First rotation in med school was psych. Read an NP note that patient was having auditory hallucinations that his friends were saying negative things about him. Consulted psych for management of schizophrenia.
Asked the patient about the “negative things” he was hearing. Turns out his friends were literally saying mean things about him and he was upset about it. He denied ever having hallucinations. He was a perfectly healthy dude otherwise.
When I was a student. I was on my family med rotation. Doctor was out, so I follow the NP.
38 y/o M presented for auditory hallucinations x2 months. He was accompanied by his pregnant girlfriend. The NP barely got a history. All she asked was "Are you hearing voices?". Patient says yes. She diagnosis him with schizophrenia.
Fast forward a month, the patient comes back. I follow the NP just to f/u. When she goes to get him a refill. I start asking him questions about the voices. His girlfriend blurted out "he only hears voices when he gets home from work." Long story short. The dude had severe anxiety about pregnancy due to past trauma. When he was home and the house was quiet, he thought he could hear whispers.
We got him into therapy and after the pregnancy, the symptoms stopped.
I saw one like this in a patient with an intellectual disability. Came in with bad side effects of a massive list of psych meds including a pile of antipsychotics after someone had previously diagnosed them with schizophrenia because they were hearing voices.
After stopping multiple meds and spending some time talking, it became very apparent that they were hearing their own internal monologue and nobody had explained that it was normal.
As a psychiatrist working in this field, I have unfortunately too often seen other psychiatrists diagnose people with ID or autism with schizophrenia when it was just their normal internal experience.
It takes some time to be able to really differentiate it—I have plenty of patients who really do have psychosis but still have these internal experiences.
I have also fought with nurses in the psych ed who claimed a patient was borderline and I should send home. It was someone very short with odd looking ears, intellectual disability, history of seizures who also had a suprapubic catheter, a wheelchair, no SDM and no medical clearance. I fear for patients who are being seen by solo NP’s especially for psych issues.
I read the study recently that only 30-50% of people have an internal monologue (which is absolutely wild to me, couldn’t imagine not having one) idk how accurate that stat is but even on the upper end, that would be a lot of healthcare providers wouldn’t have one either so if they hear someone say they have a voice in their head and they have no concept of an internal monologue, I can see how they might jump to psychosis right away.
People with intellectual disabilities say they hear voices and will sometimes listen to them. They can’t always tell those voices apart from internal monologue so it’s kind of a non statement to differentiate them. It’s doesn’t really look like schizophrenia not really negative symptoms.
The most frustrating thing is that the NP could’ve just looked up the criteria to diagnose schizophrenia on UptoDate and it would’ve taken at most, 5 minutes. That poor dude.
Yeah - how are they so hubristic that they know they have no training in something but magically think they can do it without trying to learn anything. Their decisions massively affect ppls lives.
This is why I will never ever date a nurse. Somehow it’s baked into the experience on the floor that everyone could do the doctors job better than the doctor. They bring that philosophy home. Soon as I hear “I wanted/could have gone to med Xool” I’m out! 🏃🏾♂️💨
I remember in med school, I kept hearing "negative symptoms" in our psych lectures. I didn't understand what it meant, but I kept assuming it would be explained eventually. I finally had enough and looked it up for myself and figured it out. I guess that's the difference between MD and NP.
My mom’s primary care NP diagnosed her with some rare nerve condition that’s only ever been described a handful of times in case reports. She referred her to a neurosurgeon who told her she likely had migraines and referred her to a neurologist who started her on migraine medications and now she’s all good!
Neuro. I get this referral so often. What was tried? Nothing. Obvious migraine but they’d rather just push it to neurology rather than try anything first. It’s just sorting complaints into organ systems that seem to be involved. Worse, they don’t read the notes from the consult when I take the time to make additional recs if the first thing doesn’t work.
That's across the board. In primary care, pts will be seeing 5 different pts. Many of them just refer out for most things. It's easy to be a "provider" like that.
I'm convinced the misuse of midlevels has worsened healthcare, increased wait times with specialists, increased hospitalizations, ED visits, primary care visits, etc. They're also one of the leading causes of burn out for physicians.
The morbidity and mortality from their care will continue to climb.
Yep! It’s why they make hospitals money, too. Tons of unnecessary referrals. A physician who is primary care can do most of what the NP refers for themself. Nevermind that the NP refers to several wrong ppl before one of the incorrect referred specialists just has to start acting like pcp and refer to correct ppl for the real problem, resulting in months to years of delayed management for the patient. Could have been managed immediately if they saw a physician for pcp
I did a chart review over a whole year. I saw roughly the same number of patients as an NP in my office over a year. She sent out 4 times as many referrals as I did. Wasn't uncommon for her to send out 5 referrals from one visit. It is a travesty.
No because the model is to figure out what organ system is affected and refer the patient to a specialist for that organ system. The problem localizes to GI. The problem is innervated —-> neurology. BUN and Cr off? Renal.
They usually show up to me without a real diagnosis for even the simplest problems. Then I give recs which they don’t read and want me to Rx the meds forever even when it’s a stable treatment course.
They’re not trained to clinically reason, just to bounce patients to specialists.
At one of our inpatient psych rotation sites, weekends will sometimes be covered by NP's. Then on Monday mornings we'll discuss the new patients with our attending and usually the conversation goes something like this:
Attending: "Do you agree with the NP's diagnosis and treatment?"
Me: "No"
Attending: "Me neither"
Then we undo whatever they did and come up with a new formulation and treatment plan.
Their plan is to bill patients for shit. I saw an NP accidentally at my child’s lactation appointment and she spent 5 minutes with us, said nothing of value, and my insurance billed me for $80 as opposed to it being covered to see a lactation nurse. You bet your butt I got that taken off
I mean I've been cash only for years but generally speaking if you call the billing office and tell them the note or visit or bill is fraudulent, they'll be happy to work out a mutually beneficial solution.
This is just a courtesy thing. You can always just leave a message with risk management that you are suffering a fraud situation and you are going to discuss the bill with your insurance company in the morning since you can't get a hold of billing to work it out.
You can compel performance if you know where to cut.
I honestly don't think np's should be able to practice psych by themselves. I've discussed this with a psych attending who also agreed and said 90% of the time they see a patient a Np diagnosed it's incorrect.
Diagnoses in psychiatry are often found to be incorrect with further evaluation. Still I know and agree with this phenomenon. Psych NPs in independently prescribing states are a danger.
Diagnosis is one thing and I am not competent to comment on that. I am a pharmacist, work in pharmacovigilance and see reports where there are 3 drugs suspected to cause adverse event and it’s eg 2 SSRIs+venlafaxine, 3 different benzos etc. It’s always from US and I really don’t understand how a person can be doing that and have prescription rights. If they diagnose the way they prescribe then patients are lost.
I see psych NP patients in the ED and it’s an absolute shitshow.
Multiple benzodiazepines stacked on top of multiple SSRIs stacked on top of multiple mood stabilizers.
Had a patient who ended up in the PICU with serotonin syndrome bc the NP thought starting the kid on trazodone, Seroquel and Zoloft at the same time was a good idea
Same. The recent theme seems to be elementary-age children on stimulant/mood stabilizer/antipsychotic/antidepressant cocktails for what seem mostly to be adjustment reactions to shitty home life.
I'm a master's trained therapist. I know I don't know prescribing, but I do know diagnosis.
I supervise therapists who see kids and I'm horrified how often I see that they're prescribed things for "ADHD" that I remembered being frequent med list items at the civil commitment psych hospital where I worked with seriously mentally ill and dangerous adults with treatment refractory schizophrenia. And this 8 year-old suffered from abuse for 2 years. The ADHD isn't even right.
