Psych PAs needed...

[andersenpa]

Maybe I need to put my "interview suit" back on and come back up there for another sit down....

I work with a few psych pts down here.

[Contrarian]

Yes AndersEn...

 

Pack up the Fam and move on up... they already want you for CT Surg.

[cinntsp]

This is a bit off topic but as a someone who may be interested in doing some part time or per diem psych work in the future, do you feel that PAs fresh out of school are prepared enough to enter the field? If not, what sort of experience(other than doing a residency) would be good preparation?

[EMEDPA]

we have an inpt psych unit at my facility and they have not been able to hire a pa/np to manage medical(non-psych) issues in the unit so starting next month the em pa's and docs will be on call to the unit and will do rounds there during "down times". the hospital is going to "make it worth our while" somehow...decision way above my paygrade.... they said it will probably be no more than 2 hrs of work/24 hrs. the psychiatrists will manage all psych issues and we will manage the htn, dm, etc type stuff.

[Contrarian]

the psychiatrists will manage all psych issues and we will manage the htn, dm, etc type stuff.

 

This is exactly how I got started in psych. I was practicing addiction medicine and was recruited to manage the acute and chronic primary care issues (Htn, DM, CAD, Minor Lacerations, UTIs, Tinea, Pain, diarrhea, constipation, Epilepsy, Thyroidism, etc.) of the patients involuntarly detained in a freestanding inpatient psych facility.

 

The psych prescribers eventually started asking me for my opinion on addiction medicine and other mental health matters. Then I started filling in for the psych prescribers in emergency situations (assaultiveness, combativeness, or the prescriber called in ill at last minute).

Since there will be a nationwide shortage in psychiatry prescribers for the forseeable future and I was already doing it, and I figured that when I got older, I'd quickly grow tired of trying to see a patient every 7-15mins... and wanted to start getting paid more for what I know than what I do... and I also was looking for a specialty that I could do without a HUGE overhead and with limited to non-existent SP involvement... and psychiatry fits that bill perfectly. I started seriously studying and learning psychiatry.

 

I then decided that I may as well get a credential in it , so I focused my UNMC MPAS on Psychiatry/Behavioral Medicine (Says it right there on the diploma and on my transcript).

 

Still looking forward at the future population influenced healthcare demands (Half the population over age 50 soon), and job security ... I then attended a program that led to a state credential as a certified "Geriatric Mental Health Specialist."

 

So today, while I'm still knee deep doing Internal medicine daily... in about 10 yrs, I'll probably slow down and only do psychiatry, collect my $130k/yr and chill.

 

Because as I see it... 1.5hr new patient visits and 30 min follow up visits where ALL you do is sit and listen and sometimes talk is a very easy day....

 

 

This is a bit off topic but as a someone who may be interested in doing some part time or per diem psych work in the future, do you feel that PAs fresh out of school are prepared enough to enter the field? If not, what sort of experience(other than doing a residency) would be good preparation?

 

Sort of...

 

As a psych prescriber, I mostly deal with acute or chronic... psychotic or non psychotic; Anxiety, Unipolar Depression, Bipolar Depression, Mania, and Schizophrenia... typically coupled with the ~ 70% Co-Occuring Poly Substance Use that comes with these.

 

This is not really that complex if you are well read and continually update yourself on the psychopharmocology involved.

 

So its not so much that new grads won't be able gain proficiency in Psychopharm really quick, as that's easy.

 

Developing Motivational Interviewing, Dialectic Behavioral Therapy, Cognitive Behavioral Therapy, Object Relations, Brief Interventions, or whatever therapy techniques you would use and a demeanor that fosters therapeutic interactions will take some time to develop. Thing is... this too is much easier after one has spent yrs disscussing medicine with patients and "selling" treatment plans to them.

 

Also, getting comfortable utilizing a non-directive interviewing style (which is completely opposite and mostly directive in regular medicine) may be a challenging.

To me... the larger issue and the reason why I steer all of the students I interact with (15-20/yr) away from this specialty is because this field can be a "skill and knowledge stealing medical excellence eroding suck hole" ... if those skills and that knowledge isn't firmly inculcated by repetition and experience prior to limiting one's practice to psychiatry.

