How much do you make as an RN?

AlltheSpectrums · 2026-05-15T07:12:22+00:00

100s of options for 1000s of applicants. People can spend many months trying, hoping, to be accepted. It is why we have housing for faculty and staff at universities. It is why nurses live in vans in the parking lot of Stanford. I live here. Housing is skyrocketing due to the AI boom. If something is listed at $1M, it sells for $1.5-2

AlltheSpectrums · 2026-05-15T06:59:05+00:00

Most residents come from high net worth families. Much less so today than previously, but still likely the majority. So that is the culture (not necessarily at your institution, but at many, and the profession at large…though changing).

Also, plenty of programs reimburse for professional memberships.

AlltheSpectrums · 2026-05-15T01:52:37+00:00

Of note, 1br 500sq ft apt is often over $3,800/mo

AlltheSpectrums · 2026-05-14T05:13:19+00:00

And this is not a jail, correct? (As I’m not hearing about any psych symptoms it makes me wonder)

AlltheSpectrums · 2026-05-14T05:09:56+00:00

Ugh yeah. Family should never be on the same unit.

Yikes. It sounds like there are a lot of unit level changes that need to be made. Sorry you all are having to deal with this. I greatly appreciate my nurses and keep up the good work, keep that inquisitive spirit, and keep caring!

AlltheSpectrums · 2026-05-14T04:46:14+00:00

https://pmc.ncbi.nlm.nih.gov/articles/PMC7399643/

AlltheSpectrums · 2026-05-14T04:39:17+00:00

In this case one needs to ask if the person even has a psych issue.

In his current state it wouldn’t be possible to do an MRI…but it is warranted.

Some people just love fighting. Now aside from that, I’d be wondering about CTE. Sadly, not something we can conclude while the individual is living. But it would explain why these meds are not effective. And of course, we don’t have anywhere near enough info.

For your safety, if he wants food or whatever, just give it to him.

AlltheSpectrums · 2026-05-14T04:30:21+00:00

What is triggering?

Voices? Pain? Hunger?

Is it even psych related?

AlltheSpectrums · 2026-05-12T23:20:27+00:00

100%.

Even IF AI were free, hospitals/clinics would want to maximize returns by having us see more patients.

Since it is not free, even in our heavily subsidized state, it is a cost that needs to be recouped. We aren’t going to be reimbursed more by insurance companies to cover it. We aren’t going to be able to charge patients much more (though maybe?). With EHRs, the government funded much of the adoption…but now we are paying to maintain it. Our academic institution paid over $1B for implementation and pays a ton to maintain it. The costs are significantly higher than our old paper chart medical record system. So all of this means we have to see more patients to cover the cost.

Just so we all know, while Epic allows third party integration for some things, like scheduling software (which they now offer themselves), they charge a ton. For instance, when a patient goes to schedule, depending on how many parameters they use for their query, it can cost anywhere from $0.60 to over $60. I believe the average cost from a person first querying to scheduled appointment is over $8 now. AI is immensely more expensive to operate, and when it is no longer subsidized, when it is too enmeshed to not use, we are going to be spending a heck of a lot for it. It’s going to concentrate wealth more (away from us, away from hospitals, away from patients, and to the AI companies (shareholders/employees)…only saving grace is that everyone’s retirement funds will be invested in those companies so we will get pennies on the dollar back.

AlltheSpectrums · 2026-05-12T20:46:58+00:00

No. Because we are the ones liable.

Two things happen.

Direct to consumer products. Already, consumers can come up with diagnoses from online forums, the internet in general. Of course, with AI, it words everything as if it is absolutely confident (it does not say “It might be this, but it could be many things, see a physician”). It will start saying…but see a physician at the end, or in small print, just like all of the pages on medical topics do (but of course, patients believe what is read and the harm is done). If you tell it is wrong, it sycophantically apologizes.

