A Year in Review in Psychiatry and Addiction Medicine for new grad PA-C

[rtPA20]

This is specific to my experience and I want to share what I've seen as a new PA-C and what the trajectory looks like for psychiatry for PAs. I'm currently moving to a state where preferential hiring is given to nurse practitioners for psychiatry and mental health legislation is not written to include PAs so I'm actively switching out of psychiatry, which I love, for personal reasons. 

 

I was asked to obtain my CAQ in psychiatry prior to hire as an expectation, not as an option. I have worked with more autonomy - or so I'm told- than PA counterparts in other fields of medicine. I have been the clinical lead for a variety of state funded programs, worked on consult service for residential rehab for SU, and maintained an ongoing outpatient panel as well. I have had the incredible privilege of working with a physician who has supported and invested in my growth, which I hear is a diminishing characteristic, and I've worked with every level of education in the mental health sector outside of those who prescribe. Given the requirements to obtain a CAQ, there are certain aspects of my job which I am not recognized for such as functional impairment assessments or filling out diagnosis forms which our clinic then uses to justify occupational, social, and functional assistance programs that we provide and are funded through the state. I provided every possible white paper, position statement, my actual didactic and clinical coursework, description of the summative exam, and the actual PANCE and was still viewed as not certified in a capacity to provide equal access to services as the NPs and physicians in my clinic - I'm the only PA, btw. I was specifically asked, "Can't he just write board-certified psychiatric physician assistant?" This is where nomenclature matters, and where the ethics and legality of title carry weight more so if I were to sign documentation as such and which I won't and have not done. I have thoughts through my experience and recognize that there are a variety of individuals who will read this and have their own thoughts. My goal in sharing is to not be inflammatory or to speak without substantiating my claims. 

There are not many who carry CAQs compared to the amount of PA-Cs in the country. I am thankful for lateral mobility, but as I have had to apply for other positions, in other specialties, I am not asked if I am capable or qualified to transition to another specialty but rather how do I justify leaving psychiatry after one year of practice and believing I can work in fields like pain management, palliative medicine, and family practice - yes, these are responses I have received. Mind you, I have just graduated so I haven't completely lost the mental muscle mass acquired in PA school for the generalist aspect of our training and am reviewing AAPA-provided CME to flex those muscles and refresh. I do not believe that the PA-C long-term will be enough. For me, it has not been enough despite obvious lacking of training and capacity in counterparts who have received online, diploma-mill education with maybe 3 clinical medicine courses but who have a psychiatric certification upon completion of their respective exam. This makes me think about the nature of medicine and how as we move forward as a profession, the CAQs will matter whether we believe they do add value or not. In my process of applying to psychiatric jobs, I was told by at least 3 different medical directors that they looked up if a PA is certified in psychiatry, they found out about CAQ, and asked me to obtain this prior to being considered. I have seen these same job postings remove the Psych ARNP/PA-C, CAQ-Psych preferred, and replace with Psych ARNP only, and my follow up with these organizations as I got closer to being able to sit for the CAQ in psych was, "we have decided to move forward with only psych NPs." I anticipate that hospitalist CAQ will be a future requirement or preferred when applying for a job similar to an acute care NP certification in the minds of organizations that have a predominantly APP base of staffing.

I realize the burden and the rigor of PA school and what PA-C means and how it carries weight to those who understand our training. Those who understand our training are not making decisions in the hiring process. Credentials are progressively mattering more. With NCCPA offering CAQs, it has already happened with psychiatry that we be asked for this certification, but the kicker? You must have experience and a physician willing to sign off on your CAQ which is much more stringent in nature than other professions and if you don't have experience, how do you get it if that's what's required to be hired? I found the end of my PA training to be exhaustive and the summative and PANCE took a chunk out of my academic passions and mental resilience that I'm still recovering from a year and some months later. To think that every 10 years or 6 through PANRE-LA, we must sit for both the PA-C and a separate CAQ(q 10 years) is not pragmatic nor prudent as our profession moves forward. It makes more sense, if we are aligned truly with the medical model and how physicians are trained to be able to keep our PA-C and if there is a CAQ and this is where our practice is, then we should renew what we are actively doing. This is a paradigm shift, and I am nobody in the grand scheme of our profession, but I do feel that for any new PAs who read this they might be advised or counseled in some way. 

