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Podcast Episode 8: Private Practice for PMHNPs

Enlightened Practice Podcast

In this episode, Dr. Ken Braslow invites Jackline Ngalame, DNP, FNP-C, PMHNP-BC to share her experience as both an employed and independent APRN. They discuss the importance of mentoring and challenges in setting up a PMHNP practice.

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Transcript of the podcast

Ken: Hi, everyone. Today I have a special guest on our podcast. We’re chatting today with Jackline Ngalame. She’s a duel certified nurse practitioner. She’s certified as both a family NP and psychiatric mental health NP. Jackline has a doctorate in nursing. She’s a mom, an author, entrepreneur, and wife. She’s the founder and CEO of Empower Psychiatry, LLC nurse practitioner LI LLC and When we all Precept Incorporated. Her published works include a Quick Start Guide to Private Practice for Nurse Practitioners and Smart Rotation Clinical Journal for students completing clinical rotations. Welcome Jackline! 

Jackline: Oh, thanks Ken. How are you?

Ken: I’m good, thank you. It’s a treat to have you on today. 

Jackline: My pleasure.

Ken: Great. Today, we’re going to talk about the world of nurse practitioners and I’m hoping that you can educate some of our listeners who might have some questions or confusion. And, also you could tell us a little bit about your world and what it’s like to be practicing as a nurse practitioner. And then, advice that you might have for new grads who are coming into the field and wisdom you can share with them. 

Jackline: Wow, definitely. That’s loaded, let me just put it out there. 

Ken: We don’t have to cover it all in the first step aerograph, we’ll get to it. So, for starters, tell me a little bit about your background and how you ended up where you are today.

Jackline: Wow, that’s a great question, Ken. Actually, you said it right. I’m dual certified as both a family NP and a psychiatric mental health practitioner. My original certification was a family NP. So, I’m proud of becoming a nurse practitioner. I had worked as a registered nurse in several settings to include oncology, med-search, psychiatry, both inpatient and outpatient, pediatric, geriatric, psychiatry settings. And I went to school to become a family NP because that is what I was advised or told to do, not that I wanted to become a family NP. So, I had a very great mentor. She was in a family NP program. 

She advised me that I should consider enrolling to become a family NP, because at the time I was prerequisites to go to medical school and I was almost done with my prerequisites and she told me, “Hey, medical school is going to cost you a lot of money. You’re already a registered nurse. You are practicing. Why don’t you just go the NP route?” I’m like, oh, what is NP? She began to educate me what it entails and she told me that NPs do the same thing physicians do, except that you spend less money going to school and all that. So, it sounded interesting and I was going to take MCA but I had to stop and I didn’t take MCA anymore. And as God has it I ended up applying to the same school this friend was attending and then I began taking classes to become a nurse practitioner. I finished. I was certified. To be certified as an NP you have to take just like physicians do, you have to take a license and exam. This one is a national exam. So, I’m certified by the American Association of Nurse Practitioner, AANP. And then they give you these credentials FNP, Family Nurse Practitioner – C for certified. 

So, I did not end there, I finished school and then I got a job in psychiatry as a family NP. This was in the state of Georgia. By this time I lived in Tennessee, but then somebody called me on the phone and said, “Hey, we have this role here, it’s both inpatient psychiatry and outpatient psychiatry. You’ll be rounding in an inpatient detox facility and inpatient for substance abuse. All of them are mental health patients. It was a mixture of both females and males and the beds were like 8 for males and 8 for females, and they could come in with mental health as well as detox, people that are trying to get off drugs. In the afternoons, you’ll be seeing patients in outpatient setting.” It sounded interesting and intriguing because my background was both in outpatient and inpatient psychiatry. 

So, I took the job. I mean, I interviewed over the phone and they said, “Yes, you’re hired.” I was excited. It was my first NP role. I was excited but afraid. I was excited but afraid what to expect as a provider, right. It would be my first gig as a clinician provider. I was used to taking orders, transcribing physician orders, and all that. But now, here I am. I’m about to begin to give these orders myself. So, I’m like, oh, my gosh! Patients’ lives are going to depend on every decision I take or make, so I have to be on top of my game. I remember showing up for my very first job, on the first day there was nobody to give me orientation. They just told me, “Here are the patients. This is the census.” This was in the inpatient setting. It was full, 16 patients to see that morning. This is the census, nothing about this is the EMR, none of that. 

So, they gave it to me and the patients were all lined up. I had to see these patients and decide who is going to go home. Nobody gives you a report. It’s not like nurses where you go into your shift, you have shift report. No, for this one there was no shift report, nobody, because during the night somebody’s on call. When 8 ‘o clock shows up I’m expected to run all these patients. So, I showed up there and I went to the census and I started interviewing all the patients, right.

