RN exposes deficiencies in NP education – and the growth of the NP ‘cash’ practice

In our last episode we discussed the rapid growth of nurse practitioner training programs and some of the challenges this has caused in ensuring that nurse practitioner graduates receive adequate clinical training to care for patients. Today we continue to explore concerns about nurse practitioner quality of education, as well as a new trend for nurse practitioners to seek work in cash-pay type practices, including opening medi-spas, infusion centers, medical marijuana clinics, and so on.

To help us explore these issues, we are joined again by Rayne Thoman, a registered nurse and former NP student who works to expose unethical nurse practitioner training and practice. 

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Transcript

RN exposes deficiencies in NP education – and the growth of the NP ‘cash’ practice 

Rebekah Bernard MD 0:02

Welcome to “Patients at Risk,” a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I’m Dr. Rebekah Bernard, and I am joined by my co-host and the co-author of our book “patients at risk, the rise of the nurse practitioner and physician assistant in health care,” Dr Niran Al-Agba.

Niran Al-Agba MD 0:22

Good evening

Rebekah Bernard MD 0:24

In our last episode we discussed the rapid growth of nurse practitioner training programs and some of the challenges this has caused in ensuring that nurse practitioner graduates receive adequate clinical training to care for patients. Today we will continue to explore concerns about nurse practitioner quality of education, as well as a new trend for nurse practitioners to seek work in cash-pay type practices, including opening medi-spas, infusion centers, medical marijuana clinics, and so on.

To help us explore these issues, we are joined again by Rayne Thoman, a registered nurse who works to expose unethical nurse practitioner training and practice. Rayne, thank you so much for joining us!

Rayne Thoman RN 1:09

Thank you.

Rebekah Bernard MD 1:11

Rayne, over the last few months, you have working to shed light on deficiencies in nurse practitioner training by posting on social media. Can you tell us why you are on this mission?

Rayne Thoman RN 1:23

Well, there’s a lot of denial I think [that] this is happening and it’s also a major patient safety. And if people don’t know this is happening, how can they protect themselves?

Rebekah Bernard MD 1:33

You’re exactly right. And you’re right that people don’t always believe it and so that’s why we have to show them proof with their own two eyes. And that’s exactly what you’ve been doing. And so for today’s discussion what I’d like us to do is look at some of these posts, discuss them, and try to get to the bottom of why we’re seeing this. And you actually categorize what you’re seeing into nine separate categories: educational confession/school reviews - which we talked a little bit about in our last podcast, preceptors - or lack thereof - which also we did cover in our last section. So let’s go to the next category which you call “clinical questions.” The idea of these posts is to show the public the type of questions that nurse practitioners are asking in online forums, and really sheds light on educational quality concerns. So much, in fact, as we mentioned, that the AANP has asked NPs and NP students NOT to post on social media. 

But they are still doing this, and we have loads of examples to look at together.

Rayne Thoman RN 02:37

Well, it’s become a culture at this point too, it’s become normal and I don’t think people understand that this is not normal this is not acceptable 

Rebekah Bernard MD 02:46

And one of the things that I like that you do Rayne, is that a lot of times you’ll post the question and then you’ll also include a confirmation that the person that’s posting it is actually a nurse practitioner or an NP student. Usually, you’ll have a picture of them holding their diploma or something. Because one of the accusations is that these aren’t real nurse practitioners or real students  - these are just trolls and are making it up to make NPs look bad…

Rayne Thoman RN 03:13

[That they’re] fake…or doctors are going to the groups… no, these are real people – these are licensed, real people. they’re not doctors pretending – that’s how this started – like, here’s the evidence. This is all unfortunately very true.

Rebekah Bernard MD 03:28

So, one of the posts that we have here that we’ll put up is: ‘Hi! Does anyone have a good chart or research for blood pressure meds? Specifically when to use each drug-like are calcium channel blockers better for this condition etc. Thanks in advance - my pharm class was kind of a bust.’ And a response from one person was ‘well, I just googled hypertension algorithms the other day and found something.’

