Another Psych NP vs PA thread (please hear me out!)

[chicandtoughness]

Hello.... I come in peace...

Here's the scoop. I've been working for the past several years (5-6ish) as a mental health clinician. I'm halfway through a PsyD program in Clinical Psychology that I do intend to finish. I provide psychotherapy and all its adjuncts - case management, assessments, individual, groups, family therapy, multifamily therapy (oh yes), couples/marriage therapy, you name it I've done it. I've worked inpatient, RTC, PHP, IOP, outpatient. Suffice to say I have a pretty good career in mental health. At the same time, I'm kind of sick of being stuck doing psychotherapy as my main intervention.

Yes, I want to prescribe. (I'm not gonna hide it!) But I also want to understand the person from a physical/medical standpoint as well as a psychosocial standpoint. I would love to work in a highly acute setting, but I believe to do so effectively one really does need to understand some of the medical side.

I was premed for the past 2 years but after some reflection, I don't think being a psychiatrist is the right path for me. I love psychiatry, but I don't like any other part of the med school grind, and I think it will show. It doesn't seem fair to take up a spot when there are other people who genuinely want to be a physician first, and I don't. Also not worth it to do prereqs + med school + residency for 5-6 years (depending on if I have a pure IM intern year) to get to the actual psych part. (And I would need to finish my PsyD first, so hellooooo 44-year-old resident...)

So some other options I've been tossing around are PMHNP or PA with an eventual specialization in psych. I know the PA route will not have psych specializations during schooling, but 2.5-3 years of PA school seems like it would give me great training on the medical side without taking too long.

I'm not interested in independent practice!! I am 100% happy to work under supervision/collaboration with a psychiatrist. And as "ick" as the term may sound, I actually want to be a midlevel. I love constant collaboration with those both above and below my pay grade, and I don't really want to have the final say on the care team My ideal career would be part time PMHNP/PA (ideally inpatient) and part time private practice psychotherapy (using my psychologist license only) <3

Given I will have a PsyD after a few years, do you have a recommendation for PMHNP vs. PA? I've searched many of the other threads, but most of those posters usually have no training in psych. I do agree that going straight through the PMHNP route leaves much to be desired in terms of understanding psych on a deeper level, but I believe with my PsyD I will be equipped to handle the psychotherapy side well.

I know @medium rare is a psychologist/PMHNP, and I've PM'ed them directly, but I'd love to hear other folks' thoughts!

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[Nurse Practioner]

Hello.... I come in peace...

Here's the scoop. I've been working for the past several years (5-6ish) as a mental health clinician. I'm halfway through a PsyD program in Clinical Psychology that I do intend to finish. I provide psychotherapy and all its adjuncts - case management, assessments, individual, groups, family therapy, multifamily therapy (oh yes), couples/marriage therapy, you name it I've done it. I've worked inpatient, RTC, PHP, IOP, outpatient. Suffice to say I have a pretty good career in mental health. At the same time, I'm kind of sick of being stuck doing psychotherapy as my main intervention.

Yes, I want to prescribe. (I'm not gonna hide it!) But I also want to understand the person from a physical/medical standpoint as well as a psychosocial standpoint. I would love to work in a highly acute setting, but I believe to do so effectively one really does need to understand some of the medical side.

I was premed for the past 2 years but after some reflection, I don't think being a psychiatrist is the right path for me. I love psychiatry, but I don't like any other part of the med school grind, and I think it will show. It doesn't seem fair to take up a spot when there are other people who genuinely want to be a physician first, and I don't. Also not worth it to do prereqs + med school + residency for 5-6 years (depending on if I have a pure IM intern year) to get to the actual psych part. (And I would need to finish my PsyD first, so hellooooo 44-year-old resident...)

So some other options I've been tossing around are PMHNP or PA with an eventual specialization in psych. I know the PA route will not have psych specializations during schooling, but 2.5-3 years of PA school seems like it would give me great training on the medical side without taking too long.

I'm not interested in independent practice!! I am 100% happy to work under supervision/collaboration with a psychiatrist. My ideal career would be part time PMHNP/PA (ideally inpatient) and part time private practice psychotherapy (using my psychologist license only) <3

Given I will have a PsyD after a few years, do you have a recommendation for PMHNP vs. PA? I've searched many of the other threads, but most of those posters usually have no training in psych. I do agree that going straight through the PMHNP route leaves much to be desired in terms of understanding psych on a deeper level, but I believe with my PsyD I will be equipped to handle the psychotherapy side well.

I know @medium rare is a psychologist/PMHNP, and I've PM'ed them directly, but I'd love to hear other folks' thoughts!

