AMA, partners fight loosening of prescribing rules

April 22, 2004
The AMA and several of its state and specialty society partners are fighting proposed legislation in Louisiana that would allow so-called "medical psychologists" to prescribe potent brain medications. Safe and effective prescribing of such drugs can only be ensured by limiting prescriptive authority to those who have medical education and supervised residency training.

The Louisiana Senate passed such a bill (HB 1426/SB 754) by five votes on April 21. The bill will be sent to Gov. Kathleen Blanco for her consideration. The AMA, the American Psychiatric Association, the Louisiana Psychiatric Medical Association and the Louisiana State Medical Society fiercely oppose the measure. The AMA encourages all Louisiana physicians to contact the governor to veto it. Call Gov. Blanco's constituent services line toll-free at 800-317-5918 :scared: to make your voice heard.

Learn more about the battle in Louisiana.

Add:
Please call 800-317-5918 to make your opinion on HB1426/SB754 known. This bill would allow "medical psychologists" to prescribe any psychotropic meds with only telephonic approval. This includes ability to get DEA # and prescribing benzos/stimulants to adults and children. The training is apparently going to a pass/fail course every 3rd weekend for 2 years to learn about meds. I am attached a relevant article below.


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Doctors criticize bill allowing psychologists to write prescriptions
11:14 AM CDT on Thursday, April 22, 2004

WWLTV.com


Some Louisiana doctors are saying new legislation could be dangerous to patients because it would allow psychologists without medical degrees to write prescriptions for drugs.


Currently only psychiatrists with medical degrees can issue prescriptions, but with the bill, Louisiana will become only the second state to allow psychologists to prescribe mental health drugs.




WWL-TV
Louisiana is only the second state to pass such legislation
The bill's co-author, Senate President Don Hines, said the bill would help people in rural areas who might have a long wait to see a psychiatrist. Hines said the psychologist?s scope of medications would be limited, only allowing them to prescribe medicines related to mental and emotional illness.


Hines said so far 50 psychologists in Louisiana have already taken and passed the postgraduate course, which has been around for a few years.


Dr. Patrick O?Neill, president of the Louisiana Psychiatric Medical Association, said the bill is very dangerous because there ?is no medical oversight whatsoever.?


O?Neill strongly opposes the legislation, saying psychologists don?t have the medical training to dole out prescriptions, even for mental health purposes, because that medication could interact with other medicines.


?Some of these medicines can be quite dangerous,? said O?Neill. ?You are playing with peoples brain chemistry. A lot of them have issues with drug interactions with other medications and also you can't treat a patient in a vacuum. When you treat a patient you're treating the whole patient not just the psychiatric symptoms.?


According to O?Neill, other than Oxycontin and morphine, the psychologists would be able to prescribe nearly all mental health drugs.


?They're able to prescribe any of the anti-depressants,? he said. ?There have been concerns raised on the anti-depressants by the FDA visa-vie suicide, especially in children.?


Hines said psychologists who want to prescribe medication would first have to pass a stringent postgraduate course.


Eyewitness News obtained a brochure of the postgraduate course outlining what psychologists must complete.


According to the curriculum, class meets every third weekend with 384 hours of classroom instruction is needed over two years. In the section titled ?Frequently Asked Questions,? it says students will have to spend two to three hours a week studying. The pamphlet also says the course is on a ?pass-no pass system,? meaning an average score of 70 percent is required to pass. If a student does not pass a class, the program will develop a plan to do remedial work and retake an exam


O?Neill said that program does not compare with medical school and a residency


?They don't have the medical background, they don't have any exposure to patients in the context of medical illness; they're behavioral scientists,? he said.


The bill now heads to Governor Blanco, and according to her staff, she hasn't decided if she would sign the legislation.


The Louisiana Psychological Association said they could not comment on the new bill.


New Mexico voted a similar bill into law two years ago, but because the state has not come up with an agreeable postgraduate curriculum, psychologists there are still not writing prescriptions.

Realistically, how much "medical supervision" does the average SSRI user get? Fifteen minutes with a psychiatrist once a month, or more likely even less frequent contact with a family practitioner?

The main danger of the newer AD's (which realistically, is all psychologists would probably dare to prescribe) is psychological, rather than physiological. A psychologist who is seeing a patient for 45 minutes once or twice a week is much more likely to notice a bad psychological rxn to an AD, such as derealization, suicidal ideation, etc.

Let's be honest here. The blockbuster success of the newer AD's and antipsychotics has mainly been due to the fact that they've been billed as drugs that can be prescribed without a PE, bloodwork, and with minimal concern about interactions.

The press release above makes it sound like psychologists are chomping at the bit to design MAOI/lithium/TCA cocktails for patients with BPD and Bipolar I! I seriously doubt that's the case. Psychologists don't want to get sued any more than M.D.'s, and they probably leave their psychopharmacology program scared to death of anything besides the established bread and butter benzos, SSRI's, and variants. I think they are also trained to make sure their patients have regular contact with an internist or FP.

I'm not taking a position on this issue--I just want to point out that it's a bit hypocritical to suggest that all patients on psychoactive drugs (particularly in underserved areas) are getting wonderful, regular care from medical specialists.

In practice, I suspect medical psychologists will be offering care to people who weren't getting it in the first place.

Is getting six refills of Zoloft from a busy FP you don't see for six months to a year really better than getting Zoloft from a psychologist with psychopharmicological training that you see every week?

In practice, I suspect medical psychologists will be offering care to people who weren't getting it in the first place.


The state of New Mexico says you are wrong.

NM enacted this legislation several years ago, under the SAME PREMISE that it would widen access in rural areas.

Guess how many psychologists went thru the training and are now providing care in rural areas?

ZERO.

Imagine that. Psychologists want to stay in the big cities just as much as the psychiatrists.

The state of New Mexico says you are wrong.

NM enacted this legislation several years ago, under the SAME PREMISE that it would widen access in rural areas.

Guess how many psychologists went thru the training and are now providing care in rural areas?

ZERO.

Imagine that. Psychologists want to stay in the big cities just as much as the psychiatrists.
Hope for the best but prepare for the worst :D

I have been following these meds threads with great interest. I am a doctoral student in clinical psychology and I chose this path as I am more interested in providing psychotherapy than pharmacotherapy. And even if psychologists in Canada were given prescriptions rights, I would not (gasp!) exercise them as I feel I do not have the required training and do not want the responsibility.

That being said, I wish that the psychiatrists with whom I have worked would treat my profession with more respect. As said above, a psychologist spends more time with clients so may be in a better position to judge their level of functioning. So please take our opinions into account when we call you to say we're concerned! Also, I provided CBT to a young teen with social anxiety and dysthymia. The pdoc prescribed Paxil just before the advisory came out. The parents were obviously concerned once they found out the possible suicidal risks. However, Dr. Psychiatrist took weeks to return my and their phonecalls regarding the prescription and acted extremely defensive that we were questioning her judgment.

I have been following these meds threads with great interest. I am a doctoral student in clinical psychology and I chose this path as I am more interested in providing psychotherapy than pharmacotherapy. And even if psychologists in Canada were given prescriptions rights, I would not (gasp!) exercise them as I feel I do not have the required training and do not want the responsibility.

That being said, I wish that the psychiatrists with whom I have worked would treat my profession with more respect. As said above, a psychologist spends more time with clients so may be in a better position to judge their level of functioning. So please take our opinions into account when we call you to say we're concerned! Also, I provided CBT to a young teen with social anxiety and dysthymia. The pdoc prescribed Paxil just before the advisory came out. The parents were obviously concerned once they found out the possible suicidal risks. However, Dr. Psychiatrist took weeks to return my and their phonecalls regarding the prescription and acted extremely defensive that we were questioning her judgment.
Thanks for the feedback. I do respect cl psych and I believe that they are doing a great job providing therapy to mentally ill patients. These days when I ask a patient about hsi/her OP psych F/U 99% of them talks about their therapists which show their dependence and/or respect for the therapists. I am also a firm believer in the team approach in tx planning. That said, I don't think it is a safe practice for the therapists to double as med-managers, because it's too dangerous for the patients as repeatedly pointed out in these threads.
I wish there are more level-headed individuals like you in mental health field.

Thanks for your response - glad there are understanding psychiatrists out there :) and yes I agree with the team approach although realistically it's never equal participation for all professionals working on the case...


But what did you mean about patients being dependent on their therapists? Therapy is an intensive process and is meant to be a lot of work and to provoke reflection on part of the client - so it's no surprise that they talk to you a lot about it. That doesn't make them dependent .....

According to the American Psychiatric Association, organized psychology has relentlessly pursued prescriptive rights for twenty years. Since 1993, they have made 50 attempts in twenty states. As psychiatrists and future psychiatrists, we are obligated to stop them. Psychologists outnumber psychiatrists by 4-to-1 and are dedicated to winning this war. If you really want to help, then join the American Psychiatric Association, and/or contribute to the "Fund to Defeat Psychologists Prescribing Legislation". Psychiatrists should not be the only people concerned about this issue. If you need information the phone number is 703-907-7300. Here is the website:

http://www.psych.org

With the right resources, we can show legislators and the public the dangers and shortcomings of giving prescibing privileges to psychologists: minimal education and little clinical training.

You guys should read the other side as well

http://www.apa.org/apags/profdev/prespriv.html

http://www.apa.org/apags/profdev/advancingprof.html

Cosmetologists have for many years been looking after the beauty and appearance of many people. As such, they should be allowed to prescribe Accutane and Retin-A for their patients, thus allowing more people to have access to these wonderful medications. Primary-care doctors, who have less experience in dealing with the skin than cosmetologists have been prescribing these medications, so why should dermatologists be the sole providers of cosmetic skin care?

If psychiatrists are so concerned about psychologists' lack of knowledge regarding medical conditions, why not have system in which primary care doctors evaluate and treat medical problems, including those related to psychological functioning, and then, if necessary, refer patients to psychologists who may then determine the appropriate course of action in treating psychiatric disorders? Whether this course of treatment includes psychotropic medication, psychotherapy, or a combination of both could be determined by psychologists with postdoctoral training in clinical psychopharmacology.

Keep in mind that the issue is increased access to behavioral healthcare services and patient care, not turf wars about prescription privileges between psychiatrists and psychologists. Interestingly, however, the groups that are going to benefit most from psychologists' gaining prescriptive authority are pharmaceutical companies.

The generalizations and gross inaccuracies outlined in the above referenced articles are too numerous to detail. Suffice it to say that no "training program" with 100(!) patients under supervision is even a shadow of what is needed to competently prescribe psychotropic medications.

These people will adversely affect patient care. Period. They can't comprehend the complexities of medication interactions, and the subtlties of physical exam and observation that is needed to keep patients safe. Taking 5 years off someone's life, for example, by incorrectly prescribing a psychotropic medication who is also on a cholesterol-lowering agent is not amenable to lawsuits...it is unprovable. Yet, this is what will occur.

Remember, future and current psychiatrists.....legislation granting rights are never taken away. Once obtained, they remain forever. This is why chiropractics has been so successful. If you can win one piece of legislation every 5 years, you make steady progress to eventually calling yourself "physician," prescribing medications, doing school general physicals, etc, etc.

The lie that is propagated that prescribing psychologists are needed in rural areas are just that....lies. Psychologists are not moving to underserved areas, and it will remain that way.

I've posted topics related to this some time ago with some interesting responses. Those interested should do a search.

I was in a PhD for clinical neuropsychology. I realized I wanted to prescribe medication. I felt uneasy about the "training program" I was offered when I graduated. I quit and went to medical school to ensure my competence and complete understanding of human physiology so that I keep my damage to patients to a minimum. These people have only themselves in mind - a psychological need to feel more like physicians. That's the sad truth.

Call the APA...show your support. Call the Louisiana legislature or write a letter and impress upon them that they will kill patients and that they don't want it to happen on THEIR watch.

Again, privilages obtained through legislation are never taken away...only added upon. If we don't stop it now, it will grow out of control. Of this I assure you.

The generalizations and gross inaccuracies outlined in the above referenced articles are too numerous to detail. Suffice it to say that no "training program" with 100(!) patients under supervision is even a shadow of what is needed to competently prescribe psychotropic medications.

These people will adversely affect patient care. Period. They can't comprehend the complexities of medication interactions, and the subtlties of physical exam and observation that is needed to keep patients safe. Taking 5 years off someone's life, for example, by incorrectly prescribing a psychotropic medication who is also on a cholesterol-lowering agent is not amenable to lawsuits...it is unprovable. Yet, this is what will occur.

Remember, future and current psychiatrists.....legislation granting rights are never taken away. Once obtained, they remain forever. This is why chiropractics has been so successful. If you can win one piece of legislation every 5 years, you make steady progress to eventually calling yourself "physician," prescribing medications, doing school general physicals, etc, etc.

The lie that is propagated that prescribing psychologists are needed in rural areas are just that....lies. Psychologists are not moving to underserved areas, and it will remain that way.

I've posted topics related to this some time ago with some interesting responses. Those interested should do a search.

I was in a PhD for clinical neuropsychology. I realized I wanted to prescribe medication. I felt uneasy about the "training program" I was offered when I graduated. I quit and went to medical school to ensure my competence and complete understanding of human physiology so that I keep my damage to patients to a minimum. These people have only themselves in mind - a psychological need to feel more like physicians. That's the sad truth.

Call the APA...show your support. Call the Louisiana legislature or write a letter and impress upon them that they will kill patients and that they don't want it to happen on THEIR watch.

Again, privilages obtained through legislation are never taken away...only added upon. If we don't stop it now, it will grow out of control. Of this I assure you.

Amen! I agree that all current/aspiring psychiatrists need to make their positions known through the APA, and I believe, through their local representatives. Write your state reps and let them know you don't want this to happen in your state, and steps need to be taken to prevent this. I feel we also need to educate the general public about what a serious danger this is to the patient population. If psychologists meet serious resistance from the AMA/APA, state legislatures, and the American public, they might reconsider this "prescribing privileges" campaign.

Cosmetologists have for many years been looking after the beauty and appearance of many people. As such, they should be allowed to prescribe Accutane and Retin-A for their patients, thus allowing more people to have access to these wonderful medications. Primary-care doctors, who have less experience in dealing with the skin than cosmetologists have been prescribing these medications, so why should dermatologists be the sole providers of cosmetic skin care?

I hope you're joking. Is the cosmetologist going to know to advise the fertile female on contraception when using Retin-A? Are they going to know to do a pregnancy test? Will they be aware of possible increases in LFT's? See, you've illustrated the problem with what you just said. Most non-medical professionals are unaware of the potential dangers to patients without a medical education. There is a reason we go to med school and residency for 8 years. Some of the Psych meds out there can causes QT prolongation on EKG's, Agranulocytosis on a CBC, increased LFT's, drug interactions, etc. There is NO WAY a non-medical trained person will know when to order an EKG, CBC, etc. (let alone how to read these lab tests) and what will they do when they have a comorbid patient with renal failure and/or liver failure and then prescribe a drug that becomes toxic because of their liver or renal failure? Even after 2 years of medical clinical training as a student spending every day in a hospital, I don't feel completely prepared to prescribe drugs. And, the Louisiana law is proposing 380 hours with classes every third weekend!? NO patient contact with oversight by non-medical psychologists?! Excuse me for lack of a better word, but that is INSANE.

Dr Focker:

My point was to illustrate how silly the clinical psychology arguments are by applying them to another medical specialty. ;)

Some psychologists in the US are so desperate to offer prescriptions that they have enlisted Canadian pharmacists in their efforts. Lacking medical training and authority to write a valid presciption, they order lower-priced drugs from Canada, cynically using the cost savings to entice patients into joining them in circumventing the law. This is a disgrace to the legitimate field of psychology in my opinion.

Who gets to prescribe?

By Linda Temple, USA TODAY

A group of psychologists seeking the legal right to prescribe drugs has announced it is bypassing U.S. doctors and routing prescriptions through Canadian doctors and pharmacies.
The National Society of Clinical Psychopharmacologists (NSCP) says its roughly 1,000 members, who hold doctorates in psychology and have 300 hours or more of post-doctoral pharmacology training, will have Canadian doctors review cases and countersign prescriptions for mental health drugs. They'll work with a Canadian supplier that will mail drugs to U.S. patients at cut-rate costs. (Related item:Group is the latest to try to obtain cheaper drugs from Canada)

"We're putting our necks on the line, but this is about providing our patients better mental health care," says NSCP president John Caccavale of Downey, Calif. "We know we can do better than the current system, which consists of a non-psychiatric physician and a prescription pad."

Medical groups, particularly psychiatrists, who are medical doctors specializing in mental health, have long fought giving psychologists the right to prescribe drugs, citing their lack of medical training. "I don't oppose psychologists," says Yank Coble, immediate past president of the American Medical Association. "I very much support them and the care they provide. But a prescription is a prescription because it has dangers."

The psychopharmacologists, or RxPs, say they're adequately trained to prescribe drugs, and they argue that psychiatrists aren't the ones prescribing most of the mental health, or psychotropic, drugs anyway.

According to the National Center for Health Statistics, nearly 80% of prescriptions for psychotropic drugs are written by primary care physicians during office visits. Anti-depressants are the fastest-growing segment of the drug industry's annual $132 billion in sales; the anti-depressant Zoloft is among the top 20 most often prescribed drugs in the nation.

Psychologists also argue that while RxPs have substantial pharmacology training, few medical residency programs make pharmacology training mandatory.

"Patients need intervention by someone to help reduce their medication, not prescribe more," says Jack Wiggins, secretary of the Academy of Medical Psychology. "Physicians are well-intentioned, but under managed care, they don't have time nor are they trained to provide mental health care."

Wiggins, a clinical psychologist in Phoenix, co-authored a four-year study tracking 1.6 million mental health patients, 1 million of whom took psychotropic drugs. The study, published in 1998 by the American Psychological Association, found that after treatment by psychologists, 13% of patients remained on medication, an 80% reduction.

Allowing psychologists to prescribe mental health drugs also would help fill a void created by a shortage of psychiatrists, the psychologists say.

In New Mexico, the only state to approve psychologist prescribers, just 18 psychiatrists serve everyone not residing in Albuquerque and Santa Fe, a total of 72% of the state's population.

Psychiatrists contend that it's simply not safe for psychologists to write prescriptions.

"For psychiatrists this is a patient safety issue," says Paul Appelbaum, chair of psychiatry at the University of Massachusetts. "The monitoring of side effects and the use of laboratory and other medical tests are issues that require medical training.

"For any group of professionals to claim that they can safely prescribe medication and monitor patients without that training is false," Appelbaum says. "You can't just read about these drugs in a book or have a little pharmacology training. You can't take the brain and separate it from the whole body."

Medical doctors and psychiatrists have worked to defeat psychologist-prescriber bills in the dozen states now weighing such legislation.

"To have anyone prescribing medication without medical school makes me very uneasy," says American Psychiatric Association president Marcia Goin. "It's very hard to consider any training short of medical school to be adequate."

Psychologists argue that some states authorize non-medical doctors to prescribe drugs with far less drug training, including optometrists, podiatrists, nurse practitioners, physicians' assistants, veterinarians and even some midwives.

And it's just a matter of time before RxP-trained psychologists gain legal acceptance, says Russ Newsom of the American Psychological Association. "There are now 10 or 11 institutions in this country with programs for training licensed psychologists to prescribe. The fact that these trained psychologists will be found in greater numbers than psychiatrists is going to significantly affect the public's ability to access quality care."

Goin says the American Psychiatric Association is trying to attract more psychiatrists, particularly in rural areas. "We're looking at what we can do to meet this shortage," she says, "but we don't think the answer is to give psychologists the ability to prescribe drugs."

Informative links for psychologists that wish to prescribe psychotropic medications in the United States:

Information for Psychologists That Wish to Prescribe Psychotropic Medications (http://www.aamc.org/students/applying/start.htm)

More Information for Psychologists That Wish to Prescribe Psychotropic Medications (http://www.aamc.org/students/considering/gettingin.htm)

Anyone with good hand-eye coordination can do laproscopic surgery. So why not allow top video game players to be surgeons? Because they would not know how to manage any complication that arises during surgery. Hence the long training surgeons must undertake to do what they do. Allowing psychologists to prescibe would be analogous to allowing video game players to operate, broadly speaking.

