Hello, everyone, and welcome to our workshop on leading, creating, and working in interdisciplinary psychiatric teams. My name is Rashi Agarwal. I am a program director at Rutgers NJMS, and I have with me Dr. Kari Wolfe, Dr. Lindsay Pershin, and Dr. Rebecca Lindqvist. And as they come and do their talks, they'll introduce themselves a tiny bit more. I just wanted to tell you all and share a little bit on why we decided to do this talk and the background. So we are all, or we were all members of ADPERT's task force on workforce. So we, our task force was charged at looking at the psychiatric workforce, and those of you who might not be familiar with ADPERT, it's the Psychiatry Residency Training Directors Organization. So in some ways, obviously, expanding psychiatry residency training programs is the easiest answer to workforce problems that we have, but we were also asked to look into details and see what else we could do. And one thing we realized that while our primary focus was on helping programs establish new programs or expand residency lines and support those training directors in those programs, we also realized that that, even with the best efforts, can only go so far. And Dr. Kari Wolfe will be talking a lot about the stats on where we are, what kind of shortages we have, and what that picture looks like. So as we did that work, we also realized that there's a lot of solutions in addition to expanding psychiatrists. Definitely that's the primary one. But one other aspect is that we need to, we are already doing it as psychiatrists, but we will need to be engaging more and more in the teamwork. And there are other providers that provide, are part of the mental health problems and solutions. So advanced practice providers specifically, and especially psychiatric APNs, but also psychiatric physician assistants. And one thing that became very clear on is that while many of us had some knowledge of APNs, we didn't work with them directly sometimes. We obviously worked, we had seen their patients, and we have all interacted in some indirect or direct way. Most of us did not really understand what is the difference and how do you get from being an RN to a psychiatric APN? And what kind of training do you get? What kind of clinical experiences do you have? What kind of educational experiences they have? So a lot of our expectations, like you can't really successfully work in a team if you don't understand what the other one, how the other person was trained. So we all know how psychiatry residents are trained, and while there might be a program to program difference, we have a good understanding of what to expect from somebody who has just graduated from a residency training program. But we didn't have that common language for our colleagues as psychiatric APNs. And I think to have any kind of teamwork, that's the basics. And I'm sure it's true the other way around too, but we are focusing on us as a group of psychiatrists learning more about APNs. So that's what we want to do today. And seeing that that's our goal and that's where we are coming from, I also wanted to get a sense of who you are and what your goals are. So just a show of hands, how many of you are psychiatrists? So the majority of the group. How many of you are psychiatric APNs or PMHNPs? Oh, you are the sole representative. Any physician assistants? Great. Any other professionals? And what do you do? Therapist. Okay. Social worker. Pharmacist. Wonderful. We have a very mixed group of people. So in our talk, we'll be focusing mainly on psychiatric APNs, a little bit on the physician assistants. And then as we have discussions, we'll be happy to answer other questions that you might have to the best of our ability. The goals that I'm outlining for the workshop, is that what you were expecting to have, mainly, mostly? Is there any other issues or things that we should try and address if we can? Wonderful. So I'm going to turn it over to Kari. So I'm Kari Wolfe. I'm the Chair of Psychiatry at Southern Illinois University School of Medicine. And I've had the privilege of working on this ADPERT task force, representing the chairs group on this task force. And we are four members of a much larger task force, so I'm not the only chair on that task force. Dr. Jed Megan from Michigan State has also been part of that task force. And I'm really going to focus on the shortage that we have with psychiatrists, kind of how we got here, and what the future looks like. So we know that nationally, internationally, but we're focused on the US, access to psychiatrists remains a problem. It's been a problem, and it's seemingly getting worse. Mental illness is the most costly condition in the United States, the most costly medical condition in the United States. So it's pervasive. And these are pre-COVID numbers, and so there's been a lot that's come out about how COVID has just exacerbated that access problem. We also know that two-thirds of primary care doctors have difficulty making a referral to a psychiatrist. And this is twice the difficulty of any other medical specialty. So it's really profound. And I've been to other workshops here where people have talked about their frustrations and what they hear from referring, especially primary care docs, and talking about how unprofessional it is that we won't get their patients in in a timely manner, and how an oncologist would never dream of making somebody who's in crisis with a new diagnosis of cancer wait for six months to get seen. And yet that's what many of our clinics have, is a six-month waiting list. And so this access problem really, really drives home the workforce crisis we have, as well as the need to think about different ways of delivering care. We also have an issue that 55% of office-based psychiatrists in the United States accept insurance. So 45% of outpatient psychiatrists in the United States are on a cash-only basis. And oftentimes, not always, but oftentimes those cash practices take care of lower acuity patients. So the sickest patients are not available to the entire psychiatric workforce. In fact, they only have about 55% of the psychiatric workforce available to them. We have increasing numbers of women in the profession and we're going to talk about the impact of that on access in a few minutes. We also have a maldistribution of psychiatrists that we're going to talk about in a moment as well. And we actually have declining numbers of psychiatrists right now, and this is contributing to the access problem and all of the issues that we've been discussing. So how many psychiatrists should there be? A lot more than we have, right? There are really three studies, landmark studies that have been done that have each come up with their own number in terms of what the right number of psychiatrists is. But the most widely accepted study was done by Dr. Conrad and others in 2009. And that study found that we should have 25.9, so almost 26 psychiatrists per 100,000 people. We're a long ways off from that, we'll see in just a moment. So the AAMC, the American Association of Medical Colleges, does a workforce study, publishes a workforce study every two years. So the 2022 data will be coming out later this year, or the 2022 publication, which will be based on 2021 data. So it's always lagging a year behind. But if you look at the two most recent published data points, it's 2018 data versus 2022. And let me just orient you here. No, you can't see the cursor. If you look, so the top row is the total active physicians. So that's the total number of psychiatrists. So you can see that from 2018 to 2022 we actually had an increase in the total number of psychiatrists. But that second row is essentially the practicing psychiatrists, the clinically active psychiatrists. We know that there are lots of physicians and lots of specialties who go off and be medical directors of organizations, chief medical officers in a hospital where they're not doing clinical care, or they go work for the state mental health agency, or they do administrative tasks where they're not actually seeing patients. And so that middle row is the clinically active psychiatrists. And you can see that that's actually gone down in that 2-year window. And then if you look for general psychiatrists, if you look at the child psychiatrists, it's actually gone up, which is a good thing. And then at the bottom that's that ratio that's supposed to be 25.9. And you can see that both in 2018 and in 2020 we've been stuck at this 11.7 psychiatrists per 100,000 people. So less than half of what the most widely accepted study is in terms of what we should have in our workforce. This is a busy slide. All I want you to look at is the things circled in red. This is that maldistribution of psychiatrists. So if you look at urban communities, we have almost 11 psychiatrists per 100,000. But if you look at rural communities in this country, we're sitting at just over 3 psychiatrists per 100,000. And there's actually higher ratios of child psychiatrists in this. I know we talk about the dearth of child psychiatrists and there is a dearth of child psychiatrists. But you can see from this that it's actually higher ratios than what we have of general psychiatrists. And remember 25.9 is our goal. This is, and I apologize my red circles didn't show up, but if you look at this column here down the side, that is that mean hours worked per provider type. So we have had increasing numbers of women in medicine and that brings tremendous benefits to the profession. If you look at patient