So, Hypertension is kind of a core primary care bread and butter. So, if they’re having trouble learning about managing hypertension - that sounds – that’s pretty scary.

4:02

And then there’s one: ‘Can you explain to me how to prescribe oral steroids? I am brand new and I’m in allergy and rheumatology. So, a brand-new nurse practitioner working in two specialty fields - I don’t even know how that’s possible - and asking about using steroids which are very commonly used in both of those specialties. And saying, ‘tapering is confusing, and I feel nervous every time I prescribed outside of a Medrol dose pack.’ Well, I guess you should feel nervous because you don’t know what you’re doing! 

Niran Al-Agba MD 04:35

You know what I find fascinating? Steroid medications are probably one of the most dangerous medications to use without experience. And again, I’m a pediatrician, so we’re talking about for specific uses - whether it’s an inflammatory condition or asthma - but again I see so many. I mean, I watched a kid died because someone gave them weekly steroids for a cough they had when they were laying down. And an anterior mediastinal mass got missed and she died. I was doing chest compressions on her literally and she died. And I’ve never forgotten it. It’s impacted me and how I practice for 20 to 25 years. And I’ll never forget when I’ve been talked about steroids over the years by mentors it’s like, you do not mess around with these. You think about infection because you could kill someone. You think about what you’re missing. It’s not just ‘they’re coughing - give them a Medrol pack.’ And so, sorry, that one really has triggered me a little bit just because I have watched children die from misuse of steroids 

Rebekah Bernard MD 05:33

When you see a cavalier discussion of a potentially life-threatening medication you do get upset 

Niran Al-Agba MD

I do I’m sorry 

Rebekah Bernard MD 05:40

No, I do too! And the problem as we’ve discussed before, if you’ve never really seen anything bad happen, you don’t even think about it. That’s one of the reasons why we spent all these yearrs and we see all these awful things that we need to confront so that were really careful and we really think through our decisions to whether or not a medication is truly appropriate. We have to weigh the risks and the benefits.

Ao as I mentioned a lot of times we get told, ‘well, these posts are just fake, nobody’s that uneducated coming out and practicing.’ Well, here’s some proof that Rayne posted. 

06:16

One of the things that she does is she find cases of board complaints against nurse practitioners. And she posted one recently in which a nurse practitioner prescribed a patient - the patient had hyperthyroidism - her thyroid was going too fast. 

And instead of treating it appropriately the nurse practitioner prescribed a thyroid replacement medicine. They actually gave them additional thyroid medicine on top of the fact that her thyroid was already going fast. and as it’s pointed out here is that they delayed care because they misinterpreted lab results and failed to recognize an incongruent patient presentation and made the wrong diagnosis. Something that we would consider a medicine -in primary care - really straightforward. Much less endocrinology. The difference between a thyroid that’s going too fast vs a thyroid that’s going to slow. And when you give medication and when maybe refer to someone else 

Niran Al-Agba MD 07:16

I’m sorry I’ve got to jump in, because my dad was an endocrinologist, and he would be having a literal heart attack right now simply because, you know, it’s not just a thyroid that’s too fast or too slow, right? There’s the pituitary gland, the hypothalamus, there’s all these higher level functioning and so a kid - I mean, I’ve had two children now with thyroid being off and a different child with growth hormone being off and of course before we scan the head which is a standard very knowledgeable thing, both ended up with tumors in their brain.

so again it’s not even the thyroid! So, here we are just talking about this person who just the person had a thyroid problem you have to think about the other couple layers and places where there’s a problem but if you don’t learn these things you don’t even know

Rebekah Bernard MD 08:01

Right. Rayne works in psychiatry, so I know that you’re really passionate about the care for vulnerable patients with mental illness and psychiatric health problems and that’s one of the things that we’re seeing a lot of posts about because there’s a what they refer to as a mass exodus from family nurse practice which it has traditionally been the most common type of nurse practitioner and more are choosing to go into psychiatric and mental health nurse practice. Rayne, what’s your take on why so many nurse practitioners are seeking psychiatric certification? 

