I HATE Nurse Practitioners

[Angeljho]

So the director of psychiatry and some senior psychiatrists at my hospital are in a funk. It appears surrounding hospitals are offering incentives (increased salary and other benefits) to attract psychiatrists to their institutions - and its working. So far, we have lost four psychiatrists in the past five months to nearby hospitals that are offering those incentives. Those facilities also hire FNPs and PMHNPs whereas my hospital doesn't. Clearly there is no way for my hospital to match the benefits of the other competitive institutions and there is a huge shortage of psychiatrists in the area. So... I suggested that we start hiring NPs.

Bad move.

I never seen so much hatred from health professionals. One of the senior psychiatrists actually shouted at me for coming up with "a stupid idea." He then proceeded to tell me how many years of schooling and training he's had out of some need to compare himself to a PMHNP. What really bothered me is that the director said, "I HATE Nurse Practitioners" as if that was a good enough reason for not hiring them in our facility. What they think is what they think; I can't change that. But would I be overstepping boundaries if I drew up a presentation at our next meeting to outline the benefits of hiring NPs? The chief director of psychiatry will be present at the next meeting and I really think its worth a mention.

[tobra99]

Sorry for my delay in getting back to this, I have had a full panel of hospital pts as well as clinic so it's been a busy few days.

I wanted to respond to this in a few pieces and try and generate some discussion as I think these are good topics to discuss.

I would argue that perhaps it shouldn't exclude residents. If novice NPs in the first three years of practice are similar in referral rates to 1st-3rd year residents and experienced NPs (4 or more years of experience) are similar to an attending primary care physician then the net cost to the system is exactly the same isn't it? NPs may over-refer in the first three years of practice just as medical residents due. That cost would then be a standard cost associated with training a new provider. I would be much more interested to see the data betwene experienced (>4 years) NP and attending MD.

This anecdote is actually strikingly on-par with the literature that is out there; the "inappropriate" referral rate is about 36%. Interestingly enough, of that 36% the generalist and specialist disagreed about the "inappropriateness" of the referrals 34% of the time. The study actually states a very interesting conundrum that is the catch-22 of this debate:

" Both underreferral and overreferral can affect quality of care. Underreferral can lead to inappropriate, cost-ineffective, or even dangerous treatment, and may result in costly litigation.18 Overreferral can lead to fragmented care by committee”; overtesting and repetitive testing; dangerous polypharmacy; patient confusion and isolation; and complacency on the part of generalists who lose their motivation to continually acquire new knowledge."

Personally, I would rather provider that was unsure of the correct course of action refer me!

Have you every seen patient that have been referred and have had inappropriate MRI's or other expensive diagnostics ordered? I guess in my mind I always think of the cost/benefit: an MRI bills out at $2600 while a consult is typically less than $400. I don't think I would ever refer to neurosurgery without an MRI but i often do to orthopedics. Every patient wants an MRI when something is wrong but often that MRI isn't needed so I would rather refer them to the orthopod to confirm my diagnosis if the patient insists on an MRI. I could order the MRI to show them nothing is wrong, but it would cost 4-5 times more. That same study showed that 3% of all referrals were for non-medical reasons and only 20% were for only medical reasons. Patient pressure, as much as we all want to say it doesn't matter, does. Just look at what PG scores have done to ED practice.

It would make for an interesting study to take those numbers and evaluate them using the cost of the pre-consult workup to the consult fee plus additional work-up. That would still leave out the cost associated with mis/delayed diagnosis, but it would be interesting.

What social life?

Donohoe, M. T., Kravitz, R. L., Wheeler, D. B., Chandra, R., Chen, A., & Humphries, N. (1999). Reasons for Outpatient Referrals from Generalists to Specialists. Journal of General Internal Medicine, 14(5), 281–286. doi:10.1046/j.1525-1497.1999.00324.x

Crap! I had typed up a long, drawn out response to this, and then my message got deleted before I could click submit.

I will try to re-type it when I get some motivation again.

[sauce]

I work in the hospital so I really don't refer much outpatient but most specialists seem to always want more business. It only seems like the topic of nps refer more and waste more money pops up when people are trying to down nurse practitioners. So basically the same sub specialists wanting more patients are the ones to complain that we waste their time with pointless referrals. Of course we aren't trained as long as docs but overall it's how much effort you put into your career that shows how well you do. I would have to say a newly graduated physician in general practice will have a much greater knowlege base than a new np. But as long as both continually try to improve themselves the law of diminishing returns takes over as years in practice commence and the gap will most likely narrow.

Some of our board certified er docs call our pulmonologist every time they want to adjust the bipap. In most cases why would somebody need help figuring out settings on the bibpap? Other er docs handle it all themselves. It's more The person than the degree.

[MollyJ]

BostonFNP, I am not talking about kids who are well managed and doing well on the prescribed regimen. I am talking about outliers, tough cases. But these are individuals whose less than optimal _situation_ exacts a price on the child, the family, the school and the community. If they were your kid, I assure you, you would be seeking expert resources.

But see, when we perpetuate the idea that all care can be equivalently provided by APRN's and PA's, then we lose access to that deeper level of expertise that is sometimes needed. I am not trying to argue that APRN's and PA's created this situation, please do not misunderstand me. But they have been exploited I would say. And if you are, as your name indicates, living in Boston that deeper level of expertise exists within a 30 minutes drive radius.

That is not true my area.

