Apr 25, 2014

Chatter from young psychiatrists

I stumbled on a message board for young doctors, offering a treasure trove of anecdotes about the current state of psychiatric practice. The issue at the start of the March 2014 conversation was a doctor who felt threatened by an influx of nurse practitioners (NPs). Medical doctors have significantly more training than NPs, but the economics of psychiatric practice may not reflect that differential. The conversation veers off into a discussion of the standard of care that patients demand, or are entitled to.

This is a mere bundle of anecdotes, to be sure, but a fascinating bundle. I've clipped bits and pieces from the discussion thread. It's pretty raw for doctor talk.

With what I see the psychs are seeing more patients an hour. My guess is that there are a couple reasons for this:

1) the pt is likely to get even more upset if a nurse rushes them in an out in med check style in less than 5 minutes. If someone who is an md does it, they may just assume that is what md's get to do or whatever. But if a nurse treats them that way....(again not saying it's right, but that may be the perception)

2) the psych(competent ones at least) is more likely able to practice whack and stack psychiatry because they usually can identify obvious pharmaco no-no's quicker almost as a reflex, whereas the psych np may have to think about those things for a second. So in a way the greater fund of knowledge of the psych allows them to practice relative safe whack and stack psychiatry easier.
I can't solve all the mental health problems.
But I can help the people who want my help and appreciate it.
I think people in medicine come from pretty sheltered (and generally affluent) backgrounds, which can limit our work with our patients.
The nurse practitioner question

Replying to "As far as the public goes, they can suck it. They benefit from residents keeping the lights on in Americas hospitals then then they can pay for it. It and the years of effort and sacrafice it takes to make a doc. They want to replace us. F@ck them"

Unfortunately, doctors being entitled and telling the public they treat to just suck it is one of the reasons we're fighting the things we're fighting.
This post makes me think about crossing psychiatry off the list of potential specialties. Only 1% from my school choose psychiatry in the last match, and I can't see how anecdotes of NP's replacing psychiatrists will do anything except scare off more med students and make psych even more unpopular.

The argument that psychiatrists don't have to worry about their jobs because they add more value than an NP would be laughable to a hospital MBA, owner of a practice group, or insurance exec. Adding value means adding money to the bottom line. NP's add more value than a psych if they cost less but generate the same amount of revenue and have the same malpractice risk.

Seems like the only people who care about "quality" are the very small subset of patients who can do cash pay. Otherwise, the general public has no say on the quality and value of their psych because their 3rd party payer dictates what is "value". The public only cares that someone in a white coat accepts their insurance, can see them in a timely manner, and won't kill them. It's a low standard that NP's can fulfill, just like the masses of IMG's and assorted folks who couldn't match into anything else are doing now.
I haven't followed this whole thread so I apologize if I'm repeating anything. But I just wanted to jump in, because the issue about NPs interests me. I started a job last summer after finishing residency. It's mostly outpatient with some inpatient coverage. Overall it's going pretty well. Certainly it's an improvement upon the horrors of residency. But my fellow psychiatrists here each supervise one if not more NPs, and their NPs cover the inpatient unit too. Sometimes I come on call after them, and am then asked to discharge patients the NPs have admitted and followed. The thing is, they make some astonishingly poor medication choices and their notes are the worst notes I've ever seen. At times it's impossible even to understand why they are in the hospital and what has been done. So when I have to discharge these patients I am pretty nervous. They no longer meet commitment criteria and I end up having no choice. I try to document that I recommend they stay in the hospital and recommend they try medication X or whatever instead of whatever they're on, but I imagine this documentation only will protect me so far. Last week I had a patient bounce back after such a discharge. The guy was taking 20mg q4h PRN of zyprexa for anxiety. Yes, that was one of his meds. And risperdal BID. There was no good reason mentioned as to why. Obviously I did not continue the PRN zyprexa when he left. But I don't know if the antipsychotic effect was actually helping? There sure were no notes to guide me. The diagnosis wasn't consistent or justified by his presentation.