Options for psychologists to prescribe medications:

1. Take a van down to Mexico and load it up with Effexor, Paxil, Zyprexa, etc. and then sell it to your patients for a nominal fee. This sounds like a win/win situation to me.

2. Go back to school and get your PA or RNP license. This does not allow for autonomy, but it does satisfy the need to hand out scripts ( under a supervising physician).

3. Go to medical school and residency in psychiatry. This is the optimal situation. This option will ensure the safety of patients.

4. Go to the state legislatures of weaker states like Maine, New Hampshire, Oklahoma, Georgia and Tennessee and convince them that they should water down the laws and dilute regulations so that you can supposedly become complete mental health practitioners and provide the best care for patients.
(If this is such a great option, why not start in NY or California?).

I am sure there are other options that I am overlooking. Are there other options ?

Please get your rich grandparents to send a check payable to "Fund to Defeat Psychologist Prescribing Legislation"
c/o Nikita Peete, Accounting Department, American Psychiatric Association
1000 Wilson Blvd., Suite 1825
Arlington, VA 22209

Dr Focker:

My point was to illustrate how silly the clinical psychology arguments are by applying them to another medical specialty. ;)

Thanks, PsychNOS I'm much relieved. I thought you may be trying to illustrate the absurdity of it all, but I had to check to make sure. :D

Call the Gov. of Louisiana and urge her to veto HB 1426. The Gov. is Kathleen Blanco.

Telephone Number: (225) 342-0991 or 342-7015

I've been watching and following this thread since it started. Before jumping on the bandwagon and calling Gov Blanco, I decided to look at the training being required by the American Psychological Association (ApA) and at the curriculum being required by two of the university-based training programs. I have to admit that the training looks pretty thorough and certainly more so that any FP gets. The science programs are run by Pharm.D.'s or Ph.D. in appropriate fields, not by psychologists. Both had classes taught by MD/DO's. Apparently the MD that supervised the DoD demonstration project has also gone on record saying that the psychologists performed very well and that the current programs above are sufficient for the purpose of the psychologists prescribing.

My spouse is an NP and admits that the clinical psychologists who get this training will have much more training than an NP in psychology AND psychopharm. The training is obviously more than PA's get. With the rigorous training they already get in psychology (far more than we get in our residencies, if we're honest), without data, can we honestly say that they will perform less effectively than FP's, NP's, or PA's? It doesn't seem to me that we have enough data to say that. Should we simply support their getting priv's with some sort of guaranteed collaboration so that we can continue to protect medically fragile patients?

Have you guys looked at what is being required for this post-doctoral degree they're required to get? Does anyone know anything about the national exam they are suppose to take (which is apparently already in existance)?

I'm thinking it might have been smarter to have taken a residency in neuro . . .

No matter what number of tests and classroom hours that clinical psychologists receive, their education will never equal the thoroughness of a true medical education. You cannot simulate clinical experience in the classroom. Otherwise, we could all practice medicine straight out of medical school rather than undergo the rigors of residency. I have many reservations about allowing someone who does not understand clinical medicine from cardiology, to neurology, to endocrinology, etc. to prescribe medications and be allowed to practice MEDICINE. This is what psychiatrists are doing on a day to day basis. Psychiatrists interact with other physicians through the language of medicine. Can any clinical psychologist truly discuss medical concerns with another physician with equal sophistication as someone who has an M.D.? I think not. Allowing clinical psychologists to have autonomy in terms of prescibing dangerous medications is doing the general public a great disservice.

You also say that clinical psychologists through additional training will have knowledge equivalent to that of a FP. Very untrue, since the FP understands medical pathology, diagnosis, and treatment from a medical model.

You also mention NPs. Again, the question of autonomy is brought up. NPs, to my understanding, must practice under the supervision of M.D.s. Allowing clinical psychologists to prescribe medications goes well beyond the boundaries of the M.D.-N.P. relationship.

It would be hard for me to believe that most states will pass these types of bills. It is too inflammatory and dangerous and will be opening doors for other professionals, such as optometrists and chiropracters to infiltrate the clinical previliges that medical doctors currently hold.

PsychNOS

I DID NOT intend to imply that the education of the psychologist would equal the FP's. I meant to reflect that the program in psychopharm was superior to what an FP gets, what an NP gets, and what a PA gets. That's pretty apparent. Heck, I'm not altogether certain that the training is less that what we get (SPECIFICALLY in psychopharm).

Would we say that our training in psychology is equal to that of the clinical psychologists who get 5 to 7 years of doctoral training? How about psychological assessment? How much training in psychotherapy did we get before being turned loose to mess around with people's psyche's? I got very little and all of it was via a psychologist (both in school and in residency) and I dare say that, comparatively, I think I got great training and I'm certain that I understand neurobiology and psychopharmacology very well. But, we get nearly zero training in psychological testing, yet most state laws in the US allow us to order, administer, and interpret psychological tests if we choose to do so. What sense does this make? Did our medical degrees make us capable of performing well without training?

We could pose the idea that medications can kill people and psychotherapy cannot. Therefore, the training in the former is more critical. I'm not sure, though, that the long term effect size of psychotherapy doesn't outstrip our AD's considerably and, as such, our training in psychotherapy should be MUCH stronger (or we should stop).

Let me return to my original set of questions: Do we have any data to support our position that they would do an inadequate job? Do NP's? Do PA's? Psychologists, so far, are the only folks with hard data & it appears that we have none. If we're going to take this position, we'd better get some & make sure it's unassailable because, without question, psychologists are MUCH better than we are at analyzing statistics and research data.

I'd be willing to be a staunch dissenter, but I'm a scientist at heart. I don't think that our training magically shows us the one true way. So, as in Jerry McGuire . . . "Show me the data" (and then we won't have to worry about appearing like hypocrites).

Would we say that our training in psychology is equal to that of the clinical psychologists who get 5 to 7 years of doctoral training? How about psychological assessment? How much training in psychotherapy did we get before being turned loose to mess around with people's psyche's?

Psychotherapy is not the issue here.

Let me return to my original set of questions: Do we have any data to support our position that they would do an inadequate job? Do NP's? Do PA's? Psychologists, so far, are the only folks with hard data & it appears that we have none. If we're going to take this position, we'd better get some & make sure it's unassailable because, without question, psychologists are MUCH better than we are at analyzing statistics and research data.

Where is this "hard data"?

There is significant division among psychologists about whether it would be responsible or advisable to seek legal ability to prescribe. However, there is no similar controversy in the psychiatric community. Psychiatrists strongly and virtually unanimously oppose psychologist prescribing privileges. What the psychologists are asking for is the right to practice medicine without going to medical school -- that's as dangerous as it is ludicrous.... Psychologists are trying to achieve through legislation what they don't achieve through education. Cynics claim that psychologists only support obtaining prescribing privileges because of selfish economic considerations - that if managed care companies discourage their performing psychotherapy, they must prescribe to survive. However, many psychologists seem to truly believe that acquiring prescription privileges would be safe, would serve the public good and decrease health care costs.

Psychiatrists do not agree that it is safe for non-physicians to prescribe psychiatric medications. These medications are potent, have profound effects on not only the brain but on other organ systems, have serious side effects, have dangerous effects when unwisely mixed with other prescribed medications, and can cause death and serious disability. These medications are not easy or straightforward to use. Many complex pharmacokinetic and pharmacodynamic factors must be weighed: examples include competitive inhibition at receptor sites, refractoriness of receptors, serum protein binding and displacement, multiple mitochondrial enzyme pathways and their activation or inhibition by other drugs, and biological variability - to name just a few. The safe use of psychotropic agents requires significant clinical training, experience and knowledge; sophisticated understanding of other medical conditions the patient may have; and the ability to make medical differential diagnoses. Non-physicians do not possess these skills or this expertise. It is naive to think that even two years of full-time didactic coursework coupled with supervised clinical supervision would be sufficient. The scientific knowledge and clinical proficiency which psychiatrists develop begins with pre-med undergraduate science courses, and continues with two years of didactic medical school basic science training, two years of clinical medical school clerkships, an internship and at least three years of psychiatric specialty training. Of note; psychologists who graduated from the 3-year Department of Defense prescribing training program did not earn independent prescribing privileges. These ?pharmacopsychologists? were not allowed to either start or stop a medication without direct supervision from a physician. They were not allowed to even independently monitor any individual with ?concomitant unstable medical conditions,? or those younger than 18 or over 65.

Medical training involves more than the acquisition of facts or didactic knowledge. It involves an indoctrination into a way of thinking: an acceptance of the medical model. This is an orientation that is not necessarily shared by psychology colleagues. (Smith D, Kraft, WA; Attitudes of psychiatrists toward diagnostic options and issues. Psychiatry 1989:52:66-73.) The importance of this and other differences in orientation and experience cannot be overemphasized. Psychology is at heart an academic discipline involving research, dissertations, the study of social science. It does not emphasize the understanding or treatment of disease. Psychologists do not receive training in obtaining medical histories, performing physical exams, or utilizing lab tests. During their training they do not routinely take life and death responsibility for critically ill patients. As Pies points out, the etymology of psychology is logos, ?study,? while the root of psychiatry is iarreta or iarros, ?healing or healer.? (Pies, RW, The ?Deep Structure? of Clinical Medicine and Prescribing Privileges for Psychologists. J Clin Psychiatry 52:1, January, 1991 p. 4-8.)

Some psychologists have argued that because general practice physicians don?t have much interest or training in treating the mentally ill, psychologists who prescribe would provide better care for these patients. A far better solution than training psychologists in medicine would be to train general physicians more extensively in psychiatry. Furthermore, this argument supposes that if psychologists could prescribe, general physicians would refer to them for that purpose. This simply is not the case. General physicians, themselves, do the bulk of psychotropic prescribing and this is not likely to change. Often the patients whom they refer to psychiatrists are patients who were treatment failures who require more sophisticated pharmacologic regimens. It would not be desirable for these patients to be referred to less-extensively trained non-M.D. prescribers.

Psychologists have alluded to prescribing a ?limited formulary.? It is unclear what this would constitute. Modern psychiatry uses a variety of somatic medications for psychiatric effects, including anticonvulsants, beta-blockers, antihypertensives and calcium-channel blockers. It would be unfair to have patients see practitioners who could not prescribe the full gamut of potentially effective medications. (And, as mentioned, even ?standard? psychotropics are potent and potentially dangerous.)

There are other unanswered questions. If a patient is self-referred to a psychologist, who does the medical evaluation? Does the psychologist refer the patient to a general physician? If so, then why shouldn't that physician do the prescribing? If the patient is not referred to a physician, then does this constitute quality care? Who orders the medical drug levels? Who orders lab tests? Who interprets these? Also, if a psychologist prescribes medication and the patient develops symptoms such as a rash or urinary retention, who does the medical evaluation, and what are the implications of prescribing medication without being able to handle adverse effects?

Proponents of psychologists prescribing have strenuously argued that this would allow greater access to care because there would be greater availability of psychologists in underserved areas. However, a study by Lewin in 1989 showed that psychologists tend to practice in the same geographic areas as psychiatrists - that there is no significant difference. (Geographic Access to Psychiatrists? Services: A County-Level Analysis. Lewin, ICE prepared for the American Psychiatric Association, January 1989.)

Another assertion is that costs would be reduced if psychologists prescribed. This seems particularly unlikely. The current differential between fees of psychiatrists and psychologists is not that great. If psychologists had to receive extra training in order to prescribe, clearly they would wish to raise their fees commensurately. Furthermore, their malpractice expenses would rise considerably, and their fees would have to reflect this. It seems probable that there would be an increase in hospitalization expenses due to adverse events related to an increased number of prescribing errors. If psychologists had a ?limited formulary,? it would probably exclude older drugs such as tricyclic antidepressants which are complicated to use, and only include newer, more expensive medicines such as SSRIs. Thus, aggregate medication expenses would rise. Additionally, if there were more people prescribing medications, presumably a greater volume of medication would tend to be prescribed - again increasing costs.

If psychologists were allowed to prescribe medications, what would prevent social workers from prescribing, or nurses, or marriage and family therapists, or substance abuse counselors, or mental health technicians? Where would one draw the line? If it is simply a matter of taking didactic courses, why couldn?t virtually anyone with an interest ultimately demand the right to prescribe?

It does not appear safe, or in the public interest, to have non-physicians prescribe psychiatric medications. However, discussion of these issues does help identify problems and lead to solutions. For example, of psychologists are correct that general physicians do not have sophisticated knowledge of mental illness assessment or treatment, clearly this can be remedied by improving the education of those physicians. If psychologists are correct in implying that general physicians should refer more patients to mental health specialists, clearly psychologists and psychiatrists should focus together on developing more effective and appropriate patient referral patterns from primary care physicians. If psychologists feel they cannot provide comprehensive care for their patients because of an inability to prescribe, perhaps our two disciplines can work harder at creating better clinical collaboration.

Neil Warres, M.D.

The above post is outstanding.....

Another thought: I have no idea where the notion developed that psychotropic medications effect the CNS ONLY. It is well understood that these medications can and do have proufound effects on the entire body...something no psychologist can hope to understand without full and proper medical training.

I found "HURT's" reply to be extraoridinarily well-written. That people who are already studied in discipline of psychiatry would agree with it is no surprise. I know that my writings *may* result in our having to carefully consider our "self" perceptions. It's never easy, but part of what makes a strong discipline is the ability to engage in a fearless critical review of the guild. Psychiatry must do this, as should psychology.

I also found Hurt's response to contain presumption and error, something that I'm used to carefully looking for when I read research/experimental position papers. Some parts I agreed with and others I found disturbing. So, rather than to write something that would (at least) partially be considered "flame-bait," I am carefully considering my response in hopes that my own writing will help to clarify the concern. I will post that here later.

That said, I think that there was considerable wisdom in much of what Hurt wrote. Who can argue against the point that training (in whatever discipline) makes patients safer?

S

I also found Hurt's response to contain presumption and error, something that I'm used to carefully looking for when I read research/experimental position papers.

It appears as though you're going to make the claim that while increased training will make better doctors, and therefore, patients more safe, I caution you against that which many researchers (of which I also am) forget....the concept of face validity.

Do not assume that because there is not a statistically increased incidence of patient deaths secondary to prescribing psychologists, that there is no qualitative difference. I argue that the majority of adverse effects will be subclinical, and will hurt patients over long periods of time, and over the course of decades, decrease patients' lifespans. I give but one example of a psychologist ignorant of the metabolic effects with given interactions with cholesterol-lowering medications and psychotropic agents....these patients will not die from acute processes, but rather, will have their lives shortened due to their inherent ignorance of the intricate dealings of human physiology (not just psychopharmacological knowledge).

Results such as these will not reach significance for years, if ever. As a science, and an ethical profession, however, we would be remiss to not argue against such unsafe medical practice.

Psychiatry in particular, and medicine in general does not exist in a vacuum. There are political misgivings and happenings that can and do dictate the way we practice and will influence the direction in which our profession is heading.

If psychologists were indeed interested in providing services to the underserved, they would have no qualms about prescribing under a physician's supervision - something they find demeaning and are lobbying against.

In this day and age of litigation and obsession with compensation for the past/future injustices, a disturbing trend is emitting: any organization who's feeling are hurt that they do not have enough independant practicing rights will lobby to obtain them.

In my opinion, psychologists feel inadequate because they cannot prescribe. They are successfully lobbying to obtain prescription privilages. As this trend continues, any health organization that feels they are owed the right to dispense medications via prescription privilages will obtain it, given enough time.

Remember what I mentioned in an earlier post....Rights, once obtained, are never taken away. They remain, and only increase.

Optometrists are successfully lobbying to perform opthalmological surgery, chiropractors are successfully lobbying to register as "primary care physicians," PAs are successfully lobbying to practice independently in all states, etc, etc. The human condition is one that continually seeks to elevate itself. The natural progression is obtain more independance and rights. In medicine, this will result in poor patient care.

Politicians ultimately make these decisions. What legislator wants to be called on the carpet the next election year when an opposing candidate runs an ad stating that "congressman X voted to 'cut services for the mentally ill,'" which is a well disguised attack on that congressman who rightfully voted to leave complex patient care to those who are best trained to administer it...physicians.

This post has me quite interested. I did my undergraduate education in psychology. I'm probably going to go back to get the required pre-req's so dental/medicine is possible. However, if prescription became available, I might reconsider my path toward Phd. Perhaps a doctoral PsyDmed will become available :)
I agree with portions of both Svas and Hurts arguments. They say that therapy and medicine is the most effective combination. Clinical psychologists are fully aware of this. I can understand WHY they would want to prescribe the medications. It seems silly too when clinical psychology is so difficult to get into (harder than medicine) and then they are subordinated to a helper role.
So SHOULD they? As it stands, I'd argue no. At least, not given there current level of understanding of the medical model. Most knowledge, at least at the undergraduate level, remains social science in nature. I had maybe four neuroscience courses tops, and in many ways it still remained 'cognitive' in nature. Even the 400+ hours pass/fail course is inadequate.
If psychologists are serious about prescription, The structure of the whole program should be reworked at undergrad and graduate levels. Undergrad should be framed around the medical model with psychology studied as clinical neuroscience with chemistry, biology, and pharmacology courses taken along the way.
After undergrad, why not offer a 4 year PsyDmed professional program, much the way Dentists, Chiropracters, and Optometrists are trained in their specialty. Four years would definately provide enough time to get the training to diagnose, prescribe, and look for contraindictions. What would be removed is the level of detail that wouldn't be required to successfully prescribe. Can you honestly say that everything you learned in medical school is now relevant to you as a psychiatrist? I'd argue no. Why waste 8-9 years when the same thing could be done in 4? As it stands Psychiatry is not even that popular a residency.

This post has me quite interested. I did my undergraduate education in psychology. I'm probably going to go back to get the required pre-req's so dental/medicine is possible. However, if prescription became available, I might reconsider my path toward Phd. Perhaps a doctoral PsyDmed will become available :)
I agree with portions of both Svas and Hurts arguments. They say that therapy and medicine is the most effective combination. Clinical psychologists are fully aware of this. I can understand WHY they would want to prescribe the medications. It seems silly too when clinical psychology is so difficult to get into (harder than medicine) and then they are subordinated to a helper role.
So SHOULD they? As it stands, I'd argue no. At least, not given there current level of understanding of the medical model. Most knowledge, at least at the undergraduate level, remains social science in nature. I had maybe four neuroscience courses tops, and in many ways it still remained 'cognitive' in nature. Even the 400+ hours pass/fail course is inadequate.
If psychologists are serious about prescription, The structure of the whole program should be reworked at undergrad and graduate levels. Undergrad should be framed around the medical model with psychology studied as clinical neuroscience with chemistry, biology, and pharmacology courses taken along the way.
After undergrad, why not offer a 4 year PsyDmed professional program, much the way Dentists, Chiropracters, and Optometrists are trained in their specialty. Four years would definately provide enough time to get the training to diagnose, prescribe, and look for contraindictions. What would be removed is the level of detail that wouldn't be required to successfully prescribe. Can you honestly say that everything you learned in medical school is now relevant to you as a psychiatrist? I'd argue no. Why waste 8-9 years when the same thing could be done in 4? As it stands Psychiatry is not even that popular a residency.

:thumbup: :thumbup: :thumbup: :thumbup: :thumbup:

Very well put. I have argued along these lines in previous posts. Even having a 4- to 5-year PhD/PsyD program with heavy emphasis on medical psychiatry and a required residency (2-4 years) would work. Differences between such a program and the traditional med school/residency route would be: (1) heavy emphasis on medical psychiatry, (2) heavy emphasis on empirically-proven psychotherapies, (3) more hours spent learning pharmacotherapy and psychotherapy in psychiatric practice, and (4) required thesis and dissertation. As they currently stand, clinical psychology PhD/PsyD programs are "soft" and too focused on talk therapy and convenience sample research. Some programs even teach outdated psychotherapeutic modalities with little empirical support.