 

Tldr; CAQs already carry weight in some forms, it's a matter of when, not if, that all CAQs will be a requirement. Leadership should not be reactive, it should be prudent in action and have forethought. The only ones who know how challenging it is to obtain the PA-C is are not the decision-makers. NCCPA will likely cause more harm than good as we move forward as a profession without active change. 

[rev ronin]

So, some sympathy here: I can't get psych CAQ certified, despite working in pretty much every realm covered by the exam blueprint except treating inpatient severe mental illness. I have the hours, CME, and passed the exam, and have not been able to find anyone willing to sign off on the experience attestation. That's not intrinsically wrong, because I was supervised by various non-psychiatrists when clocking in those hours: pulmonary for sleep med, even though I did insomnia CME and treated that condition. Anesthesiology for pain medicine. Family practice docs (x5 separate ones) for ADHD, eating disorders, bipolar, depression, anxiety, and panic d/o treatment). I've seen plenty of SUD including dual diagnoses, conversion disorder, selective mutism, and more weird zebras... But no psychiatrist has watched me learn, grow, and excel at patient care for the mentally ill.

What is wrong is that Psych ARNPs don't have to have a lick of post-graduation experience to sit for their boards. The CAQ is not an effective pre-requisite for entry into psychiatric care, it's a demonstration of achievement. It's all well and good that it's a higher quality credential than the Psych ARNP... but it's simply not reflected in state laws or insurance reimbursement.

[EMEDPA]

Bummer you have had problems getting sign off for the exam. An EMPA I work with got sign off for covering psych pts in the ED, took the exam, and is one of only a handful of folks nationwide with 2 CAQs(EM and psych). 

[rev ronin]

1 hour ago, EMEDPA said:

Bummer you have had problems getting sign off for the exam. An EMPA I work with got sign off for covering psych pts in the ED, took the exam, and is one of only a handful of folks nationwide with 2 CAQs(EM and psych). 

They're developing an occ med CAQ, which I should qualify for from the get go. We'll see if I can get Psych CAQ before that happens. Or whether I'll have my PhD done first...

[EMEDPA]

10 hours ago, rev ronin said:

They're developing an occ med CAQ, which I should qualify for from the get go. We'll see if I can get Psych CAQ before that happens. Or whether I'll have my PhD done first...

Then we will have to call you the right reverend doctor, doctor 

[sas5814]

Psych has always been unique and challenging for PAs because we didn't have a unique designation for it like NPs did. Now we have the CAQ. It will take time and education for that to carry the weight it should and it will be driven by insurance reimbursement. Always follow the money. Once all the insurers will pay for a psych PA we will be on equal footing.

[rev ronin]

10 hours ago, EMEDPA said:

Then we will have to call you the right reverend doctor, doctor 

Thankfully, I come from a very low church tradition so my joke of a handle will stay just that. Now, if I was Anglican Clergy in the UK, that would be some interesting possibilities for styles of address.

[iconic]

Some insurances (blue cross) actually reimburse PAs less than Psych NPs..

[SedRate]

On 9/13/2023 at 7:07 PM, iconic said:

Some insurances (blue cross) actually reimburse PAs less than Psych NPs..

That's lame. How does that get fixed? 

[PACali]

On 9/9/2023 at 9:22 AM, rtPA20 said:

This is specific to my experience and I want to share what I've seen as a new PA-C and what the trajectory looks like for psychiatry for PAs. I'm currently moving to a state where preferential hiring is given to nurse practitioners for psychiatry and mental health legislation is not written to include PAs so I'm actively switching out of psychiatry, which I love, for personal reasons. 

