PMHNP Specialization

Oldmahubbard · Jul 16, 2019

I did forensics for many years, also LTC which is largely geriatric, and private practice where you see a little of everything.

Try to find a job where you don't have to deal with addiction, and good luck with that.

Pediatrics, no. No money in it.

Forensics was the most interesting job, but LTC can be more lucrative and very flexible.

umbdude, MSN, APRN · Jul 16, 2019

Subspecialties usually fall into different DSM categories or by life stage. PMHNPs can work in any subspecialty they're interested in and they usually depend on the work setting. For example, a facility in my area primarily specializes in treating patients with eating disorders; there're also psych hospitals with distinct subspecialties units such as trauma, mood, psychotic, and addictions. If you work in one of these units, you'll be treating whatever that unit is designed for.

However, psych disorders rarely occur in isolation. Even if a PMHNP works in a subspecialty area, he/she will manage a broad spectrum of psych conditions.

Telepsych really isn't a subspecialty. It's just a mode of care delivery.

SDStudent1 · Jul 16, 2019

9 hours ago, Oldmahubbard said:
I did forensics for many years, also LTC which is largely geriatric, and private practice where you see a little of everything.
Try to find a job where you don't have to deal with addiction, and good luck with that.
Pediatrics, no. No money in it.
Forensics was the most interesting job, but LTC can be more lucrative and very flexible.

Would you mind describing what a typical day for a Forensic PMHNP would look like, what you found interesting about it and how it differs from working on something like a Psychiatric ICU (where I work now as a Psych RN) ? Forensics seems very interesting to me but unfortunately, I wont be able to do a clinical rotation in forensics as part of my PMHNP program. I am currently in clinicals at a hospital who supplies Psychiatrist/PMHNP to a large local prison in the area but, despite my best efforts, they will not let me do a rotation there.

Also, what about LTC makes it lucrative and what do you mean when you say it is very flexible ? I only ask because I would not have guessed that was the case but I have heard the same thing from other people posting on here. When I started my PMHNP program I wanted to work Pediatric Psych and was terrified of Geriatric because of how medically complicated they are. I am now most of the way through the program and have completely switched. I have not interest in doing pediatric psych but found that I actually enjoyed working in geriatrics.

Thank you very much for the info

SDStudent1 · Jul 16, 2019

4 hours ago, umbdude said:
Subspecialties usually fall into different DSM categories or by life stage. PMHNPs can work in any subspecialty they're interested in and they usually depend on the work setting. For example, a facility in my area primarily specializes in treating patients with eating disorders; there're also psych hospitals with distinct subspecialties units such as trauma, mood, psychotic, and addictions. If you work in one of these units, you'll be treating whatever that unit is designed for.
However, psych disorders rarely occur in isolation. Even if a PMHNP works in a subspecialty area, he/she will manage a broad spectrum of psych conditions.
Telepsych really isn't a subspecialty. It's just a mode of care delivery.

Regarding the DSM, thats a good way to conceptualize the ability to subspecialize in the PMHNP profession. I would not have thought to put it that way.

I feel like the deeper I get into my PMHNP program the more I hear about interesting niche roles I would never had considered. For example, I think one PMHNP one here was talking about incorporating horse therapy or something like that into her practice. Although that is not something I would be interested in doing, it's interesting to know what is possible. I guess I should have titled this subspecialties / Niche roles / unique modalities within PMHNP ?

Oldmahubbard · Jul 16, 2019

A day at the Forensic hospital started off with a review of what happened last night or over the weekend. I would go to the nurse's station to see if they needed anything. Next to my office to get ready for the daily team meeting, where we discussed everything in detail and often brought patients in if they were suitable, ie cooperative. The patients would all head off the unit for programs and I had 2 hours before lunch to review charts and prepare reports. Answer emails.

I had 99% of the same responsibilities as the psychiatrists and generally carried a caseload of about 20 pts. Perhaps half were psychotic, and 2 or 3 were usually unstable. In my state a court order is needed to medicate inmates over their objection, unless they are imminently dangerous. I appeared in court several times a year to testify as an expert witness. I only ever lost once, and that was because the pt had started taking the meds voluntarily.

Yes there were times it was very interesting, but the politics and the extreme malingering were major drawbacks. Great experience though, I did it for 12.5 years.

LTC can be lucrative, because although medicare reimbursements are not great, there is less overhead. You don't have to pay a receptionist. No shows are practically nonexistent. If you can work fairly efficiently, you can do well. No problem finishing an appointment with a patient that thinks they are going to get an hour every time, like private practice. When you are done, you get up and leave. There is no great expectation that you are going to wave a magic wand and fix a person's life. With electronic records and remote access, and email, you can do about half your work at home, on your own time. The longer you are at a facility, the more residents you know, and the more the staff know you. More referrals start coming in. It gets easier with time.

SDStudent1 · Jul 16, 2019

Both seem extremely interesting areas for entirely different reasons. Thank you very much for taking the time to answer.

Oldmahubbard · Jul 16, 2019

Things came together is a very specific way. Medicare coverage of mental health was poor prior to the 2009 bailouts, so back in the day, the patients would have gotten relatively large bills for the services in LTC. Then our governor rescinded the collaboration requirement on 1/1/2015. That helped enormously. No more bull feces!

Had I to do it all over, I would probably do fewer forensic years. But it does give one a certain confidence.

verene, MSN · Jul 17, 2019

I feel like practice specialties in psych are largely determined either by population (e.g. veterans, geropsych, pediatric psych etc) or by specialty diagnosis (e.g. OCD clinic, trauma clinic, eating disorder center), or setting (e.g. rural, FQHC, LTC, locked residential) or all of the above (e.g. secured dual-diagnosis short-term rehab for adolescents), which means even when specializing there can be a bit of overlap with other specialty areas.

Oldmahubbard - do you have any recommendations for resources or areas to brush up on for those interested in getting into forensics as a sub-specialty? I am trying to line up a fellowship placement on a forensic unit (state hospital) and want to go into the interview well prepared.

Oldmahubbard · Jul 17, 2019

In forensics, you will encounter some of the most profoundly psychotic people you will ever see, plus some of the most tenacious behavior disorders imaginable, as well as some well above average, creative, and highly motivated malingers.

On interview, I would want to know what resources does your hospital use to differentiate these patients from each other?

Did I mention there can be an overlap?

Several very standard reference books have been written about ASPD and malingering in this population. Google.

Psychosis is very easy. Clozaril if other drugs don't work.

Oldmahubbard · Jul 17, 2019

One thing that working forensics taught me. I pay little attention to subjective symptoms. People are not reliable reporters.

For example, I never ask about appetite. I check weights.

Sleep? I ask the staff.

Many people, even the folks that are not consciously trying to malinger, report fairly extreme symptoms that are not objectively verifiable.

I cannot tell you how many people have told me they have mood swings. Clearly, they do not understand what a mood swing is.

verene, MSN · Jul 18, 2019

Thank you Oldmahubbard! I appreciate the advice!