I think the University of New Mexico clinical psychology PhD program planned to restructure their curriculum in this manner. I'm not sure that they actually have done so, however.

There are people out there who are genuinely interested in psychiatry, and whose time would be ill-spent taking courses and going on clinical rotations that offer little to no practical value in their chosen specialty (I can already see posts to the contrary). Psychiatry is in crisis. The field needs more psychiatrists, more research, and more practitioners trained in pharmacotherapeutic and psychotherapeutic treatment modalites and combinations thereof. Medical students shun psychiatry because the pay is relatively poor compared to other specialties, the population is challenging, and they fear being "pill pushers" or "five-minute med managers" for the duration of their careers. With proper restructuring, PhD/PsyD programs in clinical psychology (or medical psychology, whatever you want to call it) could put a new face on modern psychiatry, with increased emphasis on combined therapeutic modalities, research, and in the process, serve more people with mental health problems.

Here comes the backlash....serotonin syndrome...malpractice...psychologists are incompetent!.....

I'd like to know what the people in support of prescription rights for clinical psychology would think of having Ph.D.'s see patients in the consult-liason service of the hospital. As it stands, you would evaluate somatization disorders, mental status changes, and competency in the medical, surgical, OB/Gyn, etc. inpatient service. Would the 4-5 year "medical psychology" plan that you propose equip its graduates to open up and sort out a patient chart that reads, "This is a 65 year-old male s/p R-sided CVA with a past medical history of HTN, CAD, and MI?"

Medical training is a 4-year program that is followed by at least a 3-year residency. Classroom hours account for only a portion of the educational process. The other portion requires hands-on patient contact and care. In order for a clinical psychologist to be truly competent, they would need to incorporate time spent with other medical specialities. Thus, they would need to do significant clinical time with other medical specialities during school and then do a residency in the inpatient and outpatient setting.

My questions is this: Would your proposed program implement enough patient contact hours and if so, wouldn't this be similar to a traditional medical school/residency route?

My questions is this: Would your proposed program implement enough patient contact hours and if so, wouldn't this be similar to a traditional medical school/residency route?

As indicated above, hard sciences should be incorporated into the doctoral curricula of PhD/PsyD programs in clinical psychology, with increased emphasis on medical sciences, physical diagnosis, empirically-proven psychotherapies, and comprehensive research training. The idea is to create a curriculum designed to produce comprehensively trained medical psychologists. This sounds like quite a bit of work, but if you cut out all the bullsquat classes like "History of Psychology" and "Theories of Personality," and beef up on pharmacology, neurophysiology, and clinical practica in basic medicine and psychopharmacology, students in such PhD/PsyD programs will be able to complete their training in 4 to 5 years. Postdoc residencies could last 2 to 4 years and could emphasize the integration of pharmacotherapy and psychotherapy in patient care, and the production of high-quality research.

How existing clinical psychology PhD/PsyD programs can go about restructuring curricula along these lines, however, is another story. There are simply too many "soft psychology college grads who want to talk about emotions" applying to PhD/PsyD programs. Slowly, this is beginning to change, but it is more in the direction of having incoming students be experienced in clinical research, not hard science. As it is, most clinical psychologists are opting for careers in clinical research because of poor reimbursements for their clinical services.

Prerequisites for "medically-oriented clinical psychology" programs will also need to change, and students pursuing entrance into such programs will also need to beef up on hard sciences at the undergraduate level.

The idea is not to have psychologists replace physicians, but instead to train psychologists to be capable of providing pharmacotherapeutic and psychotherapeutic services in a safe and effective manner. Programs providing such training will serve students who are committed to a career in medical/clinical psychology. By cutting out all of the courses and rotations that are not directly relevant to psychiatry and medical psychology, such programs will produce high-quality medical psychologists capable of serving a wider variety of patients with a wider variety of problems.

Honestly, how many practicing psychiatrists and psychologists reading this post truly believe that ALL of your medical or graduate school training is important in your everyday practice? My idea is to incorporate the best that psychiatry and clinical psychology has to offer (since the fields obviously complement each other so well) into a unified educational program focused on producing medical psychologists.

This is a 65 year-old male s/p R-sided CVA with a past medical history of HTN, CAD, and MI?"

This question is silly. A secretary can learn to understand the above abbreviations. Your question is (or should be), will they understand general pathophysiology well enough to konw how to assista a person with that condition . . . and know when consultation with the other specialists is in the best interest of the patient? I suspect that the DoD project reviewed that, but perhaps additional demonstration projects are necessary.

Let's not try to assert our position by building new straw men. Perhaps some of us should apply to go through their program to determine if, in fact, they are really sufficient? It seems to me that we're guessing and it's easy for me to tire of a priori assumptions that seem based more upon referential bias than data.

Let's not forget that these people are our colleagues, are of considerable training and intellect, and represent a valuable brain trust for psychiatry (neuropsychologists, in particular, seem well suited for this pursuit). It seems to me that psychologists gaining the right to prescribe is a "train that is definitely coming." What we need to decide is what role we'll play in shaping the outcome. Should we be offering a collaborative model, versus continuing to object and appearing to be primarily interested in "protecting our turf?" Otherwise, I'm afraid that we sound a lot like the folks who complained about the onslaught of managed care, thinking that their complaints without data would stop its arrival. (Let's not reduce ourselves to suggesting that psychologists vertically integrating more training is akin the MISmanagement of mangled care - - - we've got lots of data supporting the damage done by managed care and no one has been able to provide evidence that psychologists will mismanage patients any more than we do. Even the argument of "subclinical" damage is hard to swallow, since we're talking about something that MIGHT happen.)

We can do better than this.

Svas:

My question was not emphasizing understanding abbreviations, but as you mentioned, emphasizing the importance of understanding the integration of pathophysiology and pharnamcology into the psychiatric discipline. I think this goal is only acheived by having breadth as well as depth of training. What people that have not been through medical training don't understand is that there are significant overlaps between disciplines. I remember my dermatology rotation during medical school and being surprised by the siginifcant overlap between psychiatry and dermatology (e.g., Stevens-Johnson syndrome, neurotic excorations, etc.)

I don't believe in the doom and gloom statement that you gave about clinical psychologists being unilaterally granted prescription rights, however. I doubt that many current clinical psychologists will want to presribe medications. For the ones that do and that do gain presrciption rights, there has to be a line drawn between what areas of practice are appropriate to their education and what areas are not. I gave the example of the consult-liason service, because that is a service for which only a thorough medical education can prepare you.

The idea is not to have psychologists replace physicians, but instead to train psychologists to be capable of providing pharmacotherapeutic and psychotherapeutic services in a safe and effective manner.

...and how is this different than replacing residency-trained psychiatrists?



Programs providing such training will serve students who are committed to a career in medical/clinical psychology.


In that case, why not let marriage and family counselors and psychiatric social workers prescribe also? Assuming of course that they're "committed" and are supervised for 100 hours.


By cutting out all of the courses and rotations that are not directly relevant to psychiatry and medical psychology....


you are then no longer a psychologist.


Honestly, how many practicing psychiatrists... reading this post truly believe that ALL of your medical or graduate school training is important in your everyday practice?

If you don't, you're practicing piss poor medicine. The knowledge gained may be even almost subconscious at some point in practice....but it IS important and IS used daily.

This is exactly what psychiatrists are talking about. I'll say this again....psychiatry is not simply prescribing medications that have an effect on the brain. These medications stem from a knowledge base that must be understood in the context of the complete human body. These drugs do not exist in a CNS vacuum. They will find this out the hard way.

As a "medical psychologist," are you comfortable treating a hypothyroid-induced depression? Are you comfortable prescribing synthroid with zoloft? Are you even familiar with the complexities of hypothyroidism and aware of the dangers of incorrectly interpreting lab results? If you are, then you'd better be prepared to defend your knowledge in court.

Do you know how to properly titrate Depakote for bipolar disorder? Are you comfortable in catching the induced thrombocytopenia that may result? Who will order the lab tests? You? Who will interpret them?

Who is going to interpret the EKG on the patient you just put on Geodon? A psychologist? Will you even see the incidental right bundle branch block that the patient should be made aware of?

My point is that the concept of "medical psychologist" is nothing more than a junior psychiatrist, except with a fraction of the required knowledge to safely prescribe medication.

.....What we need to decide is what role we'll play in shaping the outcome. Should we be offering a collaborative model, versus continuing to object and appearing to be primarily interested in "protecting our turf?"


Don't you get it yet, Svas? If you read the Louisiana bill, you'll see that physicians will have NO ROLE in shaping the outcome. They want unilateral prescription rights, regulated by their OWN governing body. Their own DEA numbers, their own disciplinary committee NOT overseen by physicians.

As I mentioned in my earlier thread but that you failed to address, is that (like it or not) medicine is a scientifically and politically driven machine. If you can't see between the lines on this proposal, or are ignorant enough to think that the privilages will end there, then you need to make an effort to educate yourself on the future ramifications of this bill.


Even the argument of "subclinical" damage is hard to swallow, since we're talking about something that MIGHT happen.)

We can do better than this.

Difficult for you to swallow, because there is no "hard data" indicating taht this will occur. This does not preclude you from using your brain to contemplate the ramifications of this practice. Theories can be brought to multiple possible conclusions. Physicians in general, and psychiatrists in particular would be remiss to not carry this to its logical end in the form of patient safety and care.

There's no "might" about it. As I again stated earlier, but that nobody acknowledged: Rights, once obtained, are nary taken away. They are only added upon.

Victories will slowly be obtained, a la chiropractics, that will be added upon, with the goal of securing their own financial and personal freedoms.

...and how is this different than replacing residency-trained psychiatrists?

The difference is in the focus of the training. Instead of having students take courses that are not directly relevant to psychiatric practice (e.g., "History of Psychology," "Human Anatomy," "Osteopathic Manipulative Medicine"), the program described above would train students in the medicine, psychiatry, and clinical psychology necessary to prescribe psychotropic medications and practice effective psychotherapy, as well as in clinical research. Such training would combine elements of medical and clinical psychological training that would ultimately allow graduates to practice safe and effective pharmacotherapy and psychotherapy. I'm not talking about a few pass/fail courses and 100-hour practicum! Instead, I'm talking about a restructuring of current clinical psychology training programs.

In that case, why not let marriage and family counselors and psychiatric social workers prescribe also? Assuming of course that they're "committed" and are supervised for 100 hours.

As indicated in the original post, I'm talking about a doctoral program. The requirements for such a program would be much more than a few pass/fail courses and 100 supervised hours.

you are then no longer a psychologist.

Titles will have to be worked out if such a program ever took effect.

If you don't, you're practicing piss poor medicine. The knowledge gained may be even almost subconscious at some point in practice....but it IS important and IS used daily.

OK, so as a psychiatrist, do you use your knowledge of anatomy, pathology, osteopathic manipulation, and other remotely related sciences on a daily basis? If so, please explain.

This is exactly what psychiatrists are talking about. I'll say this again....psychiatry is not simply prescribing medications that have an effect on the brain. These medications stem from a knowledge base that must be understood in the context of the complete human body. These drugs do not exist in a CNS vacuum. They will find this out the hard way.

As a "medical psychologist," are you comfortable treating a hypothyroid-induced depression? Are you comfortable prescribing synthroid with zoloft? Are you even familiar with the complexities of hypothyroidism and aware of the dangers of incorrectly interpreting lab results? If you are, then you'd better be prepared to defend your knowledge in court.

Do you know how to properly titrate Depakote for bipolar disorder? Are you comfortable in catching the induced thrombocytopenia that may result? Who will order the lab tests? You? Who will interpret them?

Who is going to interpret the EKG on the patient you just put on Geodon? A psychologist? Will you even see the incidental right bundle branch block that the patient should be made aware of?

My point is that the concept of "medical psychologist" is nothing more than a junior psychiatrist, except with a fraction of the required knowledge to safely prescribe medication.

The hypothetical program and accompanying residency would cover this in depth. I agree that taking a postdoc and spending 100 supervised hours to get a license to prescribe psychiatric medications is ludicrous. More training is clearly required. This is why I suggested restructuring clinical psychology programs. As it is, MSWs are landing jobs typically reserved for clinical psychologists, and clinical psychologists are increasingly moving away from clinical practice and into research. This may, at least in part, explain why clinical psychologists want to become more like psychiatrists.

I'm sorry, but a PhD in psychology does not qualify you to write prescriptions for medications. These medications have broad effects on systems other than neurologic/psych. Therefore, it should be reserved for the MD's and DO's. Why do you think being board certified in Psychiatry requires one year of training in a rotating internship?

This is starting to be the most common concern on these threads...the FP's and generalists are worried about the PA's and CRNP's, the Anesthesiologists are worried about the CRNA's, psychiatrists vs psychologists, ophthalmologists vs optometrists, radiologists and teleradiology. Why don't we give RN's prescribing priveleges? How about letting chiropractors do spine surgery? Where does it end?

The answer is NOOOOOOOO. You are not qualified to write scripts for medicines that could potentially kill a patient. You do not have a medical degree. Just like I don't have a PhD in clinical psychology and won't set up a psychology practice, you shouldn't prescribe potentially lethal medications when you might not even recognize when it is becoming toxic or when it shouldn't be prescribed to begin with.

Why can't people just deal with the career they built for themselves, rather than try to change the rules? At this rate, anyone with a high school diploma will be able to prescribe drugs in the future.

Informative links for psychologists that wish to prescribe psychotropic medications in the United States:

Information for Psychologists That Wish to Prescribe Psychotropic Medications (http://www.aamc.org/students/applying/start.htm)

More Information for Psychologists That Wish to Prescribe Psychotropic Medications (http://www.aamc.org/students/considering/gettingin.htm)


:laugh: :laugh:

I agree.

My 2c on this and other related issues:

MDs, with all their training, do a bad enough job as it is diagnosing and treating patients.

The suggestion that individuals with less training be allowed to do it is simply absurd.

OK, so as a psychiatrist, do you use your knowledge of anatomy, pathology, osteopathic manipulation, and other remotely related sciences on a daily basis? If so, please explain.


Yes, I do. And so does every other competent modern psychiatrist. Understand that these classes are not just classes amongst themselves. They are building blocks for the full understanding of the human medical patient.
A few examples would be:
Anatomy: I visually look at a female obese patient sitting across from me. I notice multiple lower extremity varicosities, which are consistent with vascular insufficiency. I inquire about her comorbid conditions, and come to the conclusion that the beta blocker I was inclined to prescribe for her psychiatric condition is not the best choice, given her anatomical variances.

I recently returned from the American Psychiatric Association conference in NYC. From deep brain stimulation, to vagus nerve stimulation, to magnetic seizure therapy, transcranial magnetic stimulation, and others, anatomy is paramount in the understanding of how these things work. Psychologists will no doubt seek to administer these procedures in the future.

As for disciplines such as pathology, ob/gyn, omm, etc, it is these classes and medical school rotations that allow one to recognize the myriad disease states associated with these organ and metabolic systems. Failure to have a comprehensive understanding of them will make your job as a psychiatrist much, much more difficult.


The hypothetical program and accompanying residency would cover this in depth. I agree that taking a postdoc and spending 100 supervised hours to get a license to prescribe psychiatric medications is ludicrous. More training is clearly required. This is why I suggested restructuring clinical psychology programs.

Patients do not come into your office with no comorbid medical conditions and without other medications quite frequently. Can a prescribing psychologist afford to spend every minute looking up book-based knowledge of every disease and other medication in order to properly treat medical patients, of which most are?

As it is, MSWs are landing jobs typically reserved for clinical psychologists, and clinical psychologists are increasingly moving away from clinical practice and into research. This may, at least in part, explain why clinical psychologists want to become more like psychiatrists.

I think you're right. There is a proposed bill in the new jersey legislature that would allow bachelor's level psychology major graduates to bill medicare the same as PhD psychologists. The environment of managed care is taken a very negative toll on the quality of services.

Take this Louisiana situation to its slippery slope logical end...why not just make junior urologists that study the kidney and bladder and perform pessary surgeries or prostatectomies? Why not let teachers train in ADHD medications and allow them to prescribe them to children? Why not let social workers train to do and interpret psychological testing and allow them to open private offices? Why not let PTs train in the fixation of fractures? Why not let cosmetologists train to prescribe tetracycline for acne? Why not even Retin-A?

Any interest group interested in prescribing simply cannot be allowed to do so if their lobby is strong enough. Most of forumulary medications are prescription for a reason. Without medical training coupled with a residency, you cannot hope to take adjunctory courses which will allow you to "just not make mistakes."

btw...I thought you were thinking about dropping psych school for med school. Still thinking about it?

btw...I thought you were thinking about dropping psych school for med school. Still thinking about it?

As always, I enjoy reading your replies. You and I should talk about these issues over coffee sometime (I'll pretend I'm the psychologist prescribing you caffeine, and you can be the disgruntled psychiatrist). Sorry, couldn't resist. ;)

I opted for med school/psychiatry. I may come back to complete a PhD at some point later in my training. Clinical psych programs simply do not provide the hard science, biological basis that I sought in my education.

Ready for internship?

Ready as I'll ever be, I suppose.... :o

You'll be glad with your decision to go to med school. :thumbup: The ability to comprehensively treat a psych patient with the full gamut of medications and procedures in the future will make you a much happier camper.

As always, I enjoy reading your replies.

Oh, you're too kind. Thank you.

Oh, you're too kind. Thank you.

:confused:

The Office of Louisiana Governor Kathleen Blanco has just released a
statement about her signing into law a bill that will give psychologists
prescriptive authority under certain conditions.

Here's the statement:

[begin statement]

After much debate and consultation with medical professionals on all sides
of this issue, I have signed HB 1426. This bill, under very tight controls,
will give medical psychologists prescriptive authority.

I did not take the responsibility of this decision lightly. While the
opponents of the bill were persuasive, the proponents, including the
Speaker of the House and the President of the Senate, have assured me that
there are ample safeguards built into the legislation. In addition, Speaker
Salter and President Hines have promised that if this law does not work as
intended, they will move quickly on legislation to address any unintended
problems.

I signed this bill for a number of reasons:

In many areas of the state there is a shortage of mental health care
providers. I hope that this bill will encourage psychologists to extend
care to underserved populations. I am committed to extending quality,
affordable health care to as many of our citizens as possible.

Many physicians currently work in consultation with medical psychologists
and tell me they are comfortable prescribing in consultation with medical
psychologists.

A number of physicians have expressed this opinion to me and to members of
the Health and Welfare Committees. For these physicians, this bill will
mean little change to existing practice. Once a consultation occurs by
phone today, the doctor may call in a prescription to a pharmacist. Under
this law, after that conversation, the medical psychologist or the physician
may write the prescription.

The law requires that the psychologist obtain the agreement of the primary
or attending physician. The primary or attending physician must render
proper medical advice and is under no obligation to concur with the
psychologist. If a physician is uncomfortable with this arrangement, she or
he will not be required to give approval to the medical psychologist to
prescribe. In order to prescribe, approval of the physician is absolutely
necessary. Because of this mandatory relationship with the primary or
attending physician, the patient's total health care needs are provided for.

Prescriptive authority is limited to only those drugs related to the
diagnosis and treatment of mental and emotional disorders. This is the
specific area of expertise for medical psychologists. In addition, those
eligible to prescribe are in a very elite group of individuals who have
completed a graduate level course in psychopharmacology. The bill mandates
that this prescriptive authority shall be given only to psychologists who
have undergone specialized training in clinical psychopharmacology and who
have passed a national proficiency examination in psychopharmacology
approved by the Louisiana Board of Examiners of Psychologists and who hold
from the board a current certificate of responsibility.

I expect that the State Board of Examiners of Psychologists will promulgate
tough rules to require documentation of the required consultation by medical
psychologists prior to prescribing medications. I expect the Board to
enforce the provisions of the law. Those who do not abide by the provisions
that require prescriptions only after consultation, collaboration and
concurrence with a primary or attending physician will lose their
prescribing privileges and face misdemeanor charges as provided for in the
law.