As a Psychiatric NP, I started off first as a nurse then worked for 4years as a registered nurse before i went to NP school. To be a licensed NP, you have to have your RN license first before going to NP school. And while i was a nurse i worked inpatient and outpatient psych .So you need to start off first as an RN before going to NP school.

 

[chicandtoughness]

As a Psychiatric NP, I started off first as a nurse then worked for 4years as a registered nurse before i went to NP school. To be a licensed NP, you have to have your RN license first before going to NP school. And while i was a nurse i worked inpatient and outpatient psych .So you need to start off first as an RN before going to NP school.

Oops, would have been helpful if I included some of this info in my original post. I have my LPN from a past career, so I would probably do an accelerated BSN for the RN and then move into NP. I am not above working part time as an RN for a few years (the other half of the part time would still be psychotherapy, as I don't want those skills to go stale) before adding on the NP.

 

[deleted6669]

Speaking as a PA, I would recommend NP for psych. They own that market. If we were talking about surgery, I would say go PA.

 

[chicandtoughness]

Speaking as a PA, I would recommend NP for psych. They own that market. If we were talking about surgery, I would say go PA.

Interesting. By “own the market”, is this more of a “employers/insurance prefer them” or is it more of a “there is a shortage of psych PAs”?

 

[deleted480308]

Interesting. By “own the market”, is this more of a “employers/insurance prefer them” or is it more of a “there is a shortage of psych PAs”?

State legislators prefer them due to their more effective lobbying (they can bill independently in many places despite less training)

and no, you don’t need nursing experience prior. There are “direct entry” programs that you can apply to with a different bachelors than nursing and do it all in one shot with some extra semesters

 

[chicandtoughness]

State legislators prefer them due to their more effective lobbying (they can bill independently in many places despite less training)

Not going to lie, this makes me feel a little icky. Don't get me wrong, I have a lot of envy for nurses and social workers, both of who have encroached quite a bit on their respective fields in terms of autonomy. At the same time, it feels straight unethical to give someone equivalent practice as a physician when they are clearly not trained for independent practice.

Going to stop here before it turns into an NP vs. MD/DO thread, but I do think this is one pertinent reason why I don't want to go the NP route.

 

[deleted6669]

There are plenty of psych PAs out there. Just realize that you will not be able to work without a collaborating physician if you go this route. There are a few psych PA postgrad programs out there as well. It is doable, just like being a surgical NP is doable, but either is an uphill battle against community standards.

 

[pamac]

I’m going to share a bunch here. Take from it what you will:

If you burn through school quickly without working as an RN in psyche, you’ll miss out on some of the main things that help set psyche NPs apart from PAs that practice in psyche. At best, a psyche PA typically gets one brief rotation in psyche while in training. It makes a difference. Although one CAN blaze through to become a PMHNP quickly, that isn’t even close to being the norm, and that’s really what we should speak to. However, with your extensive experience in mental health that you have already, you probably fit the bill to be one of the most properly prepared PA new grads to ever grace the psyche PA realm if you decide to do that. Any other psyche PA out there would be lucky to have 1/10th of your exposure to psychiatric settings before practicing as a psyche provider.

If you think independent practice is all about flying solo, you are missing the boat entirely, and that’s something that folks who are fixated on the hypotheticals are missing out. If you think that a supervising physician is eager to hold your hand all day, you are wrong. If I was a PA in my practice, I’d see an SP the same amount of time that I do as the independent provider that I am, which is to say that I do my own thing all day, every day. Every once in a while, I walk next door and catch one of the docs to ask their opinion on something. It’s the same kind of thing I ask my NP peers about. And that’s it. If I was a PA, I’d have a similar existence. Nobody will give you “constant collaboration”. You’ll be the final word on everything you do. That’s what being a prescriber entails. If you don’t want that, then you need to do surgery as a PA or something like that where the doc is the main event. Even as a PA, you have the last word over what goes on 99% of the time. So why not be independent? What compelling case is there for both a doctor and a PA to be on the hook if a patient decides to sue? Why should I be dependent on having a relationship by statute with a doctor, who can then make the case that because they take on risk when they are “supervising”, that they should get paid more? Why should I get paid less because I’m not fully emancipated (and yes, PAs in psyche do tend to make significantly less than psyche NPs.... where I’m at if I was a PA I’d be making roughly $50k less... easily). That latter point might seem strange, but it’s how the market works.

You may welcome the sense that there is a safety net below you as a “midlevel”, but what I’m telling you is that as a PA, the daily grind really has no true safety net, you’ll just have it hanging over your head that you’ll need to have a physician sign off on you for you to have any ability to work. And psyche is full of plenty of physicians who run solo and won’t lend you their name so you can work. When they do lend you their name, they have power over you and many will want a cut of the action. My employers know that I can walk out the door any time and start practicing. They compensate me accordingly. They know that if I were a PA, I’d only be able to do that if I got a doc to sign off on it. You become a captive audience for the show that they run.

