As the US faces a projected psychiatrist shortage of between 14,000 and 31,000 by next year can APPs be part of the solution?
Interdisciplinary teams providing collaborative care—with closely-defined roles for each team member and tightly supervised patient treatment—are set to become still more widely established.
One such team, led by an ACLP member, was highlighted in the March issue of ACLP News.
Their expansion into more clinical areas has resulted, in part, from a severe shortage of C-L psychiatrists, exacerbated by increased demand for mental health care among patients post COVID-19, high costs of health care delivery without commensurate increases in mental health insurance reimbursement, and institutional recognition of integrated care alongside financial constraints.
Faced with a projected psychiatrist shortage of between 14,000 and 31,000 by next year, some argue that recruiting Advanced Practice Practitioners (APPs) is a better and more cost-effective mental health workforce solution than recruiting physician locums (costly, unsustainable) or using telehealth (effective for many patients, but with reach still limited by psychiatrist adopters). Others assert that stronger training, supervisory, and organizational structures are needed to adequately support a workforce expanded through APPs.
Thus, advocates who support APPs as collaborative team members and physician extenders seek to address concerns about limited experience. Both physician assistants (PAs) and advanced practice psychiatric nurses (APNs) are roles requiring graduate education, clinical training, and licensure to practice (under either a medical, an osteopathic, or a separate nursing board), and both have doctorate-level tracks.
The curriculum of the average APN program lasts approximately 16 to 24 months and includes 500 supervised clinical hours. By comparison, psychiatrists providing services to adults require 48 to 60 months of supervised clinical hours and child psychiatrists 60 to 72 months.
Many APPs have generalist training, and no additional training is required to change to specialty practice (although a specialized psychiatric mental health nurse practitioner training path is available).
Psychiatrists complete four years of medical school and at least an additional four years of postgraduate psychiatric training before starting to practice.
Within APP training, clinical rotations may provide only weeks of exposure to Psychiatry practice.
The difference between clinical training for APPs and clinical training for psychiatrists is therefore stark.
“C-L Psychiatry is a field that requires broad and deep knowledge of medicine/pediatrics and psychiatry which includes knowing ‘when there is not a pill for that’ or ‘when it is not just depression, but stage 4 esophageal cancer’ and being able to understand how and when to apply the correct psychotherapeutic and psychosocial interventions as well as psychopharmacologic treatments,” says ACLP president Maryland Pao, MD, FACLP.
“It requires extensive training and experience to be an expert C-L Psychiatry practitioner to help our patients. Help can include making the correct diagnosis, applying the right treatment, making sense and meaning out of being medically ill, and improving quality of life even with an incurable illness.”
Perceived advantages of APPs, however, are the larger number of ‘providers’ available and the comparative cost advantages. Latest available statistics show that in 2019, the US had 139,688 certified PAs; 1.9% worked in Psychiatry. For APNs, those numbers were higher: more than 355,000 were licensed in the US and 6.5% certified to work in Psychiatry.
APP salaries are typically 50%-60% of physician salaries. Although institutions may incur additional costs for physicians to supervise APPs, the total costs of an APP are calculated to be still lower than those of a psychiatrist.
In addition to lower training requirements, concerns about APPs include lack of supervision, minimal exposure to complex medical and psychiatric needs, particularly in community settings, and adherence to safe prescribing practices.
“The key issue that raises concern is about expansion of practice and independent practice that is not supported by the level of knowledge, training, experience, and expertise required for patient safety,” says Rebecca Weintraub Brendel MD, JD, FACLP, ACLP president 2018-2019, and current president of the American Psychiatric Association.
The recruitment of APPs, with their current level of training, are also seen as a potential patient safety risk by Miriam Tepper, MD, and Emily Farb, PMHNP [Psychiatric Mental Health Nurse Practitioner], writing for the American Psychiatric Association’s Controversies in Psychiatric Services series. They say: “Although all APP training programs license their graduates to treat psychiatric patients across the lifespan, many graduates do not receive child/adolescent training experiences with the depth and breadth required to treat this population safely. Additionally, most new graduates need supervision in their first few years of practice, which is not always available.”
Some argue that, rather than recruiting extra generalist ‘providers’, more innovative, personalized health care structures are needed.
For example, ACLP member Ramaswamy Viswanathan, MD, DrMedSc, FACLP—who will become APA president-elect at the conclusion of the APA Annual Meeting in May—has advocated that Psychiatry’s focus should be on training subspecialists to provide a higher level of expertise in particular disciplines. In addition to providing direct care, subspecialists would act as consultants to other physicians, including psychiatrists, to extend their reach. “Subspecialists help enrich the whole field of Psychiatry, and ultimately benefit our patients,” he says.
Yet, what is already happening on the ground through the recruitment of APPs (driven by the immediacy of a perceived ‘solution’) appears for now ‘the only game in town’ to offset demand into 2024 and beyond.
Some would say the prospect of high-performing, well-respected, interdisciplinary teams working collaboratively with closely defined (i.e.: restricted) roles for APP team members, and tight controls over patient treatment and safety, are far and away not just the only, but the best game in town—a prized workplace solution to psychiatrist shortages.
Either way, that’s why the Academy is starting a preconference course for APPs at CLP 2023, in an initial move to share and evolve expert C-L Psychiatry knowledge and experience for all interdisciplinary team members.
“The gap in training and experience that APPs receive compared to C-L psychiatrists has been highlighted,” says Dr. Pao. “ACLP seeks to become the go-to resource for best practices in consultation-liaison service delivery.”