Interesting times in psych

Specialties NP

Published

Hello from sunny Utah. I took a locums position with a mental health company out here. Well, it appears the medical director wasn't as forthcoming about my responsibilities as he should have been. I was sent to a double locked SNF where 21 of the 23 patients I saw had serious mental illness that really requires an Psychiatrist rather than an NP, with no psych training. I thought I would be dealing with anxiety and depression, nope. So they let me go today. We will head back to NC on Monday.

Sucks to be me just now. But I know that this is for the best and that there is a reason for it, I just need to be patient.

Specializes in ER, HH, CTICU, corrections, cardiology, hospice.

I've always considered myself the gate keeper for the doc's time. I handle the sniffles and the chronic conditions. They handle the addicts being seen for there post CABG f/u that have the flu with sarcardosis, maybe a little scaleraderma thrown in. What would psych NP's punt to psychiatrist? Nothing? So why settle for NP if you are doing the EXACT same thing, no deviation whatsoever? Maybe I'm being thick, obtuse, biased, mysoginistic, dopey, or grumpy, but there has to be something that the doc does that the NP does not.

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Specializes in Psychiatric Nursing.

I have had about 30 years experience in psych. I have 7 years prescribing experience. I find that if I think about a difficult patient situation long enough I find my own solution. I collaborate with MD's NP's and other disciplines. If I am at a site with formal supervision I use it, if not I figure things out and get consultation as I need to. If something is medical, I refer. If psych I prefer to do it myself with consultation. If I am not sure I get consultation. So far, this works for me..

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Specializes in psychiatric.

Nursetim, are you saying Psychiatric NP's are unnecessary? I am a Psych NP student and my clinical instructor is a psychiatrist who is in his 60's, experienced as all heck and is thrilled to death to be precepting a NP student. He has a wealth of experience and is very nurse and NP supportive. He is a resource and teacher. Psych people look at things in a different light than other specialties I think, it's what drew me to the specialty as opposed to being a 'gatekeeper' for a medical doctor. I am being taught, trained and treated as a peer, I will eventually be treating as an independent provider.

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Specializes in ER, HH, CTICU, corrections, cardiology, hospice.
Nursetim are you saying Psychiatric NP's are unnecessary? I am a Psych NP student and my clinical instructor is a psychiatrist who is in his 60's, experienced as all heck and is thrilled to death to be precepting a NP student. He has a wealth of experience and is very nurse and NP supportive. He is a resource and teacher. Psych people look at things in a different light than other specialties I think, it's what drew me to the specialty as opposed to being a 'gatekeeper' for a medical doctor. I am being taught, trained and treated as a peer, I will eventually be treating as an independent provider.[/quote']

not at all, just the opposite. If Psych NP can do it all soup to nuts, what do psychiatrists do?

I'm done, this has pretty much rocked my world. I have lost all direction and maybe medicine/ nursing isn't for me. I'm fed up with the beaurocracy of it all. I want to treat patients and not have some bean counter from the .gov or .state breathing down my neck.

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Specializes in FNP, ONP.

"They handle the addicts being seen for there post CABG f/u that have the flu with sarcardosis, maybe a little scaleraderma (sic) thrown in."

I find this POV intriguing because I do not see it that way at all. I am curious about your feelings, because my experience and opinions are so different. I see the complaints you mentioned above. I'd be so bored and frustrated if all I got to handle were the easy cases.

"So why settle for NP if you are doing the EXACT same thing, no deviation whatsoever? Maybe I'm being thick, obtuse, biased, mysoginistic, dopey, or grumpy, but there has to be something that the doc does that the NP does not."

What do you mean by settle? I didn't settle, I did exactly what I wanted to do. I don't believe that you are obtuse, but I do think it sounds as if you have been in a state with a highly restrictive NP practice act, little respect and practice autonomy and that it has shaped your own practice and your view. I can only speak for myself and my colleagues, but here there is nothing the physicians do, diagnosis or treat that NPs do not, limited by specialty, that is. I don't put in IUDs anymore, I don't read MRIs or nuclear stress tests, I don't do MOHS surgery. But with regard to internal medicine/peds practice, no, there is nothing my MD pals do that I don't/can't. I don't really get paid less either so I guess that's fair, although truth be told, I don't really care about that outside of the philosophical argument.

All of that said, I despise psych, and I do everything within my power not to treat BH conditions. It is simply impossible to avoid though, we just have too few BH providers so we are forced to have a go at it.