It’s not hard at all for a new grad psyche NP to start at $145k or more in their first job. Conversely, the best paid psyche PA I know started at the same wage as any other PA starts at here, which is like $85k. I made around that much my last year as a bedside nurse. I tell every new grad psyche NP to set their sights on making at least $130k in their first job. Anything less is ridiculous. I had peers in my graduating cohort make the following salaries at their first jobs: $145k, $165k,$140k, $260k,$360k (!), $155k, $144k, $170k, $140k ish, $168k. Thats everyone who’s salary that I personally heard or read (via text) that they made at their first job. That’s all over the western US. That’s for work that is no more than 40 hours per week... yes, even the person making $360k as a contract employee. I know far fewer psyche PAs, but only one outlier among them makes above $135. The rest make less than $120k. That’s just how it rolls when you aren’t independent. And the funny thing is that their workday doesn’t function any differently than the NPs. I’m sure that many physicians out there would love to see more PAs in psyche so that they could lord that supervisory role over them and pay them less. That’s the real reason some of the hater docs like PAs vs NPs. Don’t buy into the hype that it’s about anything else. It’s about control and money.

Here’s something you may not appreciate. You will be most valuable as a provider while working in the role of med manager. You’ll utilize your interpersonal skills and your pre NP/PA psyche experience to great effect. But the fact is that to sit and talk to someone and fix them that way takes time. Employers may not want to pay you to do that when you could be seeing more patients and getting reimbursed higher by managing their meds. Do I think counseling is great? Yes.... in fact it’s critical. Do I know any employers who want me to use my precious time and my valuable degree doing something that brings in much less revenue (and is something that a counselor can do for a lot cheaper)? No. Can I justify using my time for psychotherapy when it means turning away helping more people? No... I personally can’t. My schedule is packed. I can do my job managing meds, and a cheaper therapist can handle the psychotherapeutics. And practicing between two realms becomes problematic, because you are responsible for the the certifications you hold. For instance, imagine you are a Phys D and an NP. A patient comes into where you practice as a Phys D, and you see an issue that you can address as an NP that you couldn’t as a Phys D. You are still responsible for practicing at the level of what your NP certification requires, and you have a duty to treat accordingly. It’s the same reason that I don’t go back and dabble as an RN... because I’m an NP at any moment, whether I want to be an RN or not. I’m still responsible for practicing at the level of my NP peers. You can run into trouble when you try to take off the NP or PA name badge. You are responsible for acting according to what you see, and addressing it at the level of your knowledge. It’s just really hard to serve two masters. Instead of being excellent at one of your careers, you risk becoming mediocre at two of them.

 

[DizzyJon]

I'm a PA and worked outpatient psych doing med management for a couple years.....my opinion would be to do PMHNP route if you are certain psych is all you want to do. With your completion of a PsyD before NP school, having been an LPN, and mental health clinician, you have plenty of experience jumping right into NP program without working as an RN. As mentioned, you need to obtain your RN though first.

PsyD, NP, PA.....whichever you are, you will have final say in your treatment. You will not be in an environment that would have you run your plan by a physician for every single patient. You will collaborate with many, but it comes down to you making the decision.

If you want to be a "midlevel" (and strike that term from your vocabulary after this) and have someone else make decisions for your patients, then you should stay an LPN or mental health clinician.

Agree with PAMAC....if you're a prescriber, the practice will want you doing med management over therapy. It makes more money.

I made $150K as a psych PA and have no knowledge of PAs making less in psych then NPs. We had an NP and another PA in the office, I made slightly more then them because I was a rock star.

You can certainly have a PsyD and PMHNP and do the two different roles.

 

[deleted6669]

The places I know that use both PAs and NPs in psych (like Kaiser) pay them the same. These are large organizations, not private practices, so the patterns may be different there. For the most part, PAs/NPs in the same specialty with similar levels of experience make the same money. A few of my per diem jobs also use NPs, but they are mostly newer grads, so they make a lot less than I do.

 

[mountainPA]

It sounds like you are set on psych, but keep in mind that things may change years down the road...not just personal and professional interest, but also the market. Becoming a PMHNP will limit you to the psych arena. Being a PA will not. Keep in mind too that there are lots of specialties that also work with psychiatric conditions. I have managed psych patients in internal medicine, family practice, and urgent care. In regards to compensation, I also know multiple NPs and PAs, and there is no difference in terms of compensation. In fact, one of the PAs makes significantly more than the NPs (this is per the NPs) because they also manage various other conditions in practice that are out of scope for the psych NPs.

