Supervise PA for TMS clinic

[nexus73]

Got a recent call from a PA to 'collaborate' as they are the 'owner' of a new TMS clinic. They say, some insurances require a physician psychiatrist for initial mapping, and they want to be able to serve the population of veterans they have a soft spot for.

There are a handful of PA only clinics around me that must have a rent-a-license physician attached but not listed anywhere on the website. It seems the PA functions as everyone's favorite integrative medicine specialist, offering various infusions and bioidentical hormones for cash. All under the guise of helping the healthcare shortage and being inspired to get medical training when they saw how hard it was to access care. So they start a DPC practice with 300 patients paying annual subscriptions and boost that base with snake oil services that are also cash. Really doing the lord's work.

And now this PA went and bought a TMS machine and needs a psychiatrist to 'collaborate'. What is this insanity? If I want to do TMS I'll get my own machine not accept whatever nonsense collaboration fee this ambitious huckster is thinking will be reasonable.

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[reca]

Worst part is that he’ll easily find a psychiatrist willing to “collaborate” for a couple hundred dollars a month.

 

[forchinet121]

Got a recent call from a PA to 'collaborate' as they are the 'owner' of a new TMS clinic. They say, some insurances require a physician psychiatrist for initial mapping, and they want to be able to serve the population of veterans they have a soft spot for.

There are a handful of PA only clinics around me that must have a rent-a-license physician attached but not listed anywhere on the website. It seems the PA functions as everyone's favorite integrative medicine specialist, offering various infusions and bioidentical hormones for cash. All under the guise of helping the healthcare shortage and being inspired to get medical training when they saw how hard it was to access care. So they start a DPC practice with 300 patients paying annual subscriptions and boost that base with snake oil services that are also cash. Really doing the lord's work.

And now this PA went and bought a TMS machine and needs a psychiatrist to 'collaborate'. What is this insanity? If I want to do TMS I'll get my own machine not accept whatever nonsense collaboration fee this ambitious huckster is thinking will be reasonable.

Is this PA actually making money? How profitable is the clinic? Also is this a primary care PA or psychiatric PA? Interesting that a psychiatric PA would have a DPC model and even more interesting if a primary care PA would do TMS..

 

[finalpsychyear]

this is what medicine has done to itself. Should never have been wait there is not enough demand let us create a mid level type of provider to help out. I don't know what to say. Other than a full on revolt by docs its almost too late to do anything. Pretty much i am at the point where I need to work my ass off for the next 10 years and I fully expect all mid levels to be fully independent maybe in 5 years in virtually all states. At that point why not create specialized mid levels in rads, path, surgical, etc and ultimately in all fields.

Hospital admins will love this they will save so much money and there won't be any great data outcomes for a long time showing any difference. So make your money now and I am not sure I would send my future still to come kids in 20 years into medicine so heck maybe i need to work even longer to make sure they are going to be ok bc I truly cannot believe we let this happen and this doesn't end well it's just a question of how long does it take.

 

[annoyedpsychiatrist]

I love when people look at you with this sense of shock and disapproving look when you explain you dont want to be liable for the actions of another person. its almost as if, you should smile and thank them for allowing you to be a potential sacrifice in order to maximize profit. You dont want to solve the healthcare shortage by attaching yourself to patients youve never seen or followed with before? Thats just sick.

 

[Sushirolls]

My previous location, ARNPs had a whole bunch of machines.

The only solution, as I've parroted before, is to flood the market with physicians. Reduce licensing to step/level 1-2 only. Grant full medical licensure at graduation, states change the minimum. Perhaps at most require an intern year? Flood the medical establishment with physicians to push out ARNPs and PAs. It will make residencies highly competitive, but with time the medical sphere becomes all physician as GP & Specialists only.

 

[clausewitz2]

My previous location, ARNPs had a whole bunch of machines.

The only solution, as I've parroted before, is to flood the market with physicians. Reduce licensing to step/level 1-2 only. Grant full medical licensure at graduation, states change the minimum. Perhaps at most require an intern year? Flood the medical establishment with physicians to push out ARNPs and PAs. It will make residencies highly competitive, but with time the medical sphere becomes all physician as GP & Specialists only.