[end statement]

very sad and misguided.

This makes the role of the "medical psychologist" in LA similar to the role of nurse practioners doesn't it? They have to consult with a physician prior to prescribing medications.

The main argument that the governor gives for passing the bill is to provide greater access to mental health care, especially in rural areas. If this bill doesn't meet that goal, I wonder if other states would very hesitant to create and implement such a law.

I'll repeat . . . this train is coming. Do we want to help them shape what should be done . .. or just let it happen around us?

Here is one more set of arguments from a psychology perspective. Statistically, knowledge itself follows a bell-curve. Psychologists were able to get major bang for their buck at the 400 hours, partly because they are bright, but also because they had no prior knowledge base. More knowledge is going to require increased effort. On the other end of the curve are Psychiatrists, who I'd argue at 8 years have reached such a point of diminishing return, that they are no longer accessible to the public.
The analogy of the surgeon argument was somewhat misguided. The psychiatrist is no longer in primary care. The psychiatrist may follow a medical model, but it is the MEDICINE that actually does the job. As for the psychotherapy, psychologists can do this just as well or better than a psychiatrist.
This is precisely the point when a politician should step in and make an unbiased decision. A compromise between the psychologist who suffers from being a jack of all trades, to the Psychiatrist, who suffers from tunnel vision. The politician has to in essence find the peak of the bell curve.
In my opinion, the best option is for the psychiatric and psychology associations to actively merge first. Psychiatry is seen by most MDs as grey, whereas clinical psychology is seen as one of the most prestigious and competitive areas within academia. If a professional Psymed program was available right out of undergrad, open to anyone with the right psychology and science prereq's, just think of the brilliant talent pool that could be selected and recruited. An aptitude test could be thrown in for good measure.
Having all therapy and medicine given by the same professional would be beneficial. It would eliminate paperwork, and the same person could work with a patient from start to finish. People are not cars. This would allow therapy and medicine to be individually tailored.
Psychiatry is currently too inflexible but psychology is too fluffy. Even at its worst and most ignorant though, who cares if a few people suffer unnoticed health problems because of medical psychologists. What will 5 years off the END of a suicidal teen's life be if they end up killing themselves NOW. Besides, most patients don't stay on the medicine for their entire lives.
I agree with Svas that the psychologists are working to change things. These people are some of the most cut-throat I have ever met. Egos that I'd argue are bigger than MD's. Seriously. Best to work together to find a solution.

Dentite001

Psychiatry is currently too inflexible but psychology is too fluffy. Even at its worst and most ignorant though, who cares if a few people suffer unnoticed health problems because of medical psychologists. What will 5 years off the END of a suicidal teen's life be if they end up killing themselves NOW. Besides, most patients don't stay on the medicine for their entire lives.
I agree with Svas that the psychologists are working to change things. These people are some of the most cut-throat I have ever met. Egos that I'd argue are bigger than MD's. Seriously. Best to work together to find a solution.

Dentite001


I absolutely agree with you. We would be MUCH better off to work together toward a solution versus continuing to engage in this silliness. MD's fought DO's for years, unsuccessfully, using nearly the identical arguments that we're making with psychologists. After spending considerable time looking at the coursework that is required for the psychologist to prescribe, psychiatrists will be hard-pressed to described them as having NO training in psychopharmacology. In fact, I would argue that if we want to protect the people we serve, we should step up to the plate right now and offer to proctor the psychologists through their clinical practica, so that they will not resort to using FP's (etc), whom they already argue are less prepared than they (but obviously still licensed to practice medicine in an unlimited fashion) and so that they will have competent supervision. (BTW, I don't think that psychologists have cornered the market on self-serving, ego-centricity. We could be accused of the same thing for having the position that there is only "one true way" to learn a subject and that we have been divinely inspired to know which "one way" that is. Now . . . if PLUMBERS want to prescribe, all bets are off.)

Additionally, have you ever carefully looked at the effect sizes found in the research regarding the use of AD's versus psychotherapy (specifically cognitive)? I don't think we could call this "fluffy." Additionally, there is more research supporting the efficacy of psychotherapy than there is research demonstrating the efficacy of ANY drug, including ASA.

When it comes down to it, I think that psychiatrists NEED two additional years of training in psychotherapy (probably done by psychologists), much more than psychologists need psychopharm training (unless, of course, they wanted to collaboratively prescribe).

Finally, I was speaking with a friend of mine who is federal prosecutor. After talking about this issue, he wondered (aloud) if orgnized medicine/psychiatry wasn't risking restraint of trade or even RICO issues, given some of the methods/pressures that some of our collegues have faced when agreeing to teach in the MS Clin Psychopharm programs. I have not experienced such pressure in my discussions with colleagues, but I have heard others complain of such.

S

This makes the role of the "medical psychologist" in LA similar to the role of nurse practioners doesn't it? They have to consult with a physician prior to prescribing medications.

The main argument that the governor gives for passing the bill is to provide greater access to mental health care, especially in rural areas. If this bill doesn't meet that goal, I wonder if other states would very hesitant to create and implement such a law.

1) NPs in most states are NOT required to consult with a doctor for prescriptions. They have independent script rights.

2) New Mexico tried this and it failed miserably. Last time I checked, not a single new psychologist who went thru the program set up shop in a rural area. Apparently, Louisiana didnt do their homework or they would have discovered this. The truth is they didnt care. The governor/legislature wanted votes, and one way to do that is to promise "increased access to health care." This is purely a political move with no thought as to the medical side of things.

Here is one more set of arguments from a psychology perspective. Statistically, knowledge itself follows a bell-curve. Psychologists were able to get major bang for their buck at the 400 hours, partly because they are bright, but also because they had no prior knowledge base. More knowledge is going to require increased effort. On the other end of the curve are Psychiatrists, who I'd argue at 8 years have reached such a point of diminishing return, that they are no longer accessible to the public.
The analogy of the surgeon argument was somewhat misguided. The psychiatrist is no longer in primary care. The psychiatrist may follow a medical model, but it is the MEDICINE that actually does the job. As for the psychotherapy, psychologists can do this just as well or better than a psychiatrist.
This is precisely the point when a politician should step in and make an unbiased decision. A compromise between the psychologist who suffers from being a jack of all trades, to the Psychiatrist, who suffers from tunnel vision. The politician has to in essence find the peak of the bell curve.
In my opinion, the best option is for the psychiatric and psychology associations to actively merge first. Psychiatry is seen by most MDs as grey, whereas clinical psychology is seen as one of the most prestigious and competitive areas within academia. If a professional Psymed program was available right out of undergrad, open to anyone with the right psychology and science prereq's, just think of the brilliant talent pool that could be selected and recruited. An aptitude test could be thrown in for good measure.
Having all therapy and medicine given by the same professional would be beneficial. It would eliminate paperwork, and the same person could work with a patient from start to finish. People are not cars. This would allow therapy and medicine to be individually tailored.
Psychiatry is currently too inflexible but psychology is too fluffy. Even at its worst and most ignorant though, who cares if a few people suffer unnoticed health problems because of medical psychologists. What will 5 years off the END of a suicidal teen's life be if they end up killing themselves NOW. Besides, most patients don't stay on the medicine for their entire lives.
I agree with Svas that the psychologists are working to change things. These people are some of the most cut-throat I have ever met. Egos that I'd argue are bigger than MD's. Seriously. Best to work together to find a solution.

Dentite001

Best post in this forum, period. :thumbup: :thumbup: :thumbup: :thumbup: :thumbup: :thumbup: :thumbup:

1) NPs in most states are NOT required to consult with a doctor for prescriptions. They have independent script rights.

2) New Mexico tried this and it failed miserably. Last time I checked, not a single new psychologist who went thru the program set up shop in a rural area. Apparently, Louisiana didnt do their homework or they would have discovered this. The truth is they didnt care. The governor/legislature wanted votes, and one way to do that is to promise "increased access to health care." This is purely a political move with no thought as to the medical side of things.


Come on . . it's okay to actually read about what is going on in New Mexico. The RULE promulgation phase of the psychologist prescribing law was just approved by the oversight committee a few weeks ago. As it is, RIGHT NOW, there are NO psychologists prescribing yet in NM.

After they start prescribing, then it's okay to talk about what "actually happened." What has "actually happened" hasnt' happened yet.

Again, let's use REAL data to make our claims.

S

....On the other end of the curve are Psychiatrists, who I'd argue at 8 years have reached such a point of diminishing return, that they are no longer accessible to the public.


Where in the world did you get this notion? The majority of psychiatrists are not pure academicians, but also see patients. Just because there may be less of them does not mean they are unaccessible. Does this automatically mean that any state that has a shortage of specialists should hand over prescription privilages/medical procedures to the next-closest allied health care field?


....The psychiatrist may follow a medical model, but it is the MEDICINE that actually does the job. As for the psychotherapy, psychologists can do this just as well or better than a psychiatrist.


I'm constantly hearing about how psychiatrists do not know how to do therapy compared to a psychologist. Has anyone bothered to take a look at virtually any resident 4 year curriculum? Therapy abounds in residency, like it or not, even in biologically-driven programs. Just because many psychiatrists CHOOSE not to do much therapy again does not make the logical arguement that psychologists therefore should prescribe.


This is precisely the point when a politician should step in and make an unbiased decision. A compromise between the psychologist who suffers from being a jack of all trades, to the Psychiatrist, who suffers from tunnel vision. The politician has to in essence find the peak of the bell curve.

THE POLITICIAN? :eek:
This is absurd.
Following this to its logical end, then all medical specialties should be glorified graduate programs taking applicants from both "pools," thereby eliminating professional medicine altogether. Why not make special surgery schools where you just specialize in surgical techniques? How is it different?
--Also, psychiatrists do not have "tunnel vision." They are fully trained physicians who specialize in the diagnosis and treatment of psychiatric disorders. They come from a background of biological and physiological underpinnings, and use that understanding not only to use psychotropic medications, but to carefully delineate effects and interactions of non-psychiatric and psychiatric illness. This is not "tunnel vision."


In my opinion, the best option is for the psychiatric and psychology associations to actively merge first. Psychiatry is seen by most MDs as grey, whereas clinical psychology is seen as one of the most prestigious and competitive areas within academia. If a professional Psymed program was available right out of undergrad, open to anyone with the right psychology and science prereq's, just think of the brilliant talent pool that could be selected and recruited. An aptitude test could be thrown in for good measure.

Then who would treat the concomitant medical problems that these psychiatic patients tend to have? Are you suggesting that this "psymed" program give comprehensive courses in human disease as well? This is called MEDICAL SCHOOL.

I think psychologists tend to have this notion that psychiatric patients are simply depressed/psychotic/bipolar, etc --- and that's it. The psychiatric patient with no comorbid illness or one who is not on any other treatments is rare. Again, they'll find this out the hard way.


Having all therapy and medicine given by the same professional would be beneficial. It would eliminate paperwork, and the same person could work with a patient from start to finish. People are not cars. This would allow therapy and medicine to be individually tailored.

Have you seen conversations from the RxP (prescribing psychologist) listserv? These people make no bones about "taking a piece of the financial pie" from psychiatrists. They are mad that social workers and bachelors level therapists are undercutting their pay. Their profession is on the downswing, and they're panicing. If you think that they will simply keep their current caseload with 5 therapy patients a day and just 'happen to prescribe some antidepressants to help them' is a naive viewpoint.


Psychiatry is currently too inflexible but psychology is too fluffy.

Psychiatrists, in New Mexico, offered to work in collaboration with psychologists, and suggested that the prescription privilages be given only to those psychologists who worked in their touted "underserved areas." Well guess what - the psychologists refused it. They wanted complete autonomy.


Even at its worst and most ignorant though, who cares if a few people suffer unnoticed health problems because of medical psychologists. What will 5 years off the END of a suicidal teen's life be if they end up killing themselves NOW. Besides, most patients don't stay on the medicine for their entire lives.

I'm not quite sure how to respond to this.....


I agree with Svas that the psychologists are working to change things. These people are some of the most cut-throat I have ever met. Egos that I'd argue are bigger than MD's. Seriously. Best to work together to find a solution.


I agree with you here. Except, please understand that the psychologists want no "working together." They want autonomy. Period.

I was thinking last night....child psychiatrists do one to two extra years of fellowship to become competent to treat this patient population, and obtain board certification. Are psychologists now all of a sudden, from their weekend courses, going to treat them as well? This is just getting obscene.

Svas,

What "real data" are you talking about? The DoD study suffers from such massive selection bias that its unusable. As you know, these things are just starting to happen. What data can be available?

Don't think that the psychologists don't have a plan. They will prescribe mostly benign SSRIs for 10 years or so, all the while, gathering data about how safely they prescribe. Then, they'll again introduce legislation in the remaining states citing this data, and will falsely be at a great advantage because the "real data" is seemingly in their favor.

Here is one more set of arguments from a psychology perspective. Statistically, knowledge itself follows a bell-curve. Psychologists were able to get major bang for their buck at the 400 hours, partly because they are bright, but also because they had no prior knowledge base. More knowledge is going to require increased effort. On the other end of the curve are Psychiatrists, who I'd argue at 8 years have reached such a point of diminishing return, that they are no longer accessible to the public.
The analogy of the surgeon argument was somewhat misguided. The psychiatrist is no longer in primary care. The psychiatrist may follow a medical model, but it is the MEDICINE that actually does the job. As for the psychotherapy, psychologists can do this just as well or better than a psychiatrist.
This is precisely the point when a politician should step in and make an unbiased decision. A compromise between the psychologist who suffers from being a jack of all trades, to the Psychiatrist, who suffers from tunnel vision. The politician has to in essence find the peak of the bell curve.
In my opinion, the best option is for the psychiatric and psychology associations to actively merge first. Psychiatry is seen by most MDs as grey, whereas clinical psychology is seen as one of the most prestigious and competitive areas within academia. If a professional Psymed program was available right out of undergrad, open to anyone with the right psychology and science prereq's, just think of the brilliant talent pool that could be selected and recruited. An aptitude test could be thrown in for good measure.
Having all therapy and medicine given by the same professional would be beneficial. It would eliminate paperwork, and the same person could work with a patient from start to finish. People are not cars. This would allow therapy and medicine to be individually tailored.
Psychiatry is currently too inflexible but psychology is too fluffy. Even at its worst and most ignorant though, who cares if a few people suffer unnoticed health problems because of medical psychologists. What will 5 years off the END of a suicidal teen's life be if they end up killing themselves NOW. Besides, most patients don't stay on the medicine for their entire lives.
I agree with Svas that the psychologists are working to change things. These people are some of the most cut-throat I have ever met. Egos that I'd argue are bigger than MD's. Seriously. Best to work together to find a solution.

Dentite001
QUOTE=dentite001] ?The analogy of the surgeon argument was somewhat misguided. The psychiatrist is no longer in primary care. The psychiatrist may follow a medical model, but it is the MEDICINE that actually does the job.?
Who said psychiatrists are providing primary care? And I don't understand about the issue of "medicine doing the job".
?As for the psychotherapy, psychologists can do this just as well or better than a psychiatrist. ?
Exactly, they are cheap and they are trained to do so. No doubts about that and that's why they should stick w/ it. If they want to prescribe medicines, please do the extra 8 years of MD and post-MD training.
?This is precisely the point when a politician should step in and make an unbiased decision. A compromise between the psychologist who suffers from being a jack of all trades, to the Psychiatrist, who suffers from tunnel vision. The politician has to in essence find the peak of the bell curve. ?
Interesting. Since when politicians are taking the place of FDA and other regulatory bodies?
?In my opinion, the best option is for the psychiatric and psychology associations to actively merge first.?
It happened to certain extent in 50s and 60s as an effort to demedicalize the specialty-thank you, it didn't work and as MDs we are not going back on the same route. We talk of more neurosciences these days than neurologists.
?Psychiatry is seen by most MDs as grey, ?
What's the source of that info? For the last several yrs match rate for USMGs have been going up and that reflects an active interest in the field.
?whereas clinical psychology is seen as one of the most prestigious and competitive areas within academia. If a professional Psymed program was available right out of undergrad, open to anyone with the right psychology and science prereq's, just think of the brilliant talent pool that could be selected and recruited. An aptitude test could be thrown in for good measure. ?
Doing a 8 yr training(MD and residency) will serve the same purpose.
Having all therapy and medicine given by the same professional would be beneficial. ?It would eliminate paperwork, and the same person could work with a patient from start to finish. People are not cars. This would allow therapy and medicine to be individually tailored. ?
No doubt about it. Unfortunately 3rd party payment does not reimburse psychtx done by a psychiatrist, it's way cheaper if done by a therapist. That's why it's going to stay this way unless some radical change happens in health-care delivery system.
?Psychiatry is currently too inflexible but psychology is too fluffy. Even at its worst and most ignorant though, who cares if a few people suffer unnoticed health problems because of medical psychologists.
What will 5 years off the END of a suicidal teen's life be if they end up killing themselves NOW. ?
Really? Are you sure to practice w/ this attitude sometime in future? Good luck.
?Besides, most patients don't stay on the medicine for their entire lives.?
I differ-schizophrenia, bipolar d/o and some pts w/ depressive d/o and anxiety d/o do need lifetime tx. And I am not bringing up the other psych conditions associated w/ gen med conditions/developmental d/o blah blah blah.
The issue is all about pt safety, not the question of having bigger ego.

"I never lie. I willfully engage in a campaign of misinformation."
--Fox Mulder


Frankly, Anasazi23, the moto at the end of each of your letters reflects a very real truth in politics. That is everyone rationalizes for their own ends (or to save it). Psychiatrist and psychologists, Democrats and Republicans . . . the list goes on forever.

I have spent the last two years carefully looking at the data. I don't think that there is data to suggest either selection bias (although I do think that the military and the psychologists were careful to select competent candidates - because they didn't want to hurt anyone) or that the psychologists trained will do poorly. Moreover, since there was SO much scrutiny of the DoD program (before and after), why wasn't the selection bias you discussed pointed out early? In fact, if the selection bias was so severe, why has the DoD opted to continue to train psychologists to prescribe. Both the Air Force and Navy are picking up new psychologist who are being trained, or who have already been trained. Why did the psychiatric residents LIKE working with the prescribing psychologists. Why did the psychiatric residents experience the psychologist as better at teaching than their medical school professors when it came to discussing psychopathology? It seems that the powers that be in the military would have balked when this "selection bias" was apparent. The data appear to the contrary.

I do think that there is an active selection process occuring. Those psychologists that are bright enough to get through the science program inherently required to get a degree in psychopharm will step forward. If the person cannot get through, they'll fail or not try at all. So, sure, a selection process is present (but it probably doesn't rise to a bias.

BTW, did you read the DoD findings?

Talk about bias . . . look at McGyver's comments. This writer is talking about how psychologists didn't start prescribing in rural areas any more than the psychiatrists . . . without admitting that the first psychologist-written prescription has not been produced there. Moreover, when we talk about bias, why didn't MyGyver (or you) comment that as a result of the rural-urban problem, psychiatrists by the hoards started moving to the rural areas? We can't just point our fingers at psychologists and say "see, they're no better than us." We have to work to solve the problem if we want to improve our credibility.

I am not sure of this but how many of these medical psychologists will treat their own spouse/children/family if anyone of them happens to be suffering from mental d/o w/o consulting w/ a psychiatrist?
What do you guys think?
For myself, I am seriously thinking of making a career in becoming a plaintiff expert witness if this trend continues. :rolleyes:

Subject: [PP] Re: M2M: Louisiana joins New Mexico-prescribing by psychologists



On Sat, 8 May 2004, Ivan Goldberg wrote that is now "close to impossible

to stop" extension of psychologist prescribing to other states and perhaps

to disciplines beyond psychology.



All the intense lobbying and publicity that money can buy will not put the

cat back in the bag and will only demean the profession of psychiatry as

self-serving.



There are two strategies for making the best of the situation.



One is to eliminate all prescribing restrictions and make everything

over-the-counter. There are good arguments for this, but it won't happen,

as there are good counter-arguments (no pun intended).



The other strategy is to help the courts go after incompetent prescribers

in a way that will inhibit anyone who ventures into that territory without

the adequate preparation that only medical training can provide.