Ken: Um hmm.

Jackline: I was interviewing patients, adjusting medications. Thankfully, I had a background in psychiatry as a registered nurse. And I was familiar with taking orders from physicians and my NP program did not cover a lot in psychiatry, we did it briefly, but I mostly relied on my experience as a registered nurse and what I had learned myself to be able to be certified and in order to care for these patients. So, I interviewed patients, I would adjust medications for depression, schizophrenia. I remember having a lot of complex cases. Here I am, a family NP working inside, because in the state of Georgia you can’t do that. It’s not like physicians where you have to be both certified in psychiatry to provide psychiatric services, no. NPs, some states have leeway due to the shortage of providers in psychiatry. So, some states allow FNPs to function in that role. So Georgia is one of those states. Thankfully, I had solid knowledge and background in psychiatry and I was somebody that was eager to learn, except there was nobody to teach me. Georgia requires NPs to have supervising physicians, for me, this is so flawed because they call them supervising physicians but they don’t really supervise anyone. This person was like 300 miles away from me and he’s just your supervising physician on paper because that’s what the state requires and they get paid a hefty amount of money to do this thing. 

Ken: so, you weren’t presenting to the supervisor?

Jackline: No, I was not. I was not. You are only expected to call him if you had questions. He’s working fulltime somewhere else. It’s not like he’s sitting at his desk and waiting for the phone to ring. Hey, this is Jackie, I have this patient whose 20 years old, schizophrenic, no, not like that. This is someone they say, contact if you need. So basically, you’re on your own but the state says supervising physician, they get paid heft money, when you need them you call sometimes and they don’t answer. Are you going to sit there waiting for them to return the call? No, of course you’re going to do your best and take care of the patient. Do your best to ensure that they are safe and that the decisions you are making is helping this patient. 

I survived my first day. I discharged some, some I refused to take up. In Georgia, we have what we call involuntary admission, where they cannot be discharged even if they wanted to because they are a risk to themselves and to other people. So, there are some that will not be happy. So, I discharged those that I could, adjusted meds for those that I could and I went on to the outpatient setting. I started working and I enjoyed what I was doing. Then I began thinking, at this time I was enrolled in a doctoral program. I was trying to get my doctorate. So, I began thinking, I’m like, okay, is there a better way I can serve these patients? Because I love psychiatry and I don’t know if I’m going to go back to family practice. 

So, I started looking for schools, schools that I could attend to obtain post masters in psychiatry as a psychiatric nurse practitioner. So, luckily, I applied just to one school and I was admitted. There are so many schools out there but I was looking for one that was rigorous and also supportive. So, I applied and got accepted into the only school I applied for and it was exciting. So, I was doing a doctoral and a post masters at the same time. And I was working at the same time. You see how chaotic that could be? 

Ken: Wow! 

Jackline: Yes. So, I had to pause one of these programs because I couldn’t do both and work at the same time. So, I gave preference to pausing one semester of the psychiatry after I finished the first semester. I paused, took a break and finished my doctoral program, and then went back and finished the post masters in psychiatry. I was on clinical rotations with psychiatrists, all my rotations with psychiatrists, very good ones. I follow them for the course of my clinical rotation. And my program required I believe 650 clinical hours with a psychiatrist to be able to graduate. I finished that, then I graduated and then I studied now for another certification exam to become a psychiatric nurse practitioner. So, when I passed that, I just continued in my role. It helped a lot because during that course of that program I learned a lot about nudges. How to approach the patient interview process and how to approach medication management, not every psychiatric problem deserves appeal. There are other ways to look at things. Sometimes psychotherapy is the first line of treatment if the symptoms are not too serious. 

So, I learned all of these in my psychiatric program and I believe it made me a better clinician. And I’m very happy that I returned to school to do that. Psych is where my passion is. I don’t see myself doing anything else besides psych and I’ve been doing it now close to six years. I love it. At the end of the day, my goal is to ensure that patients can live life the way they want to and they are happy, they are safe. They are not limited by psychiatric diagnosis because they are human beings first. So, that’s my route. 

Ken: Wow, okay. So, in your day to day practice now, are you mostly doing medication management? Do you do any therapy? How do you spend most of your clinical time?