Cheapen the medical degree and you significantly reduce our comparative advantage. If you are truly threatened by the deluge of mid-levels than the smart play is to double down on quality and market segmentation. A Patek Phillipe tells time about as well as a Casio and is orders of magnitude more expensive; they still seem to be doing fine. Turbotax exists and is cheaper than almost any accountant, and yet plenty of accountants make their living doing taxes for individuals.

I still don't get why, especially for psychiatry, a flood of poorly-trained providers suddenly becomes more palatable if they have the same initials after their name that I do. Most of the academics of medical school is irrelevant to our specialty. What on earth is going to make someone who completes a general intern year a significantly better psychotherapist/pharmacologist than a competent PA?

We have to get better at marketing and hustle and in time the era of "literally get a job in basically whatever kind of setting you want wherever you want with minimal effort" may pass, but that would just make our job market more like a normal job market. If you think you're better than PAs/NPs (and if you do I very much agree that you are), figure out how to communicate that to people. If you can't figure out how to do that, then there is a more serious problem than independent practice laws.

 

[forchinet121]

Why the hell would someone go to an NP for ECT or TMS? That’s a nuanced procedure why would you trust a nurse with that?

 

[heartsink]

Why the hell would someone go to an NP for ECT or TMS? That’s a nuanced procedure why would you trust a nurse with that?

Because many don't know they're going to a nurse.

A lot of NP's will get a "doctorate" in nursing, slap "Dr. John Smith" on their website advertising ECT or TMS and patients never know to question what the doctorate was for. And even those NPs that don't get a doctorate won't correct their patients when their patients refer to them as doctor.

 

[finalpsychyear]

Because many don't know they're going to a nurse.

A lot of NP's will get a "doctorate" in nursing, slap "Dr. John Smith" on their website advertising ECT or TMS and patients never know to question what the doctorate was for. And even those NPs that don't get a doctorate won't correct their patients when their patients refer to them as doctor.

Yes it is atrocious and they know exactly what they are doing to misrepresent themselves. I don't have any answer to this other than work the next 5-10 years harder than you need to. After that if things don't go down the drain then ease back but I feel now its too risky to just play it safe. It helps me sleep better at night and i truly find 50-55 ish hours is chill if your doing outpatient no wknds, no call, no holidays ever and no nights easily sustainable. Absolutely not if your doing weekend nights or calls that is rough at least for me i did that a bit in year 1-2 but not anymore.

Goal should be FI ASAP imo because it also makes you immune to the above. Also I will add you want to feel FI during a recession like we are in now and this has shown me I am not where I wanted to be even after 6 years of working more than FT. I have also gone back to my roots of spending based on WCI "live like a resident". Of course lifestyle creep is real but I teeter at the 100k yearly spending with no house (2500 rent, 1500 2 cars will own in 3 years at 1.5%), no kids, and all loans paid but being married. There was a point prior to covid I was 30-50k in yearly spending but whatever its not that much more but feels like a lot when you 2-3x your yearly spending.

After working 10 years at the end of 2026, I will revisit where I am at. However, a house and kids will be coming in the next 1-2 years. The biggest tips I had were to spend maybe 2x your monthly residency salary as long as possible as you won't know anything other than its a lot which it really is and keep most of your money out of easy access like banks or have it diverted before it even gets there for some may be the best.

If we lived in a world without midlevels and no constant cuts in insurance and high inflation I would gladly have loved to have a more chill attitude towards this and less work but due to the unknowns I'd rather be safe.

 

[Merovinge]

Goal should be FI ASAP imo because it also makes you immune to the above. Also I will add you want to feel FI during a recession like we are in now and this has shown me I am not where I wanted to be even after 6 years of working more than FT. I have also gone back to my roots of spending based on WCI "live like a resident". Of course lifestyle creep is real but I teeter at the 100k yearly spending with no house (2500 rent, 1500 2 cars will own in 3 years at 1.5%), no kids, and all loans paid but being married. There was a point prior to covid I was 30-50k in yearly spending but whatever its not that much more but feels like a lot when you 2-3x your yearly spending.

Not trying to drag you down, but that's a really significant spending jump pre-house/kids. With plural children coming you can expect 40-50k in childcare expenses easily, not counting college funds. Any house in a good school district and big enough to comfortably support kids is going to run you more than your rent, likely significantly more. I think it's going to be a bigger deal for you then you think if you really want to get back to your roots. $750/month for 2 separate car payments is the most obvious place to look, is that luxury really getting you a real return of happiness per dollar spent? Unless you like driving cars for a long time, there will be a desire for more/newer cars not long after you pay them off and of course maintenance costs will increase. Best of luck on the FI journey, it's certainly doable for any MD, but as a parent, get ready for how expensive kids are.