Specifically, the APA should generate and make available resources for the

"plaintiff's bar" that would facilitate successful civil actions in tort

against prescribers who harmed patients (or "clients") by virtue of not

really knowing what they were doing. While this might ensnare some hapless

psychiatrists who are not up to snuff, it hopefully would have far more

influence on practitioners who will be at a disadvantage on the witness

stand when they have to disclose that their education in

psychopharmacology lacked all sorts of components that are standard in the

training of physicians and the specialization of psychiatrists.



This line of attack relies more on "science" (the idea that we know more

than psychologists and that letting them prescribe makes little sense)

than on "conscience" (the idea that politicians ought to protect their

constituents rather than deliver them to the wolves).



The APA should create documents that would be useful in court, both for

plaintiffs' attorneys and for psychiatric experts in demonstrating that a

given defendant prescriber overstepped his or her competency, was

unprepared to take a necessary medical perspective, was unable to

understand and integrate relevant data before putting a patient at risk by

starting (or continuing) a course of psychopharmacologic treatment, etc.



This would be a more dignified, effective and feasible course of action

than would trying, as Ivan Goldberg wrote, to "stop the tidel wave" of

prescribing by non-medical providers.



No drug $$ No drug stock. One nerf-brain from I forget which pharma at

the APA meeting.


Myron


Myron L. Pulier, MD

Clin Assoc Prof Psychiatry, UMDNJ-NJ Medical School

Svas,

Of course I read the DoD findings....I'm not impressed that the psychologists, working in collaboration with physicians, not treating patients with comorbid medical conditions, not treating geriatric patients, not treating children, etc. etc., did an acceptable job.

Look more closely at how the psychologists chosen for this study were recruited. No selection bias? Hardly.

While I agree with you that this process is entirely politically/financially motivated by both sides of the fence, this does not preclude the points made by the MD you quoted above. Like I said in another post, there is no "working together" with these psychologists....for them it's autonomy or bust. Nobody has refuted the more complicated vignettes I mentioned in other posts, I think for a reason. Nobody, including the legislators, completely thought them through.

Psychiatrists by the hoardes are moving to the rural areas? You don't speak lightly in your other posts, so I'm sure that you saw data somewhere for you to say this. I'd be interested in hearing some of the numbers. Frankly, this would surprise me. Which brings me to another point. If the Louisana legislators are concerned about the lack of psychiatrists in their area...have they thought about the ramifications later on? In other words, I myself know for sure (not that I had the desire - although I hear it's lovely) that I will never practice in Louisana now....and I'm also sure that other psychiatrists will get fed up with the price underfixing by psychologists and perhaps move out-of-state. What then? The state where psychologists are prescribing through primary care docs with a dearth of psychiatrists? This does not sound like a solution to the problem. The care would be then substandard, with LESS psychiatrists to treat the patients. Any thoughts?

Svas,
Look more closely at how the psychologists chosen for this study were recruited. No selection bias? Hardly.
?

I think that it's important to differentiate selection "bias" from criterion-based selection which is intended for success. I think this selection cluster was utterly conscious and done so that the military could assess the potential for training psychologists AND protect their consumers. They did that.

I've already addressed the other selection issues - we could call it intellectual or vocational selection (natural by another name).

I think that it is our responsibility to demonstrate the numbers the reflect that psychologists will not safely prescribe. Asking psychologists to prove that they will or will not prescribe safely is silly . . . *until they prescribe*. They have a base of psychologists who can & have apparently done so admirably. Where are the adverse events??? Now we'll have clusters of psychologist in two states (and counting - trust me on that one) & we'll get new data.

BTW, you can BET that psychologists are researching OUR adverse event counts. They are neither egotistical or stupid. (By the way, the number of psychologists who are also attorneys are staggering.) Their practice directorate is run by psychologist/attorney types. So before we start done the road of looking and challenging their adverse events . . . we should make sure that our own houses are not made of glass - - - and they are.

S

This is a public health policy matter. The quality of public health care has been on the decline for quite a while, in spite of increasing costs, increased technology, increased array of pharmacological tx. options, etc.
http://www.rand.org/news/press.04/05.04.html

Psychiatric care, and especially child psychiatry is at the level of public health care emergency at this time, IMHO. By APA's own statement, the "mental health care delivery system is in shambles" http://www.psych.org/news_room/press_releases/visionreport040303.pdf

Physicians and their professional associations have absolutely no political "clout" re. public health care policy matters. Some argue that a "national health care system" might provide some solutions. Doubtful, especially re. chronic diseases, including severe, persistent psychiatric disorders, developmental disabilities, etc. Look at the NHS in the UK.

What is the answer? I don't know. But I am worried, just like many of my colleagues. I have not heard so far any satisfactory answers/solutions from my mentors, nor my peers, nor my professional association, nor from the NIH. What are we to do as physicians? Do we even have the responsibility to do anything, at a national level, and, even if we do, how can we regain some of the "control" over such public health policy matters?

I am hopeful that maybe the younger generation will have some answers.

I am a psychiatry resident and I am very concerned. I think that I will ultimately leave psychiatry and obtain a residency in another specialty. This is very sad. I don't see how giving psychologist prescription writing ability is helping mental health. Psychologist will follow the money trail and will abandon psychotherapy soon enough. I gurantee you they will not go to rural areas any more than psychiatrist. How does this help? Soon there will be no one to perform psychotherapy. I am insulted that psychologist have obtained prescription writing capabilities. All physicians that have done a residency know that a PhD degree in psychology is far inferior to a medical education and residency when it comes to making medical decisions. Don't we as physicians make enough mistakes as it is, why do we need to make it worse by letting psychologist act as psychiatrist. I just don't understand this decision. It is very sad, just as psychiatry residency applications were rising and the profession was experiencing a fantastic rebound. I predict that the number of psychiatry residents will now decrease rapidly, again I don't see how this helps mental health care. Soon enough all psychiatry residencies will be filled with FMG's. Psychiatry will once again become the field of Muhammed, Muhammed, and Muhammed. My heart tells me it's wrong to grant psychologist this extra autonomy. My brain tells me it is extremely dangerous and that innocent patients will end up dead. It is sad to see one of the greatest fields of medicine dummed down in this manner.

All physicians that have done a residency know that a PhD degree in psychology is far inferior to a medical education and residency when it comes to making medical decisions. Don't we as physicians make enough mistakes as it is, why do we need to make it worse by letting psychologist act as psychiatrist. I just don't understand this decision.

Even our young residents are infected.

Psychologists are different than psychiatrists. Their thinking or abilities are not inferior with regard to making decisions about patients mental-health oriented medical care. They've been doing it for years. Psychiatrists see only a tiny fraction of mental health patients. The frequency with which psychologists see patients outstrips psychiatry. Psychologists have been recommending medication to FP's/IM/Pediatricians for decades and apparently they've been successful enough to establish strong relationships with those docs. We're not "letting" them do anything. They are doing what they are doing BECAUSE PSYCHIATRY stopped paying attention to critical social and emotional responsibilities that it had.

Psychologists have been complaining about psychiatrists and their lack of understanding of human relationship/development/cognition/dynamics for years. FP's, Pediatricians, etc., have complained about psychiatry for an equal number of years, particularly as we stopped being careful about writing to them and involving them in the care of their patients. While psychiatry was protecting its turf regarding admitting privileges (how silly was that?), psychologists were responding by developing methods to prove that their competence was being overlooked. By refusing to allow psychologists to function autonomously with their patients, psychiatry allowed itself to be protrayed as collectively acting AGAINST what was in the best interest of the patient/consumer.

Psychiatry succumbed to the power of Mangled Care and when we were threatened with "start a med in 24 hours or don't get paid" duirng hospitalization, we did as we were told so that we and the hospital could be paid. We paved the way for the "evidence" that treatment could begin IMMEDIATELY, rather than allowing enough time to go by so that we could get to know the patient through interactions, psych testings, and group exposure. Instead, we began to push meds and patted ourselves on the back for how good we had become at diagnosing/treating so quickly. We ignored effect size data with these meds and we often made decisions without sufficient medical information about patients because it couldn't be collected quickly enough to satisfy MCO's. If COLLECTIVELY we had taken a stand for what we knew was right, *I think* some of this could have been avoided. We're seen as pill pushers, complicated by the social image of our still using bolts of electricity to people's heads (whether ECT is effective or not is far beside the point and, BTW, I *DON'T think that psychologists will lobby for ECT use, but will leave that to psychiatrists for reasons that are obviously related to stigma).

Finally, the field of psychology has not blended with medicine. Those obtaining 2 year post-doc psychopharm degrees are getting them AFTER the've completed graduate school and 2 year post-docs in whatever field of specialty. They're not going to medical school because they think the medical model is wrong. Frankly, it's pretty easy to persuade the public that the medical model is wrong, particularly in the wake of publicity about AD's, Ritalin, etc. Haven't you attended to the explosion of alternative medicine clinics EVERYWHERE? Until the 1990's, psychiatrists were thought to be in a competitive race with dentists over which profession had the highest suicide rate. (I don't know who is winning anymore and yes, I know that the suicide by profession data is pretty weak.) So, psychology has proposed a new model. One that bases prescriptive authoriy upon KNOWING the patient and continuting to provide psychotherapy. And, wisely, they've built this success around the intelligent mantra of "the authority to prescribe is also the authority to NOT prescribe."

So, my suggestion is that you resist leaving psychiatry. Rather, stay here and help psychiatry to change. If psychiatry remains as it is, it will only move toward becoming obsolete. Psychiatry needs some fresh perspective because it's being killed off by old guard who incorrectly read the environment.

first excuse my many misspellings in the last post, I did not proof read. I think that your altruistic thinking is refreshing but misguided. Psychiatrist used to do mainly psychotherapy but insurance companies and the government now dictate the length of office visits and hospital stays. Psychotherapy is now allocated to much less expensive psychologist. Psychologist will soon feel the pressure to see as many patients as possible for med rechecks. Soon someone else will step in to do the psychotherapy perhaps a psychonurse practitioner. The skills psychologist learned as psychotherapist sadly will soon fall by the wayside. But congratulations, psychologist will save the government a lot of money in the short run. It is definitely a slippery slope. Honestly I can't afford with my $180,000 debt and family to gamble on my career. I definitely feel a sense of doom and gloom for psychiatrist and mental health patients.

So, my suggestion is that you resist leaving psychiatry. Rather, stay here and help psychiatry to change. If psychiatry remains as it is, it will only move toward becoming obsolete. Psychiatry needs some fresh perspective because it's being killed off by old guard who incorrectly read the environment.

I am curious, Svas, do you have any specific solutions for "helping psychiatry to change"? And when you say "Psychiatry", do you refer to the discipline/specialty in general, to Academia, to organized associations, etc.? Who exactly would be in "charge" of this changing? And, even in the broadest general sense, in what specialty have you seen that physicians have any "power" to "change anything"?

I fear you come from the perception that somehow there was a sort of "old guard collusion" that "led to the destruction of the field". Well, IMHO, this is an utterly simplistic/naive perception, and definitely does not take into account even the most basic knowledge about the history and/or the definition of the field, nor the social/historical circumstances that have shaped its evolution.

I didn't mean to beat up on you specifically. Actually, I don't even know whether you are a psych. resident or what background of knowledge you come from. So don't feel bad about this. We are all here to learn and exchange information. Young doctors in training, IMHO, especially are probably thirsty for meaningful information, not just opinions. Although, of course, this board is very good for venting and support as well. We just have to be able sometimes to differentiate between information and propaganda. This can be sometimes hard to do in this medium of communication. :)

Young doctors in training, IMHO, especially are probably thirsty for meaningful information, not just opinions. Although, of course, this board is very good for venting and support as well. We just have to be able sometimes to differentiate between information and propaganda. This can be sometimes hard to do in this medium of communication. :)

For what it's worth: http://www.defensehealth.net/reports/GAOHEHS9998.pdf

Again, the same issue. :confused:
It's not about being more smart/effecient/intelligent when we are talking about psychologist's scripting power. It means you are compromising the patient care. It's as simple as that.
Everyone needs more $-there's no problem w/ that, however you can't make more $ in putting others in danger. That's precisely what's happening here. I am asking all of you here the same question again- how many of these so-called "medical psychologists" do you think will treat their spouse/kids/family w/o taking them to a psychiatrist first? I mean a full clinical eval and proper MSE, not those "over-the-phone" BS. One of my attending used to call it as "the mom test"-rather simplistic but very effective in medical-decision making. :)
We have seen earlier a lot of stuffs being passed around as alternative medicine. Li at one point of time used to be claimed as the panacea of all ills. The consumer/client makes the ultimate decision about whether they will see a psychiatrist and a medical psychoologist or an alternative practitioner for that matter. But we have to make sure that there's no harm intended in the process and the acceptable risk should not be more than the current medical model. This basic regulation is absent in this scenaro-that's why I am concerned.
BTW, the lawsuits against Ritalin has been thrown out- because it's one of the most effective med in psychiatry. However, diagnosing ADHD is another matter. As it was mentioned before most of the cases are seen by the non-psych PCP/therapist who lack the specialized training for whom diagnosing a psych pt mean only checking those DSM criterias and using a NOS code(I must admit often it's for insurance reasons). :rolleyes:
The basic medical model is being questioned here and we have to deal w/ this squarely NOW. This may not be the best system, but at least it's working and we are ensuring pt safety and the in-built checks are auditing the negative consequences. People who don't have a clue about medicine/ MD curriculum/post-MD training are questioning the medical model which is really intriguing and dangerous for the future generations to come.

I agree, dr blue...definitely this is systems issue...and it IS NOT just applicable to Psychiatric care. Basically, as of now, in our health-care system, the demand for health-care services is overwhelmingly larger than what the current resources are available to provide. What drives this current imbalance, I wonder? Multiple factors, I assume (included, but not limited to economical ones). The other issue is: as Physicians...do we even have any SAY or any practical influence re. Public Health policy problem-solving? We are just part of the tip of the iceberg and bob up when there's a crisis, we feel the crisis on our backs, on a daily basis, etc. But what power do we have? We are not even organized in any meaningful way. Even our professional organizations have no "clout" whatsoever. Medicine, in general, although we may HATE this idea, has lost much of the prestige and power and respectability that were imbued into it around the time of the end of the 19-th century/beginning of the 20-th century, actually co-inciding with the advances in sanitation/science/tx. methods/public health, etc.
Where are we now? Academic medicine is now completely subsumed to Pharma...that's where the money comes from. Pharma's objective is: to create new markets for making money. Pharma's influence has altered any ethical notions re. health-care research/teaching, etc. It's already gone BEYOND any acceptable bounds. Socially too..people are basically desperate to get access to health-care services. Psychiatric care has always been rare/expensive/inefficient. Pharma "proposed" the model that "we can easily cure lots of diseases by lots of PILLS"...yeah, right! Just look at our public health stats...ABYSMAL...especially for our rich and powerful nation. :scared:

But, OTOH...would "national health care bring any relief"...or even more conflict/inequities/maldistribution?, etc. Just think, from the perspective of a current med student, saddled with $ 200 K in debt...how are you going to tell that person to go do public health work for a moderate wage, also burdened with a potentially onerous and dysfunctional "National Health Service scheme" responsibilities, etc. What about LIABILITY? What about ETHICAL responsibilities? :confused:

National "solutions" (including using physician-extenders, under-qualified personnel, etc.) will maybe bring some short-term relief re. demand...but then..we will have a de facto 2 tiered health-care system: one for the rich and one for the poor, further fueling maldistribution, inequities, etc. It's a freaking downward spiral, wherever you look at it from! :eek:

What's a DOCTOR to do, I wonder? I was hoping to hear some youthful enthusiasm here, among young trainees. I do not mean to discourage anyone or to bring anyone's spirits down. But Medicine is a VERY tough, lonely, self-sacrificing, arduous road. That's how it is.

Hope I didn't put you all to :sleep:

The "medical model" was mentioned above. Nurse practitioners are trained in the "nursing model" and are able to prescribe drugs. How are these models different?

To Svas and others like you:

You inspire me with your personal and professional wisdom and your scientific reasoning.

You are the kind of physician that I admire and aspire to become:
a good PHYSICIAN not a medical fundamentalist.

I am completing my psychology residency and beginning pre-med with the intention of entering med school in a couple of years and eventually completing a psychiatry residency.

I am doing this because I am committed to the biopsychosocial model of healthcare and want to be a mental health provider who is able to fully integrate the biological and behavioral dimensions in patient assessment and intervention. I also rather do this in the next 10 years than wait to do in the next 20 or 30. I agree with you that RxP for psychologists is coming but it will probably take a few decades, as evidenced by how long it has taken other healthcare practitioners to gain RxP, e.g. NP.

However, I do totally support RxP for psychologists and believe that post-doc training in psychopharmacology (using the APA/DoD formula) will result in medical psychologists who will be able to function effectively and safely as both psychotherapists and psychopharmacotherapists. If I was willing to move to NM or LA or if RxP came to FL that is what I would do.

In the mean time I intend to personally live up to the challege of two great psychiatrists, George Engel and Lawrence Kubie. I also intend to continue to support professional psychology's evolution in the Engel/Kubie paradigm and challenge professional psychiatry's reactionary attachment to the medical fundamentalist paradigm.

Engel's biopsychosocial model and Kubie's "medical psychology" model (it was he who in 1954 proposed that new discipline which was meant to integrate psychiatry, psychology, psychoanalysis, and social work and which resulted in the establishment of a Doctor of Mental Health degree in 1973 at UC Berkeley and San Francisco but which ended being abolished in 1986 in part due to the opposition of med fundas to any RxP for any non-physicians) has been slowly but progressively inspiring psychology to enter into the healthcare field not only as academicians and researchers but as clinicians, resulting in the establishment of the PsyD degree for those most trained to be practitoners while retaining the PhD degree for those most trained to be scientists.

Of course, it's not just psychologists who have embraced the biopsychosocial model. Despite the opposition of med fundas, NPs and others are gaining a seat at the multi-disciplinary treatment team table, including RxP. Today NPs have RxP in all 50 states, including independent and full formulary practice in 11 states and DC.

Interestingly enough, there is NO evidence that patients are being harmed by getting prescription meds, including controlled substances, from non-physicians in those 12 jurisdictions where NPs don't have supervision from MD/DOs. By the way, some of those NPs are PhD/PsyDs who have undertaken post-doc training in nursing. :rolleyes:

Also interestingly enough, there is NO evidence that patients are being harmed by DoD psychologists, all of whom prescribe independently in the military and some of whom actually supervise the prescribing of psychiatry residents in the armed forces. :rolleyes:

Imagine that!!! People being judged on their knowledge and skill and not on whether their doctorate in medicine is allopathic, osteopathic, behavioral, etc. :eek:

Med fundas are bound to go the way of other ideologues who demand special privileges without evidence as to why they alone should be accorded them.

They remind me of the male chauvinists who wanted to deny women the right to vote, the white supremacists who wanted segregation/apartheid, religious bigots who wanted their beliefs to be the official state ones, etc.

Ultimately, it is those who demand privilges for themselves that must DEMONSTRATE why their proposed discrimination should be enshrined in law.

Why should 4 years of med school and 4 years of psychiatry residency be the ONLY way for a clinician to be able legally to prescribe psych meds???

The evidence DOES NOT DEMONSTRATE that the current psychiatrist model is the only one (note the NP model and the DoD psychologist model) nor the best one. LET'S STOP THIS UNFAIR DISCRIMINATION...NOW!!! :mad:

Many MD/DOs already have and the LA RxP model may well further enhance collaboration between non-psychiatrists physicians and psychologists. A collaboration that may well result in patients receiving comprehensive and compassionate physical and mental healthcare; even if it does not involve hubris consumed psychiatrists asking in vain why others do not see their superiority.

Like you said, the train is coming. As a soon to be psychologist I'm glad for psychology as a future psychiatrist I'm concerned for psychiatry. Hopefully we'll all be on the train. :luck:

Again, to you Svas and others like you I say: THANKS.