satisfaction, if you look at clinical outcomes, women actually have superior outcomes and superior patient satisfaction. So it's good having women in the workforce. However, women work fewer hours. And if you look at the psychiatrist, which is kind of in the middle of that table, for every demographic other than over 65, there is a significant difference in the number of hours worked by men versus women. So even though our numbers are roughly the same, the number of hours that service is being provided by the psychiatric workforce is actually declining as we have more women enter the workforce. And you can see in 2008, 33% of all psychiatrists were women. In 2020 that had risen up to just over 40%. This again was from that 2020 AAMC workforce. At that point we had 49% of psychiatry residents were women. When I was talking with Dr. Levin at the Chair's meeting just a couple of days ago, he actually said that now we are over 50% women entering the psychiatry residencies. So the new workforce data will show it's greater than 50% of psychiatry residents are women. So just that has implications on our access. And I just want to point out that I don't feel like I actually work fewer hours. But the statistics actually show that women across the board and including in psychiatry are working fewer hours. Now Rashi talked about all the work that's been done to expand residency spots because that is an important way to impact this workforce deficit. And if you look at the number of first-year ACGME residents and fellows over the last five years, across all medical specialties that number of first-year slots has gone up by almost 12%. But in psychiatry we've actually gone up over 20%. So there's been a huge increase. Because of this access problem, places recognize that they can't get patients into mental health care and so there has been an investment in expanding psychiatry residency slots. Child psychiatry has actually gone up as well, though not as much. And we're not really going to delve into the child psychiatry workforce issue here. But that's also a critical shortage. But then if you look at the 12 years between 2008 and 2020, we've actually gone up 31%. So not just that 20-something percent. It's actually been a 31% increase in the number of PGY-1 slots for psychiatry. So we've done a lot to expand psychiatry residency slots. We know that psychiatry has become a very competitive residency and the spots are not going empty, which is a great thing. But despite that, our psychiatric workforce is still declining. Remember that graphic from earlier? Our number has actually gone down of the active psychiatrist practicing between 2018 and 2020. So why is that? Part of it is because psychiatry is one of the oldest workforces. In the 2020 data, we actually dropped from the second oldest workforce to the third oldest because we've had a number of people retire. But still we have over 60% of psychiatrists practicing in the United States are over the age of 55. So we have an aging workforce and it's because there were a large number of baby boomers who entered the field of psychiatry. And we know across the board and in psychiatry, baby boomers are continuing to retire in record numbers now. So one of the challenges we have is that actually more psychiatrists are retiring each year than graduating from residency. So even though we keep expanding our residency spots and turning out more psychiatry residents, we still have more people retiring than we have actually joining the workforce. So if you see on that graph on the left, the number of psychiatrists has been going down steadily over these last few years. And it's not actually until 2025 when we think that all the baby boomers will have retired and will be able to flip that curve and start having more people enter the workforce than retire every year. Now keep in mind also that in the 10 years before the baby boomers started retiring, in that window from about 1995 to 2014, the U.S. saw a 12% increase in the number of psychiatrists. But we actually had a 20% increase in our population. So these are population-specific numbers. And once the baby boomers started that retirement, we moved into this net loss. And then just one last thing. So this is actually from a 2018 study. And here it estimates that even by the year 2050, we're still going to be about 70,000 psychiatrists short in this country to hit that 25.9 number. But actually, if you use the current census projections from the U.S. Census Bureau, we are going to be at, by 2050, we're going to be at a deficit of between 110,000 and 120,000. They have a range for what they estimate the population to be by 2050. So just turning out more psychiatrists is not going to solve this in my career and probably in most of your careers. And with that, I'm going to turn things over to Rebecca. So hello. I'm Rebecca Lundquist. I am a program director of a new psychiatry residency that was formed to address workforce shortages in the state of Iowa. And it's not helping as much as people in Iowa have hoped. We have 99 counties. And in most of those counties, there is no psychiatrist. So addressing workforce shortages is something I live with really every day. And I know most of you do, too. So who has prescriptive authority in the U.S.? I think a lot of you already know this, but physicians, of course, advanced practice nurses, physician assistants. In some states, there's a license called registered nurse clinical specialist. Psychologists in some states have prescriptive authority and pharmacists in some states. And there probably are a few that I have missed. But those are the major ones. And we're going to focus on diving into advanced practice nurse training a little bit and then physician assistant training. I did not get details on the others. So psychiatric advanced practice nurses or psychiatric mental health nurse practitioners, PMHNP, have academic preparation as masters prepared, Master of Science in Nursing, or Doctorally Prepared Doctor of Nursing Practice. You can get details about this at the American Association of Colleges of Nursing, which oversees the education. Currently, Master of Science in Nursing to Doctor of Nursing Practice is the most common pathway that current students are using to get to be psychiatric nurse practitioners. The AACN is in favor of transitioning all programs to D&P programs. But that process is not complete yet. There's greater than 300 Doctor of Nursing Practice programs in the United States. Requires 2-4 years of full-time study. Online courses are available. And 1,000 hours of clinical practice are required for the D&P. In addition to 500 hours for the Master of Science in Nursing. So that's a total of 1,500 hours. And I broke it out, 40 hours a week equals 25 weeks or about 6 months to get to that 1,000 hours. Sites and supervision depend on the program where the student is training. And hours include the student either observing or being observed in clinical practice. There is Board certification for psychiatric nurse practitioners through the American Nurses Credentialing Center. It's an exam that's 175 questions and 3-1-1-2 hours long. Education is renewed every 5 years with 75 continuing education hours, plus an activity from a fairly extensive menu of clinical and academic options. State regulations are all over the place. And summarizing them was really challenging. But this is what we've got. So in 25 states nurse practitioners are fully independent. They do not have to be supervised by physicians. They have reduced practice in 18 states and some sort of restriction in an additional 12. And what that means varies a lot from state to state. There's no specific regulations for PSYCH NPs. And so within a state, general advanced practice nursing regulations will apply. And some state codes have some interesting specifications that have to do with psychiatry. For example, in Alabama and Florida a psychiatrist is required to cosign an involuntary commitment form. Medscape data shows that 8 percent of nurse practitioners hold certification in psych mental health nursing. Average income for psych NPs is $128,000 a year. And for comparison, psychiatrists have an average income of $275,000 a year. So that summarizes nurse practitioners. Physician assistant training. I think this is an area where I had to learn a lot because I only recently for the first time worked with a psychiatric PA. And so I didn't know a whole lot about physician assistant training. But it's two years full time. Most programs are 26 months. Non-courses are available. Requires 2,000 hours of clinical practice. The curriculum is modeled after medical school. And so during clinical rotations, they'll rotate through different specialties similarly to how those of us who are physicians did when we were in medical school. And site and supervision depends on the program. And hours include the PA student observing or being observed. PA certification. So there's two levels of certification for PAs. PAs are first certified as generalists. And they take a 5-hour, 300-question examination. They are required to maintain certification, which is 100 hours of CME for I think 10 years. Two? 100 for two. Thank you. Thank you. And okay. So it looks like then the qualifications for psychiatry, and if you can correct me in the audience if I'm going to say this wrong, are done on a little bit different time schedule. They're done on a 10-year time schedule. And require 2,000 hours of experience working as a PA in psychiatry at a station of a psychiatrist. And 