 

Think about it... we don't even use stethescopes. So its not hard to imagine that since requiring Direct Patient Care Experience prior to PA school has gone the way of the Do-Do bird... if the only experience many student today have in clinical medicine skills is limited to PA school, then like our MD/DO psychiatry counterparts, after a few yrs in psychiatry.... those skills will be GONE.

 

I'm NOT boasting in any way, but since I've been in psychiatry... I have typically run circles around every one of my SPs when it comes to general medical knowledge and treatment of most medical issues.

 

Its humbling and used to be scary when the nurses would call me at home because one of my MD SPs would defer complex medical issues with potentially life threatening consequences to my recommendations and instruct them to call me. This made me do a LOT more reading and studying since I figured "the buck stopped with me."

 

Its a odd and awkward situation when you as a PA walk into a room with 2 Psych NPs and a MD who are proud of themselves because they "discovered a UTI." Then they show you the lab, that has negative nitrates/negative Leuk estrace, but a few wbcs and rbcs... or having a boss/SP that doesn't know/remember the difference between micro-normo-macro cytosis and what they mean and has NO idea how to set up a sliding scale for insulin.

 

I always suggest that someone practice primary care (FP or IM) for a minimum of 5yrs before adopting a specialty that is so limited in scope of practice.

 

Just last week, while sitting in a medical department meeting, had a psychiatrist sarcastically suggest that I was having a difficult time limiting my practice to psychiatry and stated that I am suppose to refer patient to their PCP for primary care issues.

 

When asked for an example, the reply was some nonsense about me ordering CMP, a CBC, TSH and a HgA1c on a few new patients of mine.

 

I let this physician finish with the diatribe then calmly reminded everyone in the room that these were all Bipolar and/or patients with psychosis that was new to the practice. The patients were unreliable historians with limited/sparse previous medical records on hand and would likely need lithium (Thyroid/Liver/Kidney issues) and/or Neuroleptics (Metabolic issues) at some point. We may even need to use depakote or carbamazepine (metabolic/Blood dyscrasia issues).

 

So without BASELINE labs, how are we to know if/when this patients develops hepatitis (increased LFTs) or hypothyroidisim (Increased TSH) if itis secondary to the lithium (prescibed meds) or from something else...? 3 months from now, how are we to know if this patient already had agranulocytosis and has cancer or a HgA1c of 9 and already has T2DM when they came here to us, or the meds we are prescribing caused it...???

 

I then went on to suggest that prescibing witout this info COULD be considered "substandard care" and therefore deemed negligence buy a jury.

 

This psychiatrist just looked at me like a deer stuck in the headlights of a Mack Truck...:heheh:

 

After that meeting, the Medical Director asked me to submit a list of lab tests that ALL patients should have current in their medical records. He asked me to work with IT to develop a way to prompt each provider/prescriber to order specific labs and recommeded intervals.

So with that said...

A new grad going straight into psychiatry upon graduation will in short order find themselves as a hobbled psych NP.

 

Meaning that they will soon have very specific and "narrow" marketable medical knowledge and skills without the benefit of independent practice.

 

Just my opinion on the matter...

 

YMMV

 

Contrarian

[Guest Paula]

I'm not looking for a job...but...Contrarian...do you ever speak at PA conferences? What state do you practice in?

[ventana]

 

I always suggest that someone practice primary care (FP or IM) for a minimum of 5yrs before adopting a specialty that is so limited in scope of practice.

YMMV

 

Contrarian

 

 

VERY wise advice

 

and I would add a CAQ after 5 years in primary care (Adult IM or geriatrics)

[ToppDog]

For those that don't know, C really does have an awesome gig!

[cinntsp]

So with that said...

A new grad going straight into psychiatry upon graduation will in short order find themselves as a hobbled psych NP.

 

Meaning that they will soon have very specific and "narrow" marketable medical knowledge and skills without the benefit of independent practice.

 

Just my opinion on the matter...

 

YMMV

 

Contrarian

 

Thanks for the great input.

[Contrarian]

To me... the larger issue and the reason why I steer all of the students I interact with (15-20/yr) away from this specialty is because this field can be a "skill and knowledge stealing medical excellence eroding suck hole" ... if those skills and that knowledge isn't firmly inculcated by repetition and experience prior to limiting one's practice to psychiatry.

