Dr Michael Asbach on the Evolution of PAs in Psychiatry

Key Topics Discussed

• PA training model and the medical-model approach: How pathophysiology and gross anatomy education positions PAs uniquely in psychiatry’s “golden era” of biological treatments
• Evidence on APP quality of care: Critical analysis of the BMJ rapid review and UK Leng Report, addressing methodological limitations and workforce policy implications
• “Autonomous collaboration” versus scope creep: Reframing the workforce debate to focus on interdisciplinary team models that respect physician expertise while expanding patient access
• Psychiatry workforce solutions: The “Build, Baby, Build” approach to healthcare staffing and how APPs address critical shortage areas
• Regulatory landscape and supervision requirements: State-level practice variations, supervision ratios, and their impact on care delivery and patient access

Episode Overview

Dr. Michael Asbach, a doctorally prepared Physician Assistant (PA) and Associate Director of Interventional Psychiatry at the DENT Neurological Institute, joins The JCP Podcast to discuss the critical and expanding role of Advanced Practice Practitioners (APPs) in behavioral health. A nationally recognized educator with a career that spans from sports medicine to leading interventional psychiatry programs, Dr. Asbach shares how the medical-model training of Physician Assistants uniquely positions them to help address the growing psychiatric workforce shortage.

In a nuanced discussion, Dr. Asbach tackles the headlines and controversies surrounding the profession, including the recent British Medical Journal rapid review and the UK’s “Leng Report.” He dismantles the concept of “scope creep,” arguing instead for a model of “autonomous collaboration” that respects physician expertise while maximizing patient access. From the history of PAs emerging after the Vietnam War to the modern “Build, Baby, Build” approach to healthcare staffing, this episode provides a scalable roadmap for how interdisciplinary teams can alleviate burnout and improve outcomes in the golden age of biologic psychiatry.

The Guest

Dr. Asbach completed his Master’s in Physician Assistant Studies at Daemen University and his Doctor of Medical Science at A.T. Still University. He holds the Psychiatry Certificate of Added Qualification from the National Commission on Certification of Physician Assistants and serves on multiple national committees including the Psych Congress Steering Committee and the Psychiatric Times Editorial Board. He is also medical liaison to the American Psychiatric Association on behalf of the American Academy of Physician Associates and co-founder of White Coats of the Roundtable, a career development resource for healthcare professionals.

Further Reading

Journal of Clinical Psychiatry: psychiatrist.com/jcp/

Michael Asbach: https://www.dentinstitute.com/michael-asbach/

White Coats of the Round Table: https://healthpodcastnetwork.com/show/white-coats-of-the-round-table/

The Host

Ben Everett, PhD, is the Senior Scientific Director for The Journal of Clinical Psychiatry and Psychiatrist.com, where he oversees editorial strategy, content development, and multimedia education initiatives. He is the creator and host of The JCP Podcast, a series that brings together leading voices in psychiatry to explore the latest research and its clinical implications. Dr. Everett earned his PhD in Biochemistry with an emphasis in Neuroscience from the University of Tennessee Health Science Center. Over a two-decade career spanning academia, publishing, and the pharmaceutical industry, he has helped launch more than a dozen new treatments across psychiatry, neurology, and cardiometabolic medicine. His current work focuses on translating complex scientific advances into accessible, evidence-based insights that inform clinical practice and foster meaningful dialogue among mental health professionals.

Full Episode Transcript

This transcript has been auto-generated and may contain errors. Please refer to the original recording for full accuracy.

00:00 – JCP Podcast Kickoff and Introduction to Dr. Asbach

Dr Ben Everett (0:08)

Good morning, and welcome to the JCP podcast. I’m your host, Dr. Benjamin Everett, Senior Scientific Director with Physicians Postgraduate Press Incorporated, who is the publisher of the Journal of Clinical Psychiatry. Today I’m joined by Dr. Michael Asbach, a doctorally trained physician assistant who is Associate Director of Interventional Psychiatry at the Dent Neurological Institute in Buffalo, New York. Mike earned his Master’s Degree in Physician Assistant Studies from Damon University and his Doctor of Medical Science from A.T. Still University. He also holds the Psychiatry Certificate of Added Qualification from the National Commission on Certification of Physician Assistants, the certifying body for PAs in the United States. Mike is a nationally recognized educator and frequent CME speaker with expertise in treatment-resistant depression, bipolar disorder, and emerging psychiatric therapies.

He teaches at several universities and serves on the Psych Congress Steering Committee, the Editorial Board for Psychiatric Times, and as a medical liaison to the American Psychiatric Association on behalf of the American Academy of Physician Associates. He’s also the co-founder of White Coats of the Roundtable, a podcast and newsletter supporting career development for healthcare professionals, and recently launched the Nonclinical Collective, a podcast for healthcare practitioners by healthcare practitioners. Today we’ll be talking about the growing role of advanced practice practitioners in behavioral health and the care of patients with neuropsychiatric disorders.

So welcome, Mike.

01:34 – Expanding PA Engagement and Education in Psychiatry

Dr Michael Asbach (1:35)

Hi, Ben. Thanks for having me. So excited to be here.

I was looking through our email chain and you and I have been exchanging emails, discussing the role of PAs in psychiatry for nearly a year, so it’s exciting to be here to talk about it.

Dr Ben Everett (1:47)

That’s right. I mean, we at Psychiatrist.com, we really want to do more to, you know, recognize the work that advanced practitioners are doing as well as provide, you know, more educational venues and things like that through the website, so we’re always working on new ways of reaching and broadening our audience and providing, hopefully providing good information that can, you know, immediately impact, you know, clinical practice.

So that’s what we aim to do anyway with JCP and the primary care companion.

Dr Michael Asbach (2:16)

I think it’s so important to have those additional resources as we’ll talk about in the next hour, but the PA and NP profession especially are much more oriented towards on-the-job training, the ability to continue to grow and learn after you’ve already graduated from your formal education. So the resources that are out there are important and continuing to pour into those is just such an important part of the growth of our profession. So I certainly appreciate it from a perspective of a PA.

Dr Ben Everett (2:42)

I agree with that and I’d tell you, I’ve done a lot of lectures through the years and I found that advanced practitioners will show up to just about any educational offering. They’re highly engaged, ask really thoughtful and insightful questions. So I’ve always really enjoyed lecturing to advanced practitioners and taking questions.

Really a very curious group and very motivated group to stay on top of practice patterns and what’s new. All right, so let’s start at the beginning. We start every episode with some icebreaker questions, kind of the same format.

Try and give people just a little flavor for who you are as a person and get a little bit beyond just the professional. So what initially drew you into healthcare?

03:22 – Career Origins and Choosing the PA Path Over Medicine

Dr Michael Asbach (3:22)

Yeah, so in high school, I was a three-sport athlete. I had a lot of interest in sports medicine as a result and originally I was thinking about physical therapy. I loved the idea of doing something that would still connect me with sports and competition and I loved the environment.

And in my junior year of high school, I spent a summer internship at a physical therapy practice and the physical therapist there who was a family friend actually said, you know what, my wife is a PA. You should check out the PA profession. It’s similar level of education, a lot more flexibility, a lot more opportunity.

So I started looking into it and almost instantaneously fell in love with the concept of PA. I thought about med school for a while. I was not certain I wanted to dedicate 12 to 15 years of my life to schooling at that point.

So PA seemed like a happy compromise where I could still get into healthcare, do something that I love, but maybe not have as long of a commitment as physician training would entail.

Dr Ben Everett (4:21)

Yeah, and I’ll tell you another thing with physician training is it is quite the commitment from a time standpoint. I think of like neurosurgery, you know, people are in training for so long and I’ve got a good friend who’s a vascular surgeon that’s general surgery plus a two-year fellowship. It is really quite the commitment and, you know, tuition has just gotten so expensive.