 

[FlowRate]

Cheapen the medical degree and you significantly reduce our comparative advantage. If you are truly threatened by the deluge of mid-levels than the smart play is to double down on quality and market segmentation. A Patek Phillipe tells time about as well as a Casio and is orders of magnitude more expensive; they still seem to be doing fine. Turbotax exists and is cheaper than almost any accountant, and yet plenty of accountants make their living doing taxes for individuals.

I still don't get why, especially for psychiatry, a flood of poorly-trained providers suddenly becomes more palatable if they have the same initials after their name that I do. Most of the academics of medical school is irrelevant to our specialty. What on earth is going to make someone who completes a general intern year a significantly better psychotherapist/pharmacologist than a competent PA?

We have to get better at marketing and hustle and in time the era of "literally get a job in basically whatever kind of setting you want wherever you want with minimal effort" may pass, but that would just make our job market more like a normal job market. If you think you're better than PAs/NPs (and if you do I very much agree that you are), figure out how to communicate that to people. If you can't figure out how to do that, then there is a more serious problem than independent practice laws.

Overall completely agree. The main issue, following on what you're saying about marketing, are the many patients who are easily wooed by snake oil tactics, thinking they're an indicator of quality. I think this comes up in various shades on this forum in other places (e.g. patient ratings), as well--markers of actual high-quality medicine are different from what's immediately rewarding or compelling to many patients. I have no clue how the "consumer" segments break down, though i.e. what proportion of patients aren't fooled by pretty pseudoscience.

 

[Sushirolls]

Cheapen the medical degree and you significantly reduce our comparative advantage. If you are truly threatened by the deluge of mid-levels than the smart play is to double down on quality and market segmentation. A Patek Phillipe tells time about as well as a Casio and is orders of magnitude more expensive; they still seem to be doing fine. Turbotax exists and is cheaper than almost any accountant, and yet plenty of accountants make their living doing taxes for individuals.

I still don't get why, especially for psychiatry, a flood of poorly-trained providers suddenly becomes more palatable if they have the same initials after their name that I do. Most of the academics of medical school is irrelevant to our specialty. What on earth is going to make someone who completes a general intern year a significantly better psychotherapist/pharmacologist than a competent PA?

We have to get better at marketing and hustle and in time the era of "literally get a job in basically whatever kind of setting you want wherever you want with minimal effort" may pass, but that would just make our job market more like a normal job market. If you think you're better than PAs/NPs (and if you do I very much agree that you are), figure out how to communicate that to people. If you can't figure out how to do that, then there is a more serious problem than independent practice laws.

They aren't supposed to be a therapist or psychiatrist. They are supposed to fill the 'support' roles of mid levels. That's it. An MD/DO grad will also have a healthier respect in these roles to refer or seek assistance in a true team role, not believe they can do it all because their lobby PAC legistlated them to do so.

Us continuing to play the quality, better training card only works in a less insurance dominated market, or less PE, or less Big Box shops, or less Government control of the healthcare sector (i.e. CMS).

We know the differences of our training. Yet, the issue is akin to the Walmart/China take over for many goods and retail. Go to the store to buy a shovel, does your average American want the quality steel from the American made company with the higher Jenka Scale wood? Or do you buy the low grade steel, cheaper, with soft alder handle from China because *its a shovel*. Most people don't know the difference, nor will they use their shovel enough to identify the difference. But yet, socially, we will all lament the cheap chinese goods in the stores, the closure of main street, and the rise of Walmart. The same goes for physicians.

And a reiterance of my original point, we can still give "cheap goods" that people demand, but at least it will have Made in America MD/DO on it, instead of Made in China ARNP/PA.

 

[clausewitz2]

But if you are pushing out a bunch of MD/DOs with full medical licenses and minimal training, why on earth do you think they would just stick to "support" roles and not just directly compete with better trained people? What is the mechanism by which you intend to restrain them? If the market is truly insensitive to quality and a med appointment is just a commodity, you will need regulations or a legal barrier of some kind unless you plan to compete on cost.

