PMHPA Posted February 16, 2020 Share Posted February 16, 2020 Hey all! I'm a new grad and I've always wanted to go into psych. I got an outpatient psych job offer that sounds great, but I just want to make sure I'm not making a mistake as a new grad. I would be working at an office location basically by myself, with my supervising physician never on-site but available by phone to answer any questions. Eventually they want me seeing 10-15 patients per day, but will start lower than that and ramp up. 45 minute initial evals, 15 min follow up appointments. My question is, do you think as a new grad I'll be okay basically being somewhat autonomous from the start? I'm a pretty motivated self-learner, but I want to make sure I'm a good provider for my patients and won't be biting off more than I can chew, so to speak. Is psych one specialty where a new grad can get by without direct hands-on supervision? Any thoughts welcome! Quote Link to comment Share on other sites More sharing options...
MT2PA Posted February 16, 2020 Share Posted February 16, 2020 Would not recommend for a lot of reasons. 1 Quote Link to comment Share on other sites More sharing options...
PMHPA Posted February 16, 2020 Author Share Posted February 16, 2020 2 minutes ago, MT2PA said: Would not recommend for a lot of reasons. I'd love to know more about why you feel this way! Quote Link to comment Share on other sites More sharing options...
laurac Posted February 16, 2020 Share Posted February 16, 2020 I have worked in psych since I graduated from PA school (2 years outpatient and 2 years inpatient). It can be a great specialty but no new grad PA should be working by themselves. I started in a practice with two physicians and three other APPs and it was still tough! PA school does not give you enough didactic or clinical time to be effective on your own. I say that as someone who had two psych rotations. I was very quickly ramped up to 25 or so patients per day and was treating a primarily low income patient population with a lot of substance abuse issues which does make things more complicated. Get yourself a copy of Stahl's Essential Psychopharmacology and his Prescriber's Guide if you do take the job. I did a lot of CME at first and got my CAQ in psych after a couple of years. The patient load for your job is pretty low so you may be able to do the job sustainably for a while. 2 1 Quote Link to comment Share on other sites More sharing options...
Mayamom Posted February 17, 2020 Share Posted February 17, 2020 I think psychiatry is s great place for PA to practice. They were non-existent when I graduated but there is a huge need for more mental health providers. I think as a new grad you might want to start with follow up appointments then after a few months and being more comfortable move on to initial assessment. Does the practice offer MAT? Quote Link to comment Share on other sites More sharing options...
PMHPA Posted February 17, 2020 Author Share Posted February 17, 2020 6 hours ago, laurac said: PA school does not give you enough didactic or clinical time to be effective on your own. I say that as someone who had two psych rotations. I definitely agree! I did 2 psych rotations as well but it's still not enough. The doc tried to reassure me that he really is available 24/7 to answer all my questions by phone, but I totally get what you're saying that it's not the same as on-site supervision. Will definitely have to think about this 23 minutes ago, Mayamom said: I think psychiatry is s great place for PA to practice. They were non-existent when I graduated but there is a huge need for more mental health providers. I think as a new grad you might want to start with follow up appointments then after a few months and being more comfortable move on to initial assessment. Does the practice offer MAT? That's a good idea! And yes, a small percentage of their patients are MAT / buprenorphine patients, so I would be doing a bit of that Quote Link to comment Share on other sites More sharing options...