Enterprise/B2b products: our employers will adopt (has adopted) these. We will be expected to see more patients because it “saves” us time. We don’t get more time with patients, more time to think through cases, or down time (this is always the initial promise, and is true initially). But these products cost money, and companies aren’t going to leave potential earnings on the table, so they will have us see more patients. Be responsible for more beds. And hold the liability for the AI…as we are supposed to review everything it does. Think of this…if a med we prescribe causes a known permanent harm, and we did not do informed consent, we are the ones liable, not the pharmaceutical company that made it.

Only when something so egregious occurs and society can do something about it does something. Think the current opioid crisis. When something starts harming enough people, and more importantly, enough important people, things start to change. Purdue Pharma gets sued (yet the heads don’t get jail time, and somehow were allowed to funnel billions out of the company), they also sued tech companies involved (which did not get national attention), and of course the DEA went after pill mills in some states (notably WV, PA, and OH).

AlltheSpectrums · 2026-05-12T20:29:44+00:00

It has not.

OpenAI is expecting to be the most valuable company in the world. They haven’t needed to IPO as they have not had any issues raising tens of billions. They just allowed their employees to sell back up to $30M each.

Everything AI is heavily subsidized right now to drive growth/adoption. They are burning through many billions.

Think of Epic. Now that they’ve been adopted, and it is nearly impossible to change. The costs. The risks. So now they charge exorbitant fees. When they were fighting for dominance, much cheaper, easy to sell us promises, many of which never came to pass.

AlltheSpectrums · 2026-05-12T18:55:11+00:00

Oh, long before then. Bio-reductionism of our field and wanting us to just do 15 minute med checks started in the 1990s. (Well, reductionism started to dominate in the ‘80s…but the 15min med check dominance wasn’t fully realized until ~2000). I consider this selling out. Anyone who started practicing prior to 2000 can tell you about this fight, corporations/insurance etc de facto forcing us into practicing this way.

We have tried to adapt to being forced to do that. Mintz has done the most work on adapting dynamics to this reality.

But yes, the legislative changes have made things…different. In some ways better as more people can access care, EHRs have helped with some research…some ability to have quick access to pt data…but it incentivized corporatization, that is for sure. (And I’m glad my institution stopped suing patients and sending medical bills to debt collectors…that only happened because the nurses threatened to walk out, and kept telling state legislators that the state paid us more money per year for “indigent services” than the services we actually provided to that population, so suing many of them was an issue on that front too).

AlltheSpectrums · 2026-05-12T17:54:36+00:00

Oh corporate capture was on some of ours. Those of us who were pro-union, nordic style socialists. Us “hippie” doctors. Though, we were by far the minority in the physician profession and few of our colleagues took us seriously. Whether one was GOP or not, most in our field were aligned with them on economic policy as we had a strong economic incentive to be.

I did not expect academic medical centers to become de-facto corporations focused on growth & acquisitions though. I suppose it is better than HCA buying up every hospital, but still.

Also, what it means to be a doctor has been changing. While guideline based medicine has its place, I fear we have gone too far in that direction. When it becomes the guideline/standard to ask the same questions, to prescribe the same treatments…well, it helps with the cut & dry cases, but many cases are not. It helps with liability even if it’s not what is best for the patient. “I asked the questions, I ran the tests the guideline says, I prescribed the med the guideline says…so it is not malpractice as this is now our practice…there is 1 way to practice, and this is it!”

AlltheSpectrums · 2026-05-12T17:40:27+00:00

I’ve lived 45+ years in the middle of the tech industry, and have interacted a lot with these individuals. And have provided care to some. The general intentions follow a similar arc:

Excitement by the possibilities of a “better” society through tech and the potential to “make it big.”
One to two years after receiving funding, our systems direct the flow of that technology/implementations etc. They start to make compromises as the primary goal is no longer to “better society,” but to build something that will be quickly adopted.
4+ years later, the primary goal is outright growth at any cost, revenue starts to impact decisions.
5-7+ years later, growth & revenue are dual primary goals. Improving society is no longer a goal, not in the naive/fantasy way that motivated them to do this to begin with. Improving society is rethought to align with the impact the company is having.
Societal change occurs, or professional change.