I am suggesting that instead of trying to persuade people to buy your shovel when there is a cheap-o Walmart version that's functional, I'm suggesting you go into the business of selling backhoes. Or maybe landscape consultancy services. You should be putting out a product that is effectively different from what they are offering. I know you have said you prefer not doing therapy in a meaningful sense in appointments but this may increasingly be one of our major value adds. I know @dl2dp2 is more gung-ho on the opposite end of things with more intensive or complicated electro(magnetic)/pharmacological interventions but it's the same basic idea.

I actually don't per se lament the fact that I can buy a cheap shovel at Walmart if I want to dig a no-frills ditch. It's fine. I really don't care where the shovel happens to have been made. But that's obviously a political issue that's kind of orthogonal to this as we aren't actually talking about Chinese NP schools at this point.

 

[Merovinge]

They aren't supposed to be a therapist or psychiatrist. They are supposed to fill the 'support' roles of mid levels. That's it. An MD/DO grad will also have a healthier respect in these roles to refer or seek assistance in a true team role, not believe they can do it all because their lobby PAC legistlated them to do so.

Us continuing to play the quality, better training card only works in a less insurance dominated market, or less PE, or less Big Box shops, or less Government control of the healthcare sector (i.e. CMS).

We know the differences of our training. Yet, the issue is akin to the Walmart/China take over for many goods and retail. Go to the store to buy a shovel, does your average American want the quality steel from the American made company with the higher Jenka Scale wood? Or do you buy the low grade steel, cheaper, with soft alder handle from China because *its a shovel*. Most people don't know the difference, nor will they use their shovel enough to identify the difference. But yet, socially, we will all lament the cheap chinese goods in the stores, the closure of main street, and the rise of Walmart. The same goes for physicians.

And a reiterance of my original point, we can still give "cheap goods" that people demand, but at least it will have Made in America MD/DO on it, instead of Made in China ARNP/PA.

I think at this point your plan is impossible to carry out, independent of it's merit, as the NP/PA mills are fully in swing and even lower tier or new MD programs are much harder to expand. If the question is to say would this work in the hypothetical case, then sure, I'm all for reading debate but I don't see any world where this is remotely feasible in practice.

I think Clausewitz is spot on that the only real choice people have is to differentiate themselves in the market. The other option is to be part of a unified healthcare system that has an enforced structure in place where the MD is head of the treatment team and midlevels are used appropriately (e.g. a Kaiser conglomerate, VA).

Ironically to you Sushi, this could be done most efficiently in a single payer system. NP expansion has occurred in the US at a rate of >1000% that of the rest of the western world, of which many of the countries have more socialized medicine and thus less demand for profit to drive middle level expansion. Make no mistake, it's the USA's approach to healthcare as a profit driven industry with effectively forced monopolies and moats that have fueled the midlevel rise.

 

[allantois]

I think at this point your plan is impossible to carry out, independent of it's merit, as the NP/PA mills are fully in swing and even lower tier or new MD programs are much harder to expand. If the question is to say would this work in the hypothetical case, then sure, I'm all for reading debate but I don't see any world where this is remotely feasible in practice.

I think Clausewitz is spot on that the only real choice people have is to differentiate themselves in the market. The other option is to be part of a unified healthcare system that has an enforced structure in place where the MD is head of the treatment team and midlevels are used appropriately (e.g. a Kaiser conglomerate, VA).

Ironically to you Sushi, this could be done most efficiently in a single payer system. NP expansion has occurred in the US at a rate of >1000% that of the rest of the western world, of which many of the countries have more socialized medicine and thus less demand for profit to drive middle level expansion. Make no mistake, it's the USA's approach to healthcare as a profit driven industry with effectively forced monopolies and moats that have fueled the midlevel rise.

I don't know if it's socialized healthcare as much as low physician to population ratio:

World Bank Open Data

Free and open access to global development data

data.worldbank.org

Ofc, the data does not explain everything with Japan having even less physicians per capita

 

[finalpsychyear]

Not trying to drag you down, but that's a really significant spending jump pre-house/kids. With plural children coming you can expect 40-50k in childcare expenses easily, not counting college funds. Any house in a good school district and big enough to comfortably support kids is going to run you more than your rent, likely significantly more. I think it's going to be a bigger deal for you then you think if you really want to get back to your roots. $750/month for 2 separate car payments is the most obvious place to look, is that luxury really getting you a real return of happiness per dollar spent? Unless you like driving cars for a long time, there will be a desire for more/newer cars not long after you pay them off and of course maintenance costs will increase. Best of luck on the FI journey, it's certainly doable for any MD, but as a parent, get ready for how expensive kids are.