150 hours of psychiatry Category 1 CME. And it's time-limited. According to the website, 10 years. I'm hoping that's correct if it's not. Okay. Okay. All right. So it is two different cycles. Thank you. All right. So PA state regulations don't vary quite as much. They're a little bit easier to understand. So in 47 states, PAs are supervised by physicians. In two states, PAs are subject to collaborative agreements. And then there's alternate arrangements where things get a little bit different. New Mexico supervises PAs with under three years of experience. And specialty care PAs in Michigan, PAs work under a participating physician. And the definitions of these I did not break out for time's sake. In most states, PA scope of practice is determined within the supervising-collaborating-physician relationship, which means that it can vary. And I think a lot of PAs and physicians who work with PAs like that because they get to work it out among themselves based on what both people feel comfortable with and both people feel is appropriate. State data shows that psych PAs are rare. So only 3% of PAs work in mental health, although I think that's increasing. Mean annual earnings for a psych PA, $124,000 a year according to Medscape. And I think that is it. So I'm going to introduce Dr. Pershin. So I'm Lindsay Pershin. I'm a program director, director of residency education at Baylor College of Medicine in Houston and a member of the task force on workforce through the ADPERT. For those of you who came in late, we're a group of people who were convened by the Association for Residency Training Directors in Psychiatry to look at workforce globally as an issue in our nation, but also thinking about how that impacts then what we're talking about today, which is thinking about meeting the needs of our community and our patients through working in interdisciplinary teams. So what I'm going to kind of shift our focus to is thinking about then with the workforce shortage issues that Kari talked about and the training differences that Rebecca talked about, how we can think about collaborating and providing a structure for collaboration between psychiatrists and advanced practice providers. And again, there may be some extension into that with working with other types of providers. The way I'm going to structure this is thinking about hiring priorities, onboarding priorities, and workflow and management priorities. So I know a lot of the people in the audience are psychiatrists. What we don't know is if you're working in private practice, if you're working in health care systems, if you're working in institutions. So I think the most important thing to think about in anticipating a collaborative relationship between a psychiatrist and advanced practice provider is the setting where that might happen. So I imagine that, and just to give you guys an idea of the agenda, we're going to, after my section, break up into small groups and have some discussion. So as I'm talking, please think about how that might influence the discussion in your small groups, but also the questions you might have for us following up. I'm going to try to think about who you are, but hopefully it's getting your brain, getting you thinking about other questions. So not knowing where each of you work, you can imagine that in thinking about hiring priorities that there may be discussions even before you get to what is important for me to know as a psychiatrist who might be supervising an advanced practice provider, or as an advanced practice provider going into a hiring situation, you'll be working in collaboration with the psychiatrist. So if you are at an institution or a health care organization, probably the first place to start is talking to the leaders in that organization about scope, about what their expectations are, and thinking about, for you, what you would want to know as you approach. First we'll start with thinking about an application. So in this frame, you may be in a place where what's required for an application is already defined, but you may want additional information. And I think what Rebecca talked about pretty clearly highlights the type of training that an advanced practice provider had. So there's a lot of variability that Rebecca highlighted across training programs, whether it's online or in person, the amount of clinical exposure, and then specifically psychiatric clinical exposure. So as a residency training director, I do ask applicants to our residency training program, where did you work in your clerkship? What did you do? And that's knowing that a medical student coming into our program is going to do a lot dictated by the ACGME and me and the ABPN in terms of getting them then to the point of graduation from residency. But if you're hiring somebody to work in a specific area, you want to know, do they have experience in that area? So that's why thinking about prior experiences and training is important. There may be advantage to actually having required expanded CVs. So if you think about, I just hired a program coordinator, a senior coordinator position for a residency training program, so an administrative person. And I got a lot of CVs, and they were formatted and included quite different information. So you may want to have things expanded in terms of what types, how you would describe clinical experiences and what the applicant to a specific position is sharing. Maybe a clinical skills section with specific descriptions. Maybe post, not embedded in training, but post-graduate or fellowship training and special certifications or specialized trainings. Those may not be things you see automatically on a CV, but it's going to help you in terms of thinking about, with who I'm hiring and what I expect them to be able to do in the setting in which we work, is this person the best candidate for the position? And we'll talk about later then how that would inform your onboarding priorities. References in the same way. I think it's really important with references to ask references about the type of experiences they have with any applicant for a position. Thinking about specialized levels of acuity, specialized populations, and certain types of psychiatric environments and patient populations. And then thinking about how you're going to assess these individuals for a position. It's good to start with what I think are pretty widely used, at least in institutions and certainly larger entities like the Veterans Healthcare Administration, but thinking about structured interviews. So that there is a way to assess some of these skills and assess a candidate's ability to fulfill the job that you've defined based on competency-based questions, standardized questions, panels of people, but also you may have access to specific HR resources. I know I did. When I was hiring my senior coordinator institution, HR department has a lot of really wonderful resources for how to do the interview well and define how you would then assess for the individual candidate's ability to perform those duties or to work successfully in that environment. And that's probably one of the things we're globally thinking about, right? We're talking about leading interdisciplinary teams and for the success of the organization and the economics and the workforce issues are part of it. But also ultimately so that we all feel comfortable with the patient care and that our patients are getting the best, especially in rural communities. I'll add to Kari's point and the numbers that show the disparities in rural communities. I was the, in my previous position, I was the director of a rural and public mental health track. And I'll tell you that as exciting as it was to develop a track specifically to train psychiatric residents to provide care in that population, what became a significant barrier for me is finding supervisors for residents in rural communities. So I was very aware very early and in Texas we have 134 counties without a single mental health provider. So we have a huge workforce issue too. But trying to train residents in rural communities, it made it very obvious to me that there are not enough psychiatrists there. So you have in rural communities even less ability for the structured supervision that we're talking about. So that's what I'd like you to think about in terms of how to approach creating a position and thinking about your priorities for screening applications, reviewing references, and interviewing candidates. The next phase, once you've identified somebody you want to hire based on what may feel like a lot of things to review, but we do think it's important, is then how do we think about bringing that person on? And again, in lots of different areas where probably many of you were working, different caveats to, you know, do you have access to institutional support, organizational support, and is that standardized? What power do you have over how to onboard and get someone ready to work in your clinical environment? Rebecca mentioned it, obviously, especially if you're in private practice, very important to make sure you understand your state's regulatory requirements, and that probably is obvious, but worth saying. Consider if a skills assessment, as you're bringing somebody on, would be appropriate. And as residency training directors, I can tell you that we have, certainly residency training is dictated and standardized in a way that I think could be helpful when you're thinking about doing something new with someone who has different training than you do. So I'll