NP considering leaving practice

[rn_patrick, NP]

Hello everyone:

About 1 1/2 years ago I submitted:

https://allnurses.com/advanced-practice-nursing/np-leaving-while-1079070.html

I made it to January, gave notice. About 1 week after I left I interviewed for a Locums position at a similar type job. Was accepted and worked there for 6 months 3 days/wk. They wanted to hire. I declined. I also was getting a little tired/frustrated with the practice by the end.

I went and did some non-nursing things out of the country. They called me in January and asked if I wanted to come back for a Locums because the person they hired when I left quit. I needed enough hours like I said to get to 1000 hours for my 2022 renewal anyway.

This place is typically 12 patients a day which is low for psych visits from what I am seeing here and talking to others. The clinic made another offer, and then they offered to extend another 13 weeks. I've been stalling on saying no because I want to do it graciously.

I have concerns about this practice and like the last job they want and need to hire 2 full time NP's to meet their current patient volume. Like last post someone said "And where do they plan on finding them?" The hospital had better benefits, PTO, and pay and they had trouble hiring. This place is not going to find two APN's easily.

I'm 6 weeks in and I was short with the receptionist on Tuesday when management closed the office early for snow. That I have to sit down and apologize to her. I'm also again getting frustrated with this practice. There are some liability issues mostly from not having enough providers to see them.

The question is: This keeps happening where I keep no matter where I go getting frustrated about the staffing and patient followups. This is my 2nd community mental health clinic though. Being understaffed, underpaid, and under resourced is part of the role.

I have had periods of the hospital job where I liked it. I know I am not good at "Sitting in a box" for 40 hours a week seeing patients. I also like work/life balance and I'm wary of those 50-60 a week NP positions. I work quickly but I'm not a "5 minute doc" like some of my former colleagues.

I don't want to leave practice but I am in a place where I can semi-retire. The ACA did not get repealed by the current administration so as long as I make less than 50K a year (part time) I can get affordable coverage. I did this last year. At the end of this contract my licenses are secure until 2028 since I have the hours for the 2022 renewal. At that point I should be able to retire fully.

I also think there is a lot of good that I and we as NP's can accomplish and having licenses to prescribe medications is not a thing to be casually discarded.

I could use some advice as in books, articles, or other ideas to move forward.

[Oldmahubbard]

I cut my teeth in a Community Mental Health Center. I could write a book about what I saw there in 4 years.

Yes, they are famous for poor staffing, and many patients are really looking for disability payments, or benzo's, not help. People don't keep their appointments. Management is either stupid or they just don't care at all. The very few psychiatrists you do work with are not good role models. Low pay, poor benefits. Someone is making money off the place, but you aren't. On and on.

Upon graduation, I took a state job at a forensic facility. Now there was a real learning experience. The pay eventually got fair, and I was there long enough to get a small pension and health insurance.

I tried private practice as well. I didn't mind it, but you have to have firm boundaries with people, as you must see 3 patients an hour, most of the time.

Now I do consulting in LTC. It has it's ups and downs, like anything else. On the positive side, the expectations are lower. No one is looking for a cure. The no-show rate is minimal, although of course residents are occasionally out of the building. You can get to know residents on a long term basis, and the work is at your own pace. It is usually flexible with the hours.

The downside is working in LTC. Many very low functioning people, and you are dependent on staff to tell you how they are really doing.

Possibly it could help to reframe your expectations. Is is realistic to expect to enjoy your work, most of the time? Most of my enjoyment comes from interacting with the staff and other professionals.

It sounds like you are willing to live simply, within your means, and making appropriate plans to retire or semi-retire. I am doing the same thing over the next 5 years. Getting a little sick of the rat race, and arranging finances accordingly.

12 patients a day is not bad at all, though.

As far as books and articles, I am not sure what you are looking for. I am sure there is a ton of literature for people who have decided to retire early, and live very simply. Not specific to NPs.

Different job opportunities? I would check out local jails, prisons and nursing homes. I know, glamorous.

Community Mental Health Clinics really suck, though. I know some of the stuff that really goes on there, and it's hard to believe they get away with it.

[Jules A, MSN]

Community mental health is rough. I did a brief stint years ago although my pay was excellent. They tend to cry poor but have major financial backing and are able to pay if you insist on it. I can't imagine only having 12 patients a day unless there are 4+ intakes included as that is a very low census especially with what I suspect is a high no show rate.

I'm considering retiring early also. As much as I love what I do the new NP trends are wearing on me. I have no interest in making less than I currently do and new grads are coming out of school accepting 30% less than what they should be. Employers are near manic over the recent glut of new grads.

[rn_patrick, NP]

I appreciate the lengthy response Oldmahubbard. I did LTC when I first got out of school. Wasn't a bad gig but I would have worn a car out every 4-5 years with the mileage. Struggled a bit with the pt's families, the "Don't change the meds unless all 4 brothers and sisters have signed off on it..."