To my future psychiatrist colleagues I say:

We can all be good physicians without being medical fundamentalists. :)

*Sigh*

Forensic psychiatry looks more and more like the wave of future...

Psychologists wanting to be psychiatrists. Optometrists wanting to be ophthalmologists. Nurse Anesthetists wanting to be independent Anesthesiologists. NPs wanting to be family docs, or junior cardiologists, or whatever.

I wonder if anyone ever realizes the importance of a comprehensive medical education anymore.

It looks like psychiatrists are going to have to find specializations in order to survive financially. What we do need to formulate in 20 years if and when a national trend towards "medical psychology" materializes is what the role of the psychiatrist is and what the role of the clinical psychologist is. Can both function together similar to optometrists and ophthalmologists? Where is the line drawn between the responsibilities of the M.D. and the Ph.D.? Should we open more spots in medical schools nationwide, or create medical schools in rural areas in order to better serve the public, rather than inventing a new degree?

What does provide some hope for the future of psychiatry is that many psychiatrists do currently make a living doing psychotherapy even though there are clinical psychologists and social workers that do it also. Plenty of patients to go around, although reimbursement rates will go down even further unless clinical psychologists increase their fees (which I assume they will if they get prescription rights).

The lawyers and pharmaceutical companies are going to be living large if this medical psychology thing ever comes to fruition.

Psychologists wanting to be psychiatrists.

I don't know how to help you with this in anyway other than I have done, PsychNOS.

Again, psychologists DO NOT want to be psychiatrists. This appears to be the only way you can understand the material - but I'm not sure why?

(Frankly, I'd be overjoyed if psychiatrists were really psychiatrists again.)

S

Unfortunately, and I hate to say this as an entering psychiatry resident, the field of psychiatry is doomed for failure unless the potential of billable procedures comes to fruition. Even that will be fleeting, as I'm SURE they will lobby to perform those procedures as well to the "underserved," and so that they can "more comprehensively provide for the mentally suffering."

Sasavan argues that prescribing power should be based on knowledge, not "medical fundamentalism." That being said, all pharmacists should prescribe. All PhDs imaging procedures should clinically read MRIs, all teachers who take a weekend course for two years should prescribe Ritalin. All uberdextrious people good with their hands should take courses and perform surgeries, all chiropractors should perform laminectomies. All optometrists should perform corneal transplants, etc, etc.

The psychology prescribing train may be coming, but their train in general is derailing. I left the profession for a reason...they are in massive overproduction (so much so that the Amer. Psychological Assn. is limiting the amount of PhDs they're now producing), their salaries are plummeting, and their image is declining. Medicare will no longer pay $85 for a 40 minute therapy session...not when they can pay a psychiatric social worker half that, or even better (like is coming in NJ), a bachelor's level psychologist. Again, the psychologists on the RxP listserv make no bones about it. They want a piece of the psychiatry money pie, and will relentless pursue it until they obtain it, whilst inevitably dragging the profession into the financial sewers with it.

I hate to use a sports analogy, but this is our game to lose. When you're the champ going into a fight, people expect you to win....and if you do, you're simply defending. If you lose in an upset, there's an uproar and you've been dethroned. Another: Every team loves to beat the Yankees...they are perennial winners, and all other teams hate them. When they win, it's expected. When they lose, the other teams celebrate to no end.

Psychiatry is ours to lose. Psychiatry is at the pinnacle of the mental health model and psychiatrists are the most comprehensively trained to manage all aspects of psychiatric care. To that there is no argument. To constantly defend means inevitable defeat. Yet, working "with them" is something they have refused (NM psychologists rejected a modified bill to have them prescribe in rural areas only). What solution can there be to this? Psychiatrists are busy taking care of patients. Psychologists are largely academic in comparison and have nothing but time to lobby, promote, and propose legislation to advance their profession out of the traditional boundaries. Things look dire for a great and noble profession with a unique perspective on the human condition.

I am wondering if people realize that this very essential "debate" about the "Medical model" of health-care delivery VS. "Other models...(?)" is not currently going on re. Psychiatry only, but also re. the most fundamental specialty of Medicine, Internal Medicine, and other specialties as well.

And is this even a core "debate" within our profession, or is it mere propaganda? And what is driving it? I don't know, but I sure would like to find out. I also realize that I do not even know even the most basic definitions: what IS this "medical model"? what are the "other" models? Again, not just re. Psychiatry, but about health-care delivery in general.

Svas:

I guess my statement should read "psychologists want the same practicing privileges as psychiatrists."

All of your arguments have been based on semantics and philosophy rather than what will actually be done in practice. Fine, people don't go to medical school because they don't believe in the "medical model." But, these very same people are willing to attain the rights and responsibilities that have traditionally been given to physicians. They want to attain prescription rights and attain autonomy. They want to be the ones to be directly working with pediatricians and family docs. What I don't understand is that if psychologists don't want to be part of the medical model, why are they so willing to inject themselves into it?

Explain to me how a psychologist with a presciption pad will be different than a psychiatrist with a prescription pad IN PRACTICE. More psychotherapy? More time spent with patients? A different philosophical approach? That will disappear when the realities of managed care and medical economics come into play.

I don't understand why the current mental health care model doesn't work. I've seen practices where clinical psychologists and psychiatrists work side by side, with psychologists handling the bulk of therapy and psychiatrists handling the bulk of medication management. Both types of professionals are involved in the care of the patient. Must we be so willing to explore breaking down these distinctions? For what reason? To provide greater access to mental health care? There have been multiple postings on why this is not the primary reason that clinical psychologists are seeking prescription rights.

Should we open more spots in medical schools nationwide, or create medical schools in rural areas in order to better serve the public, rather than inventing a new degree?

The lawyers and pharmaceutical companies are going to be living large if this medical psychology thing ever comes to fruition.

There are branch DO schools popping up all over the US. Interestingly, most are located in or near so-called "rural, underserved areas." Maybe creating a psychiatry specialization track (with increased training in psychotherapy, pharmacotherapy, and research) for aspiring psychiatrists in these programs would help increase the number of physicians pursuing careers in psychiatry? If successful, these programs would produce enough psychiatrists to serve patients in otherwise underserved regions of the country, thereby eliminating the need to "medical psychologists."

In response to your second point, I wonder if any pharmaceutical companies are supporting psychologists' gaining prescription rights. They seem to love "expanding the market" in terms of medicalizing social problems, so something like this would in all likelihood be fully endorsed.

Let's give scripting rights to MSWs and any college grad for that matter, if knowledge and personal skill matters most. Who cares if we move backward wrt pt-care. :(
Also people who talk about failure of the medical model are the successors of the potent antipsychiatry movement of the 60s,70s and 80s. For those who are interested please see this http://www.antipsychiatry.org/

To Svas and others like you:

You inspire me with your personal and professional wisdom and your scientific reasoning.

You are the kind of physician that I admire and aspire to become:
a good PHYSICIAN not a medical fundamentalist.

I am completing my psychology residency and beginning pre-med with the intention of entering med school in a couple of years and eventually completing a psychiatry residency.

I am doing this because I am committed to the biopsychosocial model of healthcare and want to be a mental health provider who is able to fully integrate the biological and behavioral dimensions in patient assessment and intervention. I also rather do this in the next 10 years than wait to do in the next 20 or 30. I agree with you that RxP for psychologists is coming but it will probably take a few decades, as evidenced by how long it has taken other healthcare practitioners to gain RxP, e.g. NP.

However, I do totally support RxP for psychologists and believe that post-doc training in psychopharmacology (using the APA/DoD formula) will result in medical psychologists who will be able to function effectively and safely as both psychotherapists and psychopharmacotherapists. If I was willing to move to NM or LA or if RxP came to FL that is what I would do.

In the mean time I intend to personally live up to the challege of two great psychiatrists, George Engel and Lawrence Kubie. I also intend to continue to support professional psychology's evolution in the Engel/Kubie paradigm and challenge professional psychiatry's reactionary attachment to the medical fundamentalist paradigm.

Engel's biopsychosocial model and Kubie's "medical psychology" model (it was he who in 1954 proposed that new discipline which was meant to integrate psychiatry, psychology, psychoanalysis, and social work and which resulted in the establishment of a Doctor of Mental Health degree in 1973 at UC Berkeley and San Francisco but which ended being abolished in 1986 in part due to the opposition of med fundas to any RxP for any non-physicians) has been slowly but progressively inspiring psychology to enter into the healthcare field not only as academicians and researchers but as clinicians, resulting in the establishment of the PsyD degree for those most trained to be practitoners while retaining the PhD degree for those most trained to be scientists.

Of course, it's not just psychologists who have embraced the biopsychosocial model. Despite the opposition of med fundas, NPs and others are gaining a seat at the multi-disciplinary treatment team table, including RxP. Today NPs have RxP in all 50 states, including independent and full formulary practice in 11 states and DC.

Interestingly enough, there is NO evidence that patients are being harmed by getting prescription meds, including controlled substances, from non-physicians in those 12 jurisdictions where NPs don't have supervision from MD/DOs. By the way, some of those NPs are PhD/PsyDs who have undertaken post-doc training in nursing. :rolleyes:

Also interestingly enough, there is NO evidence that patients are being harmed by DoD psychologists, all of whom prescribe independently in the military and some of whom actually supervise the prescribing of psychiatry residents in the armed forces. :rolleyes:

Imagine that!!! People being judged on their knowledge and skill and not on whether their doctorate in medicine is allopathic, osteopathic, behavioral, etc. :eek:

Med fundas are bound to go the way of other ideologues who demand special privileges without evidence as to why they alone should be accorded them.

They remind me of the male chauvinists who wanted to deny women the right to vote, the white supremacists who wanted segregation/apartheid, religious bigots who wanted their beliefs to be the official state ones, etc.

Ultimately, it is those who demand privilges for themselves that must DEMONSTRATE why their proposed discrimination should be enshrined in law.

Why should 4 years of med school and 4 years of psychiatry residency be the ONLY way for a clinician to be able legally to prescribe psych meds???

The evidence DOES NOT DEMONSTRATE that the current psychiatrist model is the only one (note the NP model and the DoD psychologist model) nor the best one. LET'S STOP THIS UNFAIR DISCRIMINATION...NOW!!! :mad:

Many MD/DOs already have and the LA RxP model may well further enhance collaboration between non-psychiatrists physicians and psychologists. A collaboration that may well result in patients receiving comprehensive and compassionate physical and mental healthcare; even if it does not involve hubris consumed psychiatrists asking in vain why others do not see their superiority.

Like you said, the train is coming. As a soon to be psychologist I'm glad for psychology as a future psychiatrist I'm concerned for psychiatry. Hopefully we'll all be on the train. :luck:

Again, to you Svas and others like you I say: THANKS.

To my future psychiatrist colleagues I say:

We can all be good physicians without being medical fundamentalists. :)

The
Antipsychiatry
Coalition

DocBlue

Are you actually comparing psychologists who want this additional training and who want to care for mentally ill patients more effectively to the folks who came up with the Antipsychiatry Coalition???

BTW, how much training SHOULD NP's have gotten before they were able to prescribe meds as they do now?

S

i wonder if svas will be as cocky when he/she kills their first pt by missing an underlying disease or medication interaction. you can not separate biology of the brain and the rest of the body.

i am a msw and will be starting med school in august. social workers are also begining to grumble about prescription rights (and as a profession we populate rural areas much more than psychologists). i am totally against this idea. even with this "advanced" traning in psychopharm, etc. how will anyone who has not had basic science such as chemistry, organic, and biology understand the "advanced" psychopharm. you may scoff, but dosing does require a certian amount of chemistry (as does learning drugs and how they work in the body etc).

i think many people hear psychologists state "we are scientists and doctors", but this is only true for behavior and not basic physical and biological science (for the most part). testing one's IQ etc does not instill confidence in me that one understands the science behind medicine. and please don't say that a basic understanding of how drugs work through their chemistry and how a body is effected by this chemisrty is not important. it is.

the idea that psychologists are at least equal to NP's PA's is silly. they are different professions with different treatment goals! stop using loaded words such as "equal", etc. psychologists are not oppressed due to some inherent, inate intelligence only they have and all the other health care dont. both NP's and PA's have to take basic science such as chemistry, biology, and then their graduate courses that builds on the basics. also, they rotate through all different aspects of medicine while in school. again the idea to separate the brain from the rest of the body is a bad idea and is ultimately deadly.

i do not understand why psychologists as a profession does not tout more of the important role they play as part of the team and the great work they do with testing and therapy? when did this become unimportant? is this not the basis of psychology? is that not why you went to become a psychologist rather than medical school?

each profession is unique and brings its strenghts (and weaknesses) to pt care. i have no problem with any profession gaining prescriptive rights, but do it responsibly. understand what needs to be learned before you take a person's life in your hand. and to those who feel SSRI's can be dispensed like candy, three letters NMS.

MSWPHYSICIAN -

1) I am already a physician & have been licensed for 17 years.

2) I am also a professor - and have been teaching for 15 of those years.

3) Before getting my degree in medicine, I had an undergrad in psychology/biology and a Ph.D. in Chemistry. I have found that the practice of medicine (in a practical sense) to be profoundly more challenging than the study of medicine in school (or residency). It is certainly rewarding & I love what I do. In fact, I really couldn't do anything else.

4) Two of my sons have Ph.D.'s in psychology (one is a clinical psychologist and the other is a neuropsychologist). My daughter is an MSW and is getting a Ph.D. in epidemiology. My youngest, another son, is in his 3rd year of medical school (he hangs out here & is responsible for my finding this board). My wife is a physician (OB/GYN). My father was a physician (gp) and my mother was a vetrinarian. I also have a hunting dog. I'm very familiar with all of their training.

5) Congratulations on starting med school. School will be a challenge for you and will probably surprise you.

6) I happen to believe that, in general, clinical psychologists and neuropsychologists are very bright and capable. Yes, I'm biased, but I have also spent time with a large number of them and find psychologists to be uniformly curious and competent abstract thinkers. My daughter, a very bright woman, but did not obtain anywhere near the training that my sons did during her MSW program. Apples and oranges. I have little question that psychologists can be taught to prescribe within a limited, but reasonable formulary in a safe fashion. Given my background, I'm pretty sure I can do better than guess.

7) Physicians have been learning via killing patients for years. It's not glorious, but it's true. Anyone that tells you otherwise is lying to you. That's one of the reasons why we have M/M boards. Hopefully you won't, but you will probably kill someone too. Every doctor either does or gets very close. Some even kill several & it's a byproduct of their specialties, their carelessness, or bad luck. A psychologist WILL kill someone sooner or later. But that won't make them unique in this business and frankly, they will be able to defend themselve by pointing directly to the frequency and method with which we kill people. It doesn't make it a good or right thing; it just is.

There's a lot of rhetoric on this board & very little data. You will learn that there's still a lot of mystery in medicine and a lot of science. I don't think I'd change that, since the mysteries are what keep me interested and willing to stretch both my imagination and creativity. I don't find it of any value to thwart the intellectual investment of interested and bright professional colleagues anymore than it would be of value to thwart yours. I know this doesn't make me popular here but we must all move in the direction of our convictions. Good luck with yours.

S

You know, I still think that some of us are maybe concerned about this "dumbing-down" in a general sense, not as applicable to individual persons who may be quite experienced/intelligent/competent, etc. I don't want to dilute the discussion here by over-generalizing, but, remember, how the initial PA contingent came from former military medics who had years of clinical hands-on experience. Now PA's are churned aout of some programs, with as little as 2 years of clinical rotations and only 4 years of post-highschool or even post GED overall education...and then work side by side with residency trained ER docs, fellowship trained cardiologists or neurologists, functioning as de facto "specialists" in the real world. Anyone has or will have the experience of sending a patient for a specialty CONSULT (implying that one needs some expert knowledge input) and gets in return a boiler-plate exam done by a PA "specialist", who is the only "expert" who has actually seen the patient, and is essentially useless as a consultant, except maybe in some procedural cases.
OTOH, it is pretty clear that high quality expertise IS expensive and definitely we do not have the resources to provide high-quality medical care at a "mass"/national level.
At this time actually the most underserved patient population in Psychiatry is actually the sickest patient population...the ones with complex and multiple medical-neurological-psychiatric co-morbidities, the community clinic patient population. As of NOW, many of these patients do not even have a permanent primary care MD, and may only go seek medical care if urged/referred by the ONLY MD they ever get the chance to see, which is often the Psychiatrist, who identifies certain medical unadressed problems in that setting ON A DAILY BASIS as a matter of fact, by virtue of their training. Well, if the psychologists want to gain rx'ing privileges with the "altruistic" scope of serving underserved patient populations, will they go out into the community clinic world then? And what job are they able to do there, I wonder. This is not about who gets to rx. Prozac.

I'll be a PGY-1 this year and can't imagine what kind of impact this will have on my future after completing residency. I should have just skipped medical school to take a weekend pharmacolgy course. Who needs the Medicine, Surgery, Neurology, Pediatrics, Caridiology etc. after all? I mean, people are just walking brains detached from the rest of their bodies, right? No need to do EKG's, Physical Diagnosis, Labs when the brain functions independently of everything else. It saddens me, but there is nothing else in medicine I want to do, so if I have to change careers, I think I'll go to law school. Then, I'll specialize in mal-practice cases against psychologists who practice medicine without a medical degree. :thumbup: :thumbup: I'd have a regular cottage industry and would then be able to pay off my 200,000 in student loans, support a family, and buy a house before I'm 80. :idea: BTW, Does anybody wonder how much the premiums would be for a psychologist to get mal-practice insurance? :confused: Anyway, the only winners in this wave of the future will be lawyers and psychologists and the losers will be patients and physicians. I might as well be one of the winners! :laugh:

thank you svas for your comments. i do not agree with the majority of your points, but i respect them. the issue still remains of basic core knowledge. no matter one's intelligence level, you have to understand basics before you can move on to the advanced courses. i have no doubt in my mind that many if not most psychologists are equally as intelligent as physicians, NP's, PA's and MSW's. again a degree does not define a person. there are many dumb people in ALL the fields. this, however, does not mean they (psychologists) can simply pick-up advanced chemisrty and pharmocology and understand it well enough to prescribe. my point remains that doing a statistical thesis on behavior, trends, etc is not physical or biological science and does not offer any insight into these complex courses. i imagine that medical school was easy for you with a phd in chemistry. but again, this is a physical science which medicine strives to understand and use clinically.

i do not disrespect phd in any field. i have several phd psychologist friends who are totally opposed to this trend for the same reasons i have articulated. if psychologists want prescription rights, why is the accrediting body for psychology colleges not requiring a change in curriculum?

i think it is great for your sons who are psychologists. i think with such a strong medical family they are above the bell curve when it comes to discussing medical issues.

thank you for your words of encouragement on starting medical school, and i hope i kill as few pts as possible! :laugh: :meanie:

The
Antipsychiatry
Coalition

DocBlue

Are you actually comparing psychologists who want this additional training and who want to care for mentally ill patients more effectively to the folks who came up with the Antipsychiatry Coalition???

BTW, how much training SHOULD NP's have gotten before they were able to prescribe meds as they do now?

S

When you start demedicalizing the specialty, that's a possibility.I do consider providing psych w/ scripting power as a first step in that direction. Hopefully call for reforming the specialty will not be hijacked by these so-called antipsychiatrists. :(
BTW your postings are very interesting and thought provoking. :thumbup:

Reasons to Grant Prescriptive Authority to Appropriately Trained Psychologists:

1. There is a critical need for appropriate and effective psychoactive medication, but access to this type of care is limited and decreasing.

20% of all Americans suffer from mental illness at any given time.
Studies show that a combination of talk therapy and drug therapy is often the most effective treatment.
Medical students in psychiatric residencies decreased 12% between 1988 and 1994. Interest in psychiatric residencies among medical students in the United States has decreased to the point that about half of the residency slots are being filled by graduates from medical schools in other countries.
The majority of all psychotropic medications are prescribed by non-psychiatric health care providers who have limited exposure to diagnosing mental illnesses.
In the United States there are at least 444 counties that have no psychiatrists but do have psychologists . :)

2. Psychologists are highly trained specialists in mental health who can and are being trained to prescribe psychoactive medications.