 

I was asked to obtain my CAQ in psychiatry prior to hire as an expectation, not as an option. I have worked with more autonomy - or so I'm told- than PA counterparts in other fields of medicine. I have been the clinical lead for a variety of state funded programs, worked on consult service for residential rehab for SU, and maintained an ongoing outpatient panel as well. I have had the incredible privilege of working with a physician who has supported and invested in my growth, which I hear is a diminishing characteristic, and I've worked with every level of education in the mental health sector outside of those who prescribe. Given the requirements to obtain a CAQ, there are certain aspects of my job which I am not recognized for such as functional impairment assessments or filling out diagnosis forms which our clinic then uses to justify occupational, social, and functional assistance programs that we provide and are funded through the state. I provided every possible white paper, position statement, my actual didactic and clinical coursework, description of the summative exam, and the actual PANCE and was still viewed as not certified in a capacity to provide equal access to services as the NPs and physicians in my clinic - I'm the only PA, btw. I was specifically asked, "Can't he just write board-certified psychiatric physician assistant?" This is where nomenclature matters, and where the ethics and legality of title carry weight more so if I were to sign documentation as such and which I won't and have not done. I have thoughts through my experience and recognize that there are a variety of individuals who will read this and have their own thoughts. My goal in sharing is to not be inflammatory or to speak without substantiating my claims. 

There are not many who carry CAQs compared to the amount of PA-Cs in the country. I am thankful for lateral mobility, but as I have had to apply for other positions, in other specialties, I am not asked if I am capable or qualified to transition to another specialty but rather how do I justify leaving psychiatry after one year of practice and believing I can work in fields like pain management, palliative medicine, and family practice - yes, these are responses I have received. Mind you, I have just graduated so I haven't completely lost the mental muscle mass acquired in PA school for the generalist aspect of our training and am reviewing AAPA-provided CME to flex those muscles and refresh. I do not believe that the PA-C long-term will be enough. For me, it has not been enough despite obvious lacking of training and capacity in counterparts who have received online, diploma-mill education with maybe 3 clinical medicine courses but who have a psychiatric certification upon completion of their respective exam. This makes me think about the nature of medicine and how as we move forward as a profession, the CAQs will matter whether we believe they do add value or not. In my process of applying to psychiatric jobs, I was told by at least 3 different medical directors that they looked up if a PA is certified in psychiatry, they found out about CAQ, and asked me to obtain this prior to being considered. I have seen these same job postings remove the Psych ARNP/PA-C, CAQ-Psych preferred, and replace with Psych ARNP only, and my follow up with these organizations as I got closer to being able to sit for the CAQ in psych was, "we have decided to move forward with only psych NPs." I anticipate that hospitalist CAQ will be a future requirement or preferred when applying for a job similar to an acute care NP certification in the minds of organizations that have a predominantly APP base of staffing.

I realize the burden and the rigor of PA school and what PA-C means and how it carries weight to those who understand our training. Those who understand our training are not making decisions in the hiring process. Credentials are progressively mattering more. With NCCPA offering CAQs, it has already happened with psychiatry that we be asked for this certification, but the kicker? You must have experience and a physician willing to sign off on your CAQ which is much more stringent in nature than other professions and if you don't have experience, how do you get it if that's what's required to be hired? I found the end of my PA training to be exhaustive and the summative and PANCE took a chunk out of my academic passions and mental resilience that I'm still recovering from a year and some months later. To think that every 10 years or 6 through PANRE-LA, we must sit for both the PA-C and a separate CAQ(q 10 years) is not pragmatic nor prudent as our profession moves forward. It makes more sense, if we are aligned truly with the medical model and how physicians are trained to be able to keep our PA-C and if there is a CAQ and this is where our practice is, then we should renew what we are actively doing. This is a paradigm shift, and I am nobody in the grand scheme of our profession, but I do feel that for any new PAs who read this they might be advised or counseled in some way. 

 

Tldr; CAQs already carry weight in some forms, it's a matter of when, not if, that all CAQs will be a requirement. Leadership should not be reactive, it should be prudent in action and have forethought. The only ones who know how challenging it is to obtain the PA-C is are not the decision-makers. NCCPA will likely cause more harm than good as we move forward as a profession without active change. 

