October 4, 2006
Physician Assistants in Mental Health
Physician assistants (PA) are health professionals licensed or, in the case of those employed by the federal government, credentialed, to practice medicine with physician supervision.1 "The AAPA [American Academy of Physician Assistants] believes that the physician-PA team relationship is fundamental to the PA profession and enhances the delivery of high quality health care." "The traditional relationship between PAs and physicians, the hallmarks of which are frequent consultation, referral, and review of PA practice by the supervising physician, is one of the strengths of the PA profession."2
Education
To practice as a physician assistant in the United States, a person must graduate from an accredited PA program. In most programs this formal education runs approximately 26 continuous months. The first 9 to 12 months in a PA program are spent in the classroom studying such courses as anatomy, biochemistry, microbiology, pathophysiology, pharmacology, and physical diagnosis.3 The second 12 to 15 months more than 50 weeks or 2000 hours) are spent in clinical rotations, learning family medicine, emergency medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. The typical student accepted into a PA education program already has a bachelor's degree and approximately four years of health care experience.
In November of 1971 the American Medical Association's (AMA) House of Delegates, on recommendation of the Council on Medical Education, adopted the "Essentials of an Accredited Educational Program for the Assistant to the Primary Care Physician," clearing the way for the approval of educational programs that met or exceeded these requirements. The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA-PA) has overseen accreditation of PA programs since January, 2001.4 The American Academy of Family Physicians, the American Academy of Pediatrics, the American Academy of Physician Assistants, the American College of Physicians, the American College of Surgeons, the American Medical Association, and the Association of Physician Assistant Programs all cooperate with the ARC-PA to establish, maintain, and promote appropriate standards of quality for entry level education of PAs and to provide recognition for educational programs that meet the minimum requirements outlined in the Standards used by the ARC-PA for the development, evaluation, and self-analysis of physician assistant programs.
To receive accreditation, PA programs must provide training in basic medical sciences (e.g. human anatomy, physiology, pathophysiology, and pharmacology), as well as behavioral and social sciences (including personality development, child development, normative responses to stress, psychosomatic manifestations of illness and injury, sexuality, and responses to death and dying). PA students must be taught "basic counseling skills" in such areas as health care management, normal growth and development, family planning, and emotional problems of daily living.
Scope of Practice
In most states PAs may provide medical services they have demonstrated competence in by formal and informal training, that their supervising physician is also qualified to provide, that their supervising physician also provides, and that are delegated by the supervising physician. In most states this includes prescribing medications and medical devices. The ultimate role of the physician assistant cannot be rigidly defined because of variations in individual practice requirements. Diagnostic and therapeutic medical tasks common to the supervising physician's practice may be assigned to the physician assistant by a after demonstration of proficiency and competence. Within their scope of practice, physician assistants provide health care that is indistinguishable in quality from care provided by their supervising physicians.5
Employment
PAs may be employed by a variety of entities, including solo physicians, group practices, hospitals, Health Maintenance Organizations. According to the Seventh Report to the President and Congress on the Status of Health Personnel in the United States - U.S. Department of Health and Human Services, "The geographic distribution of PAs more evenly matches the population than other primary care providers."
Certification
To maintain national certification, a PA must log 100 hours of continuing medical education (CME) every 2 years and sit for recertification exam every 6 years (given by the National Commission on the Certification of Physician Assistants [NCCPA]). They are the only health care profession to require recertification by exam every 6 years.
Specialty Practice
As of 2005, there are approximately 59,000 practicing PAs. PAs practice in a variety of specialty and primary care settings. According to the 2005 AAPA census 28% of PAs practice in family or general medicine, 25% in surgical specialties, 4% in pediatrics, 18% in internal medicine specialties, 10% in emergency medicine, 2% in obstetrics and gynecology, and 13% in other specialties (including 1% in psychiatry). PAs are credentialed in general medicine by the NCCPA. There are no mechanisms for formal specialty credentialing of PAs, in any specialty.
Formal post-graduate training programs are available in some specialties for graduate PAs, including two in psychiatry (both in the state of Iowa, providing formal training for 1-4 fellows a year).
Association of Psychiatric Physician Assistants (APPA)
The APPA has been recognized by the AAPA as a specialty constituent chapter since 1998, and represents PAs who specialize in providing mental health care. According to a 2002 survey of APPA members, 32% had a bachelor's degree with advanced training, 53% had a master's degree, and 10% had a doctoral degree. Twenty-nine percent of APPA members had additional mental health practitioner licensures. The typical member had over 10 years of experience in the specialty of psychiatry. Work settings include private psychiatric practice (56%), state and county hospitals and clinics, nursing homes, non-profit mental health centers, correctional facilities, the Public Health Service, and the Veterans Administration. Duties performed by members include:
- Conduct initial psychiatric evaluations following DSM guidelines
- Diagnose psychiatric conditions
- Initiate treatment protocols and provide follow-up treatment
- Provide medication management
- Perform individual & group therapy
- Prescribe psychotropic medications
- Perform psychiatric evaluations for hospital admissions
- Write admitting orders for mental health treatment in a hospital setting
- Perform routine history and physical examinations, as needed
- Make rounds on psychiatric patients in hospitals & nursing homes
- Evaluate & treat general medical conditions in psychiatric patients
- Manage patients in alcohol detoxification
- Perform pre-ECT evaluations & post-ECT follow-up monitoring
CMS Program Memorandum AB-03-037 includes PAs as qualified mental health providers (March 28, 2003). In most states PAs meet formal definitions for "mental health providers."
Notes:
- AAPA Policy Manual
- The Pew Health Professions Commission, 1998.
- Physician Assistant Education Association - http://www.paeaonline.org
- http://www.arc-pa.org
- Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis, December, 1986. Washington, D.C.: Office of Technology Assessment, United States Congress.
Don St. John MA, PA
Association of Physician