To follow Peggy Jacklich through her day at Statesboro Psychiatric Associates, a busy outpatient practice in Statesboro, Ga., one might assume she is every bit the psychiatrist her colleagues who own the practice are.
Jacklich sees some 15 patients a day, managing medications for a range of diagnoses and performing therapy-cognitive behavioral therapy or, in cases of patients with borderline personality disorder, "dialectical" therapy.
Yet she is not a psychiatrist, psychologist, doctor, nurse, or social worker-but a physician assistant (PA), a type of allied health professional well known in many areas of medicine, but relatively new and rare in psychiatry.
PAs are sometimes called physician "extenders," a title that aptly describes their mission to extend the reach of medical expertise to patients who are not served directly by a physician. In consultation with- and under the supervision of-a doctor, physician assistants perform diagnostic tests, prescribe medicine, develop treatment plans, and carry them out.
Along with other allied health professionals, they are filling the gaps in care created by expanding patient loads that put a premium on the attention of medical doctors. And as in other fields of medicine, the appearance of PAs in psychiatric offices, community mental health centers, and inpatient wards is all about extending access to care.
"The practice was so successful," said Jacklich of her employers, "that they had a waiting list of three to four months before some patients could get in. Now, since they have hired me, people can get in almost within one or two weeks."
While PAs who work in psychiatry are still a relative rarity, they may not be so for long. The Association of Psychiatric Physician Assistants (APPA) boasts 450 members and has hosted a booth at APA's annual meeting for the last three years.
"There is a huge demand," said APPA member Don St. John, a physician assistant who works at the psychiatric outpatient clinic at the University of Iowa School of Medicine. "Each year the booth at the APA meeting receives 100 job offers, and we can't fill them all.
"A lot of PAs haven't really thought about psychiatry," he told Psychiatric News.
The provision of mental health services by PAs appears to have gained a particularly strong foothold in rural America, where the problem of access to mental health services is acute.
Jacklich is a graduate of a specially designed PA "residency" program in psychiatry at the Cherokee Mental Health Institute in Cherokee, Iowa-a state in which only 21 of the 99 counties can boast a psychiatrist, and where 80 percent of the state's psychiatrists are in five counties.
The institute, a 60-bed state mental health facility, designed the one-year program for individuals already certified as physician assistants with a particular interest in psychiatry, said Navjyot Bedi, M.D., the institute's medical director.
"There are huge chunks of rural America that have no access to psychiatrists," Bedi told Psychiatric News. "We think that 70 percent to 80 percent of the community problems in psychiatry can be handled by a well-trained, adequately supervised physician assistant. Our goal has been to increase access to the underserved that have to wait three or four months and drive 120 miles to see a psychiatrist."
Brad Dirks, a PA who is the associate director of the residency program, said that the program, which began in 1999, has graduated six or seven PAs now working in psychiatry in various capacities.
"What PAs can do is provide excellent quality care, extending the physician's coverage at a cost that is less than a full-time psychiatrist," he told Psychiatric News.
Dirks said that there is only one other specialty training program in the country like the one at Cherokee-the postgraduate residency program for PAs at the University of Texas Medical Branch Correctional Managed Care program-and Cherokee's appears to have a precarious future, having stopped and started and stopped again due to lack of money.
"It's costly and labor intensive, and we haven't found people to fund it," he said.
A short-lived federal grant has expired, and now Dirks said the institute is hoping that physicians or practice organizations seeking PAs specially trained in elements of psychiatric practice might finance a PA's training, with the PA then returning to the practice to work off the debt.
The yearlong PA residency program includes two-month rotations with each of the six psychiatrists on staff at Cherokee and the rest of the treatment team. The hands-on clinical experience is supplemented by one to two hours of didactic training every day and a yearlong psychopharmacology course. Residents go through common psychiatry texts, front to back, and receive training in psychotherapy theories and techniques, Dirks said.
Dirks and Bedi said that the institute is an ideal learning place since patients tend to stay longer than in a private setting or a general hospital. Bedi also said that learning all the technical aspects of diagnosis and treatment is as important as being able to recognize the value of transference and countertransference in any encounter- what Bedi calls "the delicate dance" between doctor and patient.
"If you have a setting such as this, the patients are the best teachers," said Bedi. "It's a place to learn the natural history of disease. I believe that if you have a good place for PA residents to learn and an interested teaching staff, you can graduate a class that functions roughly at the level of a first-year psychiatry resident."
Bedi underscored the nearly desperate need for psychiatrist "extenders" in rural America. "I tell my PAs that if you want to be more than a sidekick to someone's busy practice, you need to go to a place where you will be valued," he said. "And you will be valued only in places that are underserved."
The presence of PAs in medical practices of all kinds has grown in recent years, in part because they do function almost as apprentice physicians, having received rigorous, though abbreviated, training in the medical model (see box).
"PAs are trained to do things by the book," said Bruce Pfohl, M.D., a professor of psychiatry at the University of Iowa and past director of the university's outpatient clinic, where two PAs are now employed. "They tend to be very systematic and are well trained to practice evidence-based medicine. The majority of the patients we see respond very well to standard treatment, so it's a matter of following things by the book to decide how to treat them. PAs do an excellent job of that."
Pfohl recounted his own exposure as a patient to the good work that PAs do when he broke his clavicle and was treated by an orthopedic PA. "I was impressed with her knowledge and her ability to answer my questions," he said.
It was about eight years ago, when he was director of the outpatient psychiatric clinic at the University of Iowa, that the patient load began to overburden available staff. "PAs seemed like a good way to go, and we hired four for the department of psychiatry," Pfohl said. "They were accepted immediately by patients and staff."
Linda Madson, M.D., medical director of the adult outpatient clinic, said that PAs at the clinic practice very much like a psychiatrist. "They have their own caseload of patients they see for medication management," she said. "They make decisions about medication in consultation with a supervising psychiatrist and follow the patient over time."
Madson added that the PAs have an advantage over the psychiatry residents: there is less turnover. "A patient gets a new resident every year, while a PA is a permanent staff member. So the patient benefits from the added continuity."
Psychiatrists and physician assistants alike agree that although PAs may in many cases be acting independently, the model of care is a consultative, collaborative one.
"While they are extenders, they are not replacements," said Bedi. "To use this model correctly, you need to understand the limitations and play to the strengths. I have no problem delegating to a PA who knows how to use the medications and knows that I expect to be called for consultation. And they do extremely well in an inpatient setting because they get supervision almost daily. In this way, the psychiatrist can be in charge of 25 patients instead of 15."
St. John agreed. "We can do the general medical care for a lot of psychiatric patients, always with supervision," he said. "We never work independently, but always with a physician. That is one thing that helps us, because we are not viewed as a threat."
Madson confirmed that PAs are, by training, secure in their role as extenders, not replacements for the physician. "You can see how conscientious they are about seeking supervision when they are not sure of something," she said. "That is a big part of the comfort we have in allowing them to function independently."
Pfohl, Madson, and Bedi agreed that PAs are an answer to the shortage of psychiatrists in rural areas. "In order to provide good care to as many people as possible, we need to look at matching resources with the level of care someone needs," Pfohl said. "A large percentage of patients who see a psychiatrist don't use the full expertise that a psychiatrist has."
He urged psychiatrists elsewhere to explore the use of PAs as a solution to the problem of access to care. "I have never heard anyone say that he or she tried working with PAs and it didn't work," he said.