 

Think about it... we don't even use stethescopes. So its not hard to imagine that since requiring Direct Patient Care Experience prior to PA school has gone the way of the Do-Do bird... if the only experience many student today have in clinical medicine skills is limited to PA school, then like our MD/DO psychiatry counterparts, after a few yrs in psychiatry.... those skills will be GONE.

 

I'm NOT boasting in any way, but since I've been in psychiatry... I have typically run circles around every one of my SPs when it comes to general medical knowledge and treatment of most medical issues.

 

 

So today, I'm walking down the hall and notice that the patient exiting a physician's office and walking towards me looks odd. I can't quite put my finger on it, and it was just a "feeling" but something compelled me to engage this patient in conversation.

 

Fortunately, I had seen this patient about two months ago when the physician was unavailable, so since he knew me, I just walked up to him and asked him how he was doing.

 

He tells me that his medications are too strong and has been giving him problems with fatigue, dizziness, light-headedness, SOB, and fast/racing heartbeat. He says that the physician just lowered a few of his meds and assured him that these troublesome symptoms will go away by the time he comes back next month.

 

While he is telling me this, I'm looking at him and realize that he is about the color of a banana (which is what raised my antenna and got my attention from down the hall).

 

So I pull him out of the hallway and into my office and asked him has he noticed anything unusual like blood in his urine or stools. He reports dark/black stools.

 

I fill out a lab slip and have one of our clinicians escort him to the hospital for STAT labs.

1 hr later he is admitted with:

 

HCT- 12

HGB- 4

RBC- 2

 

The 3 physicians here was appalled... and to this one's credit, admitted that he heard the symptoms, and seen the patient, but didn't even consider a occult bleed. The others confessed that they wouldn't have considered it either. He gave me "props" and actually said "Thank GOD we got REAL, competent, and knowledgable medical providers here now.

 

That's funny because I'm the only PA on a medical Staff that includes 3 physicians (psychiatrists) and 3 ARNPs (psych NPs).

 

So to re-iterate:

 

This field can be a "skill and knowledge stealing medical excellence eroding suck hole" ... if those skills and that knowledge isn't firmly inculcated by repetition and experience prior to limiting one's practice to psychiatry.

 

While the typical Psych ARNP never had the benefit of "medical training"...

ALL/EVERY one of the Psychiatrists had more science training and atleast as much "medical" training as a typical PA-C.

Problem seems to be that after that intern year, they tossed out their stethescopes and refused to ever actually physically touch a patient ever again. They didn't spend 3-5 yrs inculcating "medicine."

 

Since you already paid for them.... just doesn't make GOOD sense to let those valuable and marketable skills erode to the point of non-existence.

 

Practice broad-spectrum general medicine for a few yrs to "lock it in" then sub-sub-sub specialize.

 

Just a few thoughts based upon my personal experiences...

 

YMMV

 

Contrarian

[EMEDPA]

good "looks bad from door" eval C!

[Guest Paula]

Contrarian: You have pinpointed the problem with psychiatry (psychiatrists). I cannot tell you how many patients I get back from a visit with a psychiatrist or behavioral health APRN, who simply have one more drug added to their daily regime. Then, they are back to see me with complaints of being drugged up, gaining weight, blood sugars raising, and the complaint they were now diagnosed with another psych condition. "I guess I'm bi-polar now". Plus, I NEVER get a note back from the psych provider even tho I referred. HIPAA is cited for that, so I jump through hoops to get the notes.