So, you know, many, I think the figure’s up to about a half million dollars of debt that a lot of kind of the average med student is when they’re finishing. That’s just a staggering amount of debt. So anyway, so you kind of answered the next one was, you know, why physician assistant?

So you got through that. So, you know, as you mentioned, the PA role and the nurse practitioner role, you can see, you know, I’ve interacted with advanced practitioners as a patient across numerous different areas of medicine. So what drew you into psychiatry?

05:11 – Discovering Psychiatry and the Appeal of Interventional Innovation

Dr Michael Asbach (5:11)

Yeah, so even through PA school up until graduation, I thought I was going to do orthopedics, emergency medicine, sports medicine. I was pretty dead set on that. And thankfully during my clinical year, I loved my clinical rotations in surgery and orthopedics, but I recognized pretty early on that it was exciting, but I wasn’t sure if I would still be excited getting called in on Christmas Eve to do a femur fracture, having to, you know, be mandated to work overtime when I really wanted to be at my kid’s birthday party.

So during clinical rotations, I started to maybe have a little bit of self-doubt that ortho, ER, these fields that felt exciting were actually going to be the right fit for me. So after I graduated, I had a couple job offers in surgery, a couple job offers in ortho, and they were all great offers, but almost all of them entailed maybe 60 to 65 hours a week. Lots of on-call time, lots of time that’s, you know, outside of traditional working hours.

So I started exploring some other options. I had done ROTC in college, so I was already, you know, committed to going into the Army. And I had a lot of interest in mental health from a military perspective.

I did my behavioral health rotation at an inpatient PTSD facility with the VA, and I loved it. At the time, I thought I loved it because it was military-focused, not necessarily mental health. So when I was uncertain, didn’t really like any of the job offers that were coming my way, my wife actually encouraged me to apply to a psychiatry job, which ironically is the same position I’m still in.

And I applied on a flyer, thought, what’s it going to hurt? Came in and interviewed, and at my first interview, within five minutes of walking into Denton Neurologic Institute, my medical director, Dr. Capote, took me to see a TMS mapping. So we went and did a transcranial magnetic stimulation mapping.

He was explaining motor threshold and making the thumb twitch to find the right area, and I was enthralled. I was in love within five minutes. And what drew me into psychiatry that I never even realized was an interest or passion of mine was I just fell in love with the idea of psychiatry as this final frontier of medicine where we don’t still understand it or really have all the answers.

And to think in my young 20s, when I was graduating, that over a 40-year career, what I do is probably going to be unrecognizable. And even, I’ve been doing this for 13 years, I run an interventional psych program here, and everything that I do in the interventional psych department, I did not learn in school. So things are just evolving and changing so rapidly.

And that’s what I love about this field. I love that we can have longitudinal relationships with patients, that we really become part of patients’ lives in such an important manner. But also that we’re in a field that even just year by year, every new journal article that comes out, you feel like there’s these big seminal shifts in our understanding of illness, and then hopefully that translates into better outcomes for patients as well.

Dr Ben Everett (8:01)

Yeah, I tell you, I agree with at least what you’re talking about with technology. I learned in grad school, technology drives science. A lot of times we’re asking the same questions we’ve been asking for 100 years, but we have new ways to think about the questions and the disorders and whatnot.

Yeah, it’s really kind of become the golden age of, I’d say, both neurology and psychiatry. We’re just learning so much in functional MRI and just all these different things. The circuits are extremely complicated, you know, and there’s so much to know, there’s so much to learn, but I think it makes it a really exciting time to be in mental health.

So what about any mentors or experiences that really influenced your decision to stay in interventional psychiatry? You mentioned, you know, you were pretty much hooked right away, but…

08:46 – Mentorship, Research Culture, and Advancing Psychiatric Treatment

Dr Michael Asbach (8:48)

If I were to narrate, there’s so many positive influences. And I do love, the psychiatric community is incredible, especially as we’re talking about advanced practice clinicians, where I think there’s a lot of turf wars. There’s a lot of tension, I think, sometimes interprofessionally in other fields of medicine.

I’ve never felt that in psychiatry. I think everybody recognizes that we’re all in this together, that there’s not enough manpower to address the need. And that, I think, leads to a very collegial, collaborative environment.

And I love that. So there’s countless number of people that have been a positive influence in my career and my development. But I think the two that I would call out is my medical director, Dr. Horatio Cabote. I’ve been in the same job for 13 years now. Obviously, you know, title role changes, but I really appreciate that right out of school, I was able to find a spot where I could make it my home, but then also just continue to learn under him, mentor. And I think the ability to not jump from job to job, but stay in one place and really become a master of that craft, I think is really valuable.

Also, he’s forever Dent Neurologic Institute, but also Dr. Capote have had an ethos of innovation and always wanting to make sure that we’re on the cutting edge. We have a research component here at, right now, I think we have over 100 clinical trials that are ongoing. So we’ve always had a commitment to continuing to forward the science, forward our understanding of medicine.

And certainly that has influenced me as well. Outside of Dent, I think one of the biggest influences is Dr. Roger McIntyre, who ironically introduced us, but Dr. McIntyre is just up the road in Toronto. So he’s only about 45 minutes away.

We’ve had the privilege of collaborating with him on some research and contributing our data sets from our practice. But his scholarship is obviously quite impressive. But I also love that he is unafraid to look at things in creative or tangential ways.

Sometimes it may look like ADD, but I think he just, he loves to find a string and just pull on it and see where it leads. And I think that really is what I love about psychiatry. What I love about medicine is the idea that we need to constantly challenge dogma.

We need to constantly challenge the way that things were previously done, because if we are just too accepting of how it was done in the past or the accepted way to approach things or understand things, then we aren’t able to achieve true innovation. So I do appreciate Dr. McIntyre’s approach to scholarship in that sense. And I think that’s also had a very heavy influence on me as I’ve developed as a clinician.

Dr Ben Everett (11:11)

Excellent. Yeah, it sounds like you’ve really got a couple of really good and strong mentors. And yeah, it’s pretty unusual, I feel like, this day and age for people to stay in one job for 13 years.

But it’s awesome not just for you getting to know your patients, but I think on the patient side as well, that continuity of care is awesome. When you can see kind of the same individual or at least team of individuals over the course of an illness of a lifetime, I think it’s excellent when a patient can see the same provider or team of providers over the course of their lifetime, over the course of their illness. I think it really helps with continuity of care.

I completely agree.

Dr Michael Asbach (11:50)

I love that. I’ve now been doing this long enough that I have patients I started to see when they were adolescents, and now they’re married with babies or getting their first big promotion in their career. And it really is just such an amazing part of medicine, but psychiatry specifically, that we are blessed.

I’m going to use the word, we’re blessed to be able to play such an important role in people’s lives, but then also have this front row seat to their life longitudinally, where we get to see them celebrate in so many triumphs, but also be there to help and support them during trials and tribulations as well. It really is just such an amazing part of medicine, and I never want to lose how special that is for us to have that.

12:28 – Understanding PA Training Models and Evolving Clinical Competency

Dr Ben Everett (12:28)

That’s awesome. And then I want to come back to, you said about 100 active clinical trials going on right now. I think that really does underscore kind of the point I said earlier about technology drives science.

We’ve got all these new TMS and all sort of interventions that we can do now, but also a lot of drugs under development for a number of different things that have really been very difficult to treat, or we haven’t had advancements in quite some time, you know, Alzheimer’s disease, schizophrenia. This is really, I feel like it’s a very exciting time to be in this space, in this field. All right.

So for our listeners who may not be overly familiar, can you explain what a physician associate or assistant is? There’s some back and forth on the nomenclature here, and some of it depends on if you’re talking about the United States or Europe. So how this role differs from physicians and nurse practitioners?

And then, you know, in your opinion, what unique contributions can PAs make in healthcare generally and in psychiatry specifically?