Unfortunately, I had to buy a car in this crazy car market and it was a hybrid rav 4 and camry hybrid at msrp. I will keep 10 years minimum. Also, a 3000 sq house is going to run me close to 5k/mo with current interest rates maybe less if rates drop. Future Kids 12-18 mo away add 40k. With house and kids I'm at 70k more or a 70percecnt increase. It is what it is. However, I did increase workload recently that will breakeven these additional expenses and actually increase savings until they are all in effect simultaneously but even then it should cancel and i will be ok with that.

 

[michaelrack]

If I want to do TMS I'll get my own machine not accept whatever nonsense collaboration fee this ambitious huckster is thinking will be reasonable.

Do you have 200k lying around to buy a TMS machine? There is a large financial and administrative burden to starting a TMS program.

 

[allantois]

Do you have 200k lying around to buy a TMS machine? There is a large financial and administrative burden to starting a TMS program.

Is it 200k tho? I think there are some much cheaper machines out there

 

[forchinet121]

Is it 200k tho? I think there are some much cheaper machines out there

Even if it was, how can the PA afford it and the doc can’t?

 

[allantois]

Even if it was, how can the PA afford it and the doc can’t?

I've been looking into this. There is a chain of TMS clinics in my state; they only have a handful of MDs and clinics seem to be NP run. I wonder how that works as it is my understanding that MD has be present for at least the mapping part for most insurances to cover the procedure

 

[finalpsychyear]

Is it 200k tho? I think there are some much cheaper machines out there

I think considering hiring a tech, machine, space etc plus there will be a time delay before it gets going. Had a few collegues who tried to do it but it was a loss due to low volume. If you have a group of psych docs then its much more affordable and doable. One collegue decided to do it with a large hospital where they paid him a flat fee of per patient they but had to actually complete the full course. He said it was mixed as some people dropped out in the middle or end and the hospital paid less due to that.

 

[nexus73]

I think there are much cheaper tms machines. I also believe some of these companies finance you and/or take a cut of each treatment so you’re not paying $200k upfront. And i don’t know this PA could be bankrolled by spouse, or just taking on mass debt to build up a practice which may or may not pan out. It seems like our local area is getting more and more TMS clinics to where the risk is too much to consider $200K investment in my opinion, with risk of market saturation and a machine sitting idle.

 

[finalpsychyear]

I think there are much cheaper tms machines. I also believe some of these companies finance you and/or take a cut of each treatment so you’re not paying $200k upfront. And i don’t know this PA could be bankrolled by spouse, or just taking on mass debt to build up a practice which may or may not pan out. It seems like our local area is getting more and more TMS clinics to where the risk is too much to consider $200K investment in my opinion, with risk of market saturation and a machine sitting idle.

i find it ridiculous that a company can sell you a machine then charge you for each time its used. never heard of this concept in medicine with mri, xray etc. of course in psych they find a way to do it.. go figure.

Also i recall neurostar charging 40-50 bucks per click, then you pay the tech who also like to charge per tx, also you have to not only pay the machine costs but the warranty crap is also not cheap. The cap is also 15 bucks roughly per patient. One of my collegues said you were getting global 150 per tx then after paying tech, neurostar, you got a grand total of 80 net which again assumes everything gets paid and collected.

Hard Pass.

 

[forchinet121]

i find it ridiculous that a company can sell you a machine then charge you for each time its used. never heard of this concept in medicine with mri, xray etc. of course in psych they find a way to do it.. go figure.

Also i recall neurostar charging 40-50 bucks per click, then you pay the tech who also like to charge per tx, also you have to not only pay the machine costs but the warranty crap is also not cheap. The cap is also 15 bucks roughly per patient. One of my collegues said you were getting global 150 per tx then after paying tech, neurostar, you got a grand total of 80 net which again assumes everything gets paid and collected.

Hard Pass.