Why can't we come out with certificates program just like PMHNP? 

Regular PA school (which already included behavioral health in didactic and clinical rotation) plus a psychiatry certification = way more training than PMHNP

 

[iconic]

5 hours ago, PACali said:

Why can't we come out with certificates program just like PMHNP? 

Regular PA school (which already included behavioral health in didactic and clinical rotation) plus a psychiatry certification = way more training than PMHNP

 

I think a CAQ would work just fine for that. The problem is that most in our profession do not want any sort of independence (which is what it comes down to), and most PAs do not particularly care about needs or issues of Psych PAs (or any one group of PAs, really). Whereas nurses seem to support each other regardless of their specialty, at least on the political level

Edited October 4, 2023 by iconic

[sas5814]

38 minutes ago, iconic said:

I think a CAQ would work just fine for that. The problem is that most in our profession do not want any sort of independence (which is what it comes down to), and most PAs do not particularly care about needs or issues of Psych PAs (or any one group of PAs, really). Whereas nurses seem to support each other regardless of their specialty, at least on the political level

I think that is kinda true but more there are too many PAs who are comfortable and don't have a clue what is happening outside their own workspace. By the time there is enough pain for everyone to notice what is going on it will be way too late.

[rev ronin]

11 hours ago, iconic said:

I think a CAQ would work just fine for that.

We have a CAQ. It is not available to those who have not yet worked in psychiatry, regardless of education or training. I can't see NCCPA authorizing two competing/overlapping CAQs.

[iconic]

17 hours ago, rev ronin said:

We have a CAQ. It is not available to those who have not yet worked in psychiatry, regardless of education or training. I can't see NCCPA authorizing two competing/overlapping CAQs.

I am not sure what you mean by 2 CAQs

[rev ronin]

6 hours ago, iconic said:

I am not sure what you mean by 2 CAQs

The psychiatry CAQ exists. It requires several things, including a psychiatrist or senior psych PA to sign off on one's 1000 hours of experience.

If there were another psych CAQ equivalent to a Psych NP board, it would not require any experience, CME, etc. just the completion of their program with whatever clinicals are involved.

For better or worse, the NCCPA has chosen the former path. There's no room for two CAQs, one for PAs with psych experience and one for PAs without, so we've got the one they architected.

[PACali]

On 10/5/2023 at 11:28 PM, rev ronin said:

The psychiatry CAQ exists. It requires several things, including a psychiatrist or senior psych PA to sign off on one's 1000 hours of experience.

If there were another psych CAQ equivalent to a Psych NP board, it would not require any experience, CME, etc. just the completion of their program with whatever clinicals are involved.

For better or worse, the NCCPA has chosen the former path. There's no room for two CAQs, one for PAs with psych experience and one for PAs without, so we've got the one they architected.

 

I am not suggesting the need for another CAQ or board specifically for psychiatry. The Psych-CAQ offered by the NCCPA is sufficient for "credentialing" purposes.

As OP pointed out, the primary challenge stems from the fact that we lack specialization in mental health. In many states, there are dedicated departments of mental health, resulting in stricter regulations compared to other medical specialties.

Many employers require evidence of specialized psych training to ensure that we are "equivalent" to PMHNP. While PA students do receive behavioral health training during both didactic and clinical years, employers are not familiar with the ARC-PA standards.

I believe that additional psych training, maybe another 15 units, would help us align with online PMHNP programs, especially from the employer's perspective. Institutions like Rocky Mountain and Lynchburg offer certificates in behavioral health, and I think we should have more programs like these to demonstrate that we are on par with, if not superior to, online PMHNP programs (Again, from the employer's perspective.)

Here are the links to the programs at Rocky Mountain and Lynchburg:

Rocky Mountain Program: https://rm.edu/psych-cert/

Lynchburg Program: https://www.lynchburg.edu/graduate/doctor-of-medical-science/behavioral-medicine-concentration/

Here is an insightful paper on this topic titled "The Future of PAs in Mental Health."

 

Edited October 21, 2023 by PACali