share some of those resources, I would say. But before you do that, I think it's really important to think about what these providers are going to be, where they're going to be working, and who they're going to be working with. So I would think about the level of complexity. So what, you know, is this an emergency room environment? Are these medically complicated patients? I've worked very successfully with advanced practice providers in a consultation liaison setting, and certainly could share how we think about training and onboarding, but then continuous assessment and scope of work for APPs on a service like that. Emergency room environments, inpatient versus outpatient, the presence and need for suicide or violence risk assessments, and the training and the skills needed for that, and for us all to feel comfortable with that. Legal, we talked about legal requirements, and training around legal processes. And you know, there may be, for those of you who are working in areas where you do procedural-based interventional psychiatry, thinking about experiences and training there. So skills assessments, let me just make sure, yeah. So I'm going to share what many of you probably remember or know. A good way to think about this is for those of us, and yes, I was still one of the lucky people who was boarded using an oral board. But since then, not long after, I'll age myself a bit, the ADPN moved to the process of a clinical skills evaluation. So this is actually just a couple of ways that this clinical skills evaluation measures and asks examiners to determine if someone has passed or not passed a clinical skills evaluation, and just to make sure I'm explaining that fully. In the past, to be boarded in psychiatry, the second step was to have an oral board exam, and they basically modified the oral board exam format to this clinical skills evaluation. So now during residency training, residents have to complete and pass three clinical skills evaluations during their training, and residency programs are required to demonstrate that they've passed in order for residents to be board eligible. So this is just an example of a way that in residency training programs, I think the parallels are pretty helpful, we have ways that we structure assessment of competence and skills. So this is something to consider if during your onboarding you think about actually having a clinical skills format exam for advanced practice providers. Obviously, observation. So thinking about is there a time period when you're onboarding where all interviews or interactions with patients or families are observed, and when you would think about when skills are attained or competence is demonstrated to more independent practice of your advanced practice provider who you're working with. I will highlight if anyone was there. I feel like 8 o'clock in the morning was kind of early, but I really appreciated Dr. Blair in the talk this morning on thinking about the social determinants of health, that he talked about this alternative routes to training and really highlighted from a disparity perspective it is important for us to recognize that in order to overcome, because access is a huge problem when we think about disparities and mental health disparities, that there is value to on-the-job training, right? That people do learn on the job. And his argument, for those of you who weren't there, was that we need to be open to in medicine in general, and he was an economist, but thinking about are there other ways to do this so people can do the jobs that maybe from a disparity perspective or an access perspective that as psychiatrists we can't do. So I would just say that the skills training and the on-the-job training is certainly the model, and he praised medicine having a really good format for this, but we're really trying to set up these providers for success in a collaborative experience. So you think about from a skills assessment, what does that skills training look like? What do you expect these individuals to be doing in your setting with the type of patients you're working with? Also thinking about is there an element of continued shadowing, supervised work and how much supervised work, graduated levels of independent practice, and then review. So observing the clinical skills evaluation is not the only way that we would assess skills. Maybe we're talking about peer review of notes, review of charts, making sure our patient satisfaction or other modes of assessing skills. I talked about how important it is to define as you're reviewing an application in past experiences if that translates to the environment where you're hiring someone to work. So think about enhanced experiences with types of patients or environments where these individuals haven't had a lot of clinical experience. So creating even specialized training or more exposure to certain areas that are more complex and might be more challenging or more vulnerable to mistakes. Inherent in the onboarding is, and Rebecca talked about certainly that in some states it's inherent, right, that you have this collaborative goal making of what are each of us going to be doing, how are we committed to each other, and how do we structure a plan for supervisor and peer feedback, and that should be a collaborative process. And I would argue that it should be for all of us. It's very important from the very beginning to set the frame for and have objective, not only structure, but also objective plans for evaluation so it doesn't feel, so it feels natural and everyone feels comfortable. Because on both sides, I think any of us who end up in a situation where we feel like we're doing something that we don't feel prepared to do, it's challenging, right? So having the ability for that to be a flexible collaborative dialogue I think is very important. Competency is a word I've used. For those of you who are not as familiar with the progress of the ACGME in the last ten years to the milestones, I'll just share with you what the milestones are, something we are very, very, very familiar with, which is basically the movement to competency-based assessment of residents. This is true. I knew about competency-based assessment from my kids before I knew about it in residency training. So it's very, very common in education, lower and higher education at this point. But just so you can see, we measure and rate residents not on are they good, are they good residents at the end of your CL rotation? No. What are they able to do? So it's based on behaviorally-based skills and there are many of them. This is just one example, which is in the patient care domain around the psychiatric formulation and differential diagnosis. But being able to ask evaluators of residents, what is this resident able to do? And the expectation is progression through these levels of skill across a residency training program. Just to orient you, the graduation, level one is where we expect residents to start. We expect out of medical school, the majority of residents would be able to function at a level one on this domain and all others. And level four is what we consider the graduation target. So this is just an example of a resource. You've got a lot of people who've been trying to define what we expect residents, specific in this one to psychiatric residents, but across all residency training, what we expect residents to be able to do by the end of their training. So you have a wonderful resource of also thinking about what is competence and how do I recognize if someone is able to do this or not. So those are the milestones. So from hiring priorities to onboarding priorities to then workflow and management priorities, you can imagine I've alluded to a lot of these pieces, is that it's not once somebody is hired and onboarded that the process stops. I think what might be even most intimidating is how do we think about this as an ongoing process. So thinking about who you leverage as supervisors in your organization or in your team. Thinking about making sure that supervisors are trained and identified and motivated to work in this collaborative process. I think it's very important to create a system of ongoing evaluation and obviously it's true probably in most of the areas where you all work but in less structured environments you may not be thinking about how do I continue to assess on an ongoing basis how I'm doing. I know we really didn't like the the PIP when it was instituted in our MOC but it does highlight just the importance of not sitting and saying I think everything's fine but continuing to improve and looking at our own clinical decision making and our own evidence-based knowledge and making sure that we know there's no there's not a finish line right that our work is about lifelong learning and professional development. So I think that's important too in thinking about evaluation. It is really important to think about how what are the skills for interdisciplinary teamwork and collaboration and I'm sure there are sessions at APA and other formats so we won't expand on just how important an intentional it is to be intentional about teamwork and structure. Think about incentives. Think about ways to actually reinforce opportunities for supervision coaching and mentorship and really reinforcing that instead of it feeling like needed unnecessary oversight it actually feel like something that is really about being the best in terms of taking care of patients and helping our practice or organization our team optimize its efficiency its quality and