Rayne THoman RN 08:35

Well because the family nurse practitioners can’t find jobs. I even saw that in my program you know. And they don’t have any psych experience. and I think some of them genuinely do you know they do say well you know I’ve seen a lot of psych when I was working primary care there’s a need OK I can appreciate that but you still should probably work in psychiatry before you do it like nurse practitioner, it’s a foundation. Like, you’re supposed to have nursing experience and psychiatry is so specialized but these schools just let them in and they make a lot more money. That’s the other thing – there’s job security but now they’re oversaturating in the market 

Rebekah Bernard MD 09:09

Well, well that’s the things that that was on some of the posts that you shared where a lot of people are speculating that to go in to psych is a very well compensated field and in fact we’ll share the screenshot of this advertisement for YouTube video that’s promoting people to choose psychiatric and it says ‘get paid more than a doctor as a psych nurse practitioner’ so there’s definitely a push towards going into psychiatry because it’s more lucrative and because maybe there are more jobs in that market 

Rayne Thoman 9:44

They don’t even hide it 

Rebekah Bernard MD

And it’s really sad because then we know we some of the post that you shared from psych fields - it just it breaks my heart. Like, there was one that you shared that actually got the attention of a senator - a state senator out in Washington. Do you have that in front of you to share that information? If not, I can read it out 

Rayne Thoman RN 10:06

I know which one you are talking about. Yeah, because somebody tagged her in there. 

Rebekah Bernard MD 10:13

Yeah so this was a Yale graduate psychiatric mental health nurse practitioner and you linked to her that -there she is - and here’s what she said. “18-year-old female with depression starting at age 11. Suicide attempt at age 16. Reports anxiety and depression worsening since starting college. And then she goes on to describe what sounds like a manic episode and also says that the patient overdosed on lamotrigine that she- the nurse practitioner - prescribed at the first visit. So this is a high-risk patient and so the nurse practitioner says, ‘I have her down as rule out bipolar disorder. She was just discharged from the hospital yesterday. I plan to see her within the week. How would you proceed? I’m thinking lithium but I’m worried about her overdosing on it.’

I just don’t even know how know how to respond to something like that. This is a young woman who is already attempted suicide twice and to treat - she’s being treated by a psychiatric nurse practitioner who is asking how to treat her on Facebook. 

Rayne Thoman RN 11:18

From strangers

Niran Al-Agba 11:19

Also there’s this point, like, a medication is her problem - if we could just change the medication we can fix the problem. And I think it’s demonstrating a real misunderstanding of what the problem is and the layer upon layer of issues that are going on. There’s family stressors, there’s, you know, probably - again this isn’t my area of expertise - but probably some depression, probably some more long-term - what we call dysthymic - which is just a really low mood or low energy. I mean, there’s so many things I could say about this one paragraph and it’s not as simple as just put someone on lithium to fix it or bandaid the problem.

Rebekah Bernard MD 11:52

Not at all. And so what I love that happened here is Rayne really made an impact because someone else saw this and they wrote, ‘well, I looked up this person on her website and I found out that there’s no supervising physician for her. What’s going on?’ 

And Rayne says, ‘that’s because it’s an independent practice state. ‘ And so someone tagged the state senator and said, ‘this is why practicing medicine without a medical license is dangerous and if you do it, don’t even try to outsource it on Facebook.’ And so Patty Kuderer is her name - she wrote, ‘I read it and I’m engaged’ and she asked him to be contacted via her government email and says, ‘thanks for reaching out.’ So, Rayne, I think that this is the type of example that gets attention because it showing how egregious this type of treatment is and how dangerous it could be. And this could be your daughter your sister and your child if this is not good 

Rayne Thoman RN 12:48

And this somebody that graduated from Yale 

Rebekah Bernard MD 12:50

  Thank you. This is not a diploma mill

Rayne Thoman RN

And has four years of experience.

Rebekah Bernard MD 12:53

That’s a good point too.  