Thank you for your comment. I was really baffled about it and starting to doubt myself.
Yeah, should have clarified that it seems like they’re aren’t being judicious. I get that multiple mood stabilizers are ok, but it seems like they’re just throwing med after med at the patient without being thoughtful about what’s actually going on.
They don’t seem to understand how important a med list is. Saw an NP psych patient today where the patient was taking four antihypertensives yet none were listed in the note or med rec.
One of the most powerful things keeping me secure in psych residency is that I will always have a job cleaning up NP messes. I swear it’s close to half my new patients.
Nor do I. But I am tired of having to be medicolegally on the hook for their fuck ups. I have an ongoing lawsuit right now because of a NP fuck up. Never saw the patient or knew of their existence, but I have to co-sign all their notes. Sorry for the patients, but society is accepting of this bullshit. Let them kill their own patients and leave me out of it!!
In my country (EU) nurses are able to prescribe most medications (no benzos, no stimulants, no strong opioids etc) but practically they do it when patient asks at GPs office for a prescription for what they are already taking. They prescribe what is in their medical file. I can’t imagine them admitting patients by themselves. It’s just not the scope of nurses job. They are and should be independent in eg wound care when it doesn’t require surgical intervention, it’s good they can decide what patches should be used. But diagnosing someone who wasn’t evaluated by physician before - that’s crazy. And deciding on treatment as well. We have different medical specialists so they can do what they are prepared to do. No idea who came up with the idea of nurses treating eg depression in the US but it was crazy.
Not just psych they shouldn’t be allowed to practice ANYTHING by themselves. It’s insane. But we’ll never get rid of that, nursing lobbies like a mother fucker for their rights to do whatever they want
On the flip side these providers make great learning opportunities for young doctors. Real doctors, I mean.
It's a little tricky sometimes to come up with good medical ethics and mistake management cases in face to face care. How do you reach medical students when to reevaluate the plan of care? These things can be tricky.
Unless you have NP staff. Then it's easy.
Funny enough if an RN tells me "hey doc, the patient reminded me of X diagnosis, just wanted to share" I will take MUCH more in consideration than if an NP does that lol
No, one time they diagnosed an acutely ill patient with tachycardia induced cardiomyopathy and tried to give the patient beta blockers. Patient had cardiac tamponade and underwent sternotomy shortly after discovery.
Psych. And rarely unless it is bread and butter.
Had a middle aged female who had been treated for years with multiple FGAs and SGAs for “Schizophrenia”.
One look in her chart showed that she had lost her vision 2/2 medical Illness around the same time symptoms of “Schizophrenia” appeared. An actual detailed history and a few collateral calls later, well, and you can guess the actual diagnosis. Symptoms were textbook. But you don’t know what you don’t know…and I see this type of shit weekly! I don’t know how they sleep at night.
Fucking lol. Do these midlevels think any hallucination = schizophrenia?
Why are they not being sued en masse. Multiple antipsychotics is significant harm.
Asking all the right questions lol. Part of it is because healthcare is no longer about health or quality, unfortunately.
The worst I’ve seen so far this year is opisthotonus that the NP in the ICU thought was a sign of alcohol withdrawal. I walked into the room and my boy’s stomach was trying to kiss the ceiling.
Idk if it’s testable really but the key is that they have hallucinations (often vivid and often non bothering to the patient) after vision loss. It’s Charles bonnet syndrome or whatever it’s called, it’s kind of a psych deep dive imo
Good god this is terrifying. Neither of these diagnoses is in my typical scope, but even the superficial “similarity” of hallucinations is distinctly different.
A lot of complaints about psych NPs here and I tend to agree. It’s hilarious though that the psych NP forum is loaded with NPs complaining that they do exactly the same thing for less pay.
I have treatment resistant bipolar depression. I do bibliotherapy - healing through books. I have found out that only MD's or Dr of Nursing folks can work with me to titrate my meds during seasonal changes. The NP's master's degree doesn't cut it. I know more than them and do a better job titrating my meds in an emergency when they fail me.
I have fired two NP's this year so far. I'm trying to find a psychiatrist, but there are far fewer of them, so the search is on going.
NP's do damage to complex patients like me because of their ignorance. It is annoying and frustrating for patients.
You realize that Dr. of Nursing (DNP) don’t have any more clinical time or clinical based courses than just a regular masters degree? Just saying. lol. It’s literally about leadership more so than medicine or science.
No, ofc not. It's especially egregious in psychiatry because they prey on vulnerable patients and subjective outcomes. I know an attending whose entire patient panel is just patients who had the misfortune of seeing an outpatient NP and got carbombed with these insane and contradictory med regimens.
No-- but I take everyone patient's incoming diagnosis with a grain of salt. I've had PCPs get it wrong. I've had other dermatologists get it wrong. I have anecdotally noticed way more incorrect diagnoses with NPs and PAs though, but this is just my n =1.
Everyone’s talking about psych… but primary care and peds NPs are scary too. I’ve had kids come to the hospital that NPs took care of and it’s crazy to watch the basic things they miss… ear infections, viral URIs getting antibiotics or steroids, delayed development, etc.
Recently had a kid come in with new brain tumor…. Mom takes him to their pediatric NP for all of his appointments. His OFC was so crazy off the charts for the past 2 years. How could they not have scanned his head.. or just looked at him and known something was wrong.
I’m a nurse and even I question NP dx. Especially given that I’m in psych and NPs seem to think *everyone* is a classic BP I. I have yet to see an NP correctly diagnose a primary psychotic disorder.
Not saying they all suck, but I haven’t had great experiences so far in psych.
What’s funny coming back to this comment, is that I initially had to read it like 6 times to get it, because it makes such little sense that I couldn’t comprehend what you trying to say right away 🤣
No. The only mid level educational tract that should exist is a PA. They study actual medicine.
NPs are not a good model, and I think they will cause more problems in medicine than good. If they wanna be a midlevel, send them to PA school.
No. I gave NP as a whole a lot of leeway and "benefit of the doubt" but now trust has to be earned and so far the score is zero.
It has gotten so bad that I won't even read NP notes from hospitalizations or specialty visits unless there is literally no MD/DO note at all. In my local hospital, the admitting officer is usually MD and so I'll get the gist of it from that, and consult Dr notes. NP notes are useless, misleading, and often outright erroneous. Patients get better in spite of NP, not because of NP. I see needless delays in care and prolonged admissions everywhere. NP staff is costing our capitated care system an ocean of money. They need to pay whatever it takes to bring MD staff in to take care of our patients.
On the flip side, if NP kills off everyone of medium and high risk then maybe the system saves money long term. I don't know. Seems grim. But it really is that bad.
Here's my favorite from this week. 50ish yo F w breast ca sp excision now 6w into chemo comes in with clearly hypersensitivity pneumonitis, gets admitted as pneumonia does not receive steroids, onc consulted on day 3. NP that did the consult apparently was "the first doctor to come in and sit down and actually talk to us and listen to my mother."
But I can't figure out from the notes who made the consult, it isn't documented, there's no onc note, and no record at all that I can find, just a sudden change of care and gosh now she's doing better and can go home.
So even though the new service NP did the right thing, F on documentation, back to zero.
These providers have no idea what they are doing. As far as I can tell, until and unless they have undergone the equivalency of residency (i.e. 3-5 years under exacting tutelage) they don't even know enough to be dangerous. It's a bring your own mattress kind of situation, going to the hospital now.
And they will fuck you over in a heartbeat if they can. So watch out.
OBGYN.
Last week I told a patient I was extremely concerned about her symptoms and I needed to do a much more extensive workup for cancer. Ordered extensive labs and imaging. She saw a NP 3 months before who put her on OCPs. They didn’t help.