its collaboration. And then part of this too for those of you who have maybe not been a boss it's something that's a relatively new job for me is remembering how important it is that performance review and what you include in performance review and how frequent you have performance through how important that is. With residency training I can say very clearly that as annoying as it is to the residents how often we meet with them and evaluate them that is about professional development and 100% is not to be punitive it's to make sure you're growing and learning so that you're optimized in your role. So those are some of the kind of pieces hopefully practical implications and I think we'll transition now to talking about in small groups so we can be helpful in thinking about where each of you are and what might be additional ways we can support you in this process. Thank You Lindsay. So I know you might have questions but I would like you to hold them for a little bit longer. So the next thing we would like you to do is sort of break into I think groups of five or six so maybe two rows each can sort of get together and discuss. Just think a little bit about what do you think psychiatrists need to know about advanced practice providers and what do advanced practice providers need to know about you and how that can lead to working well as a team as you know how to establish successful partnerships. So what do you still need to know and what we need to make sure our communities know and it's bi-directional right for both advanced practice providers to know about your training and vice versa. So we'll do ten minutes of that and then we can have a group debrief followed by questions. So I'll let you know when the time is up. All right so if you can choose somebody from your group to report out and have that person start heading towards the microphone that would be great. It's informal but this session is being recorded for the online participants that will come in a couple of weeks. So you don't have to have everything figured out but we're just trying to generate a few ideas. All right let's get started. So we have this group up front. Does somebody want to summarize what you were talking about? What were the ideas that came up? Sorry we talked a little bit about bias or like perceived bias either within the psychiatric community or patients of like getting care from different types of providers as a potential limitation and then also talked about like recruitment if there's any active pursuit in recruiting a range of providers. Thank you. Hi there, Mark Hauser from Boston, Massachusetts. We had a group with diverse experience and I think one thing we could say is that the interdisciplinary teamwork that some of us do is not well developed yet. The other disciplines have been thrust upon some of us or there's a collaborative model that works well for the social worker in our group. I have an unusual practice because I've been working with a team in a different model taking care of people with intellectual disability where the agencies that hire me insist on me working with a behavior clinician, a nurse, a group home manager, direct care staff, family at Health Com and the patient and that's a wonderful thing and 38 years later I still enjoy doing it. But that's not what you're all about in terms of regular serving the public in psychiatry. Another member of our group has been asked to supervise nurse practitioners and that's like a fantasy that there's going to be a model and that makes this panel really rich and valuable. Is there something specific from the residents perspective? Like is it positive, negative, neutral or both good and bad? Anything that you want to share from residents perspective? Like residents who work with APNs in the same team? We had a resident and he brought up a wonderful point to the point of standardization of non-physician providers and also the fact that there is a negative culture online with residents because sometimes they are or and residents and medical students sometimes they compete for procedures so that's less of an issue in psychiatry. We really liked the way that especially if you're able to structure, have a definite rubric and what's going on and supportive positions specifically like triage. This group back here had great diversity and brought up some real issues. One of the things that I thought was impressive is what happens when you have so many different people in a training team and how those people work together. One of my colleagues I think went out there but something that I think is really a problem is nurse practitioners get pigeonholed as just individuals in large clinics and don't get a chance to work as a team. I've been at this for a long time. I train a lot of nurse practitioners. I work with nurse practitioners and PAs. All of us need to be on a team. I'm worried about solo practice psychiatrists. I think psychiatrists need to be on a team too. We have to be in the business of population health care, mental health care. There's just not enough of us but I do think honest communication and being able to recognize differences. I hire nurse practitioners that have been running units for 15 years. They just happen to get certified in psychopharmacology but they are diagnosticians, team leaders, and so forth, and I hire new psychiatrists. They need the support of those people. We're individuals. We bring things. The one thing that I'm advocating, we need to bring nurse practitioners and PAs into the APA. They need to be part of our group. We are one group, and I've worked for that for a long time, particularly in the academy. We just got to keep doing it. Two generations from now, then they'll finally become associate members. Thank you. They don't have to run for president of the APA. I'm Elizabeth. I'm the lone. I am a psychiatric nurse practitioner, and our group was talking about just some of the challenges. I feel like I'm a little bit unique in that I started practicing in a rural area, and really from the get-go, I was practicing pretty independently without a lot of skills training, and we were just talking about having the time and the space to do adequate training and how psychiatrists kind of fit that into their schedule and into APRN's schedule, who kind of right off the bat, it was kind of in my first workplace, it was kind of like you needed to see patients immediately. I had one day of shadowing and then I had a full schedule, just because that was what the need was there. So, yeah, I'm really glad I came to this, and this is why I come to this meeting every year, is just to work collaboratively. And she was talking about she actually works in Canada, where they don't even have APRNs that specialize in psychiatry. They don't have that specialty there, so some of the challenges in that as well. Thank you. Hi, just also a quick question from a kind of training direction perspective, since all of you are training directors. How much of this should we be teaching our residents and fellows? That was the other question. So at some point, if we can circle back around. And I guess, you know, we've already started talking about the groups, so we can transition into the questions. Can I report out one? Oh, we have one more group to report out? Sure, yeah. So I think what we talked about is a bit that we need to understand, like, the different certifications. Like our colleague, I didn't get your name. Alexis. Alexis was talking about how, like, there are physician assistant psychiatry certification, but, you know, that's not required. And, like, when you're signing a collaborative agreement, you need to understand the background. I hire and manage psychiatric nurse practitioners at my clinic, and I think just one recommendation for you all's panel is that you should have an advanced practice provider on it next time, because I have a colleague who I interview all the advanced practice providers with. Like, she's a huge resource for understanding, like, the training, the background. And something that we've agreed on is that the clinical skills portion of the resume is pretty necessary, since it can be kind of like general resumes that are submitted, especially if you're using recruiting websites like Reload and ExecuSearch, if that's something that your organization does. And then requiring references from a manager and a collaborating or supervising MD, so you can understand the clinical skills. And then we have very robust, like, performance evaluations. We have a week of shadowing. So just as you would do for really any colleague, you should implement that. Yeah. Thank you. I just want to add one of the barriers I found within my previous location and job was having psychiatrists join me in training PMHNPs. And this wasn't even people straight out of, you know, straight out of the didactic portion of their training. These are FNPs, one who had a residency in family nurse practitioning. And my psychiatrist really struggled to give them any independence within the training setting. So, first of all, it was a stretch to get them to actually participate in helping train and provide hours. But then it was in the clinic they were treated like a medical student who just shadowed. And I think we really need to help our colleagues in psychiatry understand the value, as you all are today, trying to get the message out. I truly believe in the APA being more of an open organization for our colleagues. I just can't think that we're ever going to resolve this issue. And being a guild is not