 

Case in point: I had a patient 6 years ago who had depression/anxiety and seizure disorder. She was managed well on an SSRI (I think I had her on low dose Prozac at 20mg daily and had consulted with her neurologist who had her on lamictal, before I started her on Prozac.) I lost contact with her and in the last year she showed up in my new practice with new diagnoses of bipolar and schizoaffective disorder with major depression. She was on Wellbutrin 450 mg daily, gabapentin 600mg TID, lamictal 100mg daily, Prozac 60 mg daily, Geodon 60 mg BID, Lithium and Lorazepam 2mg TID and levothyroxine. She was a mess. She was shaking and jerking, lip smacking, eyes blinking and staring, repetitive arm and leg movements...can you say extra pyramidal syndrome or tardive dyskinesia? She had never had any follow up labs, EKG to check the side effects of her meds. She decided to stop going to the APRN and simply wanted me to renew ALL her meds. Sorry, NO. I ended up over the course of many months decreasing and taking her off meds. She now is back to her regular low dose prozac and lamictal, still has a few lasting effects from the (Geodon? my best guess) of tics, her thyroid is controlled, and she is living a fairly normal life and looks like a human being.

 

So, if PA's go into psychiatry, don't give up your stethoscope and medical skills, and get at least 5 years of primary care under your belt. Then, think of the whole body getting the meds, not just the brain.

 

Contrarian...do you ever present at conferences? You should.

[303909]

When I was a psych. tech on an adult acute ward, I was shocked at the immediate tendency toward polypharmacy. If a patient happened to see more than one provider, you could see exponential gains in the number of meds. I'm not a provider so i don't pretend to know how to do the job better but "less is more" does not seem to be in the lexicon of many psychiatrists.

[Contrarian]

Perspective:

 

For most of what we treat in "medicine," there is some sort of objective measure (scans/imaging, labs, physical exam)that we use to confirm our preliminary/working diagnosis and to direct our treatments. Unlike "regular medicine," in psychiatry 99.9% of the symptoms are subjectively patient identified and reported with only a "mental status exam" to guide us. So if we don't ask the right questions, at the right time, in the right way... we won't get the right answers that lead to the right diagnosis.

 

This in and of itself leads to different problems and issues.

 

For example, depression is usually characterized by three dimensions: pure depressive, pure anxious, and pure activation (irritablity), corresponding to three basic emotions – sadness, fear, and anger. All three of these can be unipolar depression or they could be Bipolar depression , anxiety disorder (+/- PTSD), or Disphoric Mania (as seen in Bipolar Affective Disorder).

 

Needless to say, the above distinctions may entirely elude many primary care providers.

 

IMNSHO... trying to compare/parallel the "medicine" versus psychiatry diagnostic & treatment approaches is a "fools errand."

 

Factoid: 70% of a Bipolar patient's time is spent in the Depressive state with 30% of their time spent either manic or HypoManic.

 

Full blown mania is visible and easy to spot. Its typically uncomfortable for the patient and everyone around them. So these patient's are usually readily identified. Hypomania is usually not so easy to spot and can be usefull and productive so it is not often considered a problem and therefore typically not reported in the history of a "depressed" patient by the patent.

 

So it stand to reason why so many patients with BPD are misdiagnosed.

 

Factoid: 7 out of 10 Bipolar patient's go about 10 yrs misdiagnosed (by Primary Care Providers) with UniPolar Depression resulting in lots of medication "misadventures" with anti depressants. This unfortunately, often results in life altering full blown psychotic- manic episodes and hospitalizations.

 

For instance, I have a patient who USED to be a successful Pharmacist for 22 yrs. He went to his PCP a few yrs ago complaining of depressive symptoms. He then tried and failed 4 different SSRIs so was put on a SNRI by the PCP. Within two months, his paranoid delusions had him convinced that the FBI was trying to assassinate him. So to avoid death, he went to the AIRPORT, and bought a one way ticket to the Dominican Republic. Then while at the gate, awaiting departure, he called the local FBI field office and told them that he knew of their plan to kill him and warned them that he would crash the plane if they tried to stop him. He was arrested by Homeland Security about a hr later, on that plane at the end of the runway and charged with Domestic Terrorism. He spent 18months in Jail (plea bargin) and can no longer work as a pharmacist (federal felony conviction).

 

The problem with "misdiagnosis" stems from the requirement of atleast a single identifiable manic or hypomanic episode to be present for the diagnosis of bipolar disorder and r/o of unipolar depression to be made.

 

Thing is... in reality, a patient could be bipolar and either only have "functional" hypomanic episodes that doesn't cause impairment so never gets reported, or simply has not had a manic episode YET. So the absence of a reported manic episode doesn't mean the patient is not bipolar and is by default unipolar... it just means that the patient hasn't presented with or the provider hasn't sought out a manic episode YET.