ANESMCR Posted February 17, 2020 Share Posted February 17, 2020 23 hours ago, PMHPA said: Hey all! I'm a new grad and I've always wanted to go into psych. I got an outpatient psych job offer that sounds great, but I just want to make sure I'm not making a mistake as a new grad. I would be working at an office location basically by myself, with my supervising physician never on-site but available by phone to answer any questions. Eventually they want me seeing 10-15 patients per day, but will start lower than that and ramp up. 45 minute initial evals, 15 min follow up appointments. My question is, do you think as a new grad I'll be okay basically being somewhat autonomous from the start? I'm a pretty motivated self-learner, but I want to make sure I'm a good provider for my patients and won't be biting off more than I can chew, so to speak. Is psych one specialty where a new grad can get by without direct hands-on supervision? Any thoughts welcome! In a similar situation with a rural medicine clinic in the middle of nowhere Wyoming. Have an offer where I’d be the sole provider of the entire clinic and town, without clinical support staff whatsoever. Not even an MA, LPN etc. The SP is located an hour away and only visits once per month. I’d love to take the role on and help turn the place around, and the offer is fabulous. But, as a new grad, I’ll probably have to decline. I have to agree with what everyone else has told you. 1 Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 18, 2020 Administrator Share Posted February 18, 2020 9 hours ago, ANESMCR said: In a similar situation with a rural medicine clinic in the middle of nowhere Wyoming. Have an offer where I’d be the sole provider of the entire clinic and town, without clinical support staff whatsoever. Not even an MA, LPN etc. The SP is located an hour away and only visits once per month. I’d love to take the role on and help turn the place around, and the offer is fabulous. But, as a new grad, I’ll probably have to decline. I have to agree with what everyone else has told you. Wow... how far would it be to the nearest tertiary care facility? Sounds like a good opportunity for someone who wanted to be/stay rural, but the sheer number of clinical skills you'd need to have to do that all solo would be astounding... Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted February 18, 2020 Share Posted February 18, 2020 9 hours ago, ANESMCR said: In a similar situation with a rural medicine clinic in the middle of nowhere Wyoming. Have an offer where I’d be the sole provider of the entire clinic and town, without clinical support staff whatsoever. Not even an MA, LPN etc. The SP is located an hour away and only visits once per month. I’d love to take the role on and help turn the place around, and the offer is fabulous. But, as a new grad, I’ll probably have to decline. I have to agree with what everyone else has told you. Also, really dangerous for a new grad who hasn't had the chance to see a wide variety of "about to be really sick". There's just no substitute for experience, and no substitute for having someone you can ask "hey, how does this patient look to you" or "have you seen this before - is it X?" This isn't in any way, shape, or form a knock on you - it's just that medicine takes a while to learn: lots of exposures to the wide variety of "normal" and "normal for this patient', lots of exposures to sick, looks weird but isn't sick, and to "I didn't expect that to happen". I remind many folks of the old cowboy story: How did you know to do that? Good judgment Where does good judgment come from? Experience Where does experience come from? Bad judgment 1 Quote Link to comment Share on other sites More sharing options...
Lexapro Posted February 18, 2020 Share Posted February 18, 2020 On 2/16/2020 at 10:11 AM, PMHPA said: Is psych one specialty where a new grad can get by without direct hands-on supervision? Any thoughts welcome! I'd argue that psych is very much the opposite and to be competent and effective as a mental health specialist, intense mentoring from people who are experts is essential. 1 Quote Link to comment Share on other sites More sharing options...
ANESMCR Posted February 18, 2020 Share Posted February 18, 2020 (edited) 15 hours ago, rev ronin said: Wow... how far would it be to the nearest tertiary care facility? Sounds like a good opportunity for someone who wanted to be/stay rural, but the sheer number of clinical skills you'd need to have to do that all solo would be astounding... Minimum 1.5 hours driving, about 25-30 min by helicopter. Yes, it would be great if I had several years under my belt. If any experienced folks want the info I’ll provide. It’s a decent offer with a low patient load. Edited February 18, 2020 by ANESMCR Quote Link to comment Share on other sites More sharing options...
Wellness Posted February 18, 2020 Share Posted February 18, 2020 I am graduating in a few months and will be working in an outpatient clinic with ample supervision by a doc and several PA/NPs for the first year or two. You might be able to get by in fast track in the ED with minimal supervision or even an urgent care seeing very simple cases, but you cannot do a specialty, particularly one that is barely focused on in PA school. The unfortunate fact is that PA school teaches us very little about psychiatry and psychopharmacology. I sincerely believe you need good mentorship to be successful. At least for one year. If not for you, do it for your patients. Quote Link to comment Share on other sites More sharing options...
ANESMCR Posted February 19, 2020 Share Posted February 19, 2020 4 hours ago, Wellness said: The unfortunate fact is that PA school teaches us very little about psychiatry and psychopharmacology. I don’t think that statement is at all accurate. Quote Link to comment Share on other sites More sharing options...