Dr Michael Asbach (13:25)

Yeah, absolutely. So I think a little bit of a history lesson here can be helpful. So the PA role or the PA profession was developed after Vietnam, and what ended up happening is there was medics and corpsmen that were coming back from Vietnam that were incredibly high trained, did a lot, had a very high level of scope of practice while in battlefield medicine during the Vietnam War.

And they came back, and there was really not a role for that skill set on the civilian side. So Dr. Eugene Stead at Duke identified and created the physician assistant role. So the idea behind this was to have a role that was below a physician, but would help fill physician shortages and take advantage of that very high level of training that was occurring in these military medics.

So the profession is relatively new, just developed in the past, you know, 50 or 60 years. And over time, it has certainly evolved. Back in the 1960s, I think when the PA profession first developed, it was very common for a physician to hire a singular PA, take that PA under their wing, mentor them, grow them, and work as a team and almost as an extender of the physician.

As healthcare has become more complicated, more corporate, more large scale, I think you’re starting to see the role similar with nurse practitioner evolve to be one of more autonomous practice in a multidisciplinary team. More broadly about PA training, PAs are master’s level trained. Usually the program is about two to three years long.

It’s training in the medical model. So it’s a very similar model of education to physician training, a little bit more condensed. It includes a year of clinical experience, so at least 2,000 hours of clinical experience.

The big differentiation between a PA and a physician training is certainly the didactic portion is a little bit more condensed. But when you compare it to three-year med schools, there’s not a ton of difference. The big difference is there’s no residency.

So a physician really, when I speak to my physician colleagues, almost all of them will tell you that their training, where they really cut their teeth as a physician is in residency. That’s where kind of the rubber meets the road. So the difference between PA and physician training is PAs are turned loose without residency under the auspices that on-the-job training is going to be that much more emphasized.

And there’s research that show that about seven years out of school, PAs will end up with about 15,000 hours of clinical experience or what would be equivalent to your average residency. So on-the-job training is more emphasized and that really does allow for greater flexibility where we can be deployed. Certainly a new graduate PA is going to have a very different scope of practice and level of competence versus a PA who’s been in critical care for 30 years.

So our profession is very much reliant or foundationally built on the idea that scope of practice, competence will evolve with time. And I think that’s true for any medical profession. As we talked about earlier, medicine changes very quickly.

So when we graduate from any formal didactic program, our knowledge can’t be static. Otherwise, we’ll be left behind very quickly. So I do appreciate that the PA and even the NP professions as well, I think have a very high emphasis on you are not a finished product when you leave school, but rather you’re just embarking on a lifelong journey to continue to learn and hone your craft.

16:44 – Addressing Psychiatry Workforce Shortages Through Advanced Practitioners

Dr Ben Everett (16:44)

Yeah, awesome. Thanks for all that background. So psychiatry, like many specialties in medicine, is facing a critical workforce, you know, shortage or I could say challenge maybe to make it sound a little bit more positive.

You know, we’ve got a large number of practicing psychiatrists are approaching retirement age. The number of new residents entering the field has not kept up with that. There’s a limited number of psychiatric residency programs for people to apply to.

And, you know, we combine that with just an increasing demand for mental health services and limits on residency spots, as I said. So there really does seem to be a growing number, a growing shortage of trained psychiatrists. And I’ll say we see this in other specialties as well, where they’re predicting major shortfalls.

And a lot of this goes back to the slimming down or the capping med school class sizes back in the 70s. So, you know, with this coming on and also just with the lack of mental health trained professionals generally, you know, on the therapist side and whatnot, you know, how do you see advanced practitioners as a qualified group of clinicians that can help address some of these shortages?

Dr Michael Asbach (17:51)

Yeah, it’s such a great question. And that really is the important thing is how do we fit in different professions, different skill sets if we are looking at a future of medicine that is multidisciplinary. And I think the shortage that we see in psychiatry is really a great example because other fields of medicine have, every field of medicine has physician shortages, unfortunately.

But psychiatry, primary care, there’s some specific specialties where that shortage is more acute. So we’re feeling it, I think, a little bit more rapidly than we are in other fields. So I think PAs really do have an important role.

There’s about 3,500 PAs now in psychiatry. So it’s a much smaller number than nurse practitioners, but it is growing. It’s actually one of the more rapidly growing subspecialties within the PA profession.

And I’m a huge believer in the PA model within psychiatry because as we just said, the PA profession is trained within the medical model. And psychiatry is, in my opinion, in this golden era of kind of firmly returning back to biologic origin where we have much better understanding of the underlying pathophysiology. And the PA, the medical model, means that PAs have taken pathophysiology, gross anatomy, fundamentals of medicine.

We have that fundamental training that I think really serves as an excellent foundation to build psychopharmacology on top of. So I think the PA profession is really well-suited, even though we all graduate as generalists, to build on modern psychiatry. So the PA profession, however, doesn’t necessarily have formal psychotherapy training.

So that’s the other aspect of it is with on-the-job training being more greatly emphasized in the PA profession is making sure that we recognize the need for formal programs, but then also informal training, not only in prescribing, but also psychotherapy. So I think the PA profession is really well set up to help. The goal or the key is to figure out how we fit in.

Certainly there’s stratification in medicine, and I think this is really the key as we move to a multidisciplinary future is that if physicians are in short supply, then I want to make sure that if I have a limited resource, which is my physician expertise, that that’s getting deployed in the best scenario. I think we would all agree that if we had neurosurgeons running blood pressure clinics, that would probably be an inefficient use of their expertise. So to some degree, we all accept that care stratification is necessary to efficiently run in healthcare.

And when we talk about the PA role or the NP role, that’s really what we’re saying is where’s the competency lie, where are the things that they can do, and where is the line for tasks that are physician-only and should be reserved for that level of expertise.

20:36 – Evaluating PA Outcomes and Challenges in Measuring Quality of Care

Dr Ben Everett (20:36)

Thanks for that. Yeah, and I know, you know, just thinking about like community mental health clinics, whether it’s like Region 8 or other types of things, you know, often because of funding constraints and whatnot, they might not be able to afford physicians or a full-time physician, but they’ll have a number of advanced practitioners there. And they’re, you know, keeping track of a number of patients with very, you know, difficult like schizophrenia that’s become, you know, treatment resistant, substance abuse that comes with that.

And so I think very commonly you’re seeing advanced practitioners in a number of these different areas, and I don’t think that’s going to go the other way. I think it’s going to increase and you’re going to continue to see more of those people there. All right, so let’s move on to, you know, I read this paper and then I immediately emailed you just say, hey, look, you got a hot take on this.

So, you know, a few months ago in the British Medical Journal, there was a title by Nicola Cooper and colleagues called Impact of Physician Assistance on Quality of Care. It was published as a rapid review. It was a UK-based study, sort of a meta-analysis and very, you know, objective, quantitatively trying to find out about quality of care PAs compared to physicians specifically.

And just to set up some of the details of the study, like some of these kind of meta-analyses, they had their, you know, objective criteria set up for the studies they were looking in, you know, they found 3,636 studies of those 167 were eligible, but only 40 met inclusion criteria. And what I really find interesting is they then say that 32 of the 40 studies that were included were of weak quality. So, I’m not sure we can draw too much from this one way or the other, but this was leaned very heavily on in the UK’s National Health Service Review of the Role of Physician Associates is the title they have in the UK and what’s been termed the Ling Report because Gillian Ling was the overseer or the supervisor contributing author for this study.

So, let me, you know, kind of with that as a background, you know, in your experience, what evidence have you seen that PAs, you know, improve outcomes for patients in psychiatry? And then maybe we can come back to the findings of the paper in and of itself.

Dr Michael Asbach (22:49)

Yeah, so the paper’s fascinating and I appreciate what is being done within this because I think actually the paper is a really wonderful consolidation of the work that’s out there regarding the role of PAs. And you’re correct. I think a lot of it, I think, highlights the limitations that we have in all workforce data.