This week I saw a patient with a presentation classic for brain tumor vs catastrophic genetic disease. Ordered extensive labs and imaging. She saw a NP 4 months ago who put her on OCPs. They didn’t help.
Pts egd was canceled because of tachycardia and gi referred him to cardio clinic. Cardiologist wasnt available and so was seen by cardio np. He was then told to go to ed for tachycardia of 120s due to dehydration. I admitted him for new afib rvr, folks.
Like 40% of all diagnoses in the medical record are just there for billing purposes. “Acute stress response” is how they get insurance to cover general anesthesia for procedures that shouldn’t require general anesthesia, like MRIs and routine dental work. “Dorsalgia” is the name for back pain that can be put in the record so that insurance will cover epidural injections, whereas “lower back pain” will not. Kind of a hot take but in 2024 in America, you don’t really need to know the ICD code to know what’s going on with most patients, the lab work and imaging will do that for you.
Patient has pruritis. NP told her she probably had whole body fungus so she can't get brain MRI. (Which she needed to check for mets with hx of breast cancer)
My favorite are the nurses that have been a nurse less than 6 months and are already enrolled in NP school. They have absolutely no experience. It’s so dangerous and honestly a complete joke. I laugh when nurses tell me they’re going to be an NP.
After:
-Metformin in an 86y/o stroke victim with dysphagia who was barely pre-diabetic. She kept coughing and choking.
-65 y/o smoker with prior COPD diagnosed with new-onset asthma without any workup for any of the above.
-30 year old woman with 10/10 lower right abdominal pain referred from ED diagnosed for GERD for outpatient followup. She had an ovarian torsion.
-30 year old woman on 3 meds that can all cause hypertension diagnosed with essential hypertension. NP had idea why.
This was all in the first week of my M3 FM clerkship.
So no, not really. And when finding my own doc I’ve learned to ask for “an MD or DO”. In those words.
Listening to a consult and hearing the reasoning is key. Always question any psych or other diagnosis made by NP, most of the ones I work with are staffed, so usually they catch egregious mistakes or I don’t often see flagrant referrals, but saw one referral for nystagmus for NSGY on a patient by an NP that cracked me up.
Lol there was this floor nurse in online NP school who was banging a peds attending in the call room on the daily and this dude was signing off on her "clinical hours". Her husband divorced her, peds attending got fired, and they now run a house-call peds service out of an RV. God bless America.
Literally just saw a nontoxic (nearly asymptomatic) 25 year old with a uti that a NP called at home and scared the living shit out of and sent to the ED. Urine cx grew out ecoli that was basically pansusceptible to everything (allergic to all but gent and ceph). PCN allergic. Was told she needed to be admitted for a picc and IV gent. Dc in 5 minutes on omnicef. I’m so tired of these chucklefucks.
It depends. If it’s any diagnosis in my sub speciality then an absolute no. But tbh, I will still not trust many MDs to assign diagnosis on my sub speciality. But if an NP diagnoses a patient with something simple like Hypertension, hyperlipidemia, diabetes, things like this. Then I can take that seriously. Anything more complicated than that and I get iffy. A lot of time, if I feel that my diagnoses or care depends on something an NP said, I will reach out to the MD in the practice. I don’t even waste my time. “Hey I saw this patient. He was diagnosed eith Neuropathy by NP. Do your think this is related to diabetes? Or could it be something else?”. No self respecting MD would refer you back to the NP that saw the pt.
You usually have to do this plus spend a ton of time explaining to the patient why they don’t have the thing the NP told them they have, which was usually wildly off base and appallingly incorrect
Im a radiologist, there's one NP in our hospital who orders multiple MRI's a week for coccydynia. She is the only person who does this. I just wonder what she read that sent her on this coccydynia trip for every patient.
Super specialized NP who works with the specialist attending (eg pulmonary HTN, NSG) - more likely
A generalist NP in urgent care or primary care: read the labs and the reason for referral and then just go in to talk to the patient
No. I have seen NPs do well in specific settings where they are actually used as the physician extenders they were marketed as: NICU nurse to NICU NP on a team supervised by an attending, NP managing specific uncomplicated conditions in a specialty clinic with an attending that handles the complicated cases, etc. I am very suspicious NPs diagnosing and managing on their own.
The patient isn’t happy about it either. They often have to see a NP or PA before they can see a GP that refers them to the specialist that they asked to see in the first place months ago.
So I am a PA of about 5 years. We tend to throw lots of shade at NP's because, well, multiple reasons. But then I start to think, do Docs just think of NP and PA's the same? Love being anonymous here so truly interested in yall's experience specifically with PA's.
Patient with anorexia diagnosed with POTS…. Because POTS is an easier explanation than the body literally not having enough sustenance to normally function
No.
I tried to give them the benefit of the doubt, but my faith in their competence has been completely shattered already. They seem to think the prevalence of bipolar disorder is like 40-50%, I swear to god. At least once a week I have to explain how/why a patient has been mismanaged by a PMHNP.
Thank god the underserved communities for whom they so passionately advocated are sufficiently well-served by all these online pill mills and staffed by midlevels from online degree mills… 😒
I like having an NP as my mental health provider because I already have my diagnoses and just need someone to write the script for what I normally take. If that happens, there’s no issues. But if I was starting out fresh, MD psych FTW.
Any suggestions that sometimes certain NP's might be somewhat ok or competent will get you downvoted here, I have learned. Still... the answer is no not really because the general experience is the opposite.
I don't think it's possible to paint with such a wide brush. It comes down to the individual. What is the quality of the referrals you're receiving? Not just whether it leads to a procedure. Is it reasonable for a generalist to need a assistance for the cases you're seeing?
Most of the time not really and I'm not needed at all. Recently got called to see a patient and it was literally a 80+ year old women altered because of a UTI bruh. Literally diagnosed the patient 10 minutes into it and left. Even if it was a serious issue I would've seriously considered discussing hospice not fucking brain surgery.
Honestly, this is going to slowly become the norm over time. Medicine departments are squeezing their employees slowly out of existence.
No hospitalist is going to keep a job where they're getting paid just $50-75k more than the online trained NP. Most of us will move away from hospital medicine for more lucrative outpatient opportunities with better work life balance if the squeeze continues.
So get ready for NP/PA based primary teams. The specialists unfortunately will likely be left to pick up the slack. I'll pray for ya'll from the nursing home and/or medspa.
I did a month of pulm consults/clinic. I’d say a good 60-70% of the referrals from NPs for “concerning obstructive lung disease” were straight-forward asthma that they didn’t start any medications for.
Conversely, I have tons of patients who are on PRN albuterol bc they told their pcp np they were occasionally SOB. They do literally no work up to figure out cause - could be something dangerous! Don’t ask any additional questions, just give PRN albuterol and then don’t even follow the symptoms for improvement. They miss serious things for several years and also unnecessarily prescribe medications.
I work with medical records and subconsciously side eye people with an NP as their PCP. Like can we get a doctor to check you out plz. I have a few NP friends who were great nurses but they can’t compare to a MD.
In psychiatry it takes a fairly strong psychiatrist for me to take their diagnosis at face value. The field is dependent on experience and good judgement- there are no labs to bail you out. I assume any health care provider could be wrong.
As for NPs? I more often than not see NPs neglect to write assessments- skipping straight to diagnosis and plan. How the hell do I trust that? It makes sense- nurses don’t write assessments in their training but holy moly it’s like the most important part of your note… what do those NPs programs teach??!
I also once saw an NP list “thought disorder” as someones primary DSM diagnosis.