I do think the NPs have a good rapport with patients and I'm not trying to discredit them, but I worry about my own liability coming on after them. There's no way I'll bring this up with my colleagues - I'd quit before I'd confront them because I suspect they'll be defensive, not to mention they'll have illogical justifications rationalizing how they are "working with" the NPs, and I don't want to hear it. Plus I'm in a different part of the country than where I did residency, and the medication philosophies seem to be different here. Not that it was perfect where I was for residency, of course. But even from local psychiatrists I'm seeing these gigantic doses of layered on antipsychotics, and a lot of polypharmacy. Benzos and adderall are big. Psychotherapy is done by social workers largely and from what I hear, most patients aren't big fans. Can you blame them? Maybe it's because I'm not in an academic environment, maybe that's the problem. But academia has its problems too...

1) Psychiatrists don't come up with differential diagnoses. Internists do. In psychiatry we have about 10 or so conditions we routinely use, and almost invariably the patient gets fit into one of those 10 or so, rather than a genuine process of "differential diagnosis" occurring. If you disagree then tell me the last time you made a serious list in your "assessment" section of what the problem could be, and what specific diagnostic tests, procedures, or observations you were going to do to "rule out" some of the possibilities and "rule in" others.
2) Risk assessments in real life are boilerplate. They are written with the intention of justifying whatever decision was made. They are not written and then used to make decisions.
3) Dispo arrangements should have already been done by social work.
I disagree with the differential comment. I think working through a DDx both in your head and in your notes is a useful exercise, and can help keep your mind open to different (and maybe less likely) possibilities. Probably most useful with a new patient with no known psych history. Also useful on consults, and with patients who may or may not have a personality disorder clouding their picture. I think dismissing the entire approach of using a differential (at least for difficult or complex cases) is throwing away a useful tool and strikes me as pretty sloppy. You could miss some important stuff (i.e. that "easy" case was actually complicated by heavy substance use that nobody knew about, or that simple delirium consult had focal neuro findings from a brain met that nobody really checked for).
For those of us with more experience, the differential is usually fairly simple - when I admit a psychotic patient (psychosis nos) I know that I will probably need to start an antipsychotic and if the precise dx is not known, start the work up (or suggest the workup if it is a weekend and there aren't SW's around to help)- get collateral history/check labs/get old records. Usually the diff involves primary vs drug-induced, with the rare neurologic/medical etiology. When I admit a pt, I usually spend much more time thinking about their comorbid medical problems (HTN, DM, etc) than the differential. You got to get the patient stabilized and then fine tune the diagnosis during the hospitalization. I am of course talking about psychiatry in an inpatient environment.
Now not every inpatient falls in the category where it doesn't matter if you work really efficiently and finish it up quickly vs taking a thorough and slow approach, but many do. For every 100 inpatients you see, think about how many are patients where the outcome and/or care isn't going to vary whether you spend x minutes or 4x minutes. A *lot*. At least at the different inpatient places I've worked. Yes, it does take a good bit of time to go over pt education with a low functioning family whose 19yo son is in the hospital for the first time with psychosis. But for every 1 case like that, there are 5-6 that don't have issues where time is required like that.
Now for the most part I don't think inpatient is where patients really get better or where much of anything positive happens....and that's why I'm not going to do it. But if I did do it, I think I would be pretty darn efficient at it.
Ummm what?? Are you serious about not having a differential diagnoses. I view psychiatric disorders as diagnosis of exclusion. Everyone gets a medical workup and drug screen. Anything less and you are providing substandard care and essentially not using what you should have learned in medical school. Can't say how many times I have pressed this point to medical students and insurance companies that initially deny tests only to approve it after I contact them. I have found tumors on MRIs, (+) syphillis tests, obviously numerous sub induced disorders including bath salts, etc...
People are talking about psych NPs encouragement on psychiatrists and us needing to shorten our training. What needs to happen is that within our own speciality there needs to be a better standard of care. I may poke fun at some NP med management skills, but I am appalled at some of the diagnosis and polypharmacy that is rampant in our speciality and it is quite embarrassing.
Deliver better standard of care and show superior results compared to the NPs.
As far as jobs go, everyone in my program landed a solid job. One has the same setup as ---. 60 min intake, 30 min follow up. 215K.

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