And many of the children in question are covered by Medicaid, CHIP. It would be hard to understate how poor the quality of child psych services are in my state and I am not trying to diss any practitioners that might be from my state. The system perpetuates a fantasy that these children can be solved with brief hospitalization and then tossed back to their local MHC's with no coordination or support to the MHC.

I know that over-referral has been a topic here. I am talking about a different problem. The problem of APRN's and PA's not having sufficient support or resources for them or their patients. This model suits insurers but arguably in my state it is reimbursement issues that have limited access to experts. This is a systems problem but one that affects children and families in my community.

[MollyJ]

Jules, the APRN's and PA's I refer to mostly work (but not exclusively) for community mental health center's. Their supervising MD is retired and lives 3 hours away by car. They do not for the most part have access to the bushel of child psychiatrists that exist in the state that are in private practice. My community, a decent sized community of about 40,000 people has long struggled to recruit child psychiatrists because for the most part the hospital is not willing to admit child psychiatry patients. And I am not trying to paint the hospital as a meanie--their are some real formidable reasons for their decision. The features that feed in to the undersupport of the APRN's and PA's are systemic and not single cause. Reimbursement is a big part of it.

[Jules A, MSN]

But see, when we perpetuate the idea that all care can be equivalently provided by APRN's and PA's, then we lose access to that deeper level of expertise that is sometimes needed.

The system perpetuates a fantasy that these children can be solved with brief hospitalization and then tossed back to their local MHC's with no coordination or support to the MHC.

Unfortunately if you live in an area where there are no specialists readily available that is a location problem more so than a NP and PA problem. I will say however that what you describe as a "fantasy" where patients are stabilized inpatient and then discharged to OP care rather quickly happens everywhere no matter which fancy psychiatrist has seen them or how affluent their family.

To me the average psych-NP should be able to manage them with that foundation. Again I would reiterate that the population you describe in addition to living in an area with few resources have a fairly guarded prognosis no matter who is prescribing. I think much of your concerns and they are valid are more a system wide issue rather than prescriber's credentials. I think "the powers that be" who decided that there was no need for well funded long term inpatient psychiatric services for people with chronic mental health conditions have done our most vulnerable patients a disservice.

[MollyJ]

Jules, I would like your comment "twice" if I could.

[Crazynut]

Two thumbs up! Nurses are so defensive! Look I said to think twice because that's a wise piece of advice. I tell everyone to think twice before considering a grad school program. You have to look at the bigger picture and weigh all the pros and cons. Nurses see $$$$$ in NP programs. But it's so much more that $$$$$! Take the time to stop and think is this really what I want? Will I be happy/successful in this career? We can sit here and argue this all day. Yes some MD's are jerks and don't take NP's seriously. But not all of them are like that. I have talked with several MD's and all expressed great concern over all midlevel practitioners. Even PA's. They are concerned that the lack of training impacts patient care. They went on to give specific examples. So these MD's come off as being anti nurse jerks. But there's a lot more to it. I wouldn't make a presentation at a staff meeting about it. I don't have time for that passive aggressive bs. If it really bothers you, go up to the MD and sit down. Have a conversation with him. You might be surprised. I'm sure he will learn from your point of view as well. Yes midlevel practitioners are necessary in a health care system busting at the seams. But we must ask ourselves. Is cheap labor best? I much rather see a bigger push for MD education and retention than what I like to call puppy mill NP and PA programs.

[Crazynut]

I think it all boils down to the infrastructure of health care delivery in the US. It all boils down to the almighty dollar. Yes there's all kinds of research out there. But you have to look at who funds the study. Follow the money trail and you will find the answer. I'm not anti NP or PA. They are a vital part in the healthcare system. I just think that its a sad situation when you have MD's that graduate from med school but can't get a residency in the US so they go overseas. I also think it's sad to see highly intelligent, motivated people get rejected time after time from US med schools. So they go overseas for medical education. I can not even count how many NP ads on see on a daily basis. From tv, websites, even facebook has jumped on the bandwagon. But how many MD ads do you see? When we put more focus on mid level practitioners than we do on MD education we are just asking for trouble. I mean who is gonna be my surgeon to do my hip replacement when I'm 90 yo? Smh!

[sauce]

Unfortunately this doesnt seem like a problem that will be corrected soon.

[sauce]

It is a downside that np programs are too easy to get into. soon we will be like lawyers, a dime a dozen. But the physician schools are not close behind them either with all of these private do programs opening

[Crazynut]

I disagree. I think med school have become so strict with admissions that it is driving people away from the profession. Or driving people overseas. We are hammering in the nails in our own coffin. But by God it's the American Way! Smh! So my mom told me she doesn't know why anyone would go to med school these days. she said I might as well do Media because I'd made more money. Like geee thanks mom! Lol Merica!

[PMHNP-1]

Newsboy, doesn't sound like any PMHNPs would want to work there. Similar situation in a local beh. health inpatient unit here. A colleague went in...........lasted less than a month. Treated like dirt - not just by the psychiatrists, but by the RNs as well. Paid not much more than an RN. Horrid.

The other hospitals - maybe YOU should check those out!

PS - If I'd known what I know now, I would never have gone to grad school for PMHNP. Never. Should have gone for psy-d or psychology PhD. This realllllly stinks as a career, we are disrespected, we have to be prescribing machines for the profit of docs, and with our relatively low pay and all, plus having to pay our own malpractice, DEA license, all those CEUs, licenses (expensive!), and more requirements that are added to every year, you end up with less earnings than a full time RN. It's not worth it. I regret having done this, every day. THAT said, however, we are looking at moving to a state where NPs ARE valued. Things can't be this bad as in the state where I live.