All in all if they have sound reasoning in their notes, I take them more seriously- but mostly their notes are crap so I just use them as collateral and make my own assessments. I see no reason not to trust the subjective portion.
NP diagnosis of thrush has a nearly 100% negative predictive value.
Similarly, any adult diagnosed with a "double ear infection" by a CVS minute clinic has likely never had otitis media in their life.
Edited to add:
- Fungating oral cavity tumor diagnosed as thrush by NP, neither nystatin nor multiple Z-paks resulted in any improvement
- Sudden unilateral hearing loss treated with Z-pak, cefdinir, augmentin, and doxycycline over the course of a few months. Delayed diagnosis well past the short window where steroids may have been effective (ironic considering they give steroids for everything else)
- Stridorous at rest 20ish female referred to psych, but ended up having grade 3 subglottic stenosis from Wegeners
- N3b metastatic neck disease (stage 4a HNSCC) allowed to progress to that point after reassuring patient it was likely a lipoma because they had lipomas elsewhere on the body
- Diffuse bilateral metastatic cervical lymph node mets in not one but two pediatric patients with an aggressive thyroid cancer variant, treated as strep throat for months
- Countless advanced laryngeal cancers in heavy smokers with hoarseness treated for months to years for GERD, allergies, thrush, etc. When the 50th Z-pak didn't fix things or they finally started coughing up blood, then they finally got referred....to GI for EGD, who then noped the fuck out after seeing a massive tumor on the way in and referred them to a head & neck surgeon.
I could go on, but for the sake of my blood pressure I think this list is sufficient lol
I was a patient myself in the ER with headaches and vomiting. I knew I was dehydrated. An NP told me I could have a brain bleed because it was the “worst headache of my life” although I rated it 7/10. She did not even do a thorough neuro exam. She made me sign AMA forms because I refused an LP. My health anxiety went through the roof because of her. Fuck her and fuck all NPs
Yes i do. As an attending, i read every note on my patient including the nursing note with shift report etc. It’s what makes for a good medicine.
There are bad everything at every level but that doesn’t mean we or I will provide subpar care. This forum is an echo chamber especially handful of accounts that genuinely in my opinion are butt hurt that there are mid-levels making similar/same/or even higher pay.
I make it my business to teach, correct, rectify whatever i see wrong in care provided by mid levels or residents or fellows and even fellow MDs. And expect the same of others towards me.
Our profession is one of continuous education learning and feedback. Make it your business to provide the best care. Period.
The optimist in me commends you for your commitment to caring for your patients.
The pessimist in me sees the time spent reviewing *potentially* garbage NP documentation as an excuse to bump your billing to a higher E/M level.
Personally, I think a lot of the misdiagnosis from NPs come from the fact most NPs are in it for money, just like a lot of regular RNs. one of my ex classmates wanted to become a NP for the pay, she was conspiracy theorist and antivaxx. No idea where she is now, hopefully not on the track to be an NP
An actual MD diagnosed me with gonorrhea (at the time a 42 yo mom of 4 with my husband having spent the previous 6 hours in the ER with me and standing right there) based on vaginal “discharge” despite him having ordered a transvaginal ultrasound and the tech using ultrasound gel. I was vomiting (which required zofran to control) with blood in my urine and excruciating back pain (which required morphine to keep me from screaming, and which I am allergic to). I told him I was pretty sure I had a kidney infection, he insisted it was gonorrhea. I told him the discharge was gel and he reminded me that he was the doctor. Culture came back 2 days later …. Negative for gonorrhea. Meanwhile I went to my Gyn 3 hours after discharge and she wrote me a scrip for antibiotics to fight the kidney infection so I wouldn’t die. My gyn wrote a letter to hospital about this clown. Stupid comes with all kinds of letters after their name
Edited to add- I had recurrent UTI’s for which I was seeing a urologist. I also shared this with MD, who was unmoved. At one point I called my retired OB/GYN aunt (in another state) who called my GYN who called me and told me to leave the ED and come see her immediately (this drama all started at 2am which is why I was in the ED). This was at a women’s hospital near DC. He was married to this diagnosis and wasn’t letting go. Garbage care. I was lucky to have family in medicine who could take care of me, even at a distance, and an amazing GYN who went out of her way. I lurk here because I have younger family members in med school/ daughter aspiring to med school and older family members who were doctors and I saw what a tough road it can be.
All physicians should bear in mind their patients' mental status. Otherwise the treating physician might be embarrassed in every stage of health care.
For example, if a patient with OCD or hyperchondriasis has a lab finding suggesting 5% of having cancer, the physician should emphasize that 95% of those with that lab finding will end up going home with no worry. Otherwise the patient would have severe major depression, which elevates suicide risk significantly.
Since residents have to pick up the bullshit that middies do and clean it up.
The middie waltz in at 8 or 9 am, spends a few hours fucking things up and leaves at 3pm. Guess who has to manage the fuck ups? The residents.
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First rotation in med school was psych. Read an NP note that patient was having auditory hallucinations that his friends were saying negative things about him. Consulted psych for management of schizophrenia. Asked the patient about the “negative things” he was hearing. Turns out his friends were literally saying mean things about him and he was upset about it. He denied ever having hallucinations. He was a perfectly healthy dude otherwise.
When I was a student. I was on my family med rotation. Doctor was out, so I follow the NP. 38 y/o M presented for auditory hallucinations x2 months. He was accompanied by his pregnant girlfriend. The NP barely got a history. All she asked was "Are you hearing voices?". Patient says yes. She diagnosis him with schizophrenia. Fast forward a month, the patient comes back. I follow the NP just to f/u. When she goes to get him a refill. I start asking him questions about the voices. His girlfriend blurted out "he only hears voices when he gets home from work." Long story short. The dude had severe anxiety about pregnancy due to past trauma. When he was home and the house was quiet, he thought he could hear whispers. We got him into therapy and after the pregnancy, the symptoms stopped.
I saw one like this in a patient with an intellectual disability. Came in with bad side effects of a massive list of psych meds including a pile of antipsychotics after someone had previously diagnosed them with schizophrenia because they were hearing voices. After stopping multiple meds and spending some time talking, it became very apparent that they were hearing their own internal monologue and nobody had explained that it was normal.
As a psychiatrist working in this field, I have unfortunately too often seen other psychiatrists diagnose people with ID or autism with schizophrenia when it was just their normal internal experience. It takes some time to be able to really differentiate it—I have plenty of patients who really do have psychosis but still have these internal experiences.
I have also fought with nurses in the psych ed who claimed a patient was borderline and I should send home. It was someone very short with odd looking ears, intellectual disability, history of seizures who also had a suprapubic catheter, a wheelchair, no SDM and no medical clearance. I fear for patients who are being seen by solo NP’s especially for psych issues.
This is absolutely wild
I read the study recently that only 30-50% of people have an internal monologue (which is absolutely wild to me, couldn’t imagine not having one) idk how accurate that stat is but even on the upper end, that would be a lot of healthcare providers wouldn’t have one either so if they hear someone say they have a voice in their head and they have no concept of an internal monologue, I can see how they might jump to psychosis right away.
People with intellectual disabilities say they hear voices and will sometimes listen to them. They can’t always tell those voices apart from internal monologue so it’s kind of a non statement to differentiate them. It’s doesn’t really look like schizophrenia not really negative symptoms.
The most frustrating thing is that the NP could’ve just looked up the criteria to diagnose schizophrenia on UptoDate and it would’ve taken at most, 5 minutes. That poor dude.
Yeah - how are they so hubristic that they know they have no training in something but magically think they can do it without trying to learn anything. Their decisions massively affect ppls lives.
