PA in Psychiatry

[chazwars]

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I hope it's okay that I post on here as a prospective PA with a psychiatry emphasis. I respect the mods if it's not appropriate and needs to be moved/removed.

Has anyone experienced a program/hospital etc that included PAs in fellowships, sub-internships, or shorter term residencies? I'm not looking for just stand PA rotations but an opportunity to really delve into a specialty.

Would you recommend some universities that have an emphasis on dual diagnosis and/or personality disorders? I'm exploring the following programs due to their research centers and/or connections to top psychiatric facilities: Yale, Duke, Emory, Anne Arundel (UMB), Bryant (Brown), Oregon Health, Rush and Wake Forest.

I'm open to any suggestions and plan to apply for 2016/17.

 

[st2205]

I couldn't tell you anything about the emphasis of the actual PA training at any program, but I do know that the University of Iowa has a one-year fellowship offered to PA grads. They actually pay you 15k more than a psychiatry intern and take less call.

 

[OldPsychDoc]

According to the APPAP website, there are only 2 psychiatry-focused structured fellowships: The Iowa one, and one in St. Paul MN.
Hopefully if there are more folks like you out there, more programs will follow?

 

[chazwars]

Thanks for the great information. I didn't know about that link. I've got a colleague at the location in MN. I'll definitely be reaching out to him.

 

[st2205]

I wasn't aware of the St. Paul one. Looks like they also pay pretty good (65k). This chaps my ass. We have this scam in America where hospitals bemoan the cost of training residents and get federal funding to "help offset the cost." Then it's held over the residents' head about how dedicated the hospital is about training because of the [drama]drastic cost[/drama] they are to the bottom line. Now here we've got fellowships that are 1) unfunded 2) filled by people with half the education of residents and 3) take less call / do less work, but apparently they bring enough to the table to justify paying them 130% of what they pay residents.

I'm amazed how long they've been able to get cheap (free) labor and bailout money and continue to dominate the dialogue about how "expensive" and "costly" residents are. I guess if all the money is on the line you've gotta push the narrative.

/tangent

 

[OldPsychDoc]

I wasn't aware of the St. Paul one. Looks like they also pay pretty good (65k). This chaps my ass. We have this scam in America where hospitals bemoan the cost of training residents and get federal funding to "help offset the cost." Then it's held over the residents' head about how dedicated the hospital is about training because of the [drama]drastic cost[/drama] they are to the bottom line. Now here we've got fellowships that are 1) unfunded 2) filled by people with half the education of residents and 3) take less call / do less work, but apparently they bring enough to the table to justify paying them 130% of what they pay residents.

I'm amazed how long they've been able to get cheap (free) labor and bailout money and continue to dominate the dialogue about how "expensive" and "costly" residents are. I guess if all the money is on the line you've gotta push the narrative.

/tangent

I don't pretend to understand all the economics of this, but according to one website, http://salarybystate.org/healthcare/physician-assistant-salary-by-state, starting salaries for PAs average $82,000 in MN, which is noted to be 10% less than job postings nationwide. It could be argued that a PA could be making a lot more during that year if they'd chosen not to go after additional training. A resident, OTOH, is essentially unemployable in this day and age without completing a residency (rail about it all you want, but that's the system we've got...).

 

[st2205]

I don't pretend to understand all the economics of this, but according to one website, http://salarybystate.org/healthcare/physician-assistant-salary-by-state, starting salaries for PAs average $82,000 in MN, which is noted to be 10% less than job postings nationwide. It could be argued that a PA could be making a lot more during that year if they'd chosen not to go after additional training. A resident, OTOH, is essentially unemployable in this day and age without completing a residency (rail about it all you want, but that's the system we've got...).

Agreed. But if we're arguing that we need to offer them higher pay to recruit them away from normal jobs, the principle still stands that it's obviously cost effective and beneficial for the hospital (even without federal funding), else they wouldn't be doing it. So if there's enough reserve to be throwing more money at midlevels, I'd appreciate some consistency of them not portraying residents as a gigantic burden that they're just so dedicated to that they are breaking the financial back of the institution to be able to support.

 

[TexasPhysician]

the pay is $72800 according to this
yes i think this is a slap in the face for residents but the difference is residents can't bill independently, these "fellowship" PA/NPs can during their training so actually they are getting a good deal by paying them less when they could pay them what they would get otherwise, its a not insignificant saving.

Residents can bill independently once they have their own license. It is the system that gives faculty all the credit. Residents can make faculty 4x+ as effective. For instance during pgy-3, one faculty could oversee and bill for 6 residents seeing 2 patients each per hour. No way that 1 faculty averages 12 patients per hour otherwise. Residents do have value.