Rayne Thoman RN

That’s why I say, this is very real.  I’ve had comments that say, ‘oh you’re putting someone’s name,’ but we are all licensed - that’s all public information. It also makes it abundantly clear how real this is – these are real people 

Niran Al-Agba MD 13:10

Especially Washington where I’m at of course. And you know two of the cases that you’ve pointed out -  this one in Washington state and then of course Jay Baltz is also practicing telehealth in Washington state. And I did send Senator Kuderer a copy of her book and so to follow up on the work you’re doing Rayne as well. So I did send it off I think last week or probably within a couple days after you had done this and pointed this out. And again I just think this education is so important because we are very willy-nilly – Washington state is extremely underserved for psychiatric care. a lot of us have done different pilot projects to try to help expand it but it’s being flooded with these psychiatric nurse practitioners who are just kind of throwing medication at people 

Rayne Thoman RN 13:59

right and I think that you see a lot of child psych ones because they don’t have the preparation that.. I mean, a physician has to do – it’s a two year fellowship, right? It’s two years for child and adolescent psych, correct?

Rebekah Bernard MD 14:12

 well they do four years of psychiatry and then they have to do another 1-2 years extra of child

Niran Al-Agba MD 14:19

 And sometimes three depending on the program 

Rebekah Bernard MD

Minimum 5, 6, up to seven years after medical school - not 100 hours.

Rayne Thoman 14:28

 Exactly. And I’m told that some psychiatrists won’t even touch child and adolescent even though the do have the training in that four year residency.  and I actually looked up because they do like six months – it depends on the program – I looked it up because I was curious.  so they have more, psychiatrist, has more training than a psych NP and even they don’t want to do this.

Rebekah Bernard MD 14:52

That’s because they know it’s dangerous and there is liability.

Rrayne Thoman RN

Right, and they don’t want to harm anybody.

Rebekah Bernard

Exactly

Rayne Thoman RN

and so that’s why we have a child and adolescent psychiatrist 

Rebekah Bernard MD 15:02

Right. And so these are The types of cases that they’re seeing. Here’s some more: one nurse practitioner is talking about one of her patients as a 10-year-old boy who threatened to shoot students and teachers at his middle school. And says, ‘the father wants meds, what should I start him on?’ This is a potential columbine shooter we’re talking about.  I don’t want to make it sound overly dramatic, but this is a person who threatened to shoot someone at school. It could just be an idle threat, but you got someone saying, ‘what med should I start them on?’ and you’re asking Facebook?

Rayne Thoman RN 15:40

Well, he’s a danger to others

Niran Al-Agba MD 15:43

And again, this is unusual. so when you think of how many children actually threaten - again I know the media makes it seem very common - but when you have a child at this age threatening to shoot someone at school - that you need to take seriously. And that child needs help. They need a psychiatrist, they need to have a full work up to keep the public safe. I don’t know how else to say.  I mean, this is so frightening that this is going on and being ignored and someone’s asking Facebook how to treat them. 

Rebekah Bernard MD 16:12

And the same NP says, ‘12-year-old coming to the ER with signs and symptoms of depression cut her forearm the night before. boyfriend broke up with her. bullied at school new meds should I start low-dose Zoloft or fluoxetine? Peds is new to my practice. Any advice?

You have a young girl - a young person - who’s cutting herself and high risk for potential suicide or self harm and you’re asking Facebook what meds to start 

Niran Al-Agba MD 16:41

As if the meds are going to solve your problem. I just want to be really clear here . To be honest with you in my experience meds do not solve either of these problems I cannot emphasize enough how much a low-dose Zoloft or Prozac which is what the nurse practitioners is asking - I literally cannot emphasize enough that medication - either of them - will not solve the problem because neither of these cases are solvable with medication 

Rayne Thoman RN

They need  intense therapy

Niran Al-Agba

They need an intervention, they need support 

Rayne

They need more than Facebook 

Rebekah Bernard 17:13

It really is disservice and then you know we can just go on and on. I mean there’s another case it really a seven-year-old child with what sounds like posttraumatic stress possible sexual abuse with psychotic type features and the nurse pressures listing all these different psychiatric meds that they’ve tried and saying ‘any other thoughts on what I should do this is just not the way that we take care of patients 