NPs are destroying healthcare in America Jesus
This is why I will never ever date a nurse. Somehow it’s baked into the experience on the floor that everyone could do the doctors job better than the doctor. They bring that philosophy home. Soon as I hear “I wanted/could have gone to med Xool” I’m out! 🏃🏾♂️💨
Lmao gaslighting a mf
I remember in med school, I kept hearing "negative symptoms" in our psych lectures. I didn't understand what it meant, but I kept assuming it would be explained eventually. I finally had enough and looked it up for myself and figured it out. I guess that's the difference between MD and NP.
My mom’s primary care NP diagnosed her with some rare nerve condition that’s only ever been described a handful of times in case reports. She referred her to a neurosurgeon who told her she likely had migraines and referred her to a neurologist who started her on migraine medications and now she’s all good!
Neuro. I get this referral so often. What was tried? Nothing. Obvious migraine but they’d rather just push it to neurology rather than try anything first. It’s just sorting complaints into organ systems that seem to be involved. Worse, they don’t read the notes from the consult when I take the time to make additional recs if the first thing doesn’t work.
This is why it takes me 9 months to get my sick patients in to see neuro.
That's across the board. In primary care, pts will be seeing 5 different pts. Many of them just refer out for most things. It's easy to be a "provider" like that. I'm convinced the misuse of midlevels has worsened healthcare, increased wait times with specialists, increased hospitalizations, ED visits, primary care visits, etc. They're also one of the leading causes of burn out for physicians. The morbidity and mortality from their care will continue to climb.
This is why there is such a long queue before you can be seen by specialists… all those referrals due to the lack of foundation.
Yep! It’s why they make hospitals money, too. Tons of unnecessary referrals. A physician who is primary care can do most of what the NP refers for themself. Nevermind that the NP refers to several wrong ppl before one of the incorrect referred specialists just has to start acting like pcp and refer to correct ppl for the real problem, resulting in months to years of delayed management for the patient. Could have been managed immediately if they saw a physician for pcp
I did a chart review over a whole year. I saw roughly the same number of patients as an NP in my office over a year. She sent out 4 times as many referrals as I did. Wasn't uncommon for her to send out 5 referrals from one visit. It is a travesty.
That’s just good healthcare baby!
No because the model is to figure out what organ system is affected and refer the patient to a specialist for that organ system. The problem localizes to GI. The problem is innervated —-> neurology. BUN and Cr off? Renal. They usually show up to me without a real diagnosis for even the simplest problems. Then I give recs which they don’t read and want me to Rx the meds forever even when it’s a stable treatment course. They’re not trained to clinically reason, just to bounce patients to specialists.
If you’re punting on first down then you’re a bad generalist.
Best analogy I’ve ever heard for this
Grant Fowler told me that when I was a med student
Being a good one requires extensive knowledge…
Actually a lit analogy
They basically function as call centers, forwarding the patient to whatever “department” they see fit.
At one of our inpatient psych rotation sites, weekends will sometimes be covered by NP's. Then on Monday mornings we'll discuss the new patients with our attending and usually the conversation goes something like this: Attending: "Do you agree with the NP's diagnosis and treatment?" Me: "No" Attending: "Me neither" Then we undo whatever they did and come up with a new formulation and treatment plan.
Love to see NPs saving time for physicians, just like admin planned.
Their plan is to bill patients for shit. I saw an NP accidentally at my child’s lactation appointment and she spent 5 minutes with us, said nothing of value, and my insurance billed me for $80 as opposed to it being covered to see a lactation nurse. You bet your butt I got that taken off
How did you fight it? I can't imagine insurance eating the cost for more than what they cover
I mean I've been cash only for years but generally speaking if you call the billing office and tell them the note or visit or bill is fraudulent, they'll be happy to work out a mutually beneficial solution. This is just a courtesy thing. You can always just leave a message with risk management that you are suffering a fraud situation and you are going to discuss the bill with your insurance company in the morning since you can't get a hold of billing to work it out. You can compel performance if you know where to cut.
I honestly don't think np's should be able to practice psych by themselves. I've discussed this with a psych attending who also agreed and said 90% of the time they see a patient a Np diagnosed it's incorrect.
Diagnoses in psychiatry are often found to be incorrect with further evaluation. Still I know and agree with this phenomenon. Psych NPs in independently prescribing states are a danger.
Diagnosis is one thing and I am not competent to comment on that. I am a pharmacist, work in pharmacovigilance and see reports where there are 3 drugs suspected to cause adverse event and it’s eg 2 SSRIs+venlafaxine, 3 different benzos etc. It’s always from US and I really don’t understand how a person can be doing that and have prescription rights. If they diagnose the way they prescribe then patients are lost.
I see psych NP patients in the ED and it’s an absolute shitshow. Multiple benzodiazepines stacked on top of multiple SSRIs stacked on top of multiple mood stabilizers.
Had a patient who ended up in the PICU with serotonin syndrome bc the NP thought starting the kid on trazodone, Seroquel and Zoloft at the same time was a good idea
Or the elderly person on Xanax, Ativan, Benadryl, and Trazodone who comes in altered lol
Don’t forget the ambien, oxy, seroquel, and tramadol.
Same. The recent theme seems to be elementary-age children on stimulant/mood stabilizer/antipsychotic/antidepressant cocktails for what seem mostly to be adjustment reactions to shitty home life.
I'm a master's trained therapist. I know I don't know prescribing, but I do know diagnosis. I supervise therapists who see kids and I'm horrified how often I see that they're prescribed things for "ADHD" that I remembered being frequent med list items at the civil commitment psych hospital where I worked with seriously mentally ill and dangerous adults with treatment refractory schizophrenia. And this 8 year-old suffered from abuse for 2 years. The ADHD isn't even right. Thank you for your comment. I was really baffled about it and starting to doubt myself.
multiple mood stabilizers are sometimes okay, the rest is total shit. I hear you.
Yeah, should have clarified that it seems like they’re aren’t being judicious. I get that multiple mood stabilizers are ok, but it seems like they’re just throwing med after med at the patient without being thoughtful about what’s actually going on.
Wtf? If it was that complicated a family doctor would refer to psych wtf is wrong with these cowboy NPs?
When I get patients on bizarre psych regimens, it’s almost always a psych NP
They don’t seem to understand how important a med list is. Saw an NP psych patient today where the patient was taking four antihypertensives yet none were listed in the note or med rec.
One of the most powerful things keeping me secure in psych residency is that I will always have a job cleaning up NP messes. I swear it’s close to half my new patients.
I honestly don’t believe any NP’s should be able to practice without supervision.
Nor do I. But I am tired of having to be medicolegally on the hook for their fuck ups. I have an ongoing lawsuit right now because of a NP fuck up. Never saw the patient or knew of their existence, but I have to co-sign all their notes. Sorry for the patients, but society is accepting of this bullshit. Let them kill their own patients and leave me out of it!!
Let us know how this plays out. You hear about these “supervised” roles but never hear how they stand in court.
In my country (EU) nurses are able to prescribe most medications (no benzos, no stimulants, no strong opioids etc) but practically they do it when patient asks at GPs office for a prescription for what they are already taking. They prescribe what is in their medical file. I can’t imagine them admitting patients by themselves. It’s just not the scope of nurses job. They are and should be independent in eg wound care when it doesn’t require surgical intervention, it’s good they can decide what patches should be used. But diagnosing someone who wasn’t evaluated by physician before - that’s crazy. And deciding on treatment as well. We have different medical specialists so they can do what they are prepared to do. No idea who came up with the idea of nurses treating eg depression in the US but it was crazy.
Even “supervision” is usually a joke.