 

[TexasPhysician]

i mean we can't bill medicare as a resident (moonlighting is a different thing of course). private insurance etc this seems to vary by state but where i am we cant bill independently as residents so during the outpatient years when almost none of our patients are staffed with an attending we can only get the facility fee but not the physician service. residents have value for inpatient work but not really for outpatient.

Our faculty briefly see all patients in outpatient and bill a full visit. The system keeps us from being as effective ourselves - I agree.

Getting back on track, I think a PA psych fellowship would be valuable. I've had significant trouble finding knowledgeable PA's that I trust in the field. The fellowship would definitely lead me to interview the OP.

 

[hamstergang]

I'm amazed how long they've been able to get cheap (free) labor and bailout money and continue to dominate the dialogue about how "expensive" and "costly" residents are. I guess if all the money is on the line you've gotta push the narrative.

We do cost more than our paychecks.

 

[chazwars]

Getting back on track, I think a PA psych fellowship would be valuable. I've had significant trouble finding knowledgeable PA's that I trust in the field. The fellowship would definitely lead me to interview the OP.

That is essentially what I was getting at. I'm looking into a program that has 1 psychiatric rotation and 4 elective rotations with an additional 2 research rotations. Why I am interested in this program is that they are allowing a PA to do- what they call- a subinternship or "mini" fellowship based on an area of interest. The problem is that this mini-fellowship is mixed into the actual 2 year program, so future employers, i.e. each one of you, would only see the two year and not the emphasis placed on psychiatric specialty training. Unfortunately, adding more to the resume is the only way to get reviewed and considered. Granted, I could explain this in the interview but resumes get the foot in the door.

I am 38 and plan to begin my program when I am 40 (one year of prereqs and 1 year of application/interview processing). I've been told that those in my age bracket entering the work force carry with them the assumption that we are more seasoned (I have 10 years of dual diagnosis and SPMI experience). To this point, I'm certainly going to consider the above mentioned program, doing the subinternship, and then looking into a fellowship such as this. I want to hit the ground running once one of you hires me! Lastly, I've always been told to never take the job you were interning/doing a fellowship for because they can hire you for less than what another opportunity may offer as well as cease additional training since a new facility will want to ensure you are trained properly. Thoughts on this?

Sorry to hear about the residency dilemma. I've been told psychiatric specialities are one of the longest training tracks.

 

[st2205]

the pay is $72800 according to this
yes i think this is a slap in the face for residents but the difference is residents can't bill independently, these "fellowship" PA/NPs can during their training so actually they are getting a good deal by paying them less when they could pay them what they would get otherwise, its a not insignificant saving. i assume these places are also looking to hire the people that complete this training so have an added incentive.

I'm not certain about the billing for these fellowships. It'd be interesting to know how that works. On the flip side, residents are doing work that an attending is billing for (at a higher rate, to my understanding).

the mechanics of GME funding (which is so complex most people, myself included, dont even begin to understand it) are such that it really is a different case. also psychiatry residents probably lose money rather than make money for the hospital, especially in the outpatient years. for medicine at least, the RAND corporation says 4 interns are equivalent to one attending, and 2R2s = 1 attending in terms of productivity. They found for medicine and a bunch of other specialties, that ignoring the GME funding, that hospitals make a small amount by having residents BUT this probably isn't true for psychiatry on the whole, except maybe 2nd years where the 2nd year is inpatient.

I think this depends. I don't buy the idea that it's not profitable in psychiatry. Granted, each facility/program is going to run things differently. Here, because there are residents the attendings are then freed up to have a full day of clinic after rounding. This would otherwise be a full-time inpatient job in any real facility. As far as clinic, this is a cash mill. An attending is receiving checkout from multiple residents and billing for it after seeing them for 30-90 seconds. It's interesting that it's not done that way at your program and I'd be interested to hear others chime in. I'd guess that it's more often than not run more like here than where you're at. At the VA, though (1 day/week), you checkout verbally to attending at the end of the day. But that's the VA where the reimbursement (for lack of a better word) is completely different.

i mean we can't bill medicare as a resident (moonlighting is a different thing of course). private insurance etc this seems to vary by state but where i am we cant bill independently as residents so during the outpatient years when almost none of our patients are staffed with an attending we can only get the facility fee but not the physician service. residents have value for inpatient work but not really for outpatient.

I think we should actually move to a model where residents are to be fully licensed and bill. Naturally, if every resident started billing across the nation I'm sure there'd be massive pushback from insurance (without them realizing it's already been billed previously under someone else's name). Anyway, I'm credentialed with my hospital to see patients independently after hours and bill. Not sure why that couldn't be theoretically possible, but that's neither here nor there.

We do cost more than our paychecks.

Indeed we do*. But so do nurses, social workers, support staff, janitorial staff, etc. But nobody's wanting to harass them as we're busy making sure they all feel appreciated and not looked down on.