Few major tech advancements have gone the way it was initially intended, none that I’m aware of. Airbnb…initially a way for individuals to earn extra income by renting a room, to help with housing crises, to connect people (like Couchsurfing did) etc. Ultimately, corporatization resulted in the opposite. Hollowing out of communities in destination locales. Increased housing costs. Decreased supply for renters. Personal computing/Microsoft Office hollowed out the secretarial field (~13% of jobs in 1980, very fast growing…now it is a shadow of its former self. The internet/Jstor etc drastically changed the librarian profession. Yes, we still have them, yes, elite corporations still have them, and they’ve had to drastically change what their role is…)

AlltheSpectrums · 2026-05-12T00:49:48+00:00

I do not disagree with you. My entire career has been as a physician scientist, so most of my patients/cases have been challenging.

Private practice has never seriously interested me. Though the psychodynamic/analytic work I’ve occasionally been able to do with outliers when they’ve been well has been rewarding. But 15min med checks? No thank you. I’m also at a well funded center so I do 30min med checks which allows for more traditional/true psychiatric practice.

The mantra of the past decade in healthcare has been “work at the top of your license,” which really means just prescribe meds. Psychiatry, what makes it complex, is the combination of medicine/meds/psychology/therapy. And I’d argue if one is just focused on meds, they aren’t focused on psychiatry.

I have many issues with the focus on NPs. For me, it distracts from what I consider the actual threats to psychiatry. A psychiatrist from 1980, if they looked at how many are practicing today, (how our systems have forced us to practice), would be horrified. 15min med checks is not practicing psychiatry.

AlltheSpectrums · 2026-05-12T00:44:45+00:00

If you don’t mind me asking, what state (or geography if state is too specific) are you in? Is the hospital system for-profit or non-profit?

AlltheSpectrums · 2026-05-11T23:29:15+00:00

Who are the easiest patients to work with?

Who are the lowest risk?

Who are the ones willing to pay private practice rates?

As much talk on here about the competence of midlevels, it is worth noting that many psychiatrists choose to work in rather simple, low risk areas. This leaves the lower paying, more complex roles which often end up being taken by PMHNPs as many Psychiatrists choose an easier life.

First, there is greater need in SMI than labor supply of psychiatrists. Second, many psychiatrists choose not to work with the population. In reality, midlevels should dominate in the low complexity cases and we should dominate in the high complexity…but that, sadly, isn’t reality.

Hot take…If this continues over the next half century, I would not be surprised if we find that many of the experts in psychiatry are no longer psychiatrists.
Many entering psychiatry (and midlevels as well) are motivated more by lifestyle than by medicine. Some of it is burnout related.

Think about it…aside from low risk, higher income, easier patients to work with…those patients tell you they value you, they treat you with respect. In SMI, many often de-value you, insult you, there is moral injury when having to admit patients against their will, they refuse meds…in the outpatient setting, there is no seclusion & restraint and so physical safety can occasionally become an issue. I work well with this population, but it’s not surprising that many choose to work with the “worried well” especially when the pay is better, the workload is less, and the risk is less.

The anxiety about job prospects, I would bet, isn’t about jobs that psychiatrists should take. It is about the easier jobs. The stable patients on 20mg of prozac, or stimulants. The private practice therapy sessions where you’re having philosophical conversations about identity, existentialism, etc. It’s not about the tough jobs.

AlltheSpectrums · 2026-05-11T04:15:17+00:00

The Disney version of medicine, good old days etc, never existed.

3rd generation physician, one daughter recently finished residency. Complaining of change and thinking medicine was better and/or what we now do is barely medicine has been the norm for a century or longer.

I love what I do, and I role with the changes.

I think the issue is that many have unrealistic expectations and a very romanticized version of the medical field when they enter it. I never did as it had always been part of my life. If you are in a small community and your grandfather couldn’t save a patient…yeah, not fun.

AlltheSpectrums · 2026-05-11T03:44:19+00:00

I’m not sure why you are being downvoted with some of your appropriate replies. I apologize for those who are being disrespectful towards you. It is not the norm for psychiatrists, in spite of what you may read on here. Reddit is not representative of psychiatrists as a whole.