I treat schizophrenia, BPD, personality disorders up the ying yang, along with the usual depression and anxiety. When I feel as though I'm over my head, I go to the clinical pharmacist for assistance with drugs. I always say that it is better to see a NP with a hunch and a library card, than to see no one but your imaginary friends. We muddle through and get the sickest of them to BH as soon as we can, but the 2013 state assessment suggested we are short BH providers by about 75%. The waiting list to see a BH provider here is almost a year. I have no preference b/w a psych NP or a psychiatrist for these patients. I'll pass them on to the first available person more qualified than I.

Sorry your gig didn't work out. You made it 3 1/2 days longer than I would have.

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Specializes in Mental Health.

What state do you practice in?

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there has to be something that the doc does that the NP does not.

Here is my answer.

Remember that in psych world, the practice is not limited to prescribing psychotropic. "Legal" aspect is very BIG part of psychiatric care in certain settings (jail, hospital, community mental health clinic). Like all NPs, psych NP CANNOT certify disability like psychologists or psychiatrists. This is a big deal! Many psychiatric patients need to be on disability and want disability paperwork done. For this reason, if they sees psych NP as the primary psychiatric provider, they will be put at unfair disadvantage. It is because we cannot help them much with the disability paperwork.

Additionally, psychiatrist comes into play in the role of "involuntary commitment." It is required by law in many states that psychiatrist is involved in some level in signing paperwork or documenting the care for these involuntary or court-ordered patient. Therefore, NP cannot practice solo or independently in these cases. Additionally, in some states, ACT team must be led by psychiatrist (psych NP may assist).

In some states, only psychiatrists can legally commit people for involuntary commitment in inpatient setting, which is a big deal! Most of psychiatric patients are hospitalized involuntarily. Not many people want to be hospitalized in psychiatric inpatient facility. Additionally, most hospitals (although not required by law), they requires that there will be a supervising psychiatrist and NP will be under (regardless of level of independence granted by state law).

Additionally, at state and federal level, NPs are still not recognized. Many paperwork still requires the signature from the physician or psychiatrist.

Because of the above reasons (most related to legal and rules set forth by organizations), psychiatrists are preferred over NPs. It does not matter whether NP can do most of things psychiatrists do. If the laws does not recognize NPs, then they can't do it. Oh.. and one more thing, psychiatrist can do ECT treatment, NP can't!

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You're right of course Harmonizer about legal restrictions, I disagree though with the statement that the patient is at an "unfair disadvantage"...

1. Regarding paperwork/certifications, etc - it really isn't a big deal - I have a collaborating who will sign what I fill out.

2. Involuntary commitment, at least in California, doesn't happen from a psychiatrist's office. It begins with a trip to the ER where the pt is first run through basic labs/tests followed by an assessment by an authorized Mobile Assessment Team clinician (I used to be one) who writes the hold.

3. ECT - I don't know about you, but I don't have a bunch of people asking for me to induce a seizure! TMS - we can do....and they are asking about that!

The only patients I have that "want to see a real doctor" are those that get upset because I'm tapering their Klonopin....and to them I say "no problem, let me make a phone call and you can get on his wait list...I think it's down to about 6 months"....

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I disagree with you, TheOldGuy. It may not be a big deal in California where supervision is required but it is a BIG deal when you practice in an independent practice state and in rural clinic when there is no psychiatrist! (even if you have one, they are unlikely to help you with it because these are not their patients!!). You have no "supervising" psychiatrist. You are their "primary" psychiatric provider. Why can't we help them with disability process? I am tired of patient bringing on their disability paperwork that indicates "if you are a nurse practitioner please have you supervising physician co-sign this." Sorry, my supervising will not cosign even if I have one! It is pretty sad. Some of them really needs disability and are struggling with life but they cannot get it. It is because they are under the treatment of just "nurse practitioner." Is there legal movement for this.. I would like advocate for it.

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I would advocate for it too! California doesn't really have "supervision" required - just collaboration. The key is to develop a good working relationship with a doc. They don't need to be a psychiatrist - you might work out something with a family doc (I do it with a neurologist) who sends you his psych patients and when you need him to sign something, he covers you....like I said, no big...

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you might work out something with a family doc (I do it with a neurologist) who sends you his psych patients and when you need him to sign something, he covers you....like I said, no big...

I am not sure how legit is this? They are not psychiatrist. How can they certify mental disability? I do not think this is the solution. They can forgive student loan debt based on disability but I do not think they can certify disability based on mental illness.

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Where does it say that a physician needs to be a board certified anything to certify anything....? What I'm sharing with you is how to make things work so that you are least impacted. If you prefer, you can continue to feel that you are not able to provide services - in which case your patients ARE at a disadvantage. I like to focus on how to solve problems - there's always a way. If you are really worried about it, why not establish a good working relationship with a psychiatrist who will cover you on form signing....?

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