going to allow us to continue and survive, I think, in the long term. Because I can tell you, in the state of California, the PMHNP network has become so frustrated with us that they are publishing papers saying they're better than we are. And people are believing that that's true. And I think that's a shame because I think we all need to check our own house and get them in order. And I think working with our APPs or APCs to establish the standardization around how do we do this together and make sure our psychiatry residents are supported coming out of residency to do the work they need to do and continue their professional development, and the same with APPs. Yeah. I think part of your comment is based on the fact that most psychiatrists do not really know the training. So our expectations from a new APN or a psych APN can be similar to it because, you know, their licensing sort of lets them do everything we do for the most part. So we expect them to be functioning at similar levels right out. And unless they have been a psych nurse before they went into psych APN, it's not the same. And sort of understanding their training and helping them ramp up is a very different process. But if you're not a training psychiatrist or a teaching psychiatrist, this can be challenging. Do you guys have any comments on that, on any of the comments so far? I guess our colleague needs to step out because she's winning an award. So she has to go. I guess one comment would be, well, a couple of comments. We actually do have an APP who works with us on this, and it has co-authored the paper that's going to be coming out soon in academic psychiatry. And we have also been working, as Rashi said at the beginning, this is a task force that was formed by ADPERT, which is the Psychiatry Residency Training Directors Association. And so we have put out white papers to ADPERT. We have given workshops to ADPERT about how people can incorporate this training into the residency training. So residents graduate knowing how to work effectively and collaboratively with APPs. So that is work that we're doing. I've seen a lot for psychiatrists, that a lot of psychiatrists don't have the training or don't perceive that they have the training to supervise APPs. And a lot of them kind of fear of, I guess, their license being revoked. And so some resources would be great to be able to spread to those psychiatrists so they don't feel like they're taking on additional liability by adding APPs to their team. And in some ways, you know, they are right. There is additional liability. And depending on the PMHNP you're writing, you know, you are collaborating with in their training. And that's why it is important to not just blindly think of it as, oh, we charged this amount of money, and now I can supervise so many people. I think it needs to be a little bit thoughtfully done so that you understand who the person is that you are in the collaborative agreement with and what their training is. And there is a lot of state models, actually, that actually show you. I think it's Ohio. Oh, Rebecca just left. But was it Ohio last year when we presented? Actually, it was easily accessible. So, you know, if somebody needs those resources, I can provide you the links later. Yeah, I might just add, and this is often where my drum beats when I'm thinking about more training and not having anybody in the situation that you were in that you hit the ground running. And it is about money. And it's about resources. And I think we need to, I mean, for those of you who are leaders in your organizations, I think we need to always identify the elephant in the room that more training, more time for training, it takes resources. So there is certainly, from a residency perspective, a valuable skill-based priority for residency training programs. But if those psychiatric residents who are graduating and entering systems where they don't feel comfortable that they have the amount of time to supervise and train, I don't know if we're going to solve the problem. So I think the vulnerability to, you know, liability, the vulnerability to do I feel like I have adequate time for supervision to feel comfortable with a lot of the things I talked about with the onboarding priorities and the ongoing management priorities. If there's not time and resources set to that, it's going to be hard to overcome. And, again, that may be different across different systems, but I'm pretty sure it's a universal challenge that the protected time and in private practice time is money. It's going to be a continued stuff we have to push for from a high level of advocacy. And just in terms of thinking of advocacy, I think some of us are leaders in advocacy in our states, and one of the things I've been doing with my state is actually working on trying to create some standardization for what clinical experiences PMHPs will have so that when they are looking for positions, they aren't thrown in a situation where they're seeing a patient cohort that they really have very little experience with, that there's actually some standardization of what that education looks like beyond just what the professional organizations have set. I really enjoyed the talk and also the talk this morning or this discussion with Dr. Peter Blair and kind of hearing his thoughts as an economist about how we kind of need to make more providers able to care for our patients. One thing I've noticed, like even as a trainee, when I was going through residency and kind of beyond, is kind of hearing the outrage among some of my colleagues about the expanding role of advanced practice practitioners, kind of like in a turf war sort of thing. I think it's a significant barrier to expanding access, and I'm just wondering, I'm sure you guys have thought about this quite a lot and kind of what conclusions you have drawn about what we can do about it or ways that we can try to convince some of our colleagues not to be quite so frustrated. And you didn't train in California. I know. I think that's hard, right? I think it's been highlighted that there's a lot of polarization, and I think it does, like everything else that we're living in in our socio-political climate, when you have that amount of polarization, it's hard to think about coming back to the middle, right? That even if there are people on one side who feel strongly, like I really do think that we could collaborate in a way where our training aligns and supervision aligns, that when you have strong political reasons to have groups of people who are very, very much wanting to promote in the state of California that know good, bad, black, white, it just creates, I think, a very big challenge. I don't know if you all have thoughts about how to start to get and move both groups of people to the middle. I think one of the things is, and I don't know if you came in late, but you have the slides in the app looking at the data, and even within that data, by 2050, when we're at the peak of our number of psychiatrists, we're still 70,000 psychiatrists short to meet the U.S. needs, and that doesn't account for the increased population. So your slide says 70,000, but actually, the kind of back-of-the-napkin calculations with the new U.S. Census Bureau, we're going to be 110,000 psychiatrists short. So we can't meet that need. We need to partner. And while there may be anecdotal one-offs of an agency choosing to let go of psychiatrists to hire a less expensive workforce, there aren't enough psychiatric nurse practitioners, there aren't enough psychiatric PAs, there aren't enough psychiatrists to meet that deficit that we have, so we all need to be working together and figuring out how to do that effectively. What I really appreciated about the talk this morning, the discussion was how he was saying in order to make our arguments, we should appeal to people's wallets and kind of make financial arguments rather than moral arguments. And I think that might be one way of taking this discussion. And you know, one other aspect of the TOEFL is also sort of thinking about is everyone going to do the same task or there are some tasks that are better done by this person in a team versus this person in a team. So I think Lindsey was just talking about it and our APN colleague with whom we wrote the paper was talking about in her own clinic there is a triage that happens where relatively straightforward depressed patients start with the PMH and P whereas patients who have more complicated issues, more medical problems and more complex illnesses go to a psychiatrist. Lindsey's model had where a psychiatrist sees a patient then the next time the PMH and P and every few visits the psychiatrist can circle back and there is different levels of expertise and having people involved so that everybody feels safe. There are extremes on both sides, both from the politics of it and the capability and how we assess our capabilities but I think most people feel uncomfortable with if you have only 500 hours or 1,000 hours in which you didn't even, you know, you spend many of those hours just observing, you're not ready to be on your own, have no support at all. So it is not easy for new PMH and P's either. So working together in a way that makes sense both financially and in collaborative way actually works out well. So there's actually not that big a tough work unless we feel like that's the only work we want to do, seeing non-complex patients and that's a challenge sometimes. Yeah, I just really, I mean, you said what I was gonna say and in the way that