 

Many of these "medication misadventures" could be avoided by actively and doggedly seeking out manic and HYPOmanic signs by asking pointed questions to rule it out before simply slapping a "depression" label on every patient that presents to their PCP with depressive symptoms.

 

The "Depression Rule of Threes" suggest that if a depressed patient has had:

 

Professsional Instability in life such as going to three universities without getting a degree or changing professions from one to another to yet another resulting in 3 Careers (hard to keep a job)

 

3 Marriages (hard to get along with /moody)

 

Tried on 3 different anti-depressants (at effective/max doses) that seem to work initially then lose efficacy (treatment resistence).

 

These depressed people should be considered Bipolar until proven otherwise.

 

 

Triads of behavior or traits in the patients' biographical history-as well as in the biologic kin-involving polyglottism, eminence, creative achievement, professional instability, multiple substance/alcohol use, multiple comorbidity (axis I and axis II), multiple marriages, a broad repertoire of sexual behavior (including brief interludes of homosexuality), impulse control disorders, as well as ornamentation and flamboyance (with red and other bright colors dominating) were specific for BP-II. Temperamentally, many of these individuals thrive on activity-they are indeed "activity junkies."

 

 

One way for the PCP to conceptualize this is to consider that DEPRESSION comes in 2 basic flavors:

Plain ole every day vanilla Depression and Depression that includes hypo or full blown mania. Most people should be considered Bipolar until any possibillity of them ever experiencing a manic/hyomanic episode has been explored and eliminated.

 

One reason why this is important is because the treatment for unipolar depression is radically different from the treatment of Bipolar depression.

 

Mainly the idea that in Unipolar depression, the mainstay/firstline of treatment is the use of Antidepressents (SSRIs/SNRIs/ DNRIs), whereas the mainstay/firstline of treatment in Bipolar Depression is lithium and/or anticonvulsants and low dose antipsychotics used as mood stabilizers ... and antidepressents are to be avoided and/or used with extreme caution in Bipolar Spectrum Patients.

 

We are to "First do no harm" and putting undiagnosed Bipolar patients on Antidepressents quite often does harm.

 

Or better put: To "First, Do no Harm," "Do Know Harm."

 

Another reason why this is important is because there is a statistically significant difference in suicide/death rates between unipolar and bipolar depressed patients.

 

Factoid: While some/a few patients can be successfully treated wth monotherapy (usually Lithium/Depakote/Lamictal/Teratol) ... Most Bipolar patients require multiple medications (PolyPharmacy) for management of their Affective disorder because their symptoms usually occur on a "Spectrum."

 

________________________________________________________________________________________________

 

 

So I wrote all that to say that psychiatry is not a straight forward "black or white" specialty like umm, say ... ortho, GYn, Peds or even Cardiology. We are dealing with the human brain, and mind. We are attempting to stand in the synapse and alter brain chemistry and direct neurochemistry by affecting/effecting receptors and neurotransmitters. This is done mostly by trial and error because we can't open up the head and look at the neurons/synapse and make adjustments.

 

Just a few thoughts...

 

Contrarian

[Guest Paula]

Contrarian: thanks, that was informative. I don't recall anything that in depth in PA school. Your answer is another reason why psychiatry should not be such a hush-hush profession and that behavioral health professionals cannot share any info with the PCP's or send follow up notes. It still has stigma for the patients and the prevailing laws will cause it to remain so. Maybe it's just where I work, but the hoops we have to jump through to get information from the psychiatrists is ridiculous. They won't even talk by phone citing HIPAA.

 

Medicine has been successful in removing HIV/AIDS stigma, why not mental health?

[ToppDog]

That was a good read.

[tme12]

Contrarian-

 

Thank you very much for all of your input. It was really helpful to read about your experiences in the field. I am currently in PA school and am trying to figure out what I want to practice (I am still in the didactic phase). I am definitely most interested in psych, but I do not want to pigeon-hole myself in one area, plus, I do not want to go into a specialty without a strong base of general medicine first. It sounds like many of your successes in psych come from your strong base prior to specializing. With that said, psych is something I would love to do down the road. Your advice reaffirmed my beliefs, and I appreciate it!