And its not just children that are affected.  There’s someone else asking questions about how to medically manage a pregnant woman 

another one asking how to medically manage an 80-year-old with anxiety and insomnia and saying ‘can I start her on Xanax 1 mg at bedtime would that be OK that is like a mega high dose of a controlled substance a sleeping pill that could be enough to really make an 80-year-old not wake up again especially if you’re mixing it with a bunch of other things

 I just read these and my heart sinks when I see them. So that’s some of the things that Rayne has been keeping us up at night with. But it’s really important because we need to know that this is what’s happening. And let’s transition into another aspect of what we’re seeing online and that is the search for the cash-based practice or the nontraditional practice or the alternative medicine practice and we’re seeing a lot of that right Rayne?

Rayne Thoman RN 18:41

yeah I mean there’s groups devoted to you know, side hustles and nurse business and elite nurse practitioner groups. And they’re encouraging one other to do this, and to me, that’s more alarming than anything because OK, you’re always going to have people that want to act this way.  Physicians do these things, let’s be honest. They do. You guys don’t have groups. You kind of go rogue and go do whatever shady thing, right? you’re not all, you know, this is like - they’re teaching one another, they’re encouraging it, they’re teaching courses. This is not what health care is.

Rebekah Bernard MD 19:18

yeah I think the elite nurse practitioner group is one of the most interesting examples of this and you’ve shared quite a few posts from that group but just, I mean, it’s not secret to go onto ‘the elite nurse practitioner’ and their symbol has a dollar sign for the S and Nurse and the website says it has a mission of increasing the professional and personal freedoms of NP‘s across the country and this was founded by Justin Allan he is a family nurse practitioner with a masters degree in nursing and he talks in his blogs about how he really recommends that everyone have multiple jobs, multiple side hustles as you call it Rayne and he says for example that he’s been really resilient with Covid because he says “my telemedicine part is exploded in growth. my mental health practice continued it slow and steady growth, and my medical cannabis clinic remain the same. and so he’s doing all these different types of practices and so he’s creating a curriculum and for $3-400 per course you too can learn how to start your very own: telemedicine practice course, your men’s health, testosterone course ,you could take the stem cell and regenerative injection clinic course, medical cannabis, IV infusion clinic, and I think one that’s a fun one - The advanced clinical peptide treatment course so they’re all these different complementary types of practice that he is advocating and one of the things that he says in his blogs – the reason that he advises this is he says these are cash-based practices so you are able to actually make a lot of money and you don’t have to worry about billing Medicare because Medicare doesn’t cover these kinds of services anyways. And he has a book and of course he sells his courses as well.  and so the Elite Nurse Practitioner is a really interesting place to see a lot of posts where nurse practitioners are discussing this back-and-forth and what you’re seeing a lot of is ‘what should I do?’ ‘ How can I make money?’  and one person says that ‘hey you know what you should do? You should look for a niche for patients are under served like LGBQT patients. You should look for patients that have mental health problems that you know - it’s cash-based practice and when I read this I get so sad because I really see disenfranchised patients, vulnerable patients that are potentially going to be victimized or at a minimum get ripped off for some of these treatments that are not necessarily evidence-based or necessarily safe or affective 

Niran Al-Agba 22:07

Well if I may add, I am reading I’m looking at where the elite nurse practitioner says ‘you know I require labs before every appointment – it’s my policy. you don’t want patients to question you, trust me, they’ll make your life hell. you have a policy just follow it. if they don’t like it they can go somewhere else . and then what’s even more fascinating is the Washington state medical board did a sweep of the state and every single physician at all doing any testosterone clinics growth hormone clinic things like that about vitality and health they removed the licenses of all of them 