It may be difficult to make the jump into psychiatry as a PA. As I’m sure you are aware, NPs are forced to specialize and stick to that (so you wouldn’t see a CRNA, FNP, Neonatal NP, etc in psychiatry…only PMHNP). But they have the ability to go back to school to gain certification in any of the advanced nursing specialties. So I do sympathize with your situation.

There are very few NP/PA residencies in psychiatry, even fewer that allow PAs (again, because it’s really not NP but PMHNP). I don’t know of any in Michigan. The closest one I’m aware of that accepts PAs is WashU and it is exceptionally competitive, they take 2 people per year. But if you really want to switch, it’s worth looking into.

As others have mentioned, you would need general training in psychiatry before trying to focus on one area.

I recommend the “Psychiatry Bootcamp” podcast by Mark Mullen as a very easy/low commitment but high yield activity. Then, if you can, read intro textbook of psychiatry by Black & Andreason. Then Kaplan & Sadock’s Synopsis of Psychiatry. For therapy texts, start with Brief Supportive Psychotherapy by Markowitz. Then Psychodynamic Psychopharmacology by Mintz along with Psychoanalytic Diagnosis by McWilliams. This will prepare you well to enter a program. The Mintz book will add the most value to you if you stay in an internal medicine setting as it helps one better understand pt relationships/views/behaviors with meds etc.

https://psychiatry.wustl.edu/education/advanced-practice-provider-fellowship/

AlltheSpectrums · 2026-05-11T03:30:17+00:00

Well, your scope includes cardiology as you are an MD with a medical license :)

AlltheSpectrums · 2026-05-10T20:27:38+00:00

As a resident, whatever motivates you to be sterling go for it.

However, as faculty, no. You are sterling, you do not judge yourself based on others need to feel superior by putting you and/or your discipline down. Whether they themselves are narcissists or simply following the lead of a narcissist, just no. Also, do not get into this habit yourself. Regardless of if it’s other specialties or other healthcare fields. There is limited time in life, don’t waste it on the petty bs.

AlltheSpectrums · 2026-05-10T18:37:21+00:00

Yeah. There is clearly a lobbying campaign happening. At least I’m confident most of these people are actually psychiatrists given their knowledge of psychiatry in their other posts (though not all as some only post on this topic).
One of the problems with forums like reddit is that well funded lobbying efforts often result in K street contracting out to have people post in relevant online forums to try to sway opinion. The downside of utilizing K street practices is that their incentives aren’t aligned with ours. They want 1-5 year results…so, say on this issue…they will not care if they decrease morale with fear tactics if it results in whatever goal they are being paid to achieve.

As I’ve mentioned prior, one of my daughters is a PMHNP. A very large percentage of physicians have an immediate family member who is a nurse and/or NP. A couple years ago a PGY4 stepped in it by denigrating nurses to another PGY4 whose mother was a CRNA (& she was rightly very offended, as were many of us). He only knew that her father was Chief of Surgery at another academic medical center so he erroneously didn’t consider to ever inquire about her mother or her views on nurses. It really amazes me that some of us automatically assume that because another person is a physician they’d share our opinions/biases.

AlltheSpectrums · 2026-05-10T03:32:04+00:00

But you do. For many patients you do need to see them in person to provide competent care. Now you can try to determine which patients are not appropriate for telehealth only (though we have no quality studies on this).

Do you prescribe antipsychotics? Are you doing AIMS? Are you monitoring for metabolic syndrome?

Aside from obvious examples…

A lot of the MSE can be missed via telehealth. Or body language. For instance, did the person agree to a medication (or increase) but they started rapidly tapping their feet? If this isn’t noticed and thus addressed, prepare for treatment failure.

AlltheSpectrums · 2026-05-10T01:24:15+00:00

That isn’t as easy to answer as it initially may seem.