Jackline: Wow, that’s a great question. I actually do mostly medication management, but there are times where I can see a patient that I believe would benefit from psychotherapy immediately and if we do not have a counselor who is ready to take on this patient, I will have the staff put that patient on my schedule for counseling services pending an opening with a counselor because I try to not manage both. I try to only do one because I don’t like to treat somebody and then see them again over and over because the psychotherapy sessions are sometimes weekly depending on how serious the patient’s case is. 

I try to not see many. I currently have just one patient that I provide psychotherapy for, a pediatric patient, he’s about maybe 14 years old. On top of that, even when I’m doing medication management, all my sessions, I try to incorporate some supportive psychotherapy, like supportive counseling, psycho-education. I use CBT sometimes briefly, as needed, depending on the patient’s case. 

Ken: Okay. And what’s your typical mix of diagnosis in the patient population that you’re seeing?

Jackline: Great question. Most patients that I see so far are from depression, and anxiety, sleep disorders, attention deficit. I have maybe about three or four schizophrenic patients. I’ll say about 25 percent of my patients population are bipolar disorder, bipolar depression one or two. I have a mixture of insomnia. I have about maybe 0.1 percent schizophrenia. About 45 to 50 percent would be major depression, anxiety disorders, PTSD, and I have a few OCD anxiety disorders, a few of my patients fall in that category. And then some with severe OCD, agoraphobia, panic attacks. 

Ken: Your practice represents… it sounds like the entire psychiatric population. 

Jackline: Yes. I’m actually the only full-time clinician providing psychiatric services. I work in a community health center where we have primary care, dental, physiotherapy, so most of the primary care clinicians refer patients to me. Patients come also from outside referrals. When patients come to for primary care, I try to keep them for at least a year and once they are stable on their medications I try to discharge them back to primary care so that I can take on new patients. 

Ken: Sure. Will they take them back?

Jackline: Oh, yes they do. They do, especially if they work for my company, they can always collaborate with me in-house if they have questions. I can always assist them as needed. 

Ken: All right, that makes sense. So, under the terms of your current licensure, do you collaborate with anybody or are you hundred percent independent, how does that work for you?

Jackline: Well, that’s a very good question. I’m in the state of New York. In New York NPs can practice independently when they have worked for I believe 3600 hours. Proud to come into New York, I had already worked for more than that. So I could practice independently. But my current employer is an FQHC, I don’t know if you’re familiar with that term?

Ken: No. Tell us.

Jackline: Okay. An FQHC is a federally qualified health center. They are like the non-profit organizations that provide healthcare services to people whether or not they have insurance. They have what they call a slide-in skill fee, where you might not have insurance and you just let them know what you are making yearly, and sometimes you could see me and only pay like five bucks because they get funding from the federal government to make sure they can keep up with that. So, the majority of my patients have insurance. The majority of the patients I see have insurance. 

Ken: The patients you’re seeing, where the payment is coming from, does it affect your licensure at all?

Jackline: No, no, no it does not affect licensure. Yeah, to get back to your question, you asked me if I have supervision collaboration, yes. Because my company is a FQHC, it’s what I was trying to get to. They are required to have a collaborator. They don’t call it a supervisor they call it a collaborating physician. 

Ken: Hmm.

Jackline: So, I have a psychiatrist who works like once every so many months with us who is available to me if I do need him for any patient case. And then once in a while, we just meet and we talk about patient cases and all that.

Ken: I see.

Jackline: That’s just because of the type of practice I’m working at. Other than that, I could be working anywhere else and I would be independent. I currently do tele-psych on the side for other companies and I’m independent. I don’t have no collaboration. 

Ken: You can send any prescription, any controlled substance?

Jackline: Oh, yes. I can prescribe anything I want. In New York that’s one of the states NPs can prescribe from schedule, every scheduled drug that a physician prescribes, schedule 2 all the way through, yes. 

Ken: Okay.

Jackline: All you need is your DEA to be able to do that.

Ken: All right, but in other states it varies by controlled substance class or…? 

Jackline: It does. In Georgia which is one of the most restrictive states and I used to practice there, NPs are not practitioners. They need supervising physicians. So, in the state of Georgia I could not send a controlled substance to the pharmacy, like a schedule 2. I could prescribe schedule 4, Lorazepam, Clonazepam, and all of that but I could not prescribe schedule 2. Their supervising physician has to do that in the state of Georgia. It varies where you practice. And nurse practitioners have to be aware of the laws. The state practice laws govern each state that you practice in. If you are in Arizona, you need to be aware of the state board of nursing actions and rules there. Arizona is one of the states that is independent practice. NPs in Arizona can do anything a physician does because they have independent autonomous practice for APRNs. They are about 24 or 25 closed states in the nation, so half of the county right now already allows NPs to practice independently. 