I’m especially interested. I, for some reason, have taken a special interest in watching all the debates that are happening in the emergency medicine space where there’s a lot of debate over three-year versus four-year residencies for physicians. And even though there’s, really, there’s not convincing data that a four-year residency provides better outcomes for patients, there’s a really strong push to move to a mandated four-year residency.

Similarly, there’s a strong push in the emergency medicine space to mandate that all emergency rooms must have a physician on site, on staff, 24-7. And, you know, on its surface, that sounds like a great idea, of course, right? I want an emergency room staffed by a physician, but that really can be a challenge for rural or critical access areas.

Anywhere from 10% of emergency rooms don’t have continual 24-7 physician staffing. So if you look at that issue deeper, and I know this is a bit of a tangent, if we mandate that all emergency rooms have physician staffing, two things may happen. One is if they can’t afford a physician, as you said earlier, with community mental health, they may end up having to shut down.

And if that’s the only emergency room in a two-and-a-half-hour radius because it’s out in foreign country, that may not be better for the community. But two, they may staff with a physician who’s maybe a pediatrician, a family medicine physician who’s moonlighting just to make sure that they’re checking the box. And this is where it gets a little bit complicated because certainly every situation is different.

But, you know, on its face, if you have a family medicine physician who is moonlighting here and there in a low-census rural ER, that may not provide a higher level of care or higher competence than a PA who maybe has 15 years of experience in a level one trauma center in an urban setting. So it gets very nuanced and very complicated. So I think going back to the BMJ article and looking at that, I always want to be cautious because I think very often with workforce data like this, we let the pursuit of perfection get in the way of good.

Almost all workforce studies end up being retrospective. Almost all workforce studies end up being rather weak. It’s very difficult to have prospective randomized studies looking at this.

So very often we are looking at retrospective studies after some sort of event has happened that allows us to see a before and after. But it’s almost impossible to address confounders within that. So I think we do have to be careful.

We never, and PAs will agree with you, we never want to put a PA in a position where they are asked to do something that is outside of their training, their scope, their competence. And that’s really the key here is how do we stratify care? Psychiatry is incredibly difficult because how do we measure outcomes in psychiatry?

We forever have struggled to do that. So in psychiatry, it’s even difficult to establish universally what is good quality care. Because if we say, okay, well, let’s use measurement-based care, someone will argue that a PHQ-9 or a HAMD is not actually an adequate measure.

And we’re seeing some of those arguments now in the psychedelic space where maybe we’re not seeing a huge improvement with psychedelic therapies, or at least the level of excitement that comes with it, but the proponents or believers of psychedelics will tell you that these symptom-focused scales aren’t actually capturing the benefit that comes from psychedelic therapy. So I think the challenge in psychiatry specifically is we want to make sure that we are not causing harm. That’s always the key.

But then in terms of quality of care, it’s very challenging to really truly look at and say who is providing better, worse, or equivalent quality of care. If we look at PA workforce data more broadly, even within the BMJ study, it acknowledges that there’s really not a ton of evidence that PAs are providing worse care or that PAs are causing harm. And in fact, there’s studies that are done looking at malpractice claims in mostly U.S. that show that autonomous practice, relaxing practice regulations in terms of supervision actually will improve or reduce malpractice claims and reduce physician liability because the physician is now not tethered artificially to a PA where that supervision may just be on paper. So I know this is a very long and rambling answer, but I think the key here is that we always want to make sure to put this in context. I think that workforce data is always going to be not as ideal as we’d like it to be. In a perfect world, we would love to have crystal clear empirical evidence, but sometimes that’s not possible.

And the other side of it is I think in medicine, we’re also always very, very susceptible to Parkinson’s law. The idea that we’re always going to add complication and that our instinct is always going to be more complicated is better. So we see that in clinical research.

If we want to use as an example, why is the placebo response becoming such a problem? Well, we’ve added more and more regulation, more and more data collection, more and more things. The average patient when they come in for a clinical trial visit is with us for hours, three to five hours at a time.

So there’s more things that are being added on, piled on. If you take any one part of that clinical data that we’re trying to collect, we can justify it. Well, why are we getting this data?

Well, it’s really important. But when you look at it cumulatively, it’s adding this large, large level that is probably to some degree driving increased placebo response and killing maybe some very promising medicines in the process. So it’s tough.

I don’t necessarily have a good answer. I do think when I look at the data, what I see is a lack of harm. I see PAs performing adequately.

Increasing access to care is acknowledged in both the Lange Report and the BMGA. And we have to make sure that we’re being very careful. We’re being very measured.

We never want to get too far out over our skis. But I also think about that the absence of evidence is not the evidence of absence as well. So we want to be cautious in the Lange Report.

I’m getting ahead of myself. But in the Lange Report, it identifies that PAs perform best in directly supervised roles when post-diagnosis care. And the reason that it asserts that is it says that there’s a lack of evidence that PAs perform well in undifferentiated care.

But the fact that there’s not studies in undifferentiated care doesn’t necessarily mean that PAs are performing poorly. It’s just that the studies haven’t been done yet.

Dr Ben Everett (29:24)

Yeah, it’s one of those claims that has been made without evidence to substantiate the claim. It’s really just based on an assumption that, oh, well, this is the way it ought to work.

29:24 – Rethinking Workforce Assumptions and Challenging Medical Dogma

Dr Michael Asbach (29:36)

Yeah. And it’s the same thing, as I said earlier, with emergency medicine. That’s why I’m so fascinated.

I love looking at workforce drama in other aspects of health care because you see very similar arguments playing out. And if you remove the turf war of PA versus physician or physician versus NP, I think you actually get a little bit more clarity that there’s a lot of uncertainty. And health care, I think, is evolving.

How we deliver care, how we structure interdisciplinary teams is changing very quickly. And it certainly is going to be a struggle for us to figure out the best path. And certainly, we’re not going to get it right every time.

But I think the opportunity to be open to try new things, open to maybe cutting against dogma where we say, well, this is the way it’s always been done, so it must be the correct way. I think that’s a really important thing.

Dr Ben Everett (30:22)

Yeah. And I know the other thing is with the passage of President Trump’s spending bill, there are planned cuts to Medicaid. I live in Mississippi.

We have the highest rate of poverty, heart disease, diabetes. We’re overweight as a country. And I know state mental health officials and really just public health officials are really concerned about how we’re going to provide any care and hopefully quality care to people who live in these more rural areas where right now you might have an urgent care and you have an orthopedic come in every once in a while, probably don’t have psychiatric services on staff, definitely not going to have an MD, DO trained psychiatrist on staff. And I definitely think there’s an opportunity for advanced practitioners with appropriate qualifications and training to work in those areas. It’s like, do you want to have no care or do you want to have care from an advanced practitioner versus a physician?

It’s going to be interesting to see how it all plays out, I guess.

Dr Michael Asbach (31:24)

Yeah, I think that’s so true. The way that I always think about these studies is exactly that. And again, I’m jumping ahead, but the BMJ study is largely looking at the role within the UK health system and then the Lange report similarly.

And currently, there’s about 10,000 unfilled vacancies in the NHS. So it’s not fair to look at this and say, well, PAs are replacing physicians and the quality of care is not or may not be as good, even though we don’t have evidence to say that the quality of care goes down because the alternate may indeed be nothing. Just as we talked about with rural ERs, if we mandate that a physician has to be there all the time, I would love that.

I want to double the number of physicians in this country. Absolutely. But we have a shortage of physicians.

We have to be very mindful of how we deploy a very limited resource, especially given the time and cost that we invest into training physicians. We need to make sure that the physician expertise is used in the proper context. So it really can’t be considered a substitutive thing where it’s just PA versus physician, but rather in roles where physicians, we just don’t have enough to spread out.