PMHPA Posted February 19, 2020 Author Share Posted February 19, 2020 Thanks everyone for your thoughts! I understand what you all are saying and totally agree with you. I shared my concerns with the doc and he said a couple things: 1) There will be another (experienced) psych PA at the location, just not a supervising physician. 2) Apparently this practice has a policy where ALL patients see a licensed mental health counselor first, and the counselor does the long initial history/eval and assigns the diagnoses. The PAs don't do any coding at all. Basically, the PAs don't actually diagnose the patients, they just manage their psychiatric medications based on the previously-assigned diagnosis. He seemed to think this made the role more doable for a new grad. Kind of an odd set up, I know. Curious what you all think of that approach. For what it's worth, I'm still leaning toward looking elsewhere. Quote Link to comment Share on other sites More sharing options...
DizzyJ Posted February 19, 2020 Share Posted February 19, 2020 The "safe" answer would be no. Not good for a new grad. However, everyone has different life experiences/street smarts. I did outpatient psych for 2 years and only had about 3 hours "training" by shadowing the doc. Then was given an office and a full patient schedule. I had been a PA though for 8 or 9 years at the time. I had a DSM and Stahl's books and used them constantly. I feel my street smarts/life experience/PA career had trained me appropriately to provide safe care as I quickly figured out psych. Could a new grad, with access to an experienced PA on site, figure it out and provide safe psych treatment? Yes it can be possible. However, if you're the type that needs hand holding and lots of time to be comfortable, then it is not a good idea. Quote Link to comment Share on other sites More sharing options...
Lexapro Posted February 20, 2020 Share Posted February 20, 2020 (edited) You're not diagnosing your patients yourself? Do not take this position. You still have to bill for a diagnosis code. This is a big concern to me. My experience is that many masters level clinicians/counselors do not have the breadth of experience to diagnose psychiatric conditions accurately, especially more severe mental illness, personality disorders, atypical presentations, etc. My experience is they over-diagnose PTSD and "bipolar II" disorder. Also a big part of psychiatric diagnosis is ruling out medical concerns, something that these clinicians will be entirely unable to do. I don't understand how this would work and it sounds like a terrible idea. If you don't feel comfortable fully assessing and diagnosing patients yourself (with some backup from your doc at first), you probably shouldn't be practicing in that specialty. At the bare minimum I would insist that the more experienced PA is formally required to mentor you during a certain amount of protected time (no seeing patients, no clinical tasks) once or twice a week. Honestly, I flat out wouldn't take this job and this doc sounds like he just cares about making money. Consider doing a psych PA residency. Edited February 20, 2020 by Lexapro Quote Link to comment Share on other sites More sharing options...
blackcat22 Posted February 20, 2020 Share Posted February 20, 2020 17 hours ago, Lexapro said: You're not diagnosing your patients yourself? Do not take this position. You still have to bill for a diagnosis code. This is a big concern to me. My experience is that many masters level clinicians/counselors do not have the breadth of experience to diagnose psychiatric conditions accurately, especially more severe mental illness, personality disorders, atypical presentations, etc. My experience is they over-diagnose PTSD and "bipolar II" disorder. Also a big part of psychiatric diagnosis is ruling out medical concerns, something that these clinicians will be entirely unable to do. I don't understand how this would work and it sounds like a terrible idea. If you don't feel comfortable fully assessing and diagnosing patients yourself (with some backup from your doc at first), you probably shouldn't be practicing in that specialty. At the bare minimum I would insist that the more experienced PA is formally required to mentor you during a certain amount of protected time (no seeing patients, no clinical tasks) once or twice a week. Honestly, I flat out wouldn't take this job and this doc sounds like he just cares about making money. Consider doing a psych PA residency. I agree with this post completely! Personally, I would not be happy with this type of set up, and I agree that psychiatric conditions are often misdiagnosed by those who do not have enough experience or ask the appropriate questions. A psych residency would probably be an appropriate option for you. In my situation, I was able to start out first doing inpatient psych with a lot of mentoring from my collaborating doc with a transition to doing 50/50 inpatient and outpatient work. I would have been lost if I was told to start in outpatient seeing patients without prior exposure and training. 1 Quote Link to comment Share on other sites More sharing options...