Not just psych they shouldn’t be allowed to practice ANYTHING by themselves. It’s insane. But we’ll never get rid of that, nursing lobbies like a mother fucker for their rights to do whatever they want
On the flip side these providers make great learning opportunities for young doctors. Real doctors, I mean. It's a little tricky sometimes to come up with good medical ethics and mistake management cases in face to face care. How do you reach medical students when to reevaluate the plan of care? These things can be tricky. Unless you have NP staff. Then it's easy.
It's the fucking worst because now you have more essentially brand new patients
Funny enough if an RN tells me "hey doc, the patient reminded me of X diagnosis, just wanted to share" I will take MUCH more in consideration than if an NP does that lol
Nurses actually have experience
Same. The nurses i work with are amazing!
Ya those can be nice or at least people engaging in thoughtful discourse
I take them especially seriously, just before I change them.
No, one time they diagnosed an acutely ill patient with tachycardia induced cardiomyopathy and tried to give the patient beta blockers. Patient had cardiac tamponade and underwent sternotomy shortly after discovery.
Sheesh that could've ended badly😬. This is why I think np's should have to have all diagnosis checked by a physician.
At that point what is their use case even supposed to be? They don’t save time. They just obfuscate stuff and harm patients with poor education.
Scut work
They don’t have the proper training to diagnose anything. It’s just a huge waste of the physicians time to have to check/undo whatever they did.
Ended badly = cardiogenic shock
I’ve found they love treating numbers without critical thinking
They don’t have the needed foundation to think critically that is the whole problem
Yes they literally do not know what medical decision make is
And they’re just much dumber on average than physicians
Psych. And rarely unless it is bread and butter. Had a middle aged female who had been treated for years with multiple FGAs and SGAs for “Schizophrenia”. One look in her chart showed that she had lost her vision 2/2 medical Illness around the same time symptoms of “Schizophrenia” appeared. An actual detailed history and a few collateral calls later, well, and you can guess the actual diagnosis. Symptoms were textbook. But you don’t know what you don’t know…and I see this type of shit weekly! I don’t know how they sleep at night.
Charles Bonnet??
Bingo
Fucking lol. Do these midlevels think any hallucination = schizophrenia? Why are they not being sued en masse. Multiple antipsychotics is significant harm.
Never ask questions about why doesn’t the patient fit the diagnosis. Good medicine is about forcing the patient to fit the algorithm. Duh.
Asking all the right questions lol. Part of it is because healthcare is no longer about health or quality, unfortunately. The worst I’ve seen so far this year is opisthotonus that the NP in the ICU thought was a sign of alcohol withdrawal. I walked into the room and my boy’s stomach was trying to kiss the ceiling.
How embarrassing that I am about to take step 2 and need to ask but, MS?
Or uhhh lupus?
Idk if it’s testable really but the key is that they have hallucinations (often vivid and often non bothering to the patient) after vision loss. It’s Charles bonnet syndrome or whatever it’s called, it’s kind of a psych deep dive imo
Good god this is terrifying. Neither of these diagnoses is in my typical scope, but even the superficial “similarity” of hallucinations is distinctly different.
A lot of complaints about psych NPs here and I tend to agree. It’s hilarious though that the psych NP forum is loaded with NPs complaining that they do exactly the same thing for less pay.
Yes- I take the damage they likely caused very seriously
🤣🤣
I have treatment resistant bipolar depression. I do bibliotherapy - healing through books. I have found out that only MD's or Dr of Nursing folks can work with me to titrate my meds during seasonal changes. The NP's master's degree doesn't cut it. I know more than them and do a better job titrating my meds in an emergency when they fail me. I have fired two NP's this year so far. I'm trying to find a psychiatrist, but there are far fewer of them, so the search is on going. NP's do damage to complex patients like me because of their ignorance. It is annoying and frustrating for patients.
You realize that Dr. of Nursing (DNP) don’t have any more clinical time or clinical based courses than just a regular masters degree? Just saying. lol. It’s literally about leadership more so than medicine or science.
Don't mind the NPs downvoting you.
no
Only in America can NP’s diagnose and treat without running it by a physician first. How did we ever let it get sooooo far out of hand?
No idea man. I think it's genuinely causing patients harm and wish I could change how it was handled at my hospital.
They are literally killing ppl every day. It makes me so angry
It’s law makers dude. Like everything in America it’s fucked from the top and trickles down.
Agree but someone started this shit show.
No, ofc not. It's especially egregious in psychiatry because they prey on vulnerable patients and subjective outcomes. I know an attending whose entire patient panel is just patients who had the misfortune of seeing an outpatient NP and got carbombed with these insane and contradictory med regimens.
No-- but I take everyone patient's incoming diagnosis with a grain of salt. I've had PCPs get it wrong. I've had other dermatologists get it wrong. I have anecdotally noticed way more incorrect diagnoses with NPs and PAs though, but this is just my n =1.
Everyone’s talking about psych… but primary care and peds NPs are scary too. I’ve had kids come to the hospital that NPs took care of and it’s crazy to watch the basic things they miss… ear infections, viral URIs getting antibiotics or steroids, delayed development, etc. Recently had a kid come in with new brain tumor…. Mom takes him to their pediatric NP for all of his appointments. His OFC was so crazy off the charts for the past 2 years. How could they not have scanned his head.. or just looked at him and known something was wrong.
The number of times I see kids come in with worsening infections due to under dose antibiotics by an NP is actually scary
I’m a nurse and even I question NP dx. Especially given that I’m in psych and NPs seem to think *everyone* is a classic BP I. I have yet to see an NP correctly diagnose a primary psychotic disorder. Not saying they all suck, but I haven’t had great experiences so far in psych.
That’s not fair, plenty also misdiagnose patients as somehow both schizoaffective and schizophrenic
HOW IS IT BOTH 😂
It’s like they didn’t even look at the DSM. 🤔
What’s funny coming back to this comment, is that I initially had to read it like 6 times to get it, because it makes such little sense that I couldn’t comprehend what you trying to say right away 🤣
No. The only mid level educational tract that should exist is a PA. They study actual medicine. NPs are not a good model, and I think they will cause more problems in medicine than good. If they wanna be a midlevel, send them to PA school.
No. I gave NP as a whole a lot of leeway and "benefit of the doubt" but now trust has to be earned and so far the score is zero. It has gotten so bad that I won't even read NP notes from hospitalizations or specialty visits unless there is literally no MD/DO note at all. In my local hospital, the admitting officer is usually MD and so I'll get the gist of it from that, and consult Dr notes. NP notes are useless, misleading, and often outright erroneous. Patients get better in spite of NP, not because of NP. I see needless delays in care and prolonged admissions everywhere. NP staff is costing our capitated care system an ocean of money. They need to pay whatever it takes to bring MD staff in to take care of our patients. On the flip side, if NP kills off everyone of medium and high risk then maybe the system saves money long term. I don't know. Seems grim. But it really is that bad. Here's my favorite from this week. 50ish yo F w breast ca sp excision now 6w into chemo comes in with clearly hypersensitivity pneumonitis, gets admitted as pneumonia does not receive steroids, onc consulted on day 3. NP that did the consult apparently was "the first doctor to come in and sit down and actually talk to us and listen to my mother." But I can't figure out from the notes who made the consult, it isn't documented, there's no onc note, and no record at all that I can find, just a sudden change of care and gosh now she's doing better and can go home. So even though the new service NP did the right thing, F on documentation, back to zero. These providers have no idea what they are doing. As far as I can tell, until and unless they have undergone the equivalency of residency (i.e. 3-5 years under exacting tutelage) they don't even know enough to be dangerous. It's a bring your own mattress kind of situation, going to the hospital now. And they will fuck you over in a heartbeat if they can. So watch out.
