Leaving patients no alternative
A deeply concerning example of vulnerable patients being affected by physician replacement is in the field of child psychiatry. Alison DeLuca, MD, a child and adolescent psychiatrist with a telemedicine practice had been providing care in a health provider shortage area in New Mexico for five years when she was replaced.
“I job shared with another psychiatrist. I worked two days per week, and she worked one day per week. There was also a NP who provided services on the other days,” said DeLuca. While she told me she was never told of any problem with her job performance, “the company said that they had decided to consolidate services and that they only wanted one provider,” Deluca said.
DeLuca and her psychiatrist colleague were given 90 days’ notice and told to transfer their patients to the nurse practitioner. “My patients were very upset, and I was upset for them. While I can always find another job, these patients have no alternative. This population is underserved, underprivileged, and patients are very ill with chronic disease. They can’t drive three hours away to see a psychiatrist. They have no choice.”
Instead of continuing care with DeLuca—who completed five years of psychiatry training after medical school (three in general psychiatry and two in child psychiatry)—the clinic’s patients will receive care from a Psychiatric Mental Health Nurse Practitioner (PMHNP), a certification which requires just 500 supervised clinical hours of training.
“I contacted the New Mexico Board of Medicine,” DeLuca told me. “I wanted them to know that the psychiatrist shortage in the state has nothing to do with physicians not wanting to work. It’s because we are being let go.” DeLuca said that she has not yet had any response from the board.
I spoke with another child and adolescent psychiatrist with a similar experience: Ann Marie, MD. She is using an alias because her current company director has a Director of Nursing Practice degree and she fears retaliation. Marie told me that she was also replaced by a mental health nurse practitioner. “The NP who replaced me received her degree from an online program through Liberty University. Before I was let go, she would sometimes ‘sit-in’ on my telepsychiatry sessions. But I never had any real dialogue with her, or any teaching moments.”
Marie told me that she chose to work for a Federally Qualified Health Center (FQCH) because she wanted to serve needy patients on Medicaid. In 2012, she and a colleague developed a telepsychiatry program to provide access to care to some of the most underserved patients in Maryland.
“The program flourished,” Marie told me. “Between the two of us, we were able to provide for 700 patients, and perform 1,000 visits per year.” But in May 2017, Medicaid regulations changed, and FQHCs were no longer able to provide telepsychiatry services. “We worked really hard, tried to get politicians involved, but ultimately the CEO, a nurse, decided to hire an onsite NP instead,” Marie told me.
While Marie expressed empathy for the financial situation of the FQHCs, she worries about patient care. “I spent three years doing a general psychiatry residency, and another two in pediatric and adolescent psychiatry. On top of that, I spent a year in a longitudinal autism spectrum clinic, even working with preschool children. This is not the type of experience that can be gained from an online program or just ‘shadowing’ a psychiatrist.”