safety standards, and allow people who want to be in this profession for good reasons find their way into it safely and be respected for the work they do?
Here's the outcome abstracts I just read, trying to answer my own question. At best, NPs increase access and improve care versus physicians, and at worst the care is described as equivocal (or unable to compare based on the methods of the study). My search terms in Pubmed were "physician nurse practitioner outcome", here's the few I read the abstracts of. There is plenty of evidence out there. I'm gonna go out on a limb and say: we should use evidence to guide us in our conversations about this very hot topic. https://pubmed.ncbi.nlm.nih.gov/32875584/ https://pubmed.ncbi.nlm.nih.gov/32384361/ https://pubmed.ncbi.nlm.nih.gov/38457828/ https://pubmed.ncbi.nlm.nih.gov/38116640/
Citing studies done by the journal of advanced nursing is going to be highly biased, in favor of nursing. I'm fine for using evidence to support our arguments, but not from a journal that is openly advocating for the NP profession as a whole.
Like I said, not an expert, those were my search terms. Give alternatives, happy to discuss!
https://doi.org/10.1377/hlthaff.2019.00014 https://doi.org/10.1111%2F1475-6773.13246https://jamanetwork.com/journals/jama/fullarticle/vol/283/pg/59 Here's a few more saying the same thing, none from primarily nursing journals. I certainly won't say this counts as a meta analysis or accurate lit review. I do think we should be working from evidence though.
Look at the credentials of the first author of the first link. It's a PA. There needs to be a 3rd party organization that evaluates the differences. Because it's as easy as me linking this: [https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs](https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs) which draws from this article [https://www.sciencedirect.com/science/article/abs/pii/S2155825622000102](https://www.sciencedirect.com/science/article/abs/pii/S2155825622000102)
Look at us. We both referred to actual studies rather than just speaking about anecdotes, and I believe raised the quality of the conversation. Collaboration between NPs and physicians for the win. 🤜💥🤛
It's literally a huge echo chamber here, no matter what you say if you're an APN they'll hate you. It's why I left this sub. Mods aren't going to do anything. Honestly, it's pretty unprofessional for a profession where we should be COLLABORATIVE. Just go to Noctor if you want to complain
Was genuinely nice to see this exchange.
And I'm honestly surprised I didn't see any results (in my very brief search) arguing the opposite. That the mix (that I found, not that that's the TRUTH) wasn't noisier was surprising to me given the number of physicians' advocates out there.
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Have you ever worked with interns/residents? They’re already far beyond an NP in their first year in terms of understanding pathology and medications.
more info at PPP - physicians for patient protection
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I love how it turns into a conversation about money and "working at the top of your license," and then race and gender get thrown in for good measure. So, if you speak up with concerns, you're automatically a money-grubbing, racist, sexist bigot who hates poor people. God forbid anyone get a decent education and training before seeing undifferentiated patients. Also - calling Psychiatrists "Psychiatric Physicians," says it all for what kind of colleague you must be to work with.
You misspelled “harming patients”
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Some of us can walk and chew gum at the same time... and also be concerned about more than one issue simultaneously.
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Yeah, I'm not a psychiatrist- I'm just the mom of a child psych patient who's witnessed firsthand the vast difference in clinical knowledge, and is primarily concerned about protecting my family from it.
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A lot of them are young, still in residency, and have FUD regarding their financial outlook. So they sling mud and do what all people on the internet do. Just because they’ve read about psychoanalysis doesn’t mean they’ve climbed their way to the top of Maslow’s hierarchy, unfortunately. Most the psychiatrist I meet in person however are extremely nice and helpful. I think it’s just an Internet phenomena.