in residency, starting in residency as physicians, MDs, DOs, I think redefining our role as what we are going to do in our future is where that needs to start. The framework on which we expect to work in our future, I think really needs to be said and established at that point in the training. Otherwise, and you know, we don't get to see the mild and moderate. I mean, I think a lot of us feel, whoo, I got some easy patients today and I think trying to change that role in what you're doing on a day-to-day basis and you're leading a team and being leaders for a team, I think is where I get excited and as APPs get more and more experienced, they take on that same role, but that it's sort of, you get that with experience and I'd really love to see us doing that and putting us in a different position because it happens in all other specialties, right? I mean, there are MDs who lead multidisciplinary teams or interdisciplinary teams. If you go to our cardiac cath lab, there's a lot of people with a lot of support doing the work. It's not just an MD. Yeah, my faculty and residents get sick of me, sick of hearing me talk about everybody needs to be working at the top of their license and there's a role, we haven't talked about the role that primary care has in taking care of a lot of psychiatric patients, but they're part of that psychiatric healthcare team and so really thinking about which patients should be managed by which degree of expertise and within my faculty, there are people who are all physicians, all general psychiatrists, but they have expertise in one area or another and so again, thinking about the top of everybody's license and skillset and really helping people work in that manner. And just a quick add on, like APRT is actually launching a new task force to look at residency training and curriculum and imagining what a resident or what a psychiatrist in 2040 will need. So hopefully some of these things we are talking will be reflected in that work. So I can speak directly to that. I'm a social worker working in a community health clinic here in New Orleans and so I work in the behavioral health department alongside a psychiatrist, Selene Nelson, and we are working really hard on integrating behavioral health with the primary care clinic. So the model that we've been trialing over the last couple months is, I'm actually basically being her MA, checking in her patients for her, administering the PHQ-9, checking in about any resources the patient might need and just getting a holistic idea of, you know, how are you doing? Are your symptoms getting better or worse? How's the meds? Doing the medication reconciliation at a higher level than the MA would be. And just kind of letting her know like, hey, patients stop taking their meds. I checked in with them a little bit about medication adherence. Anxiety attacks. I talked to them a little bit about some psychosocial interventions and I taught them, you know, some things. Or you might want to check on this medication because they were saying about the side effects, that kind of thing. And that frees her up, not only to focus in on the things that only she can do as a psychiatrist, you know, medication management, you know, differential diagnoses, all that stuff, but then she can teach me what she knows and she has more time to consult with the PCPs and with the NPs in the clinic who are really anxious about having to manage even very basic psych stuff. So that gives her room and space to work more directly with the clinic and it gives me experience and it means that she's not sitting there, you know, listening to a patient go on and on because they're already a little bit tired out by the time they get to her. So we're playing around with the models and I'm just, I guess I'm just saying that to say, you know, be creative within your agencies. See what people you have in place and how social workers, nurses, NPs, doctors and psychiatrists, we can all work together and bring all of our strengths to treating our patients. What is the name of that model you guys are using? Integrated Care slash, we kind of came up with it as we went. I mean, it's a long story, but I am the only social worker in the agency of 20,000 patients. Wait, no, we just hired somebody last week. So we're, and in New Orleans, we were shut down for months because of the hurricane. In front of the qualified health centers, you just do what you can with what you got. So that's a lot of it. That's great. So I came to this talk because I was actually thinking about, you know, mid-level providers, but also just the whole team in general because at our mental health center where the need is even harder to meet, and we are trying to meet rural needs with a mobile van and telehealth and all the things that you can try and it's never enough. One thing we are moving towards is trials of phase-based care with a team where someone comes in and they see a clinician or maybe even to like make sure that the clinician can use their time best, they see a peer specialist first. And then when we really know that it's the most, that a client needs a medication issue, then they get to the psychiatrist because a lot of people think they have a medication issue when it's more of a therapy resource issue. And everything you just said, very apt. But you know, I'm excited about it, but I came because I, yeah, I didn't get any training about that. I was lucky enough to work with some master's level therapists and some PAs in my residency. And that was great experience, but it was not a formalized part of it. And as has been mentioned before, that is the future of our careers. We are not going to be solo practitioners. We are all going to be leaders and team members and we're not trained as that, which is unfortunate. Yeah. It is part of the requirement for residency training for teamwork skills. It's just, I think across systems, I think training programs probably struggle, although the curriculum piece of what Adpert's going to be working towards is certainly to think about how do we, how do we scaffold and actually teach the skills? So all of us as providers have functioned in teams most likely. But how does that expand to actually, how do I lead a team, right? And it does take modeling, but I agree with you completely. I think it takes skills and probably an administrative perspective that is challenging to all programs, but certain programs more than others in terms of giving residents those experiences. So I think your point is absolutely right. Having an onboard administration for an organization to take on that team-based approach in practice. Yeah, yeah. That's a great point. Great point. Hi, my name is Seth Rosenblatt. I'm a medical director of behavioral health at a federally qualified health center. So you talked about the retiring workforce and I think there's definitely a disparity maybe in some folks' experiences working with nurse practitioners and PAs. I think the older workforce probably is not as accustomed to it, but it's the absolute reality. You can't unfortunately work in any medical director job without agreeing to supervise other practitioners whether you want to or not. I've had several jobs say, are you comfortable supervising MPs? I say, no, I really would prefer not to. Okay, we're not really looking at you. That's the reality of where things are right now for psychiatrists and MDs. The other question I have is, so nurse practitioners are specializing. We have one at my clinic. We're in an independent state who sees children. I'm not a child psychiatrist. We don't have a child psychiatrist at our clinic. So I'm curious if there's any ideas how I'm supposed to supervise this. Because that's the reality we're in. They're doing geriatrics, child psych. I'm just trying to present another view because I think everyone in here is really rosy and I really would not want advanced nurse practitioners or ARNPs or PMHNPs or PAs to be part of the APA. I mean, the APA assembly, if that's something people feel strongly about, there's ways in legislation about going about that. You can propose action papers and things like that. But there's a reason why our organization is physicians. That's just my opinion. You know, the interesting thing you just said about how do I supervise an APN who is child specialized? I think, as a program director, I really feel we have failed in, you know, because we have self-specialization, we have started feeling that when we train and graduate from residency, we are not equipped to be a geriatric psychiatrist or an addiction psychiatrist or a CF psychiatrist or a child psychiatrist because we didn't do the fellowship. And I'm really hoping in the next 10 years that's going to change. Because just so that you understand, a PMHNP training is considered broad training. So when they graduate, they can work with any population they want. So it's not necessary that they have more training than you in child psychiatry. It's just that in the 500 or the 1,000 hours we're talking about, they decided to focus on that a little bit more than the other. So for you to not feel comfortable supervising, so a lot of times, I mean, I really struggle with this because a PMHNP will cover a child service because they are comfortable enough to jump in. And I, as an adult psychiatrist, I'm saying, well, I haven't done it for a long time. Well, I did have a lot of more training, actually. Two months of child rotation. Just remember, when we're talking about APN training, they don't have calls. They do a lot of