Can we use PAs? Can we use NPs in a safe and efficient manner?

32:37 – Regulation, Role Clarity, and Key Takeaways from the Leng Report

Dr Ben Everett (32:37)

Yeah, absolutely. All right. Well, moving on, another paper.

So this was, I’m going to butcher the name, Tomás Ferreira. He’s a neurologist and neuroscientist at Bristol University in the UK. He published a piece last year, The Role of Physician-Associate in the United Kingdom, where he emphasized disparities in training and the importance of regulation.

The Ling Report carries forward that same thing and highlights the need for clarity and governance and scope. And I think that’s something that most people would probably agree with, right? Let’s make sure we have some objective standards if they’re like a national training or a national board certification type of process, like very similar to how we see USMLE and training of physicians.

So can you give us a little bit more background? We’ve referenced the Ling Report multiple times now, but yeah, can you give us a little bit more background about the Ling Report and exactly what it did say?

Dr Michael Asbach (33:29)

Yeah, absolutely. So the Ling Report was commissioned, I think it was commissioned in early 2024 or 2023 by the UK government. And it was in response to some highly publicized cases where PAs were out over their skis, I guess for lack of a better term.

And there was some highly publicized patient deaths, I think six reported by The Guardian if I’m remembering correctly. That’s right. So the UK government commissioned this report, the Ling Report, to look at the role of PA within the national health system.

So some of the key findings there is that the expansion of PAs and then anesthesiology assistance, which is a role within the UK was also included in that, was found to lack sufficient evidence of safety or effectiveness. But there was also no compelling role to abolish these, or compelling case to abolish the role. So that’s one of those, like the absence of evidence doesn’t equal.

Within that though, the report also indicates that PA distribution was in London, but then also in more rural areas. So it was indeed seemingly improving access. So there were some things in terms of the recommendations, and you mentioned role clarity and identification that were given.

And the big one is renaming from physician associate to physician assistant, which we can talk about because I’ve got many thoughts on that. But requiring standard uniforms, lanyards, badges, ensuring that there’s role clarification because one of the issues was patient confusion over whether they were seeing a physician or a PA. And then the recommendation was also for some scope restrictions that PA should not diagnose or treat undifferentiated or untriaged patients.

So first line therapy or first interaction with the healthcare system should be with a physician. Newly qualified PA should work at least two years in hospital before they branch out to general practice or other specialty settings. And that doctors should receive supervisory training and allocated time to manage line supervision.

And then beyond that, there was recommendations for more opportunities for postgraduate education, support, career advancement, things like that. So yeah, I agree with you. I think a lot of the Lange report, I actually, I found myself nodding along.

The areas that I actually take issue with is the recommendation that PA should not diagnose or treat undifferentiated patients. And the reason being is I think that is a, we’re painting with a very broad brush there. If a patient is presenting in a primary care setting with high blood pressure, that’s something that I think most of the time can be handled by a PA.

If the patient is presenting in an emergency room with a potential pneumothorax, well, that might be an undifferentiated case that requires a different level of expertise. So to simply say PA should not treat any undifferentiated patients, I think is too broad, too restrictive. The other thing within the UK that’s interesting is they’re recommending, instead of indirect supervision, going to direct supervision, which is kind of the opposite trend that we’re seeing in the US, where in the US, we historically, PAs have developed under a model of direct supervision.

And that made sense in the 60s and 70s. As I said earlier, you had much more small, independent practice for physicians where you would have a physician hire a PA, that PA would stay under or with that physician for a long period of time. Where now, most physicians are employees, they’re not employers.

So in the US, that role is changing. And certainly, it doesn’t make sense for a physician who’s employed by a large healthcare system to be directly supervising a PA when they may not be directly working with that PA. They may be a paper supervision where they’re not even collaborating or co-managing cases.

But in the UK, they’re moving to a more direct model. So one of the things I think about with this is I think it’s very important to recognize that different healthcare systems have different needs. And I very strongly believe in the PA model.

I think across healthcare systems, there’s a lot of work that’s done in healthcare that is subacute, that does not require a physician level of expertise. Almost every healthcare system has shortages of physicians. So I think every system has to deal with how to use or properly deploy physicians in the way that gets the most return on investment.

And having PAs and P’s, nurses, having multidisciplinary care really is an important thing. But, and this is just my opinion, I’m not speaking on behalf of the APA or anything like that. But the UK system is much more hierarchical top-down, where the US system has really a long history of being physician-led and having physicians in seats of power, but also really dictating how clinical care should look.

So the UK system, a lot of that work is done on the more administrative side. And I think one of the cautions when I read this is that the rollout of PAs, there may have been a little bit more of a feeling of adversarial substitutive care where PAs were getting plugged in. Physicians felt that PAs were not there to augment or extend reach, but rather to replace because administrators may have been coming in and saying, you’re going to go here, you’re going to go there.

Where in the US system, I’m actually appreciative. We can criticize maybe the US system for being a little bit more of a patchwork and not having as much of a top-down hierarchy or organization as a healthcare system. But one of the nice things that comes from that is I think the PA profession developed very organically and really developed in response to what was needed in the field, what physicians needed at that time.

And it’s an interesting thing because just in my own anecdotal experience, the AMA has been very loud about their scope of practice campaigns. I actually really, I almost never have individual one-on-one conversations with physicians that either I’m collaborating with, maybe it’s a primary care physician or someone at a hospital where I’m calling regarding one of my patients. In the real world, when I talk to physicians, they are incredibly appreciative of the role of PAs and the opportunities that we have there to make sure that care is comprehensive and accessible to everybody.

So I think really the key with this is that we never want to put any healthcare provider in a position where they’re doing something outside of their expertise, training, or scope. And some of the recommendations that are given, I think, are correct where we want to put up those proper guardrails. Some of the recommendations in the Lange Report, I think, are a bit misguided and might be a little bit of a fearful response to bad press.

But my hope is that as they continue to move forward, they’ll make adjustments. I think the big exciting thing for me is even though there was maybe some fear or maybe some uncertainty about the role of PAs, the Lange Report is not recommending abolishment. The Lange Report is still recognizing that the PA profession has a very important role to play in the UK healthcare system.

So there’s always going to be, I think, fits and starts. And as a general rule, I like debate. I think having two opposing views go at it is the best way for the best view to come forward.

So my hope is that as we continue to debate this, that we’ll figure out the best path to make sure that patients are receiving the best quality of care, but also the best access to care. And certainly that may look different in different healthcare systems. So I want to be cautious that what works in the US may not work in the UK and vice versa.

Dr Ben Everett (40:40)

Yeah, very different model of care here in the United States, obviously, than National Health Service in the UK or Canada. So I think, you know, consistent with that thought, I’ll hear people. So I travel around the country and I talk to all sorts of different people.

I find that this is typically this next question I’m going to get to, people’s thoughts about this will vary oftentimes just depending on where they train. So I’m going to say the question and then maybe we can back into where they train. But something that critics say is, you know, they will raise concerns about scope creep.

This is something I hear a lot is scope creep and dilution of training opportunities for physicians. You know, how do you see this idea of scope creep and air quotes in psychiatry specifically?

41:25 – Navigating Scope Creep Concerns and Physician Training Protection

Dr Michael Asbach (41:25)

Yeah. So thankfully, I think psychiatry is actually a little bit more protected against it, where because there is such an immense shortage, I think everyone recognizes that we need way more people to address the unmet need. And unfortunately, the demands for mental health care continue to go up.

Our collective mental health as a society is not improving, but rather getting worse. So I think psychiatry is a little bit shielded from it. The scope creep conversation though, I get somewhat frustrated with it because I think the concept of scope creep is a little bit misguided.