There are a few exceptions. I think California just passed a law maybe last month giving independent practice to APRNs in California. But some of those states have stipulations. I think California is maybe you have been practicing as an NP for maybe two years or something and in New York you have to have 3600 hours, but there are other states that do not have any hour requirements. You can just become an autonomous NP right out of school and practice independently, like Arizona, Washington State, there are so many states like that. 

Ken: Okay. And can you just clarify the difference between psychiatric nurse practitioner and then AEPR; I think there are a couple of abbreviations like that. 

Jackline: Yes, let me clarify. That’s a good point, Ken. APRN stands for advanced practice registered nurse. This refers to a registered nurse who has gone to school to obtain like a masters or a doctorate degree in either family practice, pediatric nurse practitioner, or psychiatry. What are you, a psychiatric nurse practitioner, a family nurse practitioner, a nurse midwife, clinical nurse specialist? You are considered an APRN. So, FNP is for family nurse practitioner. If you are certified you can use C at the end for certified or BC for board certified. And that depends on the kind of board that you took. There are two boards that certify NPs for family nurse practitioner rules and all this. You have the American Nurses ANCC, credentialing censor. The American Nurses Credentialing Censor certifies all NPs in addition to the psychiatric mental health nurse practitioner. That is the only organization that certifies psychiatric NPs.  

And then you have the AANP which I believe is the largest that certifies family nurse practitioners, pediatric nurse practitioners, ontology, all the nurse practitioners, acute care nurse practitioners and all that. So, the credential that an NP will use will be FNP, ANP for adorned nurse practitioner, or pediatric nurse practitioner, emergency nurse practitioner. It depends on their education as well as the board certification that they studied for.

Ken: I see. So, your ability to practice independently or not necessarily based on your degree but the state decides based on the combination of your degree and your hours, am I getting that right?

Jackline: Technically, yes and no. Let me clarify. Your ability to practice independently depends on the state in which you practice. Your ability to practice independently as an NP solely depends on the state. You could be living in New York, your license in New York. You decide that, hey, I don’t want to do this collaboration thing with supervising physician thing. You just go and get a license in Arizona. And work in Arizona but you live in New York, do tele-psychiatry for example. You get to practice independently in the state of Arizona but you live in New York but your patient population will be in Arizona. 

Ken: Interesting. 

Jackline: So, that is a way to get around it if you really, really want to practice independently but then you live in a state that is restrictive. Just get a license in another state. You don’t even have to drive there, you do it online. You apply, they issue the certification and the license and you just look for a job in that state or you open a practice in that state. 

Ken: Interesting. Okay, so what’s your take on independent practice regardless of degree or what the state governments, at what point do you think nurse practitioners should be supervised or consulting and at what point do you think they’re okay to transition over into independent practice? 

Jackline: That’s a great question, one that is hardly debated around the nation online, on radio, everywhere in both NPs and physician communities. This is a hot topic. So, as an NP I’m going to give you my view on that both as a clinician and also as an NP. When I got out of school, I’m going to use my own experience to be able to answer this question. When I graduated my NP program as a family nurse practitioner, I was not trained, I did not do residency in psychiatry like how psychiatrists would do just fully loaded psychiatry. No, I did not. In NP programs you can pick a specialty, when I was in the FNP program, family nurse practitioner program, you can pick a specialty and do 40 hours in that specialty.  I don’t even remember what I chose. I don’t remember if I chose orthopedics or psychiatry. I cannot recall it’s been so long. 

When I got out of school and I got that job, I was very excited and I was also afraid. I was like, okay, it’s all good. When they hire you, they tell you, you’re going to have support. No, sometimes it’s just not true, it’s BS. Sometimes it’s not true. They tell you all these things that you’re going to have support when you need it. You get there and you get no support. In instances like that I do not support autonomous practice for NPs. The NP education is not uniformed across state lines where there’s this requirement that you have to be a registered nurse for like three years or four years before you go to NP school. Right now, you have nurse practitioners, I’m sorry to say this but it’s true. You have registered nurses who just graduated the registered nurse program in May and are studying a nurse practitioner in August. That is not safe. That is not someone that I would advise, to graduate and just run off to start diagnosing and treating patients. But there’s a difference, if you have a registered nurse who has worked for like three to four years, or five years as a registered nurse in the setting that he or she becomes an NP. Say, you’re a psyche NP and proud to go into psyche NP school. You’ve worked in inpatient psychiatry, outpatient psychiatry. You’ve dealt with pediatric, geriatric, or adult patients and then you go to NP school and ultimately become certified and licensed. I see where you could be living in a state that provides autonomous practice for NPs and you want to go into practice and practice as an autonomous NP because you have some background into the field that you are going into. 