Psychologists have an average of seven years of doctoral training in the diagnosis, assessment and treatment of mental and emotional disorders.
Psychologists interested in obtaining prescriptive authority receive specialized post-doctoral training.
Psychologists all over the United States are already seeking postdoctoral training in psychopharmacology.
Psychologists in many professional settings are already collaborating with physicians on patients medication issues.
Ten military psychologists have been trained to prescribe, and an independent study of this group shows them to be safe and effective prescribers .
Most states have granted other non-physician providers, such as dentists, podiatrists, physician-assistants, nurse practitioners, and pharmacists, some degree of prescriptive authority, and many prescribe independently. :)

3. Prescriptive authority for psychologists increases continuity of care.

It is time consuming for patients to see multiple health care providers for the same problem. Prescribing psychologists, because of their mental health expertise, will be able to provide patients with assessment, diagnosis, and therapy, as well as psychotropics and medication management.
Psychologists trained to prescribe will provide integrated psychological and pharmacological care. :)

Prescription Privileges for Psychologists:
Frequently Asked Questions (FAQs)
by Practice Organization staff

Q: Must all psychologists prescribe?

A: No. Only those licensed, doctoral psychologists willing to seek post-doctoral training in psychopharmacology, pass a national exam, and meet other state criteria will be eligible to prescribe. Moreover, prescriptive authority would not extend to the many psychologists whose professional focus is research, teaching, consulting or other areas of psychology that do not involve seeing patients.

Q: If psychologists want to prescribe, shouldn?t they go to medical school?

A: No. Many Non-physician health care providers prescribe without going to medical school, although they are trained in other profession-appropriate institutions. Psychologists who want to prescribe must seek extensive, post-doctoral training in psychopharmacology. Recommended training is a minimum 300 hours of didactic training and a supervised 100 patient practicum, beyond the doctoral training in mental health already received.

Q: If there are so many prescribing professions why do we need another one? Isn?t there already a problem with over-medication?

A: While the numbers of prescribing heath care providers specially trained in mental health are decreasing, the number of psychotropic medications being prescribed are increasing significantly. The majority of all psychotropic medications are prescribed by health care providers with little to no training in the diagnosis and treatment of mental illness. The knowledge of psychotropic medications will allow psychologists not only to prescribe, but also to eliminate, reduce or correct medication because of their expertise in mental health and their ability to balance medications with psychotherapy.

Q: If a psychologist doesn?t go to medical school, how can he or she detect a physical illness that looks like mental illness?

A: Psychologists are the health care professionals with the greatest amount of training in the assessment and diagnosis of mental illness. Psychologists are already trained, as part of the practice of psychology, to identify which health care issues are outside the individual psychologist?s scope of competence and refer those patients to a more appropriate health care provider. Although prescribing psychologists will have an expanded area of expertise, they will continue to refer patients who should be seen by another health care provider.

Q: If psychologists and physicians are already working together, why do psychologists want to be able to write prescriptions themselves?

A: Studies show that a combination of talk therapy and pharmacotherapy is the most effective treatment for some mental illnesses. Many consumers seeking a combination of talk therapy and pharmacotherapy must see multiple healthcare providers for the same condition, resulting in added costs to the consumer. Prescribing psychologists will be able to provide this integrated therapy resulting in more efficient and more effective care.

Q: Are there psychologists already prescribing?

A: Yes. Psychologists trained by the Department of Defense to prescribe have been prescribing safely and effectively for several years. These prescribing psychologists are among the most highly scrutinized health care professionals ? independent studies have shown that these psychologists are safe prescribers.

Q: If there were a need for prescribing psychologists wouldn?t consumers be requesting this service?

A: Not necessarily. There is still a stigma attached to mental illness, or the perception of mental illness, which discourages patients and consumers from advocating for themselves. Accordingly, psychologists must often advocate on behalf of their patients and mental health care consumers as a whole. In addition, many consumers may not even realize that such a service could be an option.

[cut majority of grossly and disturbingly generalized assumptions from this "practice organization staff"]



Prescription Privileges for Psychologists:
Frequently Asked Questions (FAQs)
by Practice Organization staff.....

Q: If a psychologist doesn?t go to medical school, how can he or she detect a physical illness that looks like mental illness?

A: Psychologists are the health care professionals with the greatest amount of training in the assessment and diagnosis of mental illness. Psychologists are already trained, as part of the practice of psychology, to identify which health care issues are outside the individual psychologist?s scope of competence and refer those patients to a more appropriate health care provider. Although prescribing psychologists will have an expanded area of expertise, they will continue to refer patients who should be seen by another health care provider.



As a person who completed a Master's degree en route to a clinical neuropsycology Ph.D., I can tell you that this is no less than a joke. While many neuropsychologists clearly have some understanding of overall human physiology and disease processes related to the CNS, to state that disease or subclinical conditions manifesting as disease states will be easily recognized by non-physician psychologists is just plain wrong.

It is interesting how the answers to the above questions follow classic propaganda rhetorical techniques - deflect an irrefutable question with an unrelated fact, and buster the argument with straw-man logic to confuse the reader and assume truth.

Very sad indeed.

As a person who completed a Master's degree en route to a clinical neuropsycology Ph.D., I can tell you that this is no less than a joke. While many neuropsychologists clearly have some understanding of overall human physiology and disease processes related to the CNS, to state that disease or subclinical conditions manifesting as disease states will be easily recognized by non-physician psychologists is just plain wrong.


This reiterates an ongoing concern that I have about my fellow physicians with regard to psychology. Anasazi, I appreciate that you completed a master's degree and no one should take that from you. That's not the same,however, as completing your doctorate, post-doc, etc. I know that you know that, so this set of facts isn't part of our disagreement. However, having the master's degree doesn't make you a neuropsychologist and it doesn't entitle you to know the scope of training that psychologists/neuropsychologists receive.

You are, of course, making the same argument about psychology and medicine. Because psychologists haven't been through medical school, they don't know what they don't know." They don't know how deficient they are with regard to their psychopharm training. Correct?

We'd have to say the same thing about psychiatrists. Because they have not gone through the Ph.D's training . . . nor have we gone through their post-doctoral training, we really don't know what kind of training they are getting. Until we check it out carefully, we're also just engaging in baseless rhetoric.

If we're going to complain, let's complain with real data. I keep calling for this & people continue to suggest that I'm ignoring what they are telling me. So, perhaps someone should talk down to my level and give me the numbers.

S

It appears that we agree to disagree on what constitutes medical scope of practice in general, and what amounts to the practice of clinical psychiatry (at least in part) in particular.

While I did not complete the Ph.D. in clinical neuropsychology, I did complete two years, whilst (almost - it's a longer more boring story) completing the dissertation. As far as not knowing what the training entails because I didn't complete another year of assessment and therapy...well - what can I say.

It's akin to the third year medical student doing a medicine rotation and at that same time, a fourth year student also doing a medicine rotation...it's basically more of the same stuff. Hopefully, you have an increased knowledge base with that extra year of training, but the work is basically the same.

Your statements bring up a good point to me personally. A major reason I left the field was exactly because of what I just alluded to - the repetitiveness was simply killing me.

As I worked in my post bac premed program, I continued to work half time in a neuropsychology private practice and functioned basically on the same level as the other Ph.D. clinicians. I have no data to support this. You'll just have to take my word on it. Rethinking my opinions due to your callings made me reiterate what I had originally thought - in many cases of practicing, there is really no (and how could there be) significant knowledge gained in physical disease not related to the CNS...even more so when one is not employed in a hospital setting.

It is true that you keep asking for numbers - Nobody would like to see them more than I. However, this is a discussion board, not a research symposium. By definition, therefore, there is a lot of talking, with oftentimes little supporting data. I get the feeling that you may be holding out on us, Svas. Do you have any supporting data of your own? Perhaps we should collaborate on a joint project to obtain some. There is no doubt the American Psychiatric Association certainly needs it.

I was on call Monday night and 4 0f the 8 people I admitted to the hospital had a psych disorder, 3 of the 4 were medically related. These patients had 1) malignant mets to the brain, 2) Hypothyroidism (patient had been seeing a psychologist for 6 monthes for depression and suicidial ideations before seeing her PCP who sent her straight to the hospital) 3) Hyponatremia. I am feed up with psychologist saying they can safely prescribe psychotropics. I am not afraid to say that psychologist as a whole are not as intelligent as medical doctors and are not even close to as well prepared to take care of psychiatric patients. Applying to and getting accepted to medical school is phenomenally difficult and passing medical school is another feat in and of itself. Psychiatry is not easy. I feel as if SVAS thinks psychiatry is easy. Psychiatry is easy if your differential is short and you don't know what to ask. If you are well read and have a broad differential psychiatry is extremely difficult because you are constantly teasing out subtle psychologic and neurologic deficits. a psychiatrist needs to be as much a neurologist as much as a psychiatrist. Psychologist prescribing psychotropics is wrong, plain and simple. Psychologist prescribing psychotropics will kill patients. There is a reasong physicians feel uncomfortable prescribing psychotropics medications, because they are dangerous. The arguement that psychologist should prescribe because they spend more time doing psychotherapy is flawed in the worst kind of way. Good psychiatrist do spend time a lot of time with their patients. As soon as psychologist start prescribng their time spent with patients with decrease enormously. If psychologist start to prescribe they will be under the governments rule and then psychologist will also be be doing a little psychotherapy and a lot of med rechecks. The fact of the matter is that psychologist prescribing med's is the dumbing down of medicine, it is much, much, much easier to become a PhD psychologist. Psychologist are probably deeply affended but the truth sometimes hurts. Just because you want to become a doctor doesn't mean you should be a doctor. There are standards for a reason. This is medicine and people die, I hate talking about this with psychologist because for the most part they have not spent the night in the hospital or done an ICU rotation. I have done 3 ICU rotations and 3 months of internal medicine. I have seen many people die. I mean dead, done, bye-bye. I have had the good luck and fortune of never killing a patient, but I have seen many gifted physician kill patients. Psychologist prescribing medications is dangerous. Prescribing Psychologist will kill many more patients than prescribing psychiatrist. They simply don't have the training or intelligence. The answer to helping the mentally ill is to recruit more medical students into the wonder field of psychiatry and this is starting to happen if one looks at the trends. There are much less FMG's entering psychiatry over the past 4 years and many more US medical student applications to psychiatry. This is bound to change this year secondary to the bill that was passed in Louisiana. Medical Students feel the government is handing mental health over to less expensive and cheaper psychologist. Psychologist going to rural areas is a joke. These areas are rural for a reason and physicians don't go to rural areas for a reason. I don't blame psychologist for not going to rural areas. You need to see a certain amount of patients to make a living as a psychiatrist or a psychologist. I don't care if your a psychiatrist or a psychologist if you only see 5-10 patients a day you and your family will starve. I hope this is a wake up call for all psychiatrist, we have felt for so long that this was such a ridiculous concept that it could never possibly happen. Well it finally has. It is now time to fight for the integrity of the mental health field and for the mental health patients.

Wow . . . I don't know where to start with this one. In fact, I'm nearly speechless.

i agree psychologists should not prescribe, but i think it is incorrect to state they are not as intelligent as physicians. lets face it, there are dumb physicians as well as psychologists. a profession does not define a person or their intelligence. this does not mean psychologists should prescribe, for they should not. see my previous posts for my reasoning.

Why is everyone so politically correct. Fine psychologist and physicians are both intelligent that is easy to agree with. But, as a whole physicians are more intelligent than psychologist. Also, let's face facts. Psychologist getting the right to prescribe is purely a political move in Louisiana that was fasted tracked through the political process by some wealthy psychologists and politically motivated politicians. This decision was opposed by every faction of psychiatric medicine accept psychologist mainly because the bill is very poorly written and gives psychologist far too much autonomy far too quickly with far to little oversight. I am a physician and I have volunteered many, many hours to needy and less fortunate people and have won many awards for volunteering. I graduated near the top of my medical school class and had the choice of many residencies and choose psychiatry because I truly love helping people and there is such a great need in psychiatry. I will never be wealthy physician because I spend too much time doing charity work. That being said, I have worked with many psychologist and respect what they do greatly but they have not earned the priviledge and honor of treating medically ill patients. Psychologists play and key and pivotal role in the mental health care field. They are extremely important and their role can not be replaced. Who fills their role when they start prescribing. I also firmly believe that only the top 5-10% of psychologist would be able to survive medical school. Psychologist are not medical doctors nor "medical psychologist". I firmly oppose this trend of psychologist, PA's, nurse practitioners, optometrists, etc... from gaining more and more rights in medicine. Instead we should be focused on recurrenting more of the best and brightest into medicine and raising the current standards of medicine. Not dumbing it down. SVAS I doubt you are a physician, if you are a psychiatrist I feel you would be more concerned with recruiting great medical students into psychiatry and you would be very concerned with psychologist prescribing powerful psychotropics. The bill in Louisiana will do nothing short of scare great medical students away from psychiatry. I was speechless and the other psych residents in my program where also speechless when they heard of the bill in Louisiana passing in the speed and fashion in which it was. This bill is shady at best. There was no discussion or thorough thought process. I as well as many other great psychiatrist in training will rapidly be leaving the field of psychiatry, how does that help the mental health field. SVAS if you are truly a psychiatrist that supports psychologist, how do you envision the future of psychiatry?

Why is everyone so politically correct. Fine psychologist and physicians are both intelligent that is easy to agree with. But, as a whole physicians are more intelligent than psychologist. Also, let's face facts. Psychologist getting the right to prescribe is purely a political move in Louisiana that was fasted tracked through the political process by some wealthy psychologists and politically motivated politicians. This decision was opposed by every faction of psychiatric medicine accept psychologist mainly because the bill is very poorly written and gives psychologist far too much autonomy far too quickly with far to little oversight. I am a physician and I have volunteered many, many hours to needy and less fortunate people and have won many awards for volunteering. I graduated near the top of my medical school class and had the choice of many residencies and choose psychiatry because I truly love helping people and there is such a great need in psychiatry. I will never be wealthy physician because I spend too much time doing charity work. That being said, I have worked with many psychologist and respect what they do greatly but they have not earned the priviledge and honor of treating medically ill patients. Psychologists play and key and pivotal role in the mental health care field. They are extremely important and their role can not be replaced. Who fills their role when they start prescribing. I also firmly believe that only the top 5-10% of psychologist would be able to survive medical school. Psychologist are not medical doctors nor "medical psychologist". I firmly oppose this trend of psychologist, PA's, nurse practitioners, optometrists, etc... from gaining more and more rights in medicine. Instead we should be focused on recurrenting more of the best and brightest into medicine and raising the current standards of medicine. Not dumbing it down. SVAS I doubt you are a physician, if you are a psychiatrist I feel you would be more concerned with recruiting great medical students into psychiatry and you would be very concerned with psychologist prescribing powerful psychotropics. The bill in Louisiana will do nothing short of scare great medical students away from psychiatry. I was speechless and the other psych residents in my program where also speechless when they heard of the bill in Louisiana passing in the speed and fashion in which it was. This bill is shady at best. There was no discussion or thorough thought process. I as well as many other great psychiatrist in training will rapidly be leaving the field of psychiatry, how does that help the mental health field. SVAS if you are truly a psychiatrist that supports psychologist, how do you envision the future of psychiatry?

:laugh: :laugh: :laugh:

Thanks for demonstrating so convincingly that the "dumbing down" of medicine has nothing to do with psychologists, PAs, NPs, optometrists, etc but rather with medical fundamentalists. Again, thanks for the laugh.

:laugh: :laugh: :laugh:

thethrill's post is a remarkable push-me pull-you. You remember the beast of the kids stories who wanted to go in two different directions at once?

Thethrill's world here is all about superiority; psychologists are "dumber" than MDs. FMGs (infering from the context in which they're mentioned in the post) also inferior to US allopaths. (and fair enough, IMGs are in gerenal smaller currency come residency time-but not always). But note that in the doctoring world of stereotypes, psychiatrists are viewed often as the one's who couldnt hack it as "real doctors". But its ok! We can still feel superior! the thrill turns this one around by mentioning all that we know about the real complexity of the field. So we like the superiorty notion a lot, but when we are on the wrong end of that stick we just turn it around to show you how the other guy really just got that one wrong. Whew. Sounds more like a politician than a doctor.

Yes I agree psychologists, who dont study medicine in general and neuro in particulary shouldn't perscribe. And psychiatry is an amazing field. But anyone still looking at the world in terms of who they're better than really hasn't made it too far out of adolesence, emotionally. And I'm sure a good psychiatrist would have something to say about that.

thethrill,
Out of curiosity, what evidence do you have in the infintie inferiority of non-MD professions, aside from your evident god complex. By the way, with approx. a 3.8-4.0 gpa and standardized test scores above the 90th percentile, the top 5-10% of psychologists could definitely survive medical school. That is, of course, assuming that past grades are an accurate predictor of future accomplishment. You claim the inferiority of psychologists exists due to their lack of general medical knowledge, yet I'll bet you can't manually calculate a univariate analysis of variance. Knowledge is gained through training and has no bearing on intelligence. Now as far as prescription rights are concerned, at the moment I wouldn't advocate prescription rights for psychologists, however I am not aware of what educational requirements psychologists would have to complete. Anyone can be trained to do anything and I am confident that psychologists would be responsible and skilled prescribers with the proper training. The question is what the training should entail and if it would then be to the benefit of psychologists to undergo this training rather than leaving the system as is. As far as the need to recruit mre intelligent people into psychiatry, perhaps if the environment were not so malignant it would be easier. And I'm not just speaking of your rather obtuse assumptions,but the pre-med and medical environment in general is very stressful and much of it is not necessary. Well that's about it from me for right now. :)

Wow . . . I don't know where to start with this one. In fact, I'm nearly speechless.

Svas, and other "pro-Svas-ers": there IS a very clear-cut and simple path towards training psychologists to prescribe psychotropic medications. It is called "Medical School". Then, if they are that concerned about rapidly relocating to the underserved areas and giving care to underserved populations, they can MAYBE have an abbreviated residency training, but it MUST include a full internship covering rotations in Neurology, Internal Medicine, and Pediatrics, PLUS rotations in Inpatient Psychiatry and Consultation-Liaison Psychiatry. So, this MINIMALLY necessary training would cover approximately 6 years...all of them filled with information and practical clinical experience which IS NOT currently covered in any type of psychology program. How do you propose to fit all this NECESSARY knowledge in a brief "psychopharm. training program"? Or maybe you want to argue that much of this knowledge is NOT necessary for a competent psychiatrist?! Are you sure you want to argue this, as a physician?

Svas, you said you have 3 children in college...I can easily understand now where YOU are coming from: you worry, as a parent (as WE ALL DO) about their professional future and their well-being, especially in this current time of economical/professional turmoil, health-care crisis, etc. Maybe indeed, the era of "traditional" Medicine is nearing its end. Maybe not quite yet. Who knows? I have a daughter in college too. I worry everyday about her future and what career she'll have and whether she will EVER even be self-sufficient. BTW, she's not touching the health-care field, nor any other "academic"/liberal arts fields with a 10-foot pole! (She grew up around too much BS/bitching and moaning from doctors and teachers and psychologists surrounding her as she was growing up!) So she's going into...guess what? Public Relations! Still trying to get some mastery over the cacophony of opposing arguments that were surrounding her while growing up!

Svas, since you are one of the more "mature" members of this forum, wouldn't it behoove you to TEACH and MENTOR younger colleagues in a dispassionate manner, by good example, rather than disparaging younger colleagues who are posting here? Examine where YOU are coming from. Are you coming from a personal perspective (just trying to find a forum for your ideas to be heard), or a mentoring perspective (you just like to teach others), or are you genuinely concerned re. public health in our country and are discussing certain topics of general interest for the benefit of our junior colleagues?

Maybe thethrill was overly passionate, maybe he over-generalized re. certain aspects of his argument. It is fairly easy to see, however, that his "passion" (or what the SDN moderator called "emotionality") is actually coming from his concern for patients' well-being, and patient safety, and...also maybe physiologically from a little sleep deprivation (he was just coming off call, remember?!).