It’s a way to finance the machine..do you wanna pay 200k cash or 50 bucks a treatment until the 200k is paid off

 

[Iamnew2]

Because many don't know they're going to a nurse.

A lot of NP's will get a "doctorate" in nursing, slap "Dr. John Smith" on their website advertising ECT or TMS and patients never know to question what the doctorate was for. And even those NPs that don't get a doctorate won't correct their patients when their patients refer to them as doctor.

It is illegal for a DNPto call him/herself doctor. One recently got a significant fine for calling herself doctor

 

[nexus73]

It is illegal for a DNPto call him/herself doctor. One recently got a significant fine for calling herself doctor

depends on specific state law, California and Oregon I know

 

[allantois]

It is illegal for a DNPto call him/herself doctor. One recently got a significant fine for calling herself doctor

It’s not really illegal. She got charged for misrepresenting herself as a physician. She can call herself Dr NP.

On the subject of TMS, I’ve seen some practices use non-FDA machine from Russia..

 

[Iamnew2]

It’s not really illegal. She got charged for misrepresenting herself as a physician. She can call herself Dr NP.

On the subject of TMS, I’ve seen some practices use non-FDA machine from Russia..

Law states that you cannot call yourself doctor without explaining that it is a doctorate of nursing.

 

[ObsequiousAplomb]

I mean, if they'll pay me 10-20% of their billings to be the collaborating physician...

 

[smalltownpsych]

From what I see, the ones making the money are the people selling the machines. The midlevels I have met who are doing TMS are falling victim to this belief that there is this huge untapped market out there. Insurance companies are not going to pay for unnecessary treatments and private pay people are only so gullible. The amount of people that need or could benefit from this type of treatment from what I understand is just one small slice of the pie. The majority of our patients will do best with a little therapy or medication. In a big city with a good psychiatric practice, this could make sense as this is designed for sicker patients. A non-psychiatry PA who does this on the side? Ridiculous.

 

[allantois]

From what I see, the ones making the money are the people selling the machines. The midlevels I have met who are doing TMS are falling victim to this belief that there is this huge untapped market out there. Insurance companies are not going to pay for unnecessary treatments and private pay people are only so gullible. The amount of people that need or could benefit from this type of treatment from what I understand is just one small slice of the pie. The majority of our patients will do best with a little therapy or medication. In a big city with a good psychiatric practice, this could make sense as this is designed for sicker patients. A non-psychiatry PA who does this on the side? Ridiculous.

I do think about how many patients could benefit from TMS that I see and it's only a handful a year; I suppose if we shift the paradigm to trying TMS after 2 SSRI failures but even then the treatments are extremely inconvenient to patients

 

[Merovinge]

I do think about how many patients could benefit from TMS that I see and it's only a handful a year; I suppose if we shift the paradigm to trying TMS after 2 SSRI failures but even then the treatments are extremely inconvenient to patients

Around us they are requiring 4 med failures, has to be unipolar depression, no co-morbid PD, so relatively hard to qualify for. They also try to block people with a history of SUD, basically doing anything possible to stop pts from getting it.

 

[nexus73]

If efficacy was better and only needed 4-8 treatments I could a cash market paying $1000-2000 for a course of treatment. Just not reality.

 

[Sushirolls]

Theta burst protocols I think are now FDA approved, and can lead to remission in 4 days... but I've observed one clinic in my former area had a capable machine, had knowledge of the protocol, but never used it on any of my referrals. I suspect $ may have been a factor.

DNP using doctor title is based on state law. Each state has different statutes for who can misrepresent themselves.

Some states even allow DC or ND to call themselves physicians, too.

 

[romanticscience]

If I had to come into the office every weekday for 6 weeks for TMS, I might just factitiously remit out of annoyance!

 

[WisNeuro]

Law states that you cannot call yourself doctor without explaining that it is a doctorate of nursing.

While some jurisdictions may have side rules about doctor as a professional title, most do not. Rather, they have language about presenting oneself as a certain licensed profession without the appropriate training and licensure.

 

[the5thelement]

There is a new sheriff in town.The latest device to get FDA approval speeds up the treatment considerably.
The SAINT protocol needs 5 days vs regular TMS which takes 6 weeks.FDA granted the device breakthrough status based on impressive results from two open label trials - 86% of patients with treatment resistant depression achieved full remission. Link for the waitlist