Commentary

Physician assistants in psychiatry: Helping to meet America’s mental health needs

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Although the need for more mental health professionals—especially those who can prescribe—is well documented, PA practice in psychiatry has been underrepresented, with PAs choosing to work in the field at a rate just over one-fourth that of physicians. While there is no clear explanation for the lack of PAs in psychiatry, PA programs’ training model has been to produce generalist clinicians who can work in numerous settings, particularly primary care. However, during the past several decades, PA practice choice has shifted largely from primary care to specialty care. In 1974, an estimated 68.8% of PAs worked in primary care settings (family medicine/general practice, general internal medicine, and general pediatrics), while the remainder worked in specialty areas.11 In contrast, by 2018, only 25.8% of PAs worked in primary care settings.10 Despite more PAs choosing to work in medical specialties, the number choosing psychiatry remains very low. With the great need for well-trained mental health prescribers, the opportunity for growth in this area of medicine and increased salary incentive should serve as an impetus for PAs to consider psychiatry. Like their physician counterparts, PAs working in specialty areas of medicine tend to be paid more, sometimes substantially more.12

Training requirements

What is the level of training and experience for PAs who choose to work in psychiatry? Physician assistant program applicants generally come from a pre-med background with a Bachelor’s degree in a hard science, and often have medical experience as a nurse, paramedic, emergency medical technician, or other health profession. Physician assistants are trained in the same medical model of care as physicians, although their training is structured over an average 27-month cycle, with 1 year devoted to didactic education and 1 year or more devoted to clinical training.13 They are qualified to “go to work” soon after graduating and passing the NCCPA Physician Assistant National Certifying Examination (PANCE), and may require a state license. Upon graduation, PAs have received approximately 1,000 hours of didactic and 2,000 hours of clinical training across the general spectrum of medicine.

Physician assistants who choose to specialize in psychiatry may complete a residency/fellowship in psychiatry of approximately 1 year, and/or obtain the Certificate of Added Qualification (CAQ) in psychiatry from the NCCPA. Most PAs who work in psychiatry have done so through “on-the-job” training, where their knowledge and skills have expanded through working with their supervising physician(s) and gaining experience from their clinical practice and self-study. For many years, there were only 1 or 2 PA residency/fellowship opportunities in psychiatry in the United States for PAs wanting to acquire additional formal didactic and clinical knowledge and skills in psychiatry. Fortunately, there has been a growing number of PA residencies/fellowships in psychiatry. These programs are typically 1 year in length and can provide a PA who wants to specialize in psychiatry with an additional 300 to >500 didactic and 1,500 to 2,000 clinical hours of training in the assessment, diagnosis, and treatment of the spectrum of psychiatric conditions. Currently, there are 10 to 12 programs in the United States that offer this training to PAs, producing approximately 18 to 20 residency-trained psychiatric PAs each year. Almost one-half of PAs who are residency-trained in psychiatry are being trained in VA facilities and affiliated institutions sponsored by the VA Office of Academic Affiliations. Along with the PA’s basic education, the additional knowledge and skills acquired in residency prepare the PA to be a highly capable psychiatric clinician, with a combined 1,500 didactic and 4,000 clinical hours of training in general medicine plus psychiatry. The addition of the CAQ demonstrates the PA’s commitment to additional learning in psychiatry, as the added work experience requirements, the additional postgraduate continuing medical education requirements in psychiatry, and the psychiatry board exam clearly show dedication to a higher level of knowledge and skill in the specialty.

Because PAs have been trained as generalists who are able to work in any setting or specialty, they have a broad range of knowledge in medicine and surgery. This can be especially helpful when working in a psychiatric practice, where they can provide an added medical focus to patient care when needed. As more PAs are choosing to work in a specialty area for much or all of their practice, they are able to gain significant knowledge and skills in that specialty.

Getting more PAs into psychiatry

So what does the future hold for PAs in psychiatry? The increased need and opportunity in mental health will likely draw a higher percentage of PAs to this specialty. Hopefully, an increase in the number of PA psychiatry residencies or advanced mental health training opportunities, and the continued goal of obtaining the CAQ in psychiatry, will serve to increase the number of psychiatric PAs.14

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