 

[chicandtoughness]

It sounds like you are set on psych, but keep in mind that things may change years down the road...not just personal and professional interest, but also the market. Becoming a PMHNP will limit you to the psych arena. Being a PA will not.

I appreciate this input. Though I will say: yes, I'm absolutely set on psych, if my 6+ years in the field wasn't already an indication and that's actually the reason why I didn't want to be a physician - I'm not interested in anything else, and having to learn 90% of the other stuff to get to the 10% of psych seems daunting to me. (Endo is my other true love, but I'm honestly not sure if I would find satisfaction in the day-to-day of being an endocrinologist... I'm just in love with learning about the subject!) If I had even an inkling that I might want to do something different, then I might as well go to med school, right?

I think the flexibility of moving between specialties is one of the biggest draws of PA though, in terms of the job market. Lots to think about.

 

[pamac]

It sounds like you are set on psych, but keep in mind that things may change years down the road...not just personal and professional interest, but also the market. Becoming a PMHNP will limit you to the psych arena. Being a PA will not. Keep in mind too that there are lots of specialties that also work with psychiatric conditions. I have managed psych patients in internal medicine, family practice, and urgent care. In regards to compensation, I also know multiple NPs and PAs, and there is no difference in terms of compensation. In fact, one of the PAs makes significantly more than the NPs (this is per the NPs) because they also manage various other conditions in practice that are out of scope for the psych NPs.

I considered getting an FNP certification to round out my skills and make me more marketable. Nobody, not even my dual certified FNP/PsycheNP friends suggested that, and all of them gave me great reasons. 1) it’s hard to bill for a bunch of different things that are addressed in a visit. 2) you’ll be busy enough that you won’t need to switch gears tokeep your workload up. 3) it’s a pain to maintain two certifications. 4) Time spent doing something else is time that could have been spent getting better at one thing.... and that comes into play when you want to “be a rockstar” and make the big money.

A physician assistant probably can manage other stuff alongside a psyche issue, but that rarely translates into something that appeals to an employer. I’ve never sat with a patient and wished that I was dabbling in their physical problems. I’m not booked out 7 weeks because of people’s physical health, I’m booked out because there is such a demand for me to see them for their psyche issues. I have no time to spend duplicating something that can be done by the folks in primary care. In the current environment, you’ll be more valuable for your psyche skills, and for cultivating them. The psyche PAs that I’ve known of that are the best paid, and the best regarded are the ones that are heavily invested in psyche, not those that are doing it on the side, or have spent time in other specialties along the way.

 

[Nurse Practioner]

Oops, would have been helpful if I included some of this info in my original post. I have my LPN from a past career, so I would probably do an accelerated BSN for the RN and then move into NP. I am not above working part time as an RN for a few years (the other half of the part time would still be psychotherapy, as I don't want those skills to go stale) before adding on the NP.

Accelerated BSN is the Way to go. Good luck.

 

[deleted6669]

I think the flexibility of moving between specialties is one of the biggest draws of PA though, in terms of the job market. Lots to think about.

FWIW, lateral mobility is going away in the profession for a number of reasons. Hospitals want to see procedure logs these days and some really want you to do a residency and/or have a certificate of added qualifications(CAQ) in the specialty in which you are working. If I wanted to do CT surgery, for example, I would need to do a postgrad program at this point. I could transition to primary care, trauma, hospitalist, or intensivist work fairly easily, but that is because those overlap with my current skillset. The days of people working in multiple unrelated specialties are going away. And they should.

 

[pamac]

FWIW, lateral mobility is going away in the profession for a number of reasons. Hospitals want to see procedure logs these days and some really want you to do a residency and/or have a certificate of added qualifications(CAQ) in the specialty in which you are working. If I wanted to do CT surgery, for example, I would need to do a postgrad program at this point. I could transition to primary care, trauma, hospitalist, or intensivist work fairly easily, but that is because those overlap with my current skillset. The days of people working in multiple unrelated specialties are going away. And they should.

The lateral mobility is what always appealed to me most about what PAs had, apart from the great knowledge base that PA training provides. But the PAs I know that seem to do the best financially are the ones that are invested in one area, or like you said, are spread across realms that have a good amount of overlap. The thought of having mobility is comforting, but mobility can also be achieved in other ways, like investing in your skill set, or making a good name for yourself. The notion of doing well by changing gears every few years doesn’t always sit well with an employer that might want you to stick around if things are going well. Its really interesting how there are many folks that disregard specializing (which can tend to be more lucrative) in favor of broad skill set. Who sits on a bigger pile of cash... a specialist physician or a generalist? An FNP, or a psyche NP like myself? Or even an FNP working in psyche, or a psyche NP that is formally educated? An ER residency trained PA, or a PA without it? I think a lot of folks have been too nervous to commit, and are suffering from it.