Wellness Posted February 21, 2020 Share Posted February 21, 2020 On 2/18/2020 at 7:25 PM, ANESMCR said: I don’t think that statement is at all accurate. IIRC, we had a 3-week block for psych during didactic and were required to do 1 6-week rotation. Relatively, this isn't much less than what medical students get, but those who specialize in psychiatry have a whole residency. I'm genuinely concerned if you think that's enough to treat patients without appropriate supervision. 2 Quote Link to comment Share on other sites More sharing options...
ANESMCR Posted February 22, 2020 Share Posted February 22, 2020 (edited) 13 hours ago, Wellness said: IIRC, we had a 3-week block for psych during didactic and were required to do 1 6-week rotation. Relatively, this isn't much less than what medical students get, but those who specialize in psychiatry have a whole residency. I'm genuinely concerned if you think that's enough to treat patients without appropriate supervision. My statement was to you and your statement only (that PA school teaches you very little about psych and psychopharm); not regarding appropriate supervision and offer at hand. I’ve agreed, the OP should reconsider. I had a 3 month block and 6 week rotation of psych. You should’ve seen psych meds and patients throughout your entire didactic and clinical year. So yes, in your choice of words, I disagree with you. I suppose I should also be genuinely concerned you think a new grad in UC and ED without supervision is okay? Edited February 22, 2020 by ANESMCR Quote Link to comment Share on other sites More sharing options...
PsychiatricPA Posted February 22, 2020 Share Posted February 22, 2020 My first job as a new grad was very similar to this. So I think I can present my 2 cents to you: - Was my first job a good job? NO! 45min new eval and 15 min f/u is just not ideal even for experienced psychiatrists. - Do I regret getting that job? Not really. It was very difficult to get a job in psych as a PA. At least where I live NPs dominate the market. I'm grateful someone gave me the opportunity so I could gain experience in psych and move on. - I started seeing patients on my own on the day 2. Scary! How did I survive? I presented every single case to my CP for the first 3 months. My CP never asked to do that, but I did anyway. Sometimes I was 1+ hours behind. I didn't care. I had two goals: learning and safety. At the end of the day I would go home and study, weekends as well. Then I would go back to the office and asked my CB tons of questions. At the end of my first year I was feeling comfortable, would ask questions to my CP 1-2x per week. - Now consider this: do not go to psych for less than 6figs. I didn't. I was bringing to the company more than 1.3million per year so 6figs is fair even for a new grad. - Also this: Do not trust anyone else to diagnose your patients. The psychologists at my office would diagnose tons of my patients with MDD when in reality they had Bipolar. You need the right diagnosis to treat the patient with the right medicine. Try to treat Bipolar w/ antidepressants and you will go nowhere. - ... and a few more points: 1. Don't just add meds and more meds trying to control symptoms. I see this a lot. If somethings is not working, replace it. Your goal is to control symptoms with the least amount of meds possible. 2. Unless really needed, stay away from benzos. 3. Be kind to your patients and to yourself. - Last point: Sometimes you might feel discouraged... but if psychiatry is your passion, stick with it and know your stuff. Knowledge and kindness will take you to a better place in your professional career. Hope this was helpful. 2 1 Quote Link to comment Share on other sites More sharing options...
PMHPA Posted February 24, 2020 Author Share Posted February 24, 2020 Update: I turned down the job. I really appreciate all your thoughts! Residency isn't an option for me due to location (there are only a few psych residencies in the entire country and none where I live) but my psych preceptors have both assured me that a new grad can do just fine in psych without a residency as long as there is adequate supervision (which I agree with you all that this position did not really have). There definitely seems to be a need for more mental health providers so I'm not too worried about finding a better fit! @PsychiatricPA thanks so much for sharing your experience, I may DM you to ask a few more questions if that's okay Quote Link to comment Share on other sites More sharing options...
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