*from a superficial interpretation of the numbers, much as the Happy Meal department (or whatever it's called) isn't generating money for McDonald's.

 

[st2205]

That is essentially what I was getting at. I'm looking into a program that has 1 psychiatric rotation and 4 elective rotations with an additional 2 research rotations. Why I am interested in this program is that they are allowing a PA to do- what they call- a subinternship or "mini" fellowship based on an area of interest. The problem is that this mini-fellowship is mixed into the actual 2 year program, so future employers, i.e. each one of you, would only see the two year and not the emphasis placed on psychiatric specialty training. Unfortunately, adding more to the resume is the only way to get reviewed and considered. Granted, I could explain this in the interview but resumes get the foot in the door.

I am 38 and plan to begin my program when I am 40 (one year of prereqs and 1 year of application/interview processing). I've been told that those in my age bracket entering the work force carry with them the assumption that we are more seasoned (I have 10 years of dual diagnosis and SPMI experience). To this point, I'm certainly going to consider the above mentioned program, doing the subinternship, and then looking into a fellowship such as this. I want to hit the ground running once one of you hires me! Lastly, I've always been told to never take the job you were interning/doing a fellowship for because they can hire you for less than what another opportunity may offer as well as cease additional training since a new facility will want to ensure you are trained properly. Thoughts on this?

Sorry to hear about the residency dilemma. I've been told psychiatric specialities are one of the longest training tracks.

I haven't seen too many PAs in psychiatry. I'd imagine it's tough feeling comfortable with the limited amount of exposure to psychiatry, as opposed to the exposure in an FMHNP program that is nearly 100% mental health. I think, though, having exposure to the field gives you a good advantage of you're able to show you've got experience that you can talk about and demonstrate you know the system. If you've got some of that background and did a fellowship, I think that would place you as rather desirable over an NP, particularly in inpatient, just by having more training in medicine when most of the FMHNP programs rely on the RN portion to be the backbone of their medical knowledge. You'll have less autonomy, though, depending on the state, despite more training.

Would you give any consideration to fellowship?

 

[hamstergang]

Indeed we do*. But so do nurses, social workers, support staff, janitorial staff, etc. But nobody's wanting to harass them as we're busy making sure they all feel appreciated and not looked down on.

*from a superficial interpretation of the numbers, much as the Happy Meal department (or whatever it's called) isn't generating money for McDonald's.

I don't mean in the way I think you're saying. We take money to train. Faculty teaching us, the program coordinator, office supplies, I imagine the PRITE costs money, etc. The actual money paid out for each resident is more than what we see in our paychecks. I feel this should be taken into account, not because it necessarily changes the conclusion, but because it's the reality hospitals live with.

 

[milesed]

We perform the training for about 4 students a year in psychiatry for the required month in PA school. We just can't bill for the services or we'd hire some of them. If we did, I'd perform the extra training for them just as we do for new APRN grads who work here.

 

[chazwars]

So, I'm hearing that an NP might create more autonomy?

And, yes, what I've gathered from others is that PAs are ill equipped to jump into psych without previous experience. And, of those above mentioned programs I've already spoken with, the impression I get is that I've got a solid game plan in mind that should enhance my credibility when discussing future career opportunities.

I'm well aware that inpatient will likely be the environment I'll practice, at least until I can attach myself to a private practice. I'm sure that once the parity act really starts kicking in, we will see more outpatient services showing profitability.

As for the fellowship...I'd absolutely be interested. I'd even be willing to return to Minnesota!! Those overcast winters can be brutal.

And for solicitation purposes, anyone interested in hiring on a part time psych medical assistant while I nail out these pre-reqs? I'm in the Durham/Chapel Hill Area. It's worth a shot, right!

Thanks for all the insight. This is a great dialogue and I appreciate you all letting a future PA jump in here.

 

[hopefuldoc97239]

in Oregon, and at Oregon Health & Science Univ. especially, you would get better mental health training through a psych NP program than through the general PA program. if you wanted to do psychiatry rotations as a PA student you could make that happen, but due to time limitations built into the program you just wouldn't get that much time to dedicate to any one thing.

on the other hand, regardless of specialty most PA's get let a lot of their education "on the job" after graduation anyway. i met a PA newly hired by the urology department, and she hadn't done any urology rotations as a PA student. if you were dedicated to being a PA rather than NP, and willing to take responsibility for your own learning, you could make it work. and because medical students spend more time training alongside PAs than NPs, you would potentially have that going for you when you went looking for a job.

 

[clusterF]

How much increase in pay is there for a psych PA vs a PA who hasn't done extra training?

 

[TexasPhysician]

How much increase in pay is there for a psych PA vs a PA who hasn't done extra training?

Probably varies like everything else. Large institutions probably won't care. The more lucrative private practices probably more likely grant interviews to PA's that require less substantial training.