But you are right usually if they are not there the facility has a bigger problem.

I'm definitely aiming for more work-life balance. I read a few simplicity blogs and have been moving in that direction for a while. The main reason I came back to this place was to guarantee I have enough hours for my 2022 renewal.

[rn_patrick, NP]

Community mental health is rough. I did a brief stint years ago although my pay was excellent. They tend to cry poor but have major financial backing and are able to pay if you insist on it. I can't imagine only having 12 patients a day unless there are 4+ intakes included as that is a very low census especially with what I suspect is a high no show rate.

I'm considering retiring early also. As much as I love what I do the new NP trends are wearing on me. I have no interest in making less than I currently do and new grads are coming out of school accepting 30% less...

We have a decent number show up. The systems here need some work which is part of my frustration. There is no productivity bonus for the on-payroll NP's, so they don't need me suggesting ways to increase volume which since they are salaried means more work for the same money. I know what they pay and it's about 20-30K under market.

I'm thinking changing practice areas which may help.

[Oldmahubbard]

It is painful to realize that Medicare reimburses NPs 85% of the MD rate, and other insurances follow suit.

Yet somehow, on average, NPs typically get 50% of an MD salary, at the very most, if we are fortunate.

I recall, 20 years ago, in a different context, being told that Physical Therapists keep their pay high by keeping their numbers low.

Psychologists have done very much the same.

Lawyers have not, and the results have been disastrous.

Many, if not most, NPs seem satisfied to work for 10 or 20k more than their RN salary. This is nothing new, unfortunately.

After taxes and the student loan, it isn't even a raise.

Some NPs are satisfied nonetheless, and others are not.

We are the low-paid workhorse of the health care system. Decades ago, NPs were disrespected because they had 3 years of education, fewer than a kindergarten teacher.

Over the years, as educational requirements advanced to the MSN, we still had various state practice laws in many places that made it seem like we needed close supervision by a physician.

In reality, this rarely happened, but someone collected the money.

The profession is changing rapidly, and I am a fairly old lady. It will be interesting to see what will happen over time with the DNP, and the largely online educational model.

[rn_patrick, NP]

For me the pay raise was not the dominant factor though it helped. It was more breaking out of the every other weekend rotations. Yes I know there are RN positions that have that as well but typically they pay really poorly but many RN's would gladly take a pay cut to be home every weekend and every holiday.

I think the DNP is a waste of time and money and a way to get 100% more (40 credits vs 80 credits) revenue for the graduate schools.

[Oldmahubbard]

It would be very hard to make anything in LTC if you are a consultant, only seeing maybe 5 patients by referral here, then drive 20 or 30 miles, see another 5 patients, rinse and repeat.

I am part of a team, I carry my own patients, and see many of them monthly. Most of my facilities are quite near my home. Less than 5 miles.

The few that are not that close, have negotiated a substantial stipend, in addition to the billing.

My state has long been in the process of discharging the chronically mentally ill to the community, and they end up in LTC.

Some of local SNF's are full of schizophrenics.

They are very poorly managed by PCPs.

I have also taken over several facilities where "psychiatrists" took the facility stipend, and didn't show up for months at a time.

I am there each week, or every other week, according to the contract.

I am known for my willingness to work with other professionals to come to a consensus, and I even give out my home phone number and email to encourage communication.

For all you truly sucky psychiatrists that are worried that NPs will take your job?

You should be.

[rn_patrick, NP]

It would be very hard to make anything in LTC if you are a consultant, only seeing maybe 5 patients by referral here, then drive 20 or 30 miles, see another 5 patients, rinse and repeat.

I am part of a team, I carry my own patients, and see many of them monthly. Most of my facilities are quite near my home. Less than 5 miles.

The few that are not that close, have negotiated a substantial stipend, in addition to the billing.

My state has long been in the process of discharging the chronically mentally ill to the community, and they end up in LTC.

Some of local SNF's are full of schizophrenics.

They are very poorly managed by PCPs.

I have also taken over several facilities where "psychiatrists" took the facility stipend, and didn't show up for months at a time.

I am there each week, or every other week, according to the contract.

I am known for my willingness to work with other professionals to come to a consensus, and I even give out my home phone number and email to encourage communication.

For all you truly sucky psychiatrists that are worried that NPs will take your job?

You should be.

That's how I got started 5 years ago. The corporate group had a couple not-so-great nursing homes and assisted living type group homes and I was given three of them to take care of. One of the Geriatricians turned out to be the medical director of the local hospital and got me in the door of their psych practice.

I just saw an ad for the former collaborative MD from that corporate group went and started his own company and the starting salary for that is 40K more than the CMH clinic pays. I was really green when I worked with him last, but definitely could try and talk to him about a position.

I'm really starting to focus on Quality of Life as I enter midlife. Some of that continues to also feel that we are doing good work by being engaged and helping this population. I don't push paper around an office.

I appreciate all the comments. I'm thinking either changing specialties, or working for a group like you are may be a good choice.