We’re accepting when we use that term, we’re accepting from the start that changes to state by state supervision, collaboration, regulations is changing what PAs and NPs are doing in their practice settings. So a recent Medscape survey, actually it’s an annual survey, but a recent survey found that a majority of PAs reported that they practice autonomously, even if their practice setting was in a supervision state with a physician supervisor. So the majority of PAs currently right now are practicing in an autonomous setting.

Even in our clinic, the way that we’re set up, we have 10 PAs, we have three psychiatrists, we have a couple therapists, and the PAs all carry their own panel of patients. Now, interestingly, the way that we run is we have three physicians and we feel that their expertise is incredible. So what we do is we actually will try to have the consultation done by the physician, not because we don’t trust PAs to do undifferentiated care, but because we have a very high level of expertise.

Our medical director has been doing this for a very long time. Our other physicians are all wonderful. So if we have an opportunity to have first eyes on the patient be the highest level of expertise, we think that that’s really important.

But the flip side to that is if our consult waitlist gets too backed up, because it’s several months for someone to get in to see us for an appointment, we have no reservations of having the PAs do consultation as well. So it’s not that one model is good versus bad. Now, in terms of residency training, I’m always incredibly sensitive to that because I really try and approach these issues somewhat agnostically.

Obviously, I’m a big believer that PAs are part of the solution, but I also never want to be just so blindly following PA as the answer that every answer ends up being, yep, PAs can fix it when maybe they can’t. So in my efforts to be agnostic with this, I want to make sure that anytime there’s an opportunity to expand the number of physicians that are practicing in the U.S., that I am side by side helping argue and advocate for that. So whether that’s increased residency slots, increased funding with Congress, more physicians are needed.

In psychiatry, thankfully, I don’t experience or see competition where PAs or NPs are potentially taking away from the residency training opportunities. Certainly, I think that’s talked about in other specialties. In the U.K., that was actually a complaint that the residents had, is that the role of PA would potentially diminish or impair their training opportunities or quality. But I think that is something that we have to be very careful with. In academic healthcare settings, you know, using residence isn’t always the most efficient path to providing healthcare, but we do it because it’s a really important way to train and make sure that we’re investing in the future physician workforce. So in our efforts to find efficiency, in our efforts to find cost, cost reduction, we have to be very cautious that we’re not doing so in a manner that may impair our physician development pipeline.

But thankfully, in psychiatry, I haven’t observed too much of that.

Dr Ben Everett (45:04)

Well, that’s good. And sort of a corollary to that, you mentioned this Medscape report where, you know, the majority of PAs report working autonomously. You know, do you think we’re doing enough?

Do you think we’re doing enough to ensure patient safety in this model? Because I know that’s a concern that a lot of people have.

Dr Michael Asbach (45:23)

Yeah. So specific to psychiatry, there’s really, there’s no data or there’s very little data. So it’s hard to know.

We have to be incredibly cautious because I think I’m a huge proponent that we shouldn’t let the absence of evidence prevent us from trying new things. But at the same time, when we try new things, we need to be very careful and make sure that we’re looking to make sure that there’s not a new safety signal that wasn’t there prior. So a great example of that is during COVID, many states temporarily suspended or relaxed supervision requirements, recognizing that we needed to have more flexibility in how PAs were deployed.

And in New York, the suspension of supervision was in place for, I think, two years. So during that two-year period, there was not a significant change in safety. There was not a significant change in malpractice claims.

I think we’re far enough out now that we’re starting to see some research and studies of that COVID era that demonstrate that there was not a drastic change in patient outcomes or safety with the relaxation of supervision. So those are the types of things that I think are incredibly important as we move forward is we want to move forward. We don’t want to be, you know, have paralysis by analysis where we don’t do anything.

But at the same time, I think it’s always good for us to look backwards and make sure that we’re looking at the retrospective evidence, claims data, the national provider database, and making sure that we’re not missing something along the way. But yeah, I think one of the things I think about a lot, not just in terms of workforce and how we stratify care, but more broadly in psychiatry is psychiatry is a field where we drastically and grossly lack objective outcomes where we can universally agree this is good quality care. And that’s, I think, something my hope, I mean, this is a separate conversation, Ben, we can have on a different time.

But my hope is that maybe AI, passive data monitoring, ecological momentary assessment, that we’re reaching a point that we maybe get there. I think about all the criticism with the DSM-5 and how we still are not at a point of having good biomarkers. We’re still just looking at collections of symptoms.

And I don’t know, you know, maybe we get to a point where we never find biomarkers. I hope we do. I still have faith that we will.

But if we don’t, maybe the alternate approach is technology reaches a point where our accuracy in identifying these symptom collections using AI, using big data allows us to be much more precise in our treatments, but then also provide more accurate measures of quality of care and outcome as well.

47:51 – Building Effective Interdisciplinary Psychiatric Care Teams

Dr Ben Everett (47:52)

I would love to see that day come because it is, yeah, psychiatry really is very interesting. Like I had Steve Brannon, who is the chief medical officer of Corona on a couple of weeks ago. And we were talking about just this idea of objective measures.

And, you know, there’s what’s used in clinical trials for regulatory approval. But so often those objective validated measures are not used routinely in the clinic. And it can be for a number of reasons.

Like you said, just on the research side, these patients are there for three or four hours. You know, there’s a lack of time. There’s no reimbursement for doing a longer like PNSS or like a CAPS-5 and PTSD type of assessment.

And many of those assessments require specialized training to be able to do the assessment. So, yeah, it’s difficult to get to these objective measures without biomarkers. But I also am hopeful that we’ll get better.

I mean, we’ve got some good ones for Alzheimer’s disease now that we didn’t have previously. So you’ve talked on this a little bit earlier, but I want to kind of move into like the idea of an interdisciplinary team. So, you know, Dent, you’ve explained sort of your model is very interdisciplinary.

How do you see that model being replicated across the country? You know, personally, what you see, and then again, come back to this Medscape survey where you have all these PAs reporting, working autonomously. So, you know, how do you see the best model if there is a best model?

And there probably isn’t for any given situation. As we’ve talked through large cities, you’re going to have better access to things. Whereas if you’re in a more rural area, you’re not going to have the same access.

So it’s kind of a lot to pack through there, but all yours.

Dr Michael Asbach (49:35)

All right. Yeah. I think you hit on something really important here is every practice setting is going to be different.

And this is one of the biggest reasons that I think elimination of state-mandated supervision is such an important thing is the PA profession is not out there saying we don’t need physicians. Rather, we’re advocating for relaxation of supervision because that allows greater flexibility to have collaboration, to have interdisciplinary teams that works at the practice level because every setting is going to be different. So it gives them a much greater level of flexibility to build a team in the way that works for that setting.

So let me expand a little bit more of what we do at Dent. So as I said, we generally try to have our physicians do consultation, and we really like that model because it allows us to tap into that expertise. The physicians like it because it almost lets them function as like a consult liaison type of service where they see the patient, they give an assessment, they do the diagnosis, and then that also gives an opportunity to assign that patient to a PA or assign to a counselor and maybe have a little bit of a sense of what may be a good fit because a lot of our PAs are somewhat niched.

We have some PAs that really have a passion for maternal mental health, some that do a lot of work in developmental disability. So that initial consult also gives the physician opportunity to try and align care. But once that patient is assigned to the PA, the PA is then autonomously managing that patient’s care.

We really do value collaboration within the team. So every two weeks, we have care meetings. We all sit down as a provider group.

We go through any tough cases. And within that, it’s certainly it’s not just a PA presenting a case and then the physician saying, this is what you should do, this is what you shouldn’t do, but rather as a team working through it, talking about what the data indicate, talking about the available evidence, different approaches. So it really ends up being an excellent, almost grand rounds or an M&M that we do.