Rebekah Bernard MD 22:44

wow 

Niran Al-Agba MD

And it expanded into Pennsylvania. I’ve done a lot of medical research on the medical board for other reasons, and it expanded into Pennsylvania. Because some of these doctors were working back and forth and collaborating they all now have a black mark on their record and have been pulled and yeah – theyre unable to practice. and yet it’s going on in Washington state right it’s going on because if you’re a nurse practitioner you can do these testosterone/ growth hormone clinics and nobody is going to oversee that or pull your license so to me that’s really been a frustration because some of these docs will tell you this is how I was doing it no one has died you know I was following this protocol this is the science behind it and what’s interesting is that if you’re a nurse practitioner you can just do it

Rebekah Bernard MD 23:22

wow yeah it worries me because number one a lot of what they’re doing is not evidence-based and it’s just really for making money and for two because we’ve been sold the nurse practitioner and physician assistant profession as one that was created to fill the gap of the supposed position shortage and to reach underserved patients and provide primary care and of course nobody these days is that interested in doing that kind of work because it’s really hard, because it requires a lot of dedication and studying, and because it’s not always as well compensated and there’s a lot of challenges with documentation and getting compensated for your work. so I get all that but the answer is not just pursuing these cash practices and letting nurse practitioner do them autonomously 

so some of the posts that I have here – there are just so many nurse practitioners that say that they want to go into aesthetics that’s the big thing don’t you see that a lot Rayne?

Rayne Thoman RN 24:18

 yeah I think I tweeted three of those today

Rebekah Bernard MD
   everybody wants to do that

Rayne Thoman RN

 I mean, who are all these women going to these med spas there’s one around the corner from me it’s a nurse practitioner she owns it. You see this, you’re not just seeing this on social media 

Rebekah Bernard MD 24:36

it’s everywhere it’s not just the aesthetics. so you’ve got your Botox and selling different products for cosmetic appearance but also what you’re seeing is people that are getting into areas like IV therapy and that’s something that I worry about a lot because they say, ‘you know, it’s no big deal, you just put an IV in somebody and give them this cocktail of vitamins and fluids,’ and you know anytime you do a medical intervention to someone there are risks involved. I have a patient that received a lot of antibiotic IV therapy for his Lyme disease- supposed Lyme disease chronic- and his veins are so scarred now that you can’t even draw blood on him because of all this IV antibiotic that went into him and so here’s a person that posted on the elite nurse practitioner group saying ‘I just finished the IV course and I was wondering if someone could help me with an IM question’ - that’s intramuscular – ‘we are not quite ready to start IV therapy but we want to offer some IM options while we get ready which ones would you get besides B complex?’ and someone wrote ‘well you can give glutathione – it’s supposed to given IV but you can give it IM, it just burns a little. she didn’t mention the dose  she uses but it can be done so I mean this is just talking about doing things that you really don’t even understand it’s really just a matter of you trying to make money and you don’t even necessarily know how to do it . I think it’s so dangerous and it’s so egregious on so many levels.

And then lots of people looking for IV hydration it’s a big thing and in fact what’s happening is some of these nurse practitioners are hiring nurses to run the clinic so you used to have physicians hiring nurse practitioners and now you have nurse practitioners hiring nurses and in fact, Rayne, you posted a board sanction of a nurse practitioner who owns a clinic called ‘the drip nurse’ in dripping Springs Texas and that nurse practitioner was accused of having a registered nurse administer intervenous and injectable nutritional and vitamin supplements without even really evaluating the patients so again just really being done for moneymaking and not being done really under supervision as it supposed to be

Rayne Thoman RN 26:58

I think it’s interesting to read these complaints and read some of their rebuttals to this, and I’m like, you really you said this to the board of nursing?  he said vitamins intravenous vitamins are an emerging industry and believes there’s no prescriptions required for intravenous and injectable vitamins because consumers may order over the counter and self administer. I mean 

Rebekah Bernard

it’s amazing 

He said this to them? like oh well people can go and buy over-the-counter vitamins and injectthemselves with them so this is OK. What? 

