4 Comments to Career Analysis: The Psychiatric NP

  1. Hello. Thank you for your very detailed description of PMHNPs and how they compare to MD Psychiatrists.

    Your numbers for each medical occupation were totally spot on.

    Q: How do you feel about prescribing psychologists? What additional medical training do they have to undertake along with usual career path? How are they different careerwise from psychiatrists?

    1. Hi Jeremy,

      Great questions!

      I view prescribing psychologists with contempt (just kidding). I actually feel sorry for them because they are, in general, overeducated and overtrained for what they do. If you take a look at page 6 of the report from the Congressional Research Service (click on “Take a look at this publication” in my original blog post) and compare the scopes of practice between the psychologist and the Advanced Practice Psychiatric Nurse (or NP), you’ll see that psychologists generally CANNOT prescribe medication. So what’s the value proposition of being a psychologist?

      Apparently, it’s in the ability to administer and interpret psychological tests.

      This means that doctorally prepared psychologists are not as versatile (because they generally cannot prescribe medication) as masters prepared NPs and PAs, even though psychologists may spend twice as much time (and sometimes longer) in school. This is a good example of education being overrated. The take home message is that one’s degree is not as important as one’s credential.

      Here’s some proof:
      The average salary for a psychologist is $83,967, while the average salary for a Psych NP is $122, 963.

      Even though psychologists have terminal degrees and thousands of hours of training, they still make less than Psych NPs, most of whom only have masters degrees. The marketplace values the ability to prescribe (the value proposition of the Psych NP) over the administration/interpretation of psychological tests (the value proposition of the psychologist).

      In terms of your question on additional medical training for prescribing psychologists, please see this link.

      I would say that prescribing psychologists are different from psychiatrists in that the former group is much more limited in practice. That is, prescribing psychologists can prescribe only in a handful of states, whereas psychiatrists can prescribe in all states.

      Thanks for your interesting questions!

  2. There is tremendous propaganda from Nursing organizations, created to justify what is in sum, a push for higher salaries. I cannot hate that whatsoever, but the lies involved in attempting to say that Nurse Practitioners are similar to MD’s is sad. It is more accurate to say that Nurse Practitioners that are trained well and motivated to do MUCH reading independently (to catch up to what physicians get in those extra years of training) can mirror the scope of practice of a below average physician, only because their training involves memorizing treatment algorithms, created by physicians, and literally practicing on patients when they begin working (as most do not do postgraduate training equivalent to residencies for doctors, where physicians also practice their skill set, under multiple layers of supervision, for years). This is significant, because scope of practice alone doesn’t tell one the difference that patients should expect. They are trained to mirror the scope of practice and parrot it fairly well because common disorder presentations are common after all. The difference is the level of depth of insight, which is crucial in order to go beyond the very limited DSM categories. NPs are designed for insurance-company style medicine, which requires clean diagnostic categories and algorithmic treatment. Medicine is way more complex than this, which is why people are not happy with the current US system of care, as it is obviously money driven, with clean decision making and much collateral damage (e.g. people being discharged from ERs and hospitals too soon). Physicians draw from vast depths of medical knowledge, arduously learned in medical school and prove their knowledge by passing the US medical license exam and specialty board exams, which are incredibly difficult (e.g. by the time a psychiatrist is certified for practice, they have passed 3 eight hour tests and one 16 hour test). I can tell you that drawing on this wealth of medical knowledge is essential in order to adequately assess and treat patients. Anything less is literally asking for mistakes to happen. This is not meant to degrade Nurse Practitioners, as they have a crucial role as the primary care faces of psychiatry and any specialty they practice. The problem is that many are flocking to independent practice, believing the mountains of propaganda put out by nursing organizations, that they are equivalent to physicians. This is truly dangerous, as I’ve taken care of many, many patients, who have NP’s as their primary mental health provider and the mistakes made are basic, representing fully, this knowledge gap. Again, it wouldn’t be bad if they knew to refer when they were out of their depth. The problem is that they did not know to refer, which happens when one believes the propaganda, and practices outside of their scope without knowing it. One has to wonder, why does one have to try so hard to convince the public that verifiable differences in knowledge and experience do not matter? Simple, follow the money. This field is offering a very lucrative path for ambitious nurses who want to go beyond traditional nursing roles. There is nothing wrong with this, yet pretending to be something they are not (e.g. I challenge any NP to sit for all three parts of the US Medical Licensing Exam and the specialty board exam, the failure rate would be over 90%, no exaggeration) is disrespectful to physicians who sacrificed more than the lay public would know (10+ years after medical school in order to just begin mastering their crafts). It is also potentially very dangerous for patients (side effects can kill and one must absolutely know the pharmacology behind prescribing, not just algorithmic directions). Now, I don’t mind NPs, as the AMA supported limiting medical residency spots, creating a bottleneck and thus a physician shortage, so they fill crucial care gaps. I also feel no competition, as I have worked with many NPs, and trust me, the different in knowledge depth is huge, so why would one be angry, and frankly, patients who need expertise, find this out eventually. I am just bothered by the immoral push by nursing societies to fool the public into believing that they are equivalent to physicians. The self-sacrifice by many physicians I know, to become masters at what they do is the stuff of legends. One cannot shortcut their way to that level of mastery.

    1. Hi Michael,

      I agree with everything you said. Your response was well written and very convincing.

      I think this is the crux of the issue: the public has to struggle against two competing stories. The first story is often shouted by doctors and sounds like this: “NPs lack medical knowledge and thus cannot be compared to doctors.” The second story is ejaculated by NPs and sounds like this: “there is no evidence that doctors are safer than NPs! In fact, some studies indicate that NPs are safer than doctors!”

      Which story will win in the end? A lot of money is at stake! A lot of pride is at stake!

      I think the irony is that the field of medicine has created its own enemy: the NP. Physicians are so skilled in regulating who gets into the medical profession that market forces have turned to the next best “provider” to address the demand for medical services: the NP. That said, I think at the end of the day, most states will eliminate scope-of-practice barriers for NPs simply because there are not enough doctors. The laws of supply and demand will reign supreme.

      In other words, I believe NPs will increasingly see their scope-of-practice barriers removed, allowing NPs to climb the ladder toward equivalency with doctors.

      What do you think, Michael?

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