 

Thank you.

[discogenic]

Contrarian-

 

Thank you very much for all of your input. It was really helpful to read about your experiences in the field. I am currently in PA school and am trying to figure out what I want to practice (I am still in the didactic phase). I am definitely most interested in psych, but I do not want to pigeon-hole myself in one area, plus, I do not want to go into a specialty without a strong base of general medicine first. It sounds like many of your successes in psych come from your strong base prior to specializing. With that said, psych is something I would love to do down the road. Your advice reaffirmed my beliefs, and I appreciate it!

 

Thank you.

 

What is it about psych that makes it attractive?

[cinntsp]

What is it about psych that makes it attractive?

 

What is it about any field that makes it attractive? Different strokes.

[discogenic]

What is it about any field that makes it attractive? Different strokes.

 

For someone like myself who hasn't had any exposure to psych, it would be interesting to hear what it is about psych that those who practice it enjoy/find rewarding/strive toward/dislike/etc.

[cinntsp]

For someone like myself who hasn't had any exposure to psych, it would be interesting to hear what it is about psych that those who practice it enjoy/find rewarding/strive toward/dislike/etc.

 

I personally find it interesting because there is no set answer to the neurotransmitter soup that we each have. It's a challenging field of trial and error in which you get to see remodeling of the brain through therapy and drug intervention. The brain is an amazing thing.

[discogenic]

I personally find it interesting because there is no set answer to the neurotransmitter soup that we each have. It's a challenging field of trial and error in which you get to see remodeling of the brain through therapy and drug intervention. The brain is an amazing thing.

 

Interesting take.

 

When you replied earlier, I couldn't help but picture you in a PA school interview, with the program director asking you "So, wutthechris, why do you want to be a PA?", to which you replied "Why does anybody want to be anything? Different strokes." :wink:

[futurePAS]

Sorta off-topic but as a future PA I'm very very very thankful for PAs like Contrarian who blazed the trail for us!

[rcdavis]

Truth speaks to power. (regarding contrarians above note)

[PASunny]

This is exactly how I got started in psych. I was practicing addiction medicine and was recruited to manage the acute and chronic primary care issues (Htn, DM, CAD, Minor Lacerations, UTIs, Tinea, Pain, diarrhea, constipation, Epilepsy, Thyroidism, etc.) of the patients involuntarly detained in a freestanding inpatient psych facility.

 

The psych prescribers eventually started asking me for my opinion on addiction medicine and other mental health matters. Then I started filling in for the psych prescribers in emergency situations (assaultiveness, combativeness, or the prescriber called in ill at last minute).

Since there will be a nationwide shortage in psychiatry prescribers for the forseeable future and I was already doing it, and I figured that when I got older, I'd quickly grow tired of trying to see a patient every 7-15mins... and wanted to start getting paid more for what I know than what I do... and I also was looking for a specialty that I could do without a HUGE overhead and with limited to non-existent SP involvement... and psychiatry fits that bill perfectly. I started seriously studying and learning psychiatry.

 

I then decided that I may as well get a credential in it , so I focused my UNMC MPAS on Psychiatry/Behavioral Medicine (Says it right there on the diploma and on my transcript).

 

Still looking forward at the future population influenced healthcare demands (Half the population over age 50 soon), and job security ... I then attended a program that led to a state credential as a certified "Geriatric Mental Health Specialist."

 

So today, while I'm still knee deep doing Internal medicine daily... in about 10 yrs, I'll probably slow down and only do psychiatry, collect my $130k/yr and chill.

 

Because as I see it... 1.5hr new patient visits and 30 min follow up visits where ALL you do is sit and listen and sometimes talk is a very easy day....

 

 

 

 

Sort of...

 

As a psych prescriber, I mostly deal with acute or chronic... psychotic or non psychotic; Anxiety, Unipolar Depression, Bipolar Depression, Mania, and Schizophrenia... typically coupled with the ~ 70% Co-Occuring Poly Substance Use that comes with these.

 

This is not really that complex if you are well read and continually update yourself on the psychopharmocology involved.

