DrCOVID

She fired me and found another provider. I think that is a great idea and going to add that to my disclosure, thank you!

It has to do with scope of practice, do you have any idea what ADHD, bipolar, or Schizophrenia look like? TBH even after school, it took me about a year in practice to see it present clinically, as well as reading a few books by specialists before I really could recognize them quickly... That was after 4 years of post graduate study. Moreover, I have heard of a psychiatrist getting sued for prescribing antibiotics to a patient. We just don't do that clinically, so...

Having done my doctoral capstone at a FQHC, I am really sad to say that is not changing any time soon. I had to present my project to a board of NPs, MDs, and the CFO for approval - they had to put me on the itinerary in advance, and could have said no. The CFO was also hesistant on my project and barely let it slide. I can only imagine what you have to do for a raise in a place like that. I think sadly unless you want to dedicate yourself to policy, you might find the satisfaction somewhere else. You are going to be fighting through huge walls of red tape and the funding from what I have seen so far is really dependent on where you are, in public health/federally/state funded places - you are going to be overworked and underpaid independent of your relative location.

This is a great idea - in theory - but that is about it. I just don't think it is practical to do in practice. I am currently using advancedMD and it is beautiful chart notes prepopulate from previous sessions, so you can just update what you need, HPI, ROS, Plan, meds, for follow ups which take just a minute or so. Psychotherapy notes are protected and your documentation is something like "supportive therapy for interpersonal distress" if you are doing that. Otherwise HPI elements are just like SI, depression scale, anxiety, sleep, etc. Then there is proofing - at that point you might as well do what most providers do, copy and paste from a template and update based on your targeted assessment/problem for the patient.

Want to manage their own medicine? I recently had someone on Xanax that wants to adjust her dose and get an early refill. She just messaged me directly asking for a week early refill because of "the holiday (July 4th)" claiming this would impede her ability to get the medicine. When I called her out, she says, "I been wanting to increase my dose anyway" and made no mention or didn't take responsibility for her own mistake. The fill date according to PMP would have made her due on July 9th, I checked twice. Thankfully, in 1 year this is the only time this has really happened. I haven't had someone NOT on a controlled substance do this with me. If they want to, they AT LEAST usually ask me first, instead of trying to backwards-rationalize their own treatment... This person was on Xanax TID for a long time before she met me... I mean firstly her actions were unethical/manipulative, but I can't help but feel guilty seeing as HER report was that WEED and XANAX are the only things that help her nausea & panic... She lives in a state where THC is legal... praise the government and their dysregulation of damaging psychotropics!

I am often involved in collecting and expected to somehow evaluate insurance issues, when I am just not really trained on that... but learning more as I go bc it is a problem sometimes. Opening a practice I think is hard... but I have thought about that multiple times. Maybe in a year or so that might be easier when I save up a little more. I also have a full caseload in the immediate week which took about 6 months ?

Thank you for the breakdown - but yes, it is a large group with like probably 100+ more therapists/NPs ... I often do my own scheduling (while I am talking to my client)... so new intakes are all that is needed there. I know a percent goes to the biller, but I thought it was lower, like 3 ... I guess it could go up to 10 but that seems like a rip off. I do my own billing slips and for psych it is always the same like 2-4 codes! I got offers of 40/60 and 50/50 as well even in IP states. My group rep did mention that 19% is pretty much required as this cost goes directly to overhead.

So my initial contract was 30% to the group as a 1099. This seems a bit excessive - I still have to pay tax, and do most of my own admin work as it can't be delegated such as take calls, emails, PAs, and they can't help with even basic support, such as calling EMS in an emergency. Is 20-80 fair or is that unfair? The group made more than enough for 2 full time admin staff from me last month.

The DNP programs are at least 1000, mine was 1200. I feel like this was barely enough. We were lucky to even find a good psychiatrist to precept us. Another huge problem is blind leading the blind. My teachers barely knew what they were doing. Didn't discuss any of the documents that govern practice and of course billing/coding (which is the basis for practice) is not discussed.

There is nothing novel here per say... just wanted to vent I guess. I just started this year and all I can say is no wonder NPs get a bad rap. I have had several patients come to me and tell me the previous NP wasn't listening to them or fill the meds they have been on for 10-20 years... pt this AM (the provider had diagnosed them with insomnia, GAD and a personality disorder) so that he could write them off as "crazy"... mind you this woman was very pleasant and everything she told me was congruent with what I found in the PMP for her state. Didn't even ask me for meds. The provider also clearly had no idea what elements to type in an HPI. She endorsed being bipolar and was stabilized on 5 medicine. Why would we not trust this information? Oh, because the patient uses 20mg of Ambien to sleep at night which is higher. That was what he wrote in the note. I find that amusing. She was using it properly according to the PMP! I am ones I guess - I do a lot of extracurricular learning (MD psychopharm/psychology/psychiatry podcasts) to brush up on conditions I see frequently & I did rotations under some good NPs (other mid-horrible ones as well) and then a few psychiatrists in the inpatient environment. By in large the other NPs I have seen have no idea how to write a proper HPI or ask questions to lead to a proper diagnosis. This is the scary thing. How are you treating people properly when you FAIL to take a proper history? I have had multiple pts come to me and they were clearly BIPOLAR and were on SSRIs or did not have the right diagnosis (obviously, no clear history was taken). Seems like most other NPs aren't even asking what sleep has been like for the pt's entire history which is always telling and points to some diagnosis. My friend that works with the PsychMD in the hospital said the same thing about the other NPs. The MD doesn't want to hire ANY NP that doesn't train with them. Well yeah I agree with that from what I have seen! HPI documentation - which by the way is published in a document from the APA - I literally had to teach my GRAD SCHOOL teacher how to do an HPI properly... and she was an FNP for YEARS. WOW! I don't know what the point of this post is, other than our profession is just really in a *** state. Schools need to up the requirements, online schools SHUT DOWN and better and clinical hours/training. Every time a see a new pt that had another provider I'm just like GOD D*#N what am I gonna find this time!? We really NEED to elevate our profession. I take pride in being an DNP now but Jesus. RNs are the most trusted profession but how will we keep that trust if we generally SUCK at essentials of the APRN?