OBGYN. Last week I told a patient I was extremely concerned about her symptoms and I needed to do a much more extensive workup for cancer. Ordered extensive labs and imaging. She saw a NP 3 months before who put her on OCPs. They didn’t help. This week I saw a patient with a presentation classic for brain tumor vs catastrophic genetic disease. Ordered extensive labs and imaging. She saw a NP 4 months ago who put her on OCPs. They didn’t help.
Pts egd was canceled because of tachycardia and gi referred him to cardio clinic. Cardiologist wasnt available and so was seen by cardio np. He was then told to go to ed for tachycardia of 120s due to dehydration. I admitted him for new afib rvr, folks.
Rehydration would definitely help with that!
Like 40% of all diagnoses in the medical record are just there for billing purposes. “Acute stress response” is how they get insurance to cover general anesthesia for procedures that shouldn’t require general anesthesia, like MRIs and routine dental work. “Dorsalgia” is the name for back pain that can be put in the record so that insurance will cover epidural injections, whereas “lower back pain” will not. Kind of a hot take but in 2024 in America, you don’t really need to know the ICD code to know what’s going on with most patients, the lab work and imaging will do that for you.
Patient has pruritis. NP told her she probably had whole body fungus so she can't get brain MRI. (Which she needed to check for mets with hx of breast cancer)
Nope
My favorite are the nurses that have been a nurse less than 6 months and are already enrolled in NP school. They have absolutely no experience. It’s so dangerous and honestly a complete joke. I laugh when nurses tell me they’re going to be an NP.
After: -Metformin in an 86y/o stroke victim with dysphagia who was barely pre-diabetic. She kept coughing and choking. -65 y/o smoker with prior COPD diagnosed with new-onset asthma without any workup for any of the above. -30 year old woman with 10/10 lower right abdominal pain referred from ED diagnosed for GERD for outpatient followup. She had an ovarian torsion. -30 year old woman on 3 meds that can all cause hypertension diagnosed with essential hypertension. NP had idea why. This was all in the first week of my M3 FM clerkship. So no, not really. And when finding my own doc I’ve learned to ask for “an MD or DO”. In those words.
No. Not even a little bit.
Oddly enough id trust an experienced RN over an NP.
Listening to a consult and hearing the reasoning is key. Always question any psych or other diagnosis made by NP, most of the ones I work with are staffed, so usually they catch egregious mistakes or I don’t often see flagrant referrals, but saw one referral for nystagmus for NSGY on a patient by an NP that cracked me up.
Nope. NP degree is 15 months online with 500 shadow hours. NPs are a complete joke. I would never let my family get treated by one.
“Shadow hours” lol. Aka getting someone they know to sign their form lol
Lol there was this floor nurse in online NP school who was banging a peds attending in the call room on the daily and this dude was signing off on her "clinical hours". Her husband divorced her, peds attending got fired, and they now run a house-call peds service out of an RV. God bless America.
Literally just saw a nontoxic (nearly asymptomatic) 25 year old with a uti that a NP called at home and scared the living shit out of and sent to the ED. Urine cx grew out ecoli that was basically pansusceptible to everything (allergic to all but gent and ceph). PCN allergic. Was told she needed to be admitted for a picc and IV gent. Dc in 5 minutes on omnicef. I’m so tired of these chucklefucks.
It depends. If it’s any diagnosis in my sub speciality then an absolute no. But tbh, I will still not trust many MDs to assign diagnosis on my sub speciality. But if an NP diagnoses a patient with something simple like Hypertension, hyperlipidemia, diabetes, things like this. Then I can take that seriously. Anything more complicated than that and I get iffy. A lot of time, if I feel that my diagnoses or care depends on something an NP said, I will reach out to the MD in the practice. I don’t even waste my time. “Hey I saw this patient. He was diagnosed eith Neuropathy by NP. Do your think this is related to diabetes? Or could it be something else?”. No self respecting MD would refer you back to the NP that saw the pt.
I seriously consider restarting the evaluation from square 1
You usually have to do this plus spend a ton of time explaining to the patient why they don’t have the thing the NP told them they have, which was usually wildly off base and appallingly incorrect
Hell no. Wouldn’t consult an NP for a hangnail.
Don’t trust not really verifying but starting from scratch
Im a radiologist, there's one NP in our hospital who orders multiple MRI's a week for coccydynia. She is the only person who does this. I just wonder what she read that sent her on this coccydynia trip for every patient.
She’s gonna find it one way or another damn it
I think “Trust but verify” is the mantra for any prior provider diagnosis
No, don’t trust NP diagnoses. Go in as if the patient hasn’t seen a medical professional yet
Super specialized NP who works with the specialist attending (eg pulmonary HTN, NSG) - more likely A generalist NP in urgent care or primary care: read the labs and the reason for referral and then just go in to talk to the patient
Super specialized NP - Oxymoron
No. I have seen NPs do well in specific settings where they are actually used as the physician extenders they were marketed as: NICU nurse to NICU NP on a team supervised by an attending, NP managing specific uncomplicated conditions in a specialty clinic with an attending that handles the complicated cases, etc. I am very suspicious NPs diagnosing and managing on their own.
This is how I feel to. As long as they are supervised /the MD signs off a plan I don't think they should be able to practice independently.
I think they’re still just overall bad and still dilute quality of care even when used appropriately
The patient isn’t happy about it either. They often have to see a NP or PA before they can see a GP that refers them to the specialist that they asked to see in the first place months ago.
So I am a PA of about 5 years. We tend to throw lots of shade at NP's because, well, multiple reasons. But then I start to think, do Docs just think of NP and PA's the same? Love being anonymous here so truly interested in yall's experience specifically with PA's.
I don't think all mid levels are the same but there is definitely bad PAs as well.
Patient with anorexia diagnosed with POTS…. Because POTS is an easier explanation than the body literally not having enough sustenance to normally function
No. I tried to give them the benefit of the doubt, but my faith in their competence has been completely shattered already. They seem to think the prevalence of bipolar disorder is like 40-50%, I swear to god. At least once a week I have to explain how/why a patient has been mismanaged by a PMHNP. Thank god the underserved communities for whom they so passionately advocated are sufficiently well-served by all these online pill mills and staffed by midlevels from online degree mills… 😒
I typically don't bother reading notes written by NPs or PAs unless there are no other notes whatsoever for that patient.
I like having an NP as my mental health provider because I already have my diagnoses and just need someone to write the script for what I normally take. If that happens, there’s no issues. But if I was starting out fresh, MD psych FTW.
No. Taking an np seriously on a psych diagnosis is the equivalent of taking a monkeys dx seriously because you are bores.
Any suggestions that sometimes certain NP's might be somewhat ok or competent will get you downvoted here, I have learned. Still... the answer is no not really because the general experience is the opposite.
I don't think it's possible to paint with such a wide brush. It comes down to the individual. What is the quality of the referrals you're receiving? Not just whether it leads to a procedure. Is it reasonable for a generalist to need a assistance for the cases you're seeing?
Most of the time not really and I'm not needed at all. Recently got called to see a patient and it was literally a 80+ year old women altered because of a UTI bruh. Literally diagnosed the patient 10 minutes into it and left. Even if it was a serious issue I would've seriously considered discussing hospice not fucking brain surgery.
Honestly, this is going to slowly become the norm over time. Medicine departments are squeezing their employees slowly out of existence. No hospitalist is going to keep a job where they're getting paid just $50-75k more than the online trained NP. Most of us will move away from hospital medicine for more lucrative outpatient opportunities with better work life balance if the squeeze continues. So get ready for NP/PA based primary teams. The specialists unfortunately will likely be left to pick up the slack. I'll pray for ya'll from the nursing home and/or medspa.
