FNP to PMHNP--Is it Better?

[raycna]

Hello, 

Has anyone made the switch from FNP (primary care) to PMHNP (psychiatry)? If so, what were your reasons, and was it worth it? 

I graduated as an FNP in 2020, completed a yearlong residency, and though I'm doing fine at work, I'm struggling to find work-life balance and am really disillusioned with how little time I have with patients and how rushed our visits are.

I am considering the post-master's PMHNP certificate because I want to have the luxury of time to spend with patients--at both of my jobs, psychiatry gets 30-60 minute appointments with patients versus 15 minutes for primary care. I also like the idea of flexibility. It seems psychiatry has more options for remote work. Becoming an expert in one area, rather than a jack of all trades, also appeals to me. 

I'd love to hear the perspective of people working in the field. Perhaps the grass is not greener--I want to know before I drop another $40k on school ? Thank you for insight!

[Li Lei]

Hello, 

I've worked in Psych for over 20 years and actually own 4 practices, Have worked on mergers, acquisitions and the day to day.  I prefer Psych over the work I've done as an FNP however, I have generalized in Primary care with my FNP and that is the work I did not prefer. With saying that,  I also branched into aesthetic medicine about 2 years ago and love this and would not have (as much) credibility with just a PMHNP.  

We do 45 minute new patient evaluations, 15 minute med checks (30 at times if clinically indicated) and average 32 patients per day. So its the same time increments almost as Primary. With saying that the patients comes in more routinely and once stable the visits are fairly smooth sailing so that is nice as well.  If anyone has specific questions about Psych or starting a Psych practice etc. I would be happy to answer them. I can be reached at leidy at USC.edu

[Rnis, BSN, DNP, APRN, NP]

I am dual certified and just made the switch to psych.  I think it is too early for me to make a judgement call.  My employer, made pay structure changes to the FNP position that were not acceptable to me (it actually raised my pay but drs. got paid extra/or penalized  for my productivity(there was no reward/dock for me)) and this felt uncomfortable for me.  This spurred my decision to do the post-grad program, which I had already been considering.  

I was very comfortable in the FNP role and and generally ran on time and left on time so there wasn't a huge burnout issue for me. I got 30 minutes per patient...no matter the issue. 

In psych, I get 60 minutes for new and 30 minutes for follow up.  I am still building my practice so I am not full yet.  I had already been doing a lot of mental health prior to the transition, so I feel like it has been a fairly smooth transition. However, the needs are high and it can feel a little intimidating. There are also a lot of controlled substance dumps from their pcp and that can feel really frustrating. A lot of patients do video visits, and there isn't a lot of interaction between co-workers(we are all hybrid), which is something I really miss about family medicine .  I don't hate telemedicine, but I really enjoy when patients come in person. 

I did get a pay raise with the switch which was nice. 

[LibraSunCNM, BSN, MSN, CNM]

Tagging onto this thread as a CNM who lurks frequently due to an interest in mental health.  I've always been interested in psych although midwifery is my original passion, and someday as I get closer and closer to not being physically able to works nights as often, I may bite the bullet and get a post-master's in PMHNP. 

Question for those of y'all working in psych, though--how much of your practice would you say involves working with patients with ADHD?  As a mom and an APRN I feel like I've seen an explosion on social media in the last few years of adults, particularly women, getting diagnosed with ADHD.  It's like the hip new thing, it seems like, and because it presents differently in women, their symptoms have often been overlooked.  I wouldn't say I look down on any one particular psych diagnosis over another, but I'm not super drawn to assessing and medicating ADHD in the same way I am about, say, perinatal mood disorders.  Do any of you psych providers simply choose not to manage ADHD and refer elsewhere?  My fear would be fielding constant requests for stimulants (not that there's anything wrong with needing/taking stimulants, but they're obviously inherently trickier given their addictive nature).  But I would want to balance that with being able to offer relatively holistic care, rather than cherry pick patients.

Sorry if that's a bit of a ramble.  Just curious what others in the field are seeing/doing and how you manage it.

[Li Lei]

This is a great question. If you are in an outpatient practice that screens clients, (as the one I work at does) then this is an easy request. Yes, we do have some providers that choose not manage this at all. We often will refer to the Psychologist for psych testing if we are on the fence and if they are an adult then 1 of 2 things... first, they most likely have been dx in childhood and treated or 2) if they have not and insist they are ADHD but not previously treated and I do not see the presentation to support the dx, I encourage them to do therapy to work on ways to manage their symptoms b/c I'm not going to treat just based on subjective data alone when it comes to anything controlled (this also includes anxiety eg:benzos) Ultimatey, you can shape the clients you treat and the practice you want to create. 