So, I support autonomous practice in that regard for nurses that have experience. Proud to go into NP school in the field in which they are pursuing an NP certification. Say, if you’re a family nurse practitioner, the patients would better sit if you had worked in oncology or med-search where you have all the patients. In med-search you see everything. If you did rotations med-search flow you have everything. You have from stroke, respiratory COPD, GI, all of that. If you did that for three to four years and you went to NP school and did rotations. You had some good preceptors that educated you and taught you to bring you up to the provider standard. I could see you getting out of school and practicing with minimal support. 

For independent practice as a whole, if the NP program could have a set standard for all the schools. It’s going to be very difficult because this is something that I think a lot of people would wish that existed that the standards are the same no matter what school you go to. If the standards were the same where before somebody could even think of applying to an NP school, this person has worked as a registered nurse for at least two to three years. The first year you are basically learning, the second year you are implementing what you’ve learnt, the third year, you are becoming your own where you can do rounds, you can teach and mentor other people. 

So, if our programs could be standardized like that then I could see where NPs could become independent right out of school. But as long as they are not, I believe that some NPs need to have that supervision and collaboration when they are just starting out before branching out to become autonomous NPs, even if they live in independent practice states. 

Ken: So, what would you say to psychiatrists who are ambivalent or opposed to it?

Jackline: Well, I would say this. First of all, I have very good friends that are psychiatrists. I have very good friends that have worked with me and that would trust me to care for patients in their absence and they did trust me to do that. I have psychiatrists that are friends of mine that trusted me to be able to provide not just safe and effective healthcare to their patients in their absence, that’s evidence based, not what I learned on the street, what I learned in the books, in the groups and things. Clinical rotations and reading the guide and mentorship that I got along the way. So, psychiatrists should be open minded and give NPs a chance. For them to just say, “No, their education is not equal to ours.” I don’t believe that’s a healthy conversation to be had because they are both different tracks. The NP education and the MD their routes are two different routes. Even though when we get to the clinical setting psych NPs and family NPs do basically the same things that psychiatrists do and family doctors do. The training is different because from a nursing standpoint, ours is a nursing model. The MDs is a medical model. 

So, they need to just understand that is a different track and most RNs that become NPs that I know, did not just get out of high school or college and just say they want to become NPs. They’ve worked in many settings many times before somebody becomes an NP. Those that are friends of mine they’ve done clinical care, ICU, ER, and then they end up becoming an ICU nurse practitioner. They’ve been there and done that so they know what that role entails. It would be good for psychiatrists if they meet an NP that they try to at least understand their educational background first before just putting everybody in the same basket. It’s good to maybe talk to that nurse practitioner and try to get an overview of their education and training before casting doubt as to the clinical ability, because you’d be amazed if you talk to some NPs. They are good. Nurse practitioners are very good. 

They are thorough, and we provide care that is nurturing. Nurses nurture people, you know. Patients like to see me, I’m going to speak for myself, because they tell me that, “When I come to you, I just want to stay here because I feel so good.” Like, yes, because I don’t look at a patient like an obstacle. I look at patients like they need a little bit of help to live life that will lead them to a better path. A lot of this is education. Nurses are good at educating patients about the reasoning. I do not make any decision without telling the patient the reasoning for that decision. And sometimes they are bound to disagree with me. But I try to involve them in that. I don’t say, “No, this is Prozac, go pick it up.” No. I tell you that okay, you got depression. Maybe it’s not. I believe that we should maybe pursue therapy first. Give it a couple of months, just follow up with me, and then if it’s not getting better then we can talk about meds. And then we will get to that. I don’t just say okay, we’re going to start Prozac. No. I tell you there are choices. This is the first line. This is the second line. Okay. I go through side effects profile based on each patient. You know, pick like two of three meds and then educate them and ask them, “Which would you like to try based on all these things that I have told you about this medication?” 

Tell me what symptom are you finding the most? What is most distressing to you? And that’s how I inform them. And by that, they are able to tell me, okay, because you said A, B, C would help me, let’s try that first. So, psychiatrists should be open and speak to NPs and not put everybody in the same basket because there are NPs that are very knowledgeable, that are passionate about the care they provide, and when we hear that, “Oh, NPs cannot practice independently” it sucks. It sucks. There are so many patients that need help. And there’s a huge shortage of psychiatrists around the country in many communities. Some patients wait six months to get seen. That is just unacceptable in the United States. So, anything that can be done alleviate patient anxiety and stress and get the patient taken care of, we should be thinking about those things and open a broader conversation to educate. If you feel somebody is not up to par, educate them. Train them. 