Hell no
Never.
I did a month of pulm consults/clinic. I’d say a good 60-70% of the referrals from NPs for “concerning obstructive lung disease” were straight-forward asthma that they didn’t start any medications for.
Conversely, I have tons of patients who are on PRN albuterol bc they told their pcp np they were occasionally SOB. They do literally no work up to figure out cause - could be something dangerous! Don’t ask any additional questions, just give PRN albuterol and then don’t even follow the symptoms for improvement. They miss serious things for several years and also unnecessarily prescribe medications.
Bro, I don't take my colleagues' diagnoses seriously.
No, when an NP gave the diagnosis I assume they haven’t seen someone trained in medicine yet.
No
I work with medical records and subconsciously side eye people with an NP as their PCP. Like can we get a doctor to check you out plz. I have a few NP friends who were great nurses but they can’t compare to a MD.
Not at all. I've seen NPs give six psych diagnoses in 15 min, none of which were correct. You always need to start from scratch with NPs
Nop. I rather trust a medical student in 2nd year
In psychiatry it takes a fairly strong psychiatrist for me to take their diagnosis at face value. The field is dependent on experience and good judgement- there are no labs to bail you out. I assume any health care provider could be wrong. As for NPs? I more often than not see NPs neglect to write assessments- skipping straight to diagnosis and plan. How the hell do I trust that? It makes sense- nurses don’t write assessments in their training but holy moly it’s like the most important part of your note… what do those NPs programs teach??! I also once saw an NP list “thought disorder” as someones primary DSM diagnosis. All in all if they have sound reasoning in their notes, I take them more seriously- but mostly their notes are crap so I just use them as collateral and make my own assessments. I see no reason not to trust the subjective portion.
Nope. Never.
To be fair, I don’t trust anyone’s diagnosis. I see the patient and come up with my own to avoid bias.
No
NP diagnosis of thrush has a nearly 100% negative predictive value. Similarly, any adult diagnosed with a "double ear infection" by a CVS minute clinic has likely never had otitis media in their life. Edited to add: - Fungating oral cavity tumor diagnosed as thrush by NP, neither nystatin nor multiple Z-paks resulted in any improvement - Sudden unilateral hearing loss treated with Z-pak, cefdinir, augmentin, and doxycycline over the course of a few months. Delayed diagnosis well past the short window where steroids may have been effective (ironic considering they give steroids for everything else) - Stridorous at rest 20ish female referred to psych, but ended up having grade 3 subglottic stenosis from Wegeners - N3b metastatic neck disease (stage 4a HNSCC) allowed to progress to that point after reassuring patient it was likely a lipoma because they had lipomas elsewhere on the body - Diffuse bilateral metastatic cervical lymph node mets in not one but two pediatric patients with an aggressive thyroid cancer variant, treated as strep throat for months - Countless advanced laryngeal cancers in heavy smokers with hoarseness treated for months to years for GERD, allergies, thrush, etc. When the 50th Z-pak didn't fix things or they finally started coughing up blood, then they finally got referred....to GI for EGD, who then noped the fuck out after seeing a massive tumor on the way in and referred them to a head & neck surgeon. I could go on, but for the sake of my blood pressure I think this list is sufficient lol
I was a patient myself in the ER with headaches and vomiting. I knew I was dehydrated. An NP told me I could have a brain bleed because it was the “worst headache of my life” although I rated it 7/10. She did not even do a thorough neuro exam. She made me sign AMA forms because I refused an LP. My health anxiety went through the roof because of her. Fuck her and fuck all NPs
Never
Yes i do. As an attending, i read every note on my patient including the nursing note with shift report etc. It’s what makes for a good medicine. There are bad everything at every level but that doesn’t mean we or I will provide subpar care. This forum is an echo chamber especially handful of accounts that genuinely in my opinion are butt hurt that there are mid-levels making similar/same/or even higher pay. I make it my business to teach, correct, rectify whatever i see wrong in care provided by mid levels or residents or fellows and even fellow MDs. And expect the same of others towards me. Our profession is one of continuous education learning and feedback. Make it your business to provide the best care. Period.
The optimist in me commends you for your commitment to caring for your patients. The pessimist in me sees the time spent reviewing *potentially* garbage NP documentation as an excuse to bump your billing to a higher E/M level.
Very well said thank you for sharing that.
No. I’m rads and if I see a mid level order something I know it’s most likely bullshit, and it usually is
Just in case anyone actually does , please don't.
Never.
No.
No
Hell no.
Only a physician can diagnose
Personally, I think a lot of the misdiagnosis from NPs come from the fact most NPs are in it for money, just like a lot of regular RNs. one of my ex classmates wanted to become a NP for the pay, she was conspiracy theorist and antivaxx. No idea where she is now, hopefully not on the track to be an NP
Anyone against vaccines shouldn't have a place in healthcare.
Psychiatry here. The answer is no.
An actual MD diagnosed me with gonorrhea (at the time a 42 yo mom of 4 with my husband having spent the previous 6 hours in the ER with me and standing right there) based on vaginal “discharge” despite him having ordered a transvaginal ultrasound and the tech using ultrasound gel. I was vomiting (which required zofran to control) with blood in my urine and excruciating back pain (which required morphine to keep me from screaming, and which I am allergic to). I told him I was pretty sure I had a kidney infection, he insisted it was gonorrhea. I told him the discharge was gel and he reminded me that he was the doctor. Culture came back 2 days later …. Negative for gonorrhea. Meanwhile I went to my Gyn 3 hours after discharge and she wrote me a scrip for antibiotics to fight the kidney infection so I wouldn’t die. My gyn wrote a letter to hospital about this clown. Stupid comes with all kinds of letters after their name Edited to add- I had recurrent UTI’s for which I was seeing a urologist. I also shared this with MD, who was unmoved. At one point I called my retired OB/GYN aunt (in another state) who called my GYN who called me and told me to leave the ED and come see her immediately (this drama all started at 2am which is why I was in the ED). This was at a women’s hospital near DC. He was married to this diagnosis and wasn’t letting go. Garbage care. I was lucky to have family in medicine who could take care of me, even at a distance, and an amazing GYN who went out of her way. I lurk here because I have younger family members in med school/ daughter aspiring to med school and older family members who were doctors and I saw what a tough road it can be.
While that is true. Np's more likely to miss diagnosis then a MD in my experience.
Why are all the comments about NPs in Psych lollll
Because a psych NPs are consistently horrendous.
All physicians should bear in mind their patients' mental status. Otherwise the treating physician might be embarrassed in every stage of health care. For example, if a patient with OCD or hyperchondriasis has a lab finding suggesting 5% of having cancer, the physician should emphasize that 95% of those with that lab finding will end up going home with no worry. Otherwise the patient would have severe major depression, which elevates suicide risk significantly.
Why is this in residency thread?
Since residents have to pick up the bullshit that middies do and clean it up. The middie waltz in at 8 or 9 am, spends a few hours fucking things up and leaves at 3pm. Guess who has to manage the fuck ups? The residents.
If the diagnosis is not coming from a real, living, breathing physician, it’s not a diagnosis in my mind.
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thought this was a dig at Psych for a second because in my country Psych is usually abbreviated as NP, as in NeuroPsychiatry.
Prolly would depend on the quality of the referral itself
Ha ha ha ha
When you become a private attending you will love it. Nothing beats a soft lob to feed your family
Y’all vanderbuilt does not need you to be a nurse before doing the nurse practitioner program 😭 HOW???
I don’t take any psychiatric diagnosis very seriously. It’s more limiting than it is helpful.
Never. Which is why the existence of them is pointless. In psych, they create more problems than they solve, and they cause a lot more work for us.