Rebekah Bernard MD 27:35

it makes no sense and this is a nurse practitioner who owns this clinic, and I like how you put a picture of him and you’ve got a screenshot from his website and it says thanks to Jonathan’s extensive experience he has experience in the following areas: sports therapy with Olympic and professional athletes. so somehow that gives them credentials that I guess you administer intravenous vitamin and therapies to patients

Rayne Thoman RN 28:01

Well he’s a chiropractor too

Rebekah Bernard MD

oh I didn’t even see that – oh, you’re right, he is!

Rayne Thoman RN

Was he even a registered nurse?  It says registered nurse nurse/ nurse practitioner for three years for a pain physician. I don’t know. You want to give somebody the benefit of the doubt  - maybe he didn’t know  because he didn’t have nursing experience?

Niran Al-Agba MD 28:29

 what was the complaint about?  Was it a patient who complained?

Rayne Thoman RN

 you know they don’t say who complained it could have been the register nurse because – this one didn’t – sometimes they do, but in Texas they don’t

Rebekah Bernard MD 28:48

Well the other thing you know although maybe intervenous vitamin know you don’t have a huge risk of harm but I’ll tell you something that does and that is testosterone therapy. we had Dr. Amy Townsend on discussing the case of Kevin Morgan, the nurse practitioner who lost his license after being accused of causing the deaths of two patients and harm to seven others by inappropriately prescribing testosterone and yet you’ve got people on these online forums talking about testosterone as if it’s an innocent and harmless product. people saying’ hey I have I need a little help I have a transgender patient that has been off of medicine and now wants to restart I’m unsure of the dosing because I have never done this before’ so of course they go on Facebook to ask on the elite nurse practitioner instead of doing some research and learning how to appropriately treat and so there’s another question about testosterone where they’re asking they’re more interested in knowing how do you charge for it and also for weight loss and  the elite nurse practitioner answers and says ‘well, I charge off of the duration that they purchase. If they come in for injection or want to do a home  supply then and they are on a monthly recurring payment then I charge them $129 a month if you want to buy 3 to 12 months in bulk then I disoucnt it. the highrollers buy the bulk deal most everyone else is mostly on the recurring payment. so I can’t imagine giving someone 12 months of testosterone bulk. that that would not be considered appropriate and as far as I know because you need a monitor testosterone levels so I would be pretty concerned about that but I’m looking at a lot of the financial benefit 

and then we’re also seeing questions about can you we open a medical marijuana dispensary and one of the big things and I’m seeing in my area is ketamine clinics which is an anesthetic medication that is being used now - it’s been approved to treat depression in some cases and these are popping up all over the place and the elite nurse practitioner says ‘yes this is a very lucrative practice  to start for a nurse practitioner’ and they recommend it, and someone says, ‘do you have to be a psychiatric nurse practitioner ?’ and someone says ‘no, you can be a family nurse practitioner, it is not outside of your scope” and ketamine in this case is being used – it’s an anesthetic, so you might have an anesthesiologist using it or in this case is for depression so it would be you think of psychiatric specialstis, A psychiatrist ideally but instead you have had all sorts of nurse practitioners including family nurse practitioners ordering them and treating patients with ketamine which is generally safe and well tolerated for the right patient but can have very serious and life-threatening side effects for some. 

31:39

and then I think it’s very interesting that he’s doing an advanced clinical peptide treatment course and Niran you kind of alluded to this this is like growth hormone and something that call like wellness hormones, and there’s just this slew of them

Niran Al-Agba MD 31:55

It’s this thing of vitality – you know, it’s this idea, let’s give you some performance enhancement, let’s add some testosterone, throw some growth hormone on there. and I loved that he said the best part about peptides it’s a cash it’s safe and provides significant results and the safe part I’m with Rayne on this one like I wonder who these people are that are paying so much money to get all these hormones and things that haven’t been proven and the fact that it flies under the radar of the medical board and the nursing board to me is is absolutely phenomenal and I think as more people die obviously it’s going to become more popular thing so I do think many cash practices have not been successful I do live in an underserved area and many of these - people have tried to do them and they haven’t done well so I’m with Rayne wondering like who has all this money to pay for these unproven treatment and how are these nurse practitioners generating this cash cow 