Ken: Do you find the psychiatrists that you’ve worked with are open to what you’re thinking about here?

Jackline: Actually, that’s a very good question because when I interviewed for a job once, when I walked in, you know before you go in you send your resume, and they already looked at it and diced it, how they’re going to grill you during the interview process. When I walk in, and I had interviews with everybody, the Medical director, the HR staff, now they took me to the psychiatrist who was going to be the ultimate decider on whether I get that job or not. When I walk in his room with my resume in his hand, he was like, “Welcome Dr. Ngalame.” I was taken aback. I’m like, “Oh my God, really?” Okay. “Have a seat.” I sat. And we chatted and joked He was like, “Your resume is very impressive, you know. I like what I see. So, why don’t you tell me.” I mean, we just chatted like we were colleagues. That was refreshing. 

Not every psychiatrist is like that. Not all of them. So, like I said, not every nurse practitioner is not good. There are very good ones. Just like there are very good psychiatrists who understand and respect what NPs bring to the field. I mean, I had a very good relationship with the psychiatrist because just the very first meeting I was like, “Okay, this is unheard of.” Because of what you hear, the chatter you hear online about groups fighting each other. No, it’s not healthy. A workplace, there’s got to be some professionalism, open communication, and collaboration is not a bad thing. Collaboration is actually very healthy and very good. Even physicians collaborate among themselves. Yeah. Collaboration is not just among practitioners, it’s a two-way street. Because I’m qualified in both family practice and psychiatry, I have physician friends of mine call me when they have complex patients diabetics, dialysis, they call me to get my knowledge on how they should approach the case. So, collaboration is not a bad thing. It’s actually a good thing. NPs can collaborate with psychiatrist. And the reverse is true. 

Ken: Um hmm. Yeah. You all have something to offer each other in that context. That’s a nice way to put it. 

Jackline: Definitely. What is your take on that?    

Ken: Collaboration is what’s best for patients and clients, and it’s a really complex system for them. I think I can understand arguments on both sides of the equation. But ultimately, that’s where we’re at today. And could the system be better in general? Yes. That’s probably a conversation for another podcast. But for where we’re at today, working together is in the patient’s best interest. 

Jackline: That’s true. I agree. 

Ken: So, I’m curious about your thoughts for new grads. Nurse practitioners finishing up their training and thinking about what pathway they should be pursuing. How would you help them think through that process?

Jackline: Wow, excellent question, Ken. Actually, if you are a student NP that is in school about to graduate, I’m hoping that before you went to NP school you had some experience in the track that you are pursuing, be it family nurse practitioner, psychiatric nurse practitioner, pediatric nurse practitioner, or what have you. Your decision as to how you are going to get into the field of the role of a clinician very much depends on your background that you bring to the field. It very much has to do with it. For me, like I said, I took a job in psychiatry because I knew that I had worked in psychiatry as a registered nurse for so long. I was familiar with the medications. I knew what to look for, safety issues in the setting and all of that. So, a nurse practitioner getting out of school should evaluate all those things. 

I recommend NPs not just getting out of school, even though I’m for autonomous practice, I am not for autonomous practice right out of school. I am for NPs getting out of school, get experience. Try to get a job where you are going to be trained by psychiatrists or psychiatric nurse practitioners, or family nurse practitioners depending on your clinical role. Getting mentorship is very important when you get out of school.

Ken: What should they be asking psychiatrists or the clinic director about supervision? I’m just thinking about your experience in Georgia.

Jackline: Yes.

Ken: It was supervision in name only. 

Jackline: Yeah, in name only. And it’s like that in many cases. I’m not an exception. I’m telling you, I hear from NPs all around the country that complains that they have to be paying this money for supervision, especially those that have private practices of their own. But then the physician is only available by phone when needed. It’s not like he’s there going through every patient case till you’re done, no issues with that, no. They just go to the computer and sign ten percent of your charts. That is not healthy supervision or collaboration. 

So, if I were interviewing for an NP position as a new graduate, I would be asking, what support is available to me? Is the support going to be here or phone the person? How often can I get this support? I will be asking the employer, are you going to be incorporating time into my schedule where I can meet, say maybe weekly with this collaborating physician if that’s the case? So that we can review cases, talk about things. I’ll also advise NPs that ask employers about – support is number one. That practice support is very important. Clinical support where you have a case or I don’t know what to do, can this person just meet? Creating time, because when you create time and you do case presentation with your collaborator. It also opens your mind to all the things you maybe neglecting, right. 