 

So its not so much that new grads won't be able gain proficiency in Psychopharm really quick, as that's easy.

 

Developing Motivational Interviewing, Dialectic Behavioral Therapy, Cognitive Behavioral Therapy, Object Relations, Brief Interventions, or whatever therapy techniques you would use and a demeanor that fosters therapeutic interactions will take some time to develop. Thing is... this too is much easier after one has spent yrs disscussing medicine with patients and "selling" treatment plans to them.

 

Also, getting comfortable utilizing a non-directive interviewing style (which is completely opposite and mostly directive in regular medicine) may be a challenging.

To me... the larger issue and the reason why I steer all of the students I interact with (15-20/yr) away from this specialty is because this field can be a "skill and knowledge stealing medical excellence eroding suck hole" ... if those skills and that knowledge isn't firmly inculcated by repetition and experience prior to limiting one's practice to psychiatry.

 

Think about it... we don't even use stethescopes. So its not hard to imagine that since requiring Direct Patient Care Experience prior to PA school has gone the way of the Do-Do bird... if the only experience many student today have in clinical medicine skills is limited to PA school, then like our MD/DO psychiatry counterparts, after a few yrs in psychiatry.... those skills will be GONE.

 

I'm NOT boasting in any way, but since I've been in psychiatry... I have typically run circles around every one of my SPs when it comes to general medical knowledge and treatment of most medical issues.

 

Its humbling and used to be scary when the nurses would call me at home because one of my MD SPs would defer complex medical issues with potentially life threatening consequences to my recommendations and instruct them to call me. This made me do a LOT more reading and studying since I figured "the buck stopped with me."

 

Its a odd and awkward situation when you as a PA walk into a room with 2 Psych NPs and a MD who are proud of themselves because they "discovered a UTI." Then they show you the lab, that has negative nitrates/negative Leuk estrace, but a few wbcs and rbcs... or having a boss/SP that doesn't know/remember the difference between micro-normo-macro cytosis and what they mean and has NO idea how to set up a sliding scale for insulin.

 

I always suggest that someone practice primary care (FP or IM) for a minimum of 5yrs before adopting a specialty that is so limited in scope of practice.

 

Just last week, while sitting in a medical department meeting, had a psychiatrist sarcastically suggest that I was having a difficult time limiting my practice to psychiatry and stated that I am suppose to refer patient to their PCP for primary care issues.

 

When asked for an example, the reply was some nonsense about me ordering CMP, a CBC, TSH and a HgA1c on a few new patients of mine.

 

I let this physician finish with the diatribe then calmly reminded everyone in the room that these were all Bipolar and/or patients with psychosis that was new to the practice. The patients were unreliable historians with limited/sparse previous medical records on hand and would likely need lithium (Thyroid/Liver/Kidney issues) and/or Neuroleptics (Metabolic issues) at some point. We may even need to use depakote or carbamazepine (metabolic/Blood dyscrasia issues).

 

So without BASELINE labs, how are we to know if/when this patients develops hepatitis (increased LFTs) or hypothyroidisim (Increased TSH) if itis secondary to the lithium (prescibed meds) or from something else...? 3 months from now, how are we to know if this patient already had agranulocytosis and has cancer or a HgA1c of 9 and already has T2DM when they came here to us, or the meds we are prescribing caused it...???

 

I then went on to suggest that prescibing witout this info COULD be considered "substandard care" and therefore deemed negligence buy a jury.

 

This psychiatrist just looked at me like a deer stuck in the headlights of a Mack Truck...:heheh:

 

After that meeting, the Medical Director asked me to submit a list of lab tests that ALL patients should have current in their medical records. He asked me to work with IT to develop a way to prompt each provider/prescriber to order specific labs and recommeded intervals.

So with that said...

A new grad going straight into psychiatry upon graduation will in short order find themselves as a hobbled psych NP.

 

Meaning that they will soon have very specific and "narrow" marketable medical knowledge and skills without the benefit of independent practice.

 

Just my opinion on the matter...

 

YMMV

 

Contrarian

 

Dear Contrarian;

 

I am in need of a mentor. Your description above is quite impressive. I'd love to PM you if you have even a remote interest. Thanks in advance.