And that’s something that we’ve always prioritized. And I fear that in a lot of community mental health settings and a lot of outpatient settings where so much of our compensation is driven by RVUs, it’s really hard to prioritize setting aside clinic time that could be revenue generating for the practice for yourself to make sure that you’re prioritizing collaboration, mentorship, and continuing to build the team. So that’s something that we’ve always valued here.

But within that, I think our goal is to make sure that our PAs who are all at very different levels of experience, we have some PAs that have only been doing this for a year. We have some PAs that have been doing this for a decade, that everybody understands where their limits are. The most dangerous thing in medicine, and this is not unique to PA, this is anyone, is if you have a provider who is going outside beyond their abilities.

So from a physician standpoint, the one that I think of is the Dr. Death documentary that was done by I think Wondery or whatever podcast, where that physician somehow made it through neurosurgical training despite very few cases and in very little clinical experience because they spent almost all of their time in the lab. That is dangerous. And the whole point of a residency program is to try and prevent that.

And generally it does. It would be very tough to get through residency in that way. So I don’t think that that’s reflective of a problem in residency training, but maybe more of a one-off.

But the goal in healthcare should always be to make sure that patient complexity is aligned with that provider’s level of experience. And within our team, we really emphasize it is never a bad thing to ask for collaboration, whether that’s internally within our department. If you’re seeing a patient and you feel like the case is maybe a little bit more complicated than you know what to do or you’re confident with, go talk to a teammate, go talk to a supervisor, go talk to someone, a mentor.

But even beyond that, we don’t want to hang on to patients in our clinic in an outpatient setting that are maybe not appropriate candidates. If that patient needs an intensive outpatient program, then it doesn’t help the patient for us to hang on to them in a med management clinic. So we also talk a lot about when is it appropriate to refer on to a higher level of care because our practice setting is also going to have a limited scope just based on what we do.

We’re not set up to do intensive DBT counseling. We’re not set up to do intensive outpatient or really anything that’s related to very structured therapy other than some very basic maneuvers. So I think it’s a really important thing that we continue to have those conversations because autonomous practice does not equal practicing in a vacuum.

And as psychiatry is more diverse, as the ability to have a physician working on site at a practice becomes more challenging, especially in more rural areas, it may take some creativity. And telemedicine technology might give an opportunity to address that is maybe in more rural settings and community mental health settings, they don’t have the resources or the ability to have a psychiatrist on staff. But maybe they have a consult liaison or kind of a psychiatrist that’s in a supportive role where the psychiatrist is there and available for consultation, maybe does collaborative meetings with the providers.

There’s a lot of different ways that we can make sure that we’re performing medicine in a team-based setting, even if we don’t have a physician available on site for direct supervision. And that’s, I think, what the biggest thing, the biggest benefit of changing these state by state practice regulations is then it allows more flexibility. The one thing I’ll say to finish, and I feel like I keep rambling for you, Ben, but in our practice setting specifically, New York has had a supervision ratio.

So New York actually is a very friendly state for PA practice. Our scope of practice is unlimited in the sense that scope of practice is not defined by the state, but rather defined by the supervisory setting. So I can’t conduct anything that is outside of the scope of my supervising physician, who’s my medical director.

So in New York, historically, we used to only have four PAs per physician for supervision. It’s now up to six, but there’s still a ratio. A couple months ago, our medical director had some health issues and was out of the office for three months.

And thankfully, when he went out of the office, he had these health issues. We had backup supervision. We had other psychiatrists that were able to step in.

If we were not able to do that, if we were not able to have other psychiatrists ready and available, 6,000 to 8,000 patients would have immediately lost access to care because the PAs that we have managing these patients autonomously would not have been able to practice. That seems really silly to me. So that’s a great example where it’s team-based medicine and we are practicing in a way that is highly collaborative, but the state regulation is such that if our physician, if our medical director is out for a health issue, it’s not just disrupting his panel of patients, but potentially disrupting thousands of patients and their access to care.

And as we all know, psychiatry is not something where if 6,000 patients all of a sudden did not have access to psychiatric care, they couldn’t just call the next psychiatrist that’s three doors down. They would have had an incredible care disruption and inability to readily find alternate care.

56:44 – Supervision Ratios, Access Disruption, and Real-World Patient Impact

Dr Ben Everett (56:45)

That is an amazing example. And it doesn’t change which PA the patient is seeing, because again, continuity of care, the PA is already involved with that person’s care. But if you limit it to the supervisory physician, yeah, wow, that’s really staggering, a staggering number of patients.

Dr Michael Asbach (57:03)

And he’s doing great now, by the way. So our medical director is back fighting fit and back in the saddle, which is all the most important thing.

Dr Ben Everett (57:10)

Absolutely. That’s great news. So, all right, well, let’s kind of move on and got an eye on the clock here.

I don’t want to keep you too long. So in terms of like leadership and advocacy, you know, as I said in the intro, you serve as a medical liaison to the APA from the AAPA, you’re on several editorial boards, you’re on the steering committee for Psych Congress. So what are the biggest issues that you’re advocating for when it comes to, you know, advanced practitioners, PAs and specifically in psychiatry and healthcare in general?

Dr Michael Asbach (57:40)

Yeah, so psychiatry is interesting because it’s one of the emerging fields for PA. We don’t have as large of a representation. So just to give a frame of reference, if I’m doing this off of memory, but physicians and then NPs, about 5% of the total workforce is in psychiatry.

In the PA world, it’s about 2%. So we are, as a total percentage of our workforce, psychiatry is underrepresented. If we brought that number up to 5% to be in line with physician and nurse practitioner, there’d probably be about 10 to 11,000 PAs in psychiatry.

And as I said earlier, the role of PAs in psychiatry is growing quite rapidly. So one of my main focuses in my role as the medical liaison for the American Academy of PAs is just continuing to kind of preach from the mountaintops that this is a really amazing field of medicine. I think a lot of times PAs just don’t recognize that it’s a field that they can enter, that it’s one that I think is a possibility.

The PA profession has specialty certification. We have what’s called the Certificate of Added Qualification. Unlike nurse practitioners, which will specialize in their didactic training, all PAs graduate as generalists and then have the opportunity after they’re done to accumulate clinical practice hours, additional CME, additional didactic training, and then sit for that certificate.

So we do have a psychiatry Certificate of Added Qualification, which helps, once again, represent an additional level of expertise and commitment to the field. So I think just continuing to encourage more PAs to consider mental health as a field is one of my main objectives. As I said earlier, I’m so thankful for our colleagues, for the workforce within psychiatry, because it’s so supportive and collegial.

So I think thankfully we are somewhat sheltered from some of the turf wars that you see in other professions. But within that, I think I also try and focus a lot and have a lot of discussions on autonomous practice, not necessarily independent practice. I know we’re splitting hairs here, but really that removal of supervision, relaxing state regulations is not about replacing physicians.

It’s not about expanding a PA scope of practice, but rather adjusting regulations to reflect the modern healthcare environment where each practice setting has to be flexible to make sure that we’re promoting high-quality care, but also collaborating in a way that makes sense. Yeah, great.

1:00:04 – Burnout, Non-Clinical Career Paths, and Retaining Expert Clinicians

Dr Ben Everett (1:00:06)

All right. So you’ve got a couple of podcasts going now. So can you tell us about White Coats of the Roundtable?

So what inspired you to do that? And how have you seen it help?

Dr Michael Asbach (1:00:16)

Yeah, so it’s my fun little passion project. So we developed White Coats of the Roundtable, and then the next iteration of that is called the Nonclinical Collective. And the goal with it is to help identify just atypical pathways for healthcare providers.

And that can be physician, PANP. We’re seeing healthcare change so rapidly. We see very high rates of burnout across the board in almost every medical profession.

And I think that’s really challenging. So the example I always like to think about is if you go to law school, only about 2% of people that graduate law school will actually argue a case in a courtroom. So people that go to law school don’t necessarily do so with the expectation that their only career path will be litigation, but rather there’s many different things.