You see your own view. Like, there are times where I meet with my collaborating physician and we’ll be discussing a case, and I’ll say, “This is what I think. What do you think about it?” And he would talk to me and say, “You know, yeah, but if the patient is doing this, you just say this is the policy. This is for their own good.” For example, case in point, I had a patient for example, who had a long history of opioid use, right? And this patient the history is not like a one or two year thing, it’s a history of opioid use disorder that has gone over maybe 15 to 20 years. And this patient was on pain medication and because I do prescribe the Buprenorphine, Suboxone, for opioid use disorder. He found out that I can prescribe that so he wanted to come off his pain medicines so that I could prescribe the Buprenorphine immediately. I said no, there’s a process. I said, it’s for your own good. There’s a process. I can’t just say, this is a script for the Buprenorphine, too many grams of Lingual, no we can’t do it that way. I said, given that you’ve been on this thing as chronic use, I need you to be inpatient for detox first. 

You’re going to first make up your mind if that’s what you want to do. Discuss this with your pain management physician, right, and let him let you know how to proceed. I believe the right course is going inpatient for detox first. Because inpatient you’re going to be morning taught and if there’s any issues they’re going to stabilize you before they discharge you to the out-patient setting. And they’re going to be prescribing the Buprenorphine in there before you are discharged. I said, that’s a safe course. No, he wanted it immediately. I said no. So, I had this discussion with my collaborating physician, I said, even though he doesn’t prescribe the Buprenorphine, because see that’s the thing, I have a collaborator who doesn’t prescribe the Buprenorphine, right. So, I’m telling him my case. He’s like, “No, you are right. Yeah, this is the process. The patient has to understand safety is number one.” I said yeah, yeah, yeah. So, you see my beef with collaboration and supervision? 

Ken: Ironic there. Right. Okay. So, in terms of thinking through being an employee versus a contractor or just having your own private practice, what would you advise for that? 

Jackline: Well, you know, every patient’s scenario is different and people have unique needs in what they are looking for in a job. Like, if you are just getting out of school, I recommend being an employee first. Being an employee first you’re going to learn a lot if you have support in the practice. You’re going to learn a lot not just about yourself, but your clinical priorities. You’re going to learn a lot about your clinical ability, ability to talk to patients. Because when you’re in clinical rotations, for us it’s just like a mock exam. You’re practicing. When you get out into the real world, it’s different. Somebody can be presenting as normal, within 10 minutes its chaos. So, psych is unpredictable. I’ll tell my answer to anybody that consider being an employee first. Be an employee first for at least a couple of years. And then if you want to venture on your own, at least you’ve learned something. Get a mentor and then see what role fits you. If you want benefits, then you want to be an employee, if you need benefits, medical health insurance, paid time off, and all that. 

Ken: What’s the best way to get a mentor do you think?

Jackline: Hmm, mentorship, for me I believe, connections you make. It’s easier to connect on a professional level with those that you’ve known either through your education, your clinical rotations, or your years as a nurse, right? So, that’s why it’s very important for registered nurses to work first before they pursue an advanced degree as nurse practitioners because it allows you to create connections. You don’t make connections sitting at home or in the classroom. You cannot be a career student and create connections like that. They’re going to be just students like you. With all of you at the same level nobody can mentor the other one. You need to network with those that are in the field and those that taught you, to be able to get good mentorship. 

Ken: That’s a really nice way. So you’re really not just building your clinical expertise. You’re building your community and your ability to be a part of something that’s bigger than you are and absorb the knowledge from that.    

Jackline: Definitely. And you can also do that by volunteering. I used to volunteer for a non-profit that provided services to those that do not have insurance in the state of Georgia. Just volunteering once a week, so on Tuesdays, I just go give like two or three hours of my time seeing patients for free. In that environment, you never work with physicians that are retired, NPs that are retired. But that come under the same thing and that’s a source you can’t create. You connect like that and that’s how I’ve been able to meet most of my mentors. Through either volunteer work or my training, or like the psychiatrist I used in Georgia for my collaborating physician when I was in the state of Georgia is a good friend today. He’s a good mentor. I call him. He calls me and we talk about cases most times. You cannot create mentors in a classroom if you’re a clinician. You need to create them across the board. 

Ken: Okay. One more question. So, let’s say you’ve been employed for a few years and you’re thinking about private practice, it makes sense what you’re saying, the benefits and things like that. But, let’s say that weren’t an issue and you’re just debating being out on your own versus being in a clinic as an employee. What do you think are some of the pros and cons of just finally being out on your own and in private practice?

