Well the way APPs are being used, at least in psychiatry, is clearly unsustainable. I blame it on our complete failure to be able to operationalize our clinical functions and the willingness of some providers to practice in a facile way and live down to the description of 'prescriber'. If people are going to practice in a way that does not draw on neuroscience, therapy skills, social and cultural formulation, the capacity for dynamic interpretation, etc., then we are allowing psychiatry to be a fairly replaceable specialty and we can't expect to make 3x as much as people who do a similar job for very long. On the other hand if we do a better job of making it clear why there is great complexity in what we do it will either force APPs to pursue additional training (in which case I am fine with them making the same salary) or for them to be situated in less complex roles (in which case they can't be used to replace the physician workforce). But I don't see it going this way as there are too many psychiatrists who want to see 12 inpatients in 3 hours and then are surprised that people think that what they are doing isn't very complicated.