Rebekah Bernard MD 32:47

I think there are a lot of desperate people that are seaking to feel better and they’re looking for anything you know I had a patient that unfortunately didn’t do well he was severely depressed and he went to a wellness type center where they said ‘oh we think that you might have a parasite that’s why you’re not well we need to give you antiparasitic said we need to give you all the supplements and IV therapy and he actually did really poorly and had a very bad outcome after he sought that level of care instead of going towards a more appropriate medical care that  maybe would’ve helped him but he was looking for help he was looking for answers and I think I worry for patients that are being preyed upon this isn’t just about the vitality this is also patients that have serious medical problems or serious psychological problems and they’re just looking to feel better and they’ll do anything and they’ll pay any amount and we need to make sure that they’re not taking advantage of 

33:42

you know you mentioned about the boards taken coming down on this -  it’s starting to happen. Rayne posted a screenshot of someone asking ‘has anyone use amniotic fluid trigger point injections or joint injections?’ I mean I wouldn’t even imagine something like this and ‘ is there an issue with that?’ 

and then Rayne posted a board sanction of a nurse practitioner but I’ve been practicing for like one month I think and then performed an experimental procedure using human potential tissue that she injected into a patient’s lower back and in response to that she said that she thought it was OK because she gave other kind of trigger point injections so why not due amniotic fluid injection? and then another one doing something like that with a human umbilical stem cells so this is popping up everywhere the poor side of the boards are sanctioning it but I’m sure a lot of it is slipping under the radar 

Niran Al-Agba 34:43

until the boards are sanctioning we have Rayne to help keep us abreast of what’s going on because you’re like a one woman dynamo finding these cases

Rayne Thoman RN

people send me them! When I got on those message boards when I’m still in school I found other like-minded people and we would send them to each other like oh my god look at this – and other people send me them

Rebekah Bernard MD 35:14

Rayne, have you gotten a lot of pushback or had been bullied or mistreated because of speaking out?

Rayne Thoman 35:22

well it’s funny because the last one we just posted it – the amniotic fluid one was a while ago - but I remember somebody – it was a nures practitioner- jumped on there and was like, you’re exaggerating! Like, they didn’t really do that! Doctors inject amniotic fluid.

and you know yeah some people they’re not - yeah I get crazy messages sometimes. Somebody posted a abackground check that they paid for me a few weeks ago, that was lovely

Rebekah Bernard MD 35:49

 Niran and I get a lot of that too. We you been thoroughly investigated and vetted and fortunately we seem to have come out relatively unscathed. I think if you speak the truth people will look for ways to punish you for that and that’s why we try to hold ourselves as carefully as we can knowing that we all mess up, we’ve all made mistakes but we’re just trying the best that we can do ensure that patients get safe and effective treatment

Niran Al-Agba 36:14

And you deserve a lot of credit for that, Rayne. I mean I figure even if one patient across the country per day sees your post and sees what you’re exposing and what you’re trying to do I think you’re saving lives so honestly to me that’s really incredible 

Rayne Thoman RN

Hopefully

Niran Al-Agba MD

I don’t even think it’s hopefully I think it’s happening because I think it’s really important. no one saying don’t go see a nurse practitioner right no one saying don’t see a PA.  we don’t feel that way . what we’re saying is know who you’re seeing and know what their expertise is and I think you’re showing there’s this kind of loosey-goosey approach to this expertise and it’s not regulated and so you are saving lives in my opinion there’s no doubt 

Rebekah Bernard MD 36:56

 thank you so much for joining us again and thank you all for listening we encourage you to subscribe to our podcast where ever you listen to it’s called patient at risk and also if you are YouTube channel encourage you to get our book patient the rest of the rise of the nurse practitioners help you’re available at Amazon and Barnes & Noble and if your position and you’re interested in learning more about this visit us at physiciansforpatientprotection.org thank you Rayne Thoman so much for joining us

Niran

Rayne, you’re my hero. I’m dead serious 

Rebekah 

And we hope to have you back for more exciting discussions and interesting topic thanks so much we’ll see you next time.