Jackline: Hmm. I’ll start with the pros first. The pros are that you’re going to be your own boss, which a lot of people want to be their own bosses. You’re going to be the practice owner. Thankfully your dream is realized, right?

Ken: Yeah. 

Jackline: It’s no longer a dream. It has definitely come through. And you’re going to be able be responsible for the income, expense, you’re going to be managing employees if you do have employees and all of that.

Ken: Right.

Jackline: So, it’s a big responsibility. It’s not easy because some nights you will not sleep. It’s a very, very big responsibility. 

Ken: Right.

Jackline: Yeah, it’s a very, very big responsibility, right.

Ken: Yeah. Right.

Jackline: The cons, the cons of being self employed and owning your own practice is that every decision you make, be it vacation or what, you’re going to be thinking, okay, who is going to cover for me?

Ken: Um hmm, right.

Jackline: Because you cannot just take a one month and disappear and leave your patients hanging. You want to be able to have coverage for these patients, or maybe you’re just to hand out scripts, so that they’re not without medication and don’t get paid. If you were there, you’ll be seeing these patients, right. Are you going to bring in somebody to cover in your absence? So, you cannot, versus if you’re an employee, you just put your request for time off, that’s it. You don’t worry about who is going to cover. 

Ken: Right. 

Jackline: You just put in your request, “Hey, I’m going to France in three weeks or one month.” you just put it in. If you have your PTO, you get paid and you’re gone. You don’t worry about the management. The practice manager worries about that. You don’t worry about it. You just put in your PTO and you’re gone when you’re an employee. When you’re an owner, it doesn’t work like that. You’re going to be responsible to ensure that your patients are not without a clinician, without medications and all of that before you even go anywhere. And sometimes you might work late. If you are employed, you are 8 to 4. At 4 you are gone, right, in most cases. If you are owner, it doesn’t end when you’re finishing the last patients. Sometimes you go beyond the working hours you set for yourself. 

So there are pros and cons. It just depends on everybody’s situation. And you’re going to be thinking about your own benefits, maybe you want to set a retirement, right and you are self employed, you need some money for when you retire. You are not going to work forever, right. As an employee, your paycheck is guaranteed. As an owner, it is not, especially when you are beginning, right, you’re just trying to build up your shelf volume. So, there are some hard choices to be made, money to be saved, right. And if you have employees, you’re going to pay them whether or not you see one patient. So, those are some conversations that you have to have with yourself and plan so that you do not fail.

Ken: Well, it’s a lot to think about and similar for a psychiatrist starting out, as we’re building up our practice. And sometimes when I work with new grads, I recommend they do part time employees, so they have the solid foundation and then they can slowly build up their practice over time with the patient population they want to work with and without feeling the stress and the pressure of having to take on private practice all at once. It can be overwhelming.

Jackline: Yes. That’s true. And that’s a good point you made, because that’s one advice I give most people, I said that they are my colleagues, I said, if you want to practice, don’t quit your job. Don’t. If you work five days a week, if you can go down to five times and have maybe two or three days in your schedule, do that. You put those two or three days in your private practice and you work where you get some money coming in, and maybe sometimes in the beginning, you might have to put more time in your practice by maybe working weekends even if you didn’t want to do that. Maybe that’s when you can see patients on a Sunday, right. I tell colleagues of mine, if you live in, say, New York, don’t open a practice in New York. Open a practice in Arizona. They are three hours behind. Three hours behind in Arizona, you can get off work in New York and it’s only 1 o’clock there. You can go see.

Ken: The after work crowd in Arizona and have your schedule aligned.

Jackline: Um hmm, yes, yes and you go home, you start working, you see patients in Arizona and you’re like 2-6, in Arizona, its only 3pm. So, think about ways like that. Be creative. And with technology today, you can do that, because there’s teleside. You don’t even have to leave your house, right, so there’s a lot.

Ken: Oh, that’s great, Jackline. All right, well, we have covered the whole gamut here and I appreciate, Jackline, you coming on and giving us a lot to think about. This has been a learning experience for me, so I hope to be able to hear how your practice is going over time, and come back and visit us soon and we’ll see how things are playing out in the world. But I think you’ve brought a lot to the table here and a lot for listeners to think about, so I hope it stimulates some good conversation amongst our listeners.

Jackline: Definitely my hope.

Ken: Yeah.

Jackline: I hope it does that, definitely, Ken. And thank you for inviting me. I look forward to coming on as more chance as you want me to.

Ken: That sounds great. All right, thanks Jackline. Take care.

Jackline: You too. Bye bye.Ken: Bye bye.


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