[LibraSunCNM, BSN, MSN, CNM]

Li Lei said:

This is a great question. If you are in an outpatient practice that screens clients, (as the one I work at does) then this is an easy request. Yes, we do have some providers that choose not manage this at all. We often will refer to the Psychologist for psych testing if we are on the fence and if they are an adult then 1 of 2 things... first, they most likely have been dx in childhood and treated or 2) if they have not and insist they are ADHD but not previously treated and I do not see the presentation to support the dx, I encourage them to do therapy to work on ways to manage their symptoms b/c I'm not going to treat just based on subjective data alone when it comes to anything controlled (this also includes anxiety eg:benzos) Ultimatey, you can shape the clients you treat and the practice you want to create. 

Thank you for your response!  That is very helpful.  Anecdotally, do you also feel like the number of adults getting diagnosed with ADHD is spiking lately?     

[Li Lei]

No, I don't.  The percent of adults we see for ADHD is roughly 25% and of those sure there are some malingering but our practice has gotten smarter too.. they have to come in monthly, they can't fill early, they have to be employed (else why else do you need a stimulant to "focus"), have a history and/or clearly symptomatic. Sometimes we try a non-stimulant, or sometimes, if there is a history of addiction it doesn't preclude them from receiving a stimulant but we may have them come in for random pill counts, for others we are conflicted about we do UDS to show they are taking the meds versus selling.. lots of ways you can show due diligence and reduce diversion. This gets around and others think twice about coming to you for pill shoppoing. With saying that.. we find more PARENTS taking their kids or diverting their meds than adults coming in that do not meet criteria so if this is your concern you will see in the pediatric population as well. You could always say at screening, "we do not treat ADHD/ADD with medication" and that eliminates all the hassle. I have found some parents that work with me on sleep hygiene plus diet to reduce symptoms and with working with teachers on a behavior plan can manage children without medication. 

[psychrn5]

StellaAnn said:

I have spent the last year in a post-graduate PMHNP program at George Washington University, and just graduated. Personally, I think the work of a PMHNP is more rewarding compared to FNP. I feel like I am really helping my clients achieve their goals. There are more people than ever seeking mental health care, which is great for job stability...and being dual certified will help make you more marketable. More perks: the pay is higher, and yes - remote work is more accessible for PMHNPs. I have to say, with regard to remote work, it's only worth it if you're licensed in a lot of states or have a large local client base who prefer telehealth. I have been working the last year remotely for three national telehealth companies as an FNP, and the licensing is VERY expensive and tedious to keep up with. I was lucky enough that one of the companies licensed me in about 20 states and has paid for my licensing renewals. Most of these telehealth companies are start ups and have more negatives than positives IMO. The pay can be inconsistent, pill mill vibes (Cerebral is a good example), scheduling is inconsistent, always restructuring something, internal communication is weird, lots of lay offs, and typically there are no benefits as they're 1099 positions.  Also...most telehealth companies specializing in mental health do not follow the standard of care, only allow 30 minute intakes and 15 minute follow-ups. With that said - I'm heading back into the office for a new behavioral health clinic job because consistency in pay, 1 hr intakes and 30 min follow ups, and benefits are very important to me...and I want to work closely with a team especially as a new PMHNP. 

@StellaAnn did you feel the GW post-master's NP Program prepared you well for the PMHNP role? Did the program help you get good clinical experience?

[Randall Sexton]

I am a civilian PsychNP working for the Army, which is better than being in the Army, and have done so for 11 years at the same post.  We make more than the FNP's and they scramble all day long vs me who sees up to 7 patients a day. I get 1.5 hours for intakes and 30" for follow ups. I don't have to stick my fingers into orifices or collect specimens and I have a sit-down job. I have an RN that takes care of med reconciliation and VS for 3 of us, 2 PsychNPs and one psychiatrist.

I work in a multi-disciplinary clinic and we also have other PsychNP's and psychiatrists working in embedded behavioral health units. My clinic is in the hospital and we also have a small inpatient unit. All of us prescribers provide on call coverage for the unit. When on call we take our laptop home and when a social workers evaluates someone in the ED that needs admitting we crank up the laptop and put in admission orders. The prescriber covering the unit will see the patient the next day. We also make rounds on about 1 weekend every 6 weeks. We, civilians vs active duty prescribers, get pain doe being on call as well as when we go in to make rounds. This easy work really jacks up my pay! 

I really enjoy my patient population which ranges from age 18 to 40-50 active duty Soldiers. Unlike in the community mental health clinic which I worked in for about a year and seeing patients every 20", all my patients have easy access to meds and other healthcare. Almost all my patients have sleep issues so I have advanced training here as well as for PTSD. I've also trained in hypnosis which is about the coolest intervention ever! Most days my notes are completed the same day. I'm 72, by the way, and intend to work until I no longer enjoy driving to work. The psychiatrist in the office next to mine is in her 80's. I like to work out with elastic bands which I usually have time to do so between patients. If I was motivated enough I could go across the street to the fancy gym to work out. I had back surgery 07 April and went back to work via tele-health visits from home on the 24th. I would not want any other profession, other than rock star, at my age!

If you have any further questions let me know.