observation. It's not all hands-on experience the way we have. So even the two months we spend on child, we do a lot more work, and then we see the children in ED and other places. But because we always associated with child psychiatrists, we will not do it. And I think a lot of it is licensing issues and board certification issues, and those are things we created for ourselves. And PMHNPs came later, so they, I guess, were smarter about that, is all I can say. But those things do need to change. I don't know, Kari, how you think. Yeah, and we're general psychiatrists. We're not adult psychiatrists. And if you think, so I don't think I ever worked a 60-hour work week as a resident, although I trained before duty hours. But if you wanna just average at 60 hours of a work week, you did 500 hours or almost 500 hours in child psychiatry during residency. And so you have the equivalent of what a master's level nurse practitioner has in their entire clinical experience. So it's, again, this false dichotomy that we as a psychiatry profession have created that we have these fellowships. But you know what? I've worked in rural America for a lot of my career, and I've taken care of little kids because there was no one else to do it, and I'm a general psychiatrist. And so we kinda need to get over ourselves in that regard. Hi, my name's Nancy Chinoy, and I'm a psychiatry resident in Houston. So I had a question about physicians for patient protection. So the other side of the aisle, I suppose, has, I guess, these kind of concerns. So physicians for patient protection doesn't really, many of the people who belong to that don't feel comfortable with the idea of, not supervision, but independence of advanced practitioners. And their theories are sort of that it's a patient safety issue because medical education is more lengthy, and that it involves not really any sort of algorithmic learning, but I guess an algorithm of so many different subjects, whereas the training is shorter. Now, given the shortage, that being the major argument to counter that, what other things should we sort of respond to if faced with colleagues who espouse the viewpoints shared by PPP? Well, I'll start. I mean, I think it comes back to that having the right skillset, taking care of the right patient population. And frankly, I know this isn't popular. I don't know if it's going to be unpopular in this room, but it's unpopular with psychiatrists. We ran away from the patients who need us most. 45% of us are doing a cash pay business, not taking care of the chronically mentally ill, the most complex patients. And so someone had to fill in the gap. And so we need to get back to taking care of the patients that we are trained to take care of. And when we do that, then there's going to be this whole cohort of patients that can't get in to see us, but don't need our level of expertise. And they're going to be taken care of very well by psychiatric nurse practitioners, by psychiatric PAs, by primary care doctors, by other people on the team. And so we have such a shortage that it's just a maldistribution of who's taking care of which patients. We have one psychiatrist with 20,000 patients. I'd also just like to add to that as a PA. So hopefully I'm taking liberty to speak for a lot of my profession. So we do not come into the PA world and profession intending to operate independently. And the notion of the scope creep that is prevalent and honestly pretty pervasively negative, which is a lot of the feedback we're getting. What the organizations that represent PAs and really legislate across the country in terms of the language we're using, in terms of the agreements we share with physicians in order to determine our scope truly during the day-to-day work, that's the general work of what the organizations are in place to do, is try to nationally standardize the language being used so that we don't have these discussions where there are five different physicians around me saying, yeah, I really am not sure what to expect when I get a PA out of school and what their abilities are really without running them through this lengthy process, which we may not have the time for, the money or the resources, et cetera. So the organizations that we look to to really legislate for us and speak for us, they're really focused on the language surrounding what especially PAs are agreeing with with their collaborative physician. The notion of the scope creep is really not true to the nature of the purpose of what our organization is pushing for. And again, we don't get into this. I would say we do get into what we're doing knowing fully what we're getting ourselves into and what those limits are. So this is not a notion amongst the actual practitioners. So I would just like to dispel some of that belief myself. Thanks. And I would like to add that PAs are trained in a medical model. I don't know if you've had experience with PA students or the PA training program, but their classes and clinical rotations are side by side with medical students and are very similar to what medical students get. And so they don't get the residency piece necessarily. They can do a fellowship in psychiatry, but they don't get the residency piece. But they're in a lot of ways equivalent to a graduating medical student in terms of their global medical knowledge, physiology, pharmacology, all of that. Thanks, that's really helpful. I think now, I guess, when interacting with residents, it's easier to have this conversation knowing more of the information that was discussed today. So thank you all. And I just also want to add something more about the turf war because I think slowly we are talking about the elephants in the room, which are very hard to talk about. There are horror stories that I have read and heard about and each of us have read and heard about and seen in Facebook groups and things like that. And I think it's important to remember that there are horror stories from every spectrum and every end. And if we make an environment where the team structure is such that no organization is either forced to hire or hires a PMHNP for a role they're not prepared for or they're not thrown into those things, where we are integrating into a team structure where everybody's doing patient care that's appropriate for them and their level. And it's also true, by the way, as somebody said, a PMHNP who's been working in the same clinic for 20 years is different from a PMHNP who's just started. The same way as when I was a psychiatry resident, that's the best advice I've ever given. Check with the nurses on what you normally do before you do anything, right? So we're used to learning from each other. And we have psychiatrists who are not that well trained sometimes. So we just have to be humble and be aware of all the ramifications as we do this. It's a very complex issue. And in this room, we haven't gotten to all the aspects. But I think we're talking about the starting points. And I guess psychiatry needs to change too. And it's time to think about how we are training our residents. I just want to make one comment that at least in the state of Illinois, or possibly in all states, you are licensed to practice in all field of medicine. You're certified general psychiatrist. As a general psychiatrist, you can practice in any of the specialty, subspecialty of psychiatry. I was the only psychiatrist in the state of Illinois that was running only state-operated psych unit. And I did for five years. And I'm not a child psychiatrist. So your license allow you, it's your comfort level, based on your training, what you want to do. So I don't work addiction psychiatry because I don't feel comfortable with it. But license does not restrict me from doing so. Thank you. You know, talking about comfort, we were just talking about, because many of us have administrative roles. So if you go back, and I'm a CL psychiatrist, but I have covered inpatient unit, I have covered ED. But even though I'm a CL psychiatrist, there was a long time when I was covering ED. So when I went back to CL for the first day, there's a level of discomfort. So depending on what you, it's okay to recognize that. And it's very important to recognize that. And know that it will take you a little bit more reading and catching up if you've been away from something. And it's true for all of us. Yeah, I might just wrap up and thank everyone who spoke, actually. Because I do feel like, although there's people from different perspectives, we were able to have what I think is critical. And again, I could make a broader political statement about this, but we live in a world where division and, I can't think of the right word, but we're reinforced in our own opinions. And so having that kind of tunnel vision and not being able to think about the realities that Kari presented very well of what exists for now in the future and thinking about how to bridge that gap without it becoming extreme bad or good, but instead collaborative and positive moving forward. I appreciate everybody who spoke. Because I think that we had a productive discussion that did allow everyone in the room to get perspectives from both sides. So thank you all for that. Thank you for being a wonderful audience. Yes, thank you. Thank you. Thank you.

psychiatrists

advanced practice providers

psychiatric workforce shortage

training differences

hiring priorities

onboarding

clear communication

interdisciplinary teamwork

incentives for collaboration

performance reviews

professional development

patient safety