Ohhh not this crap again! YES I DO - I introduce myself as DOCTOR and explain I'm a Nurse PRACTIITONER with a DOCTORATE

I did some digging and calling - these huge national companies should be shut down along with all the "online only" for profit easy 2 year NP schools.

Legally? Sure of course. You are always an RN if you are an NP. Can't be an NP without RN. RN license is TIED to NP license. But uhh... practically? What the hell... why would you wanna split the two? You should be an NP all the time, and do RN tasks!!

Hey NPs, has anyone trained to do neuropsych testing? Seems that you need a degree to do this... like a PhD in neuroscience/neuropsychology. Does the APA publish guidance? https://www.apaservices.org/practice Thanks!!

Kinda depends on the setting. I have a colleague that does inpatient under a psychiatrist in a hospital, she does on 7 days, and then it decreases from there until she has a week off. She recently told me that the MD recently did 12 days on. RIP. I feel bad, since I was going to work with them, but she is SALARIED and is working a LOT of what would be OT since they are short staffed.... not to mention your sanity. She is already burned out. I myself, am in an IP state and private company with insurance. I see all pts from home (no COVID) & I make my own schedule and am doing 4 x 8 hrs to start. Money is not worth QOL/sanity. At the FQHC I did rotations in, they allowed PMHNP to do 4 x 10 or 5 x 8. DNP also started at 120 instead of 90-100k

I feel like a good % of people don't actually meet criteria for their DX history. All of the people that have come to me with "ADHD" have already had stimulants (mostly Adderall) many times.

Right, the main concern is misuse/abuse. I had my main problem child turn meds into the police 2 weeks ago since he was collecting them rapidly... I always check the PMP before any stimulant RX. Always try to use the XR formulation for these yes. I would never early fill one of these for a person who has demonstrated poor use or issues with other OTC substances. I never thought of a UDS but thats a good idea. I haven't even been able to get regular people to have labs done though. I can't help but feel my hands are ultimately cuffed in some way. Busted, I am a crack dealer with 2 licenses and 6 background checks in the last year (school, different state licenses and DEA)!

I'm a private outpt only practice as an independent entity. The problem is, these pts usually have had the medicine they are requesting from another provider. Seems that providers hand these out like candy for anyone that says they can't focus. I am pretty sure 1-2 of my "ADHD" are actually bipolar and not ADHD.

I don't think there is a black and white answer to this. The base is you have to be familiar with the nurse practice acts and practicing outside your scope. Moreover, if you haven't been trained or didn't learn in school to do something... you are setting yourself up for failure/litigation. I would be hard pressed to say that the FNP base licensure would prep you for any of that stuff. Those are all basically surgical procedures and you don't train for those in an FNP curriculum/clinical.

I have already had several patients come to me seeking specific types of medications (take a wild guess which ones) why STIMULANTS of course. I am a relative new grad and it makes me a bit uneasy RXing these for people that have demonstrated they have issues with substance use. I recently tapered someone off of 120 mg of Amphetamine D ... seriously WOW!? Some MD was giving them to this person and they ran out WEEKS EARLY. This guy was so numb he couldn't feel anything, and honestly, he seems better without them. I have another patient basically stating the only thing that will work is a stimulant. He also does OTC drugs like 1 PPD of cigarettes among other things ... seeing as this is going to be a common theme... What are the ethical/legal implications for this? Other than it being **** advanced nursing, as long as I do my due diligence, document in the record the patient agreed to use them properly, what is the risk for just handing them out bc the person asks? I imagine this is what started the opiate crisis. TIA

No, institutions don't grandfather you a degree. DNP is a degree. I have essentially two years more than the typical MSN in didactic and clinical time. DNP capstone is done in a clinic fyi. I learn about psychiatric disease and medications in my project. You can argue all you want that clinical time doesn't matter, and it doesn't. Not even 10k *residency* hours makes you a better provider. Treatment outcomes are actually based on your therapeutic alliance and empathy than anything else: https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/therapeutic-alliance-part-1 https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/2020/3/19/getting-better-results-from-your-patients-as-a-psychotherapist?rq=empathy

https://allnurses.com/DNP-project-t731713/

So number 1 is psych is like one of the lowest matched specialties for both MD and NP. It is only 2% of NPs got certified in psych as of 2018. Finding a good PsychNP is pretty hard in the first place. The best thing to do is network. That really helped me find mine, of course that was pre covid. But yeah look on internet groups on facebook and other NP organizations. I would start cold calling places that offer psychiatry in your local area. I would try to get in with a small private practiced owned by a small group or individual. Also, precepting requires a lot of patience, and time. Training someone is no easy quick process. And in Houston one of the students in my program had to pay as that is the standard there. I had some *** preceptors. Like one's that don't understand the basics.

Your first clinical round you should mostly be observing?

My primary preceptor had 2-4 almost all the time, but would only have 1 on one day. We doubled up sometimes but even then the other 2 students would barely even talk while I was there. Even in my program that had extra hours, you can often work around the other students as you only have to be there a few times a week. Either way if I were in your situation, I wouldn't focus so much on 'attention'. I would focus on completing your education as that is more important. Theoretically speaking, a lot of things should be different for APRN licensure.