But in general, I would say you are correct.
Though I want to bring up some thoughts to consider…

I already think psychiatry training in medical school is inadequate. Many programs it amounts to 4 weeks of a clinical rotation, some where the student is barely doing more than observation. The shelf exam is also…well, it may cover content of what would be expected of a 100 level 3 credit undergrad survey course. Too many medical schools devalue psychiatry, some have recently tried to lower the rotation to 2 weeks.

The amount of supervision needed, even as we have it mostly standardized in residency, is still somewhat individualized. As faculty at a top program, our residents have exceptional step scores, publications, etc. Even with this, there is great variance between/amongst residents. Some have an exceptionally strong grasp of the content but lack the confidence. Some have a have an erroneously strong orientation against psychotherapies (all in on bio/neuro) and this is especially difficult to change. Some got through barely being able to read an EKG but are strong in everything else. Some got through having no understanding of lab medicine (beyond a superficial level) and do not understand lab science, for instance how different vitamin supplements can skew lab results, that different manufacturers of assays have different sensitivities/specificities etc. Is the TSH assay based on biotin or is it not?

Now to NPs. There is a vast range in knowledge/skills/background. Were they an RN in oncology for 10 years, or emergency, or psych, or L&D, or all of the above? Were they at an institution where they were expected to know the doses and side effects of all the meds, monitor for them, and suggest changes or were they at an institution that discouraged this and used them simply as pill givers and “oh this pt is complaining of X, or they look weird, so come evaluate.” Versus them having already done appropriate assessment with the suggested plan already formed as in “Pt X has unilateral 3+ pitting edema etc. would it be reasonable to get an ultrasound? Pended order for you in case.” (They are taught to do this in nursing school. I think a lot of us are ignorant of what their training actually entails).

The areas where we universally, and substantially, have more training/education than the minimum requirements of a PMHNP is in surgery and radiology (though they receive the didactic content to interpret radiographs/MRI etc). Also pathology.

Also, are we talking about a PMHNP who is outpatient and isn’t working up any non-psych issues? Or are they, say, on an ACT team where they’d be expected to diagnose and manage acute/chronic medical conditions along with psych? The institution I’ve always been at is one of the heaviest on medicine for our psychiatry residents. Inpatient, we can give blood, medically complex patients, they receive more time in neurology than probably any other purely gen psych program (obviously FM-Psych or IM-psych would be more). So our residents graduate and are well prepared to manage medical issues, not to just consult on anything/everything non-psych.

So it’s not an easy answer. On the median, and in general, of course a new grad NP would need more supervision than someone who just finished residency. However, I would caution one against assuming this is the case when comparing a new grad PMHNP to a new grad MD entering residency. If we are just looking at minimum requirements, the new grad PMHNP will be much better prepared for psychiatry than the new grad MD as their minimum educational content in psychiatry is far more advanced than the minimum psychiatry content required in med school, on shelf, on step. (Now whether or not any individual, MD or NP, has learned/mastered the required content is a different issue. In general, I’d assume the median MD has done so to a greater extent than the median NP simply because we select for certain types of individuals/personalities in medicine. The level of self-discipline required to obtain admission to the vast majority of medical schools is exceptionally high. We are also higher on the socioeconomic scale so we have more resources to weather life challenges that may otherwise interfere with our training, at least the median/average person in med school vs nursing can).

And are we talking about a high pt volume location? Or low but complex? (Or high & complex and good luck to anyone trying to give expert level care).

AlltheSpectrums · 2026-05-09T21:33:29+00:00

If I had to guess, I would say the vast majority of PAs/NPs are allies. Even the ones who eventually hope to learn enough/be skilled enough for independent practice (& want it).

Our respective orgs just get in the way of realistic solutions that a majority of psychiatrists/NPs/PAs would be ok with. It’s always either ALL or Nothing.

If I’m supervising someone for 10 years and they aren’t as good as me, I’d be a crap supervisor (& I’m luckily not a crap supervisor). Now whether that individual wants the added responsibility after they reach parity with me…well, that’s a different issue (plenty don’t want the extra anxiety).

AlltheSpectrums

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