It’s a springboard that provides infinite opportunity. And yet for some reason in healthcare, we don’t see it that way. So I think PA, especially because there’s maybe a little bit of a less sunk cost fallacy, it’s a little bit cheaper and quicker than physician training.

And certainly when we have such a shortage of physicians, I want to make sure that we don’t combat physician burnout by encouraging them to leave clinical practice, but rather help and support them. But I think the PA profession offers a lot of opportunity to take atypical paths, to do nonclinical work. One of the areas that I’m seeing PA’s representation just explode is in these nonclinical roles.

And I think it actually is tied into physician shortages, where if you have a physician, you want to make sure that they’re seeing patients, you want to make sure that you’re using that level of expertise. So I think you’re seeing more growth of PAs in other nonphysician roles, pharmacists, NPs in administrative positions, in leadership roles. And I think that’s a really great utilization of our skillset, where we have enough training in the clinical setting to understand what’s needed from a clinical perspective, but then also we don’t have a half million dollars of debt.

We don’t have salary expectations that are maybe unreasonable for an administrative role. So I’m excited that I think the future moving forward for PA especially is one where we can see more and more growth of that clinician-administrator combo or hybrid, where I think so much of medicine, you have a lot of people in roles as decision makers on the policy side in health tech that maybe don’t actually understand the clinical experience from a PA physician standpoint or even from the patient standpoint.

So the more that we can plug in clinical expertise into those nonclinical roles, I think that’s going to benefit healthcare more broadly. So that’s the goal with those projects is to try and just continue to encourage, highlight different opportunities for all healthcare providers to consider atypical career paths that may not be clinical.

Dr Ben Everett (1:02:59)

You know, I think you’ve really hit on something there in terms of clinician burnout and the number of hours just because of the way healthcare has changed here. And you mentioned, you know, very people just hang a shingle now. Most people are an employee in some type of larger hospital setting or group practice or something like that.

But burnout is very real and it’s a problem. I’ve got a good friend who’s pulmonary critical care and has so many critical care doctors coming out of the pandemic was just really, really hard, really burnt out. And he’s now transitioned into an administrative role and he’s really only doing no clinic and he’s doing some ICU work, you know, one weekend a month essentially.

So what do you think about advice for people that are facing burnout? And yeah, they’re thinking, okay, yeah, I can’t do patient care anymore. But, you know, the problem with that is we certainly want to respect people’s decisions and how they want to go and what they want to do with their life.

But at the same time, when you’ve got someone who’s been doing, you know, psychiatry, interventional psychiatry, pulmonary critical care for 20 years to see that person really in the prime of their career, their life, decide, I can’t do this anymore. I think that’s kind of a, it can be very challenging to find, okay, well, who are we going to find to fill this gap that has the same level of expertise and experience? So how do you think about, you know, burnout and working through that with people so that we can, you know, continue to maintain, you know, consistent quality of care for patients?

Dr Michael Asbach (1:04:36)

Yeah, a couple different things. So first, I think about burnout in healthcare very similar to the way that I think about the rising cost of housing in the U.S. And I know that’s maybe a weird connection, but I am very much a build, baby, build approach to housing where I think one of the challenges that we see, especially in, you know, blue states like California and New York is that it is so difficult to build new development that that constrains supply and it increases cost. And then it locks out a lot of people from homeownership. I think housing is something where the more we build, the more affordable it gets, the accessible it is to more Americans.

And that’s a really important thing. Healthcare is very similar where the more people that we bring in as helpers, the better. So I want more physicians.

I want more PAs. I want more NPs. I want more nurses.

I want everybody practicing at top of scope. And I think having more help so that we’re not asking as much from the limited supply that we have right now, I feel like we’re in a doom loop where we have physician shortages, we have shortages across the board. And as a result, we’re asking the limited workforce that we have to do more and more.

We’re not only adding more clinical expectations, but we’re also adding EMR documentation burden, malpractice, defensive medicine concerns. We’re adding more and more to the plate, but not necessarily providing solutions to help them do that. So one of the best solutions, in my opinion, is we need more bodies.

We need more people to join the workforce so that we can ease some of those constraints on limited supply. But the more people that we get in healthcare, that also gives more flexibility. I only see patients three days a week.

My other two days, I do administrative work for my practice. I also like to teach. I like to lecture.

And that really is a wonderful thing. It gives me a little bit of a diversity in what I do so that every day is a little bit different. I can’t imagine seeing patients back to back to back to back five or six days a week.

Yet so often, that’s what we’re asking our healthcare providers to do. I think having identity diversity, having a career where it’s okay to say, hey, one day a week, I’m going to go teach at the university. One day a week, I may do a little bit of consulting for a health tech company.

I think that really is a wonderful thing, but that’s hard to do when we have such a limited supply of adequate, competent healthcare providers. Build, baby, build all the way through. I think the more people we bring in, the better.

That’s why I’m so passionate about PAs as a solution, but also just more broadly, increasing physician residency slots, reforming medical education, making medical education quicker and cheaper. The other thing within this, we didn’t talk about it, is if PAs and NPs have shown that a lot of healthcare can be done competently with less training, I want to make sure that we look at physician training. Is there an opportunity to go to three-year med schools, as we’ve seen some schools test with?

Is there an opportunity to move residency from a time-based residency to a competency-based residency, where we check the boxes of competency and the timing of that is not as important as making sure that the critical skills are learned? Anything that we can do to get more people into the workforce is going to help the burnout.

Dr Ben Everett (1:07:48)

Yeah, that’s great. All right, so in closing, I want to thank you for your time, your availability, and really just all of your insight into advanced practitioners and the way you’re thinking about this. If you had to summarize the future of advanced practice providers in psychiatry in one to two sentences, what would you say?

1:08:09 – Future of Advanced Practice Providers and Closing Reflections

Dr Michael Asbach (1:08:10)

I think the future of advanced practice providers is going to be one that is collaborative, autonomous, and interdisciplinary. That’s awesome.

Dr Ben Everett (1:08:20)

And finally, what’s the most rewarding part of your job right now? What gets you out of bed in the morning? Oh, man.

Dr Michael Asbach (1:08:27)

So I think the most rewarding part of the job is probably right now training other providers that are joining our team. We’ve been in a period of rapid growth. We can’t keep up with demand.

We still have a wait list for new consults that is many months long. And it’s just really exciting to see these young PAs, these physicians joining the team, buying into our vision, buying into what we’re trying to do here, and providing a high quality of care to our patients. It really is rewarding when you can start to see that as a force multiplier, where it’s not just your role, your work with patients, but then also your department, your team, and what they’re accomplishing.

Dr Ben Everett (1:09:06)

That’s great, Mike. Well, in closing, I want to thank Dr. Asbach for joining us today on the JCP Podcast and for sharing his experiences and expertise on advanced practitioners and PAs specifically, and behavioral health and psychiatry. Coming up on the JCP Podcast, our Behind the Manuscript series continues with Dr. David Feifel, a psychiatrist, neuroscientist, and professor emeritus of psychiatry at UC San Diego. Dr. Feifel pioneered the world’s first ketamine infusion program for depression and is also founding president of the Kadima Neuropsychiatric Institute in La Jolla, where he leads research in cutting-edge treatments, including psychedelics. We’ll be discussing his recent journal, Clinical Psychiatry Paper, results from a long-term observational follow-up study of a single dose of psilocybin for treatment-resistant depression or major depressive disorder. So he’s going to share that paper, which is one of the Compass Therapeutics papers that they published.

So don’t miss that insightful conversation with one of the leading voices in novel therapeutics, and we’ll talk about psychedelics for the first time, but certainly not the last time. It’s a very exciting area of medicine right now. This has been the JCP Podcast.

Insightful, evidence-based, human-centered. Thanks for joining us. Until next time, stay curious, stay informed, and take care.