YES, IMHO, psychotropics ARE indeed very dangerous substances, in spite of the pretty ads from Pharma.

You are, of course, making the same argument about psychology and medicine. Because psychologists haven't been through medical school, they don't know what they don't know." They don't know how deficient they are with regard to their psychopharm training. Correct?

S

I find this statement, while simple, to be effectively powerful. I think that perhaps this may be the key issue to which many of us had been alluding, but did so in a much more drawn-out manner.

How will this be brought up in a psychopharm training course? I tried to put myself in the psychologists' shoes, thinking about how to effectively create a psychopharm program that would address all the potential pitfalls of missed comorbid conditions, masquerading illnesses, etc. If that were not hard enough, then to propose training that would allow one to competently and confidently prescribe medications to these same patients.

Not surprisingly, the web of "what if's" and "well if you're going to address this, you'll have to address that" syndrome and the cornucopia of subtle physiological processes made me feel that this undertaking is simply too large to address in a training program. Even if it were possible from a classroom standpoint, what about clinical practicums in which the psychologist would learn how to recognize these medical conditions?

In sum, I feel that the statement "they don't know what they don't know" has great relevance and just could be a driving force behind future studies which will examine adverse patient reactions, delayed treatments, and even deaths in the scientific literature. However, it will be a long and unfortunate wait for said data.

Not surprisingly, the web of "what if's" and "well if you're going to address this, you'll have to address that" syndrome and the cornucopia of subtle physiological processes made me feel that this undertaking is simply too large to address in a training program. Even if it were possible from a classroom standpoint, what about clinical practicums in which the psychologist would learn how to recognize these medical conditions?

This is along the lines of the type of program I described in earlier posts. Combine the best of both worlds -- medical psychiatry and clinical psychology. Create an integrative curriculum with training in all aspects of medicine and psychology relevant to psychiatric practice. This includes research. With the dizzying array of psychotropic medications, empirically-based psychotherapies, and emerging procedures to treat psychiatric disorders (e.g., rTMS), I'm surprised such programs are not already in operation!

I know of several people (including myself) who would love to enter such a program. In fact, most of these people are torn between medical school/psychiatry and graduate school/clinical psychology. To my knowledge, there is not a single MD/PhD program that allows you to pursue a PhD in clinical psychology. You have to complete the degrees independently, or take a PhD in a "hard science." Of course, there are extra courses that need to be taken toward the clinical psychology PhD that would take additional time to complete, as opposed to the overlap in basic science coursework found in traditional MD/PhD programs.

Why not create a rigorous program that allows students who have an interest in psychopharmacology, psychotherapy, and psychiatric/psychologic research to pursue an advanced degree that would allow them to function as comprehensive behavioral healthcare providers, and if so inclined, researchers?

Public Health:

I understand where you're coming from, but having a special program separate from medical school distances the mental health profession from other fields of medicine. Part of the goal of medical school and residency is to acquire a shared body of knowledge and experience with other medical specialists. The point of this is to know how to recognize pathology outside of your field of expertise and when to refer.

I know that the program that you are proposing may cover some of these concerns. However, as I've been stating, why replicate a parts of a curriculum that already exists within medical school and residency? I realize that medical school and psychiatry residencies are deficient in areas where clinical psychology are strong, namely psychotherapy and psychometric testing. But why not improve these compenents within psychiatric residencies rather than embarking on a radical campaign to create a new degree? Or, why don't we just allow clinical psychologists to continue doing what they do, but with more collaboration with psychiatrists?

You seem to like my idea of expanding medical school seats in rural areas as a means to expand mental health care coverage. I'm glad that there are rural DO branches, but what i think we also need to do is to recruit existing medical students into psychiatry and to provide financial incentives for physicians in general to practice in rural areas (e.g., loan forgiveness, better compensation, etc.).

First there is no place in medicine for individuals with a "God Complex". Furthermore I have no beef against midlevel providers, they serve a great need. However, there needs to be strict standards for patient care or they will get hurt/dead. My wife is an optometrist and one of my best friends is a psychologist who inspired me to go into psychiatry. There is simply no comparision in the training between psychologist and psychiatrist. Just look at the curriculum and the amount of time spent in the clinical setting. I know, my friend is a psychologist he golfed his way through his PhD program and was home by at least 6pm every day and always slept in his own bed. My point about FMG's is that all residents know that residency programs prefer US Grads because they get more funding for US Grads and much less funding if any for FMG's. FMG's mainly just fill spots. You can easily judge the status of a residency program by the number of FMG's. Finally I love being a doctor and nobody would ever accuse me of having a "God Complex", I am however extremely passionate about medicine/psychiatry. I am almost always the first one at clinic or the hospital and usually one of the last to leave at the end of the day. I have been given numorous awards for teaching nurses, medical students and residents. I strongly believe psychologist are not prepared or qualified to prescribe medications. I can understand PA's and NP's doing it under a physicians guidance. I even support psychologist doing certain med rechecks under a physicians guidance but, the law passed in Louisiana gives psychologist complete autonomy and over sight by their own governing body which has never prescribed a medication. Medicine is dangerous. This is life and death we are talking about and the law makers are letting this happen like it is a great experiment. I agree a degree that combines medicine, research, psychotherapy, and psychopharm would be great, fortunately someone already thought of that. It's called a psychiatry residency. We do a lot of psychotherapy as a matter of fact that is most of what we do, we all have to do a research project to graduate, and we do a preliminary year of medicine. The answer is not giving psychologist prescription rights the answer is to make psychiatrist more available and to increase reimbursements so that medical students with and an average debt close to $200,000 can consider do psychiatry. I appreciate everyone's place in medicine, I insisted our program invite the hospital cafeteria staff to our graduation party. I do however believe there needs to be the highest of standards when it comes to patient care. All mentally ill patients deserve to be seen and evaluated by a medically trained PSYCHIATRIST. There are no short cuts in medicine. Short cuts kill patients. Well gotta go admit another patient...

...Why not create a rigorous program that allows students who have an interest in psychopharmacology, psychotherapy, and psychiatric/psychologic research to pursue an advanced degree that would allow them to function as comprehensive behavioral healthcare providers, and if so inclined, researchers?

The program you propose is interesting. And if it was well received and established, I may have sought out such a program at one time. However, (and people can't stand it when I do this - they call it a 'logic flaw,'" where will these boundaries end? This slippery slope makes me envision a world of medicine where everyone is trained in one specific area, without a generalized view of the entire spectrum of medicine and surgery.

Why not train people just to deal with womens' health and delivery issues? Why not train people to just do laparoscopic cholecystectomies? Why not train people just to read radiologic films? Why not train people just to recognize and treat illness and disease in children? Why not train people just to perform ORIFs?

Said trained people may perform well with the right training, but they lack an overall view of human medicine. It would be interesting to see how such a system would affect the overall quality of healthcare in the United States. I suspect that in the long run, it wouldn't be time-saving or money-conserving. I imagine it may well result in the opposite due to medical error, complications, and the like.

This is why I was thinking earlier that the "real" issue to be actually solved by our Public Health institutions is how to improve the qualitative delivery of health-care, including mental health-care to the public. I think this is the main problem we are probably struggling with at this time, at a national level. Quality is perceived by many as going down, while the system seems to be overwhelmed by demand vs. the available resources.
First of all, I want to emphasize that this is a perception, not necessarily a truism, although I have just seen this recent article too http://www.rand.org/news/press.04/05.04.html
(so maybe indeed quality is going down).
Second of all, how can one deliver high-quality en masse? I have no idea. I don't even have the tools needed to even study this question, since I am not a specialist in public health delivery issues.
Third, re. this narrow focus on who prescribes psychotropics, at this time we don't necessarily need MORE prescribers; we need BETTER prescribers. What makes one a BETTER prescriber? Typically, training and experience, built upon a required base of general medical knowledge. Furthermore, in our current mental healthcare delivery system, which is indeed in shambles, as seen from ground-level (by experts, physicians, and public all alike)- who rx.'s psychotropics is only ONE of the multitude of problems. Most of the problems have to do with funding for community supportive services. Don't forget, in Psychiatry, the very vast majority of patients DO NOT have any insurance, nor any means to pay for anything themselves. So even if proponents of psychologists prescribing psychotropic meds say that "psychiatrists are just afraid of psychologists encroaching on their turf", this is a baseless argument.
Psychiatry is about delivering health-care to patients with psychiatric problems. Even now, the quality of psychiatric care is probably poor across the board, because the demand for services outstrips the resources. Psychiatric patients typically also have multiple medical co-morbidities due to self-neglect, lack of supports, and difficulty in accessing primary care services too.
Increasingly, the problem of QUALITY vs. QUANTITY has been cropping up...not just in Psychiatry...but across the board, for Medical care for our public, in general. (The psychologists prescribing promoting groups are just exploiting this current crisis to further their own agenda.). What REALLY worries me, as a physician and as a psychiatrist, is that the people who are "in charge" re. legislating the system or re. proposing regulatory issues or system reform issues, are seemingly promoting narrow agendas with actual disregard for the well-being of our own public.
I realize, for our younger colleagues in training, this may sound like a discouraging and/or possibly depressing point of view. Actually, at an individual level, a psychiatrist's job is still AT THIS TIME one of the most interesting and challenging jobs there is. And it's FUN too. Just BECAUSE it combines knowledge from various fields of medicine, allows for continued study opportunities, satisfies the deep needs (experienced by MOST physicians by virtue of their make-up) for fulfilling intellectual curiosity, abnegation, variety of work settings and situations. Psychiatry is NEVER "boring". And most definitely IS NOT just about psychotropic prescribing, although we are indeed fortunate at this time to have a wide array of psychtropic tools that can be helpful and even life-saving IF used appropriately, judiciously, AND drawing upon our best of medical knowledge accumulated during medical school.
IMHO, the current challenges for Psychiatry seem to be almost like a warning bell, or like a mirror, for the current challenges of our overall health-care delivery system in general.
Also, re. the perceived need for overwhelming demand vs. lack of resources in psychiatry...I really encourage our younger colleagues to brainstorm, to become educated in political, administrative, and public health issues...because it is up to you, ultimately, to help promoting an improved system, improved clarity of the nosology and problems to be solved, improved quality of psychotropic management AND other tx. modalities that are to be delivered.

http://www.sq.4mg.com/IQ-jobs.htm

at this time we don't necessarily need MORE prescribers; we need BETTER prescribers.

I completely agree. However, I don't think that the model of improving the ability of the FP will meet the demand. I don't recall the exact figure, but someone in another post pointed out that there are 400+ counties nationwide with no psychiatrists. Around here, there's a 3 to 6 month waiting list to get an appointment with one.

Psychologists who are far better trained mental health professionals than any other non-physician (and it's simply arguable whether physicians are better trained in mental health issues), and are far better trained in mental health than FP's, PA's and NP's. To suggest otherwise is silly. A psychologist who correctly makes a diagnosis of a mental health patient, often must continue to support the patients that NEED medication, but without psychiatric support. So, in order to adapt, most of them refer to FP's and then they TELL THE FP WHAT AND HOW MUCH TO PRESCRIBE. Aren't we aware that this is what is happening all around us?

A worse scenario: the FP who gets a psychiatric patient and decides to treat it him or herself without competent mental health care support (either because of being inaccurately self-assured or because it's not available).

Come on . . . *we* can train psychologists to do a good job with a limited formulary. We can argue for a collaborative model that will support our model, support the patient, and support the US health care delivery system. A collaborative model, and not an indentured slave model, *that WE suggest and recommend*, I believe, would be acceptable to them. It would fly through legislatures and we would have some control over the outcome. Otherwise, this is going to occur in our faces and without our input. The options look obvious to me.

S

All of you complaining here should be sending letters to congress and money to the AMA! ;)

I'm a member of the AMA and send money to AMPAC. We must stand together as physicians to prevent back door non-physicians becoming medical doctors and surgeons. This is scary! If psychologists want to prescribe systemic medications, then they should go to medical school.

Ophthalmology is in a constant battle with optometrists:

http://forums.studentdoctor.net/showthread.php?t=119156

thethrill's post is a remarkable push-me pull-you. You remember the beast of the kids stories who wanted to go in two different directions at once?

Thethrill's world here is all about superiority; psychologists are "dumber" than MDs. FMGs (infering from the context in which they're mentioned in the post) also inferior to US allopaths. (and fair enough, IMGs are in gerenal smaller currency come residency time-but not always). But note that in the doctoring world of stereotypes, psychiatrists are viewed often as the one's who couldnt hack it as "real doctors". But its ok! We can still feel superior! the thrill turns this one around by mentioning all that we know about the real complexity of the field. So we like the superiorty notion a lot, but when we are on the wrong end of that stick we just turn it around to show you how the other guy really just got that one wrong. Whew. Sounds more like a politician than a doctor.

Yes I agree psychologists, who dont study medicine in general and neuro in particulary shouldn't perscribe. And psychiatry is an amazing field. But anyone still looking at the world in terms of who they're better than really hasn't made it too far out of adolesence, emotionally. And I'm sure a good psychiatrist would have something to say about that.

Stephew,
Those posts were just absurdly funny :laugh:
Prejudice againsts osteopaths (or allopaths), FMGs (US or otherwise), or allied healthcare profesionals, in my opinion has no place in medicine.
It's actually a little bit disconcerting that someone who is so prejudiced is a physician since it reveals very poor scientific reasoning. Anyway, enough about that.
The real issue is under what circumstance should psychologists (PhD/PsyD) be permitted to prescribe (RxP)?
I fully support PhD/PsyD having RxP for those who are appropriately trained.
I myself am completing my psychology residency after four years of working with psychiatric and medical patients, including a year long C-L rotation, however, I do not believe that I am at this point prepared to prescribe.
The big APA (the psychology one has 150,000 members as opposed to the little APA-the psychiatry one has 35,000 members) agrees and so it proposes a post-doc masters program to train licensed clinical psychologists to become psychopharmacotherapists.
Like you, the big APA would have PhD/PsyD study (and practice under physician supervision) medicine before gaining RxP.
There are currently different models as to just how this post-doc masters program of study and practica will look, among these are the DoD, the NM, and the LA.
I think the future of mental health is both exciting and a little bit confusing.
From PhD/PsyD's point of view the issue is whether healthcare providers can become prescribers without going to med school; study medicine yes, med school no. As the DoD project and NP practice indicate the answer is "yes."
BTW, I myself intend to become a psychiatrist; along with completing my psych residency I am doing my pre-med reqs-don't ask :scared:
I want to be able to fully function as a psych PhD/PsyD as well as a psych MD/DO. However, though that is my path I don't believe that it has to be everyone's. I believe that diversity, biological and otherwise, is good and that ultimately mental health will benefit from both psychologists and psychiatrists capable of functioning as psychotherapists and psychopharmacotherapists. While both disciplines will have similar tools at their disposal each will utilize these in the context of different philosophical perspectives.
As a soon to be psychologist (and a future psychiatrist) all that I ask of open minded physicians such as yourself is to consider the scientific evidence; I believe that those who do so will not prematurely conclude that med school is the ONLY or even the best route to prescriptive authority for all providers.

P.S. Please don't forget to include a clinical health psychologist in your future oncology practice. :luck:

Before medical school, I was a Psychology major, my wife is PhD candidate in Psychology, and my dad is a Psychotherapist here in Texas, so I am aware of the issues surrounding this debate. About a year ago, my dad got a flier froma course offering a psychotropic pharm seminar to PhD's in Psychology (who've never had any such training). He went to this weekend course to get some CEs, just because, having seen patients on these drugs, he had little understanding of them pharmacologically. He came back and told me that he was shocked by the implication made at the conference that someday Psychologists might prescribe, as this was a two-day seminar on anti-depressants only. The main deterrent most noted by his colleagues: malpractice costs.

Oddly, when I talked to my wife she agreed that the practical risks are too high for most PhD's to do prescribing. Psychotropic meds can have negative side effect profiles, and PhDs are even more scared of lawsuit than we are., and their current malpractice rates can be laughable. For example, my wife pays $800 for malpractice insurance annually.

Also, she told me that PhDs in big cities don't want to move to the psysician economic model of 15 minute visits. She makes $150 an hour, fee for service (no insurance taken) as a PhD candidate here in Houston. With a doctorate, she can clear $200. Most M.D.s make 60-100 per consult, or $400 an hour, but that is a fast pace to see patients, and overhead, malpractice, etc. that PhDs don't have. PhDs, if they could prescribe would have to compete in the marketplace, and, frankly, most folks who go into PhD programs aren't looking to work 70-80 hour weeks. So to me, the threat is pretty small.

The bigger threat, IMHO, is FPs prescribing psychotopic willy nilly. Here in Texas, even where there are Psych folks, a lot of our patients seem to turn up with meds prescribed by FPs only...

I completely agree. However, I don't think that the model of improving the ability of the FP will meet the demand. I don't recall the exact figure, but someone in another post pointed out that there are 400+ counties nationwide with no psychiatrists. Around here, there's a 3 to 6 month waiting list to get an appointment with one.

Psychologists who are far better trained mental health professionals than any other non-physician (and it's simply arguable whether physicians are better trained in mental health issues), and are far better trained in mental health than FP's, PA's and NP's. To suggest otherwise is silly. A psychologist who correctly makes a diagnosis of a mental health patient, often must continue to support the patients that NEED medication, but without psychiatric support. So, in order to adapt, most of them refer to FP's and then they TELL THE FP WHAT AND HOW MUCH TO PRESCRIBE. Aren't we aware that this is what is happening all around us?

A worse scenario: the FP who gets a psychiatric patient and decides to treat it him or herself without competent mental health care support (either because of being inaccurately self-assured or because it's not available).

Come on . . . *we* can train psychologists to do a good job with a limited formulary. We can argue for a collaborative model that will support our model, support the patient, and support the US health care delivery system. A collaborative model, and not an indentured slave model, *that WE suggest and recommend*, I believe, would be acceptable to them. It would fly through legislatures and we would have some control over the outcome. Otherwise, this is going to occur in our faces and without our input. The options look obvious to me.

S

From my experience working in many FP rotations, the FP's had no problems doing psych pharm. If they felt like more counselling was needed which they didn't have time for they would refer to a Psychologist. Psychologists may be more trained in psychotherapy than physicians, however they ARE NOT MORE TRAINED IN MEDICINE THAN NURSES, PA's, and PHYSICIANS. You're suggesting since a Psychologist may be better trained in psychotherapy, that translates into better pharmacotherapy. You continue to ignore the potential side effects/interactions along with co-morbid conditions. How are psychologists that aren't trained in Physical diagnosis, reading EKG's, Labs, etc., etc., going to function without seriously hurting or killing people? Just look at the side effects and potential lethality of TCA's, Lithium for example.

Your worse case scenario is that the FP has NO CLUE how to treat mental health care and therfore the patient suffers from bad mental health care. First of all, that is not only insulting but ignorant. FP's deal with Psych issues EVERY DAY and have done superbly in dealing with them. Shouldn't the worse case scenario be a Psychologist with script rights prescribes Drug X and causes toxic levels of Drug Y. Are they going to know to order a CBC and how to read it for a patient on Clozaril, or do a physical exam and detect potentially fatal Myocarditis on Clozaril? Will they know how to read an EKG and know how to look for ST-T wave changes? My worse case scenario is the PhD KILLING a patient because he/she cannot perform physical diagnosis and doen't have the MEDICAL knowledge necessary to prescribe SAFELY. YOU CANNOT PRESCRIBE WITHIN A VACUUM. If patients only presented with mental health problems and the drugs had no side effects or interactions with other drugs, then you could prescribe within a vacuum. This is simply not the case. I understand your bias having children with Psych PhD's, but as the scientist you claim to be, you simply keep ignoring FACTS.

It seems to me that the postdoctoral psychopharmacology programs are lacking. Courses every other weekend, pass/fail courses, disreputable institutions, etc. As indicated by Anasazi and others, psychologists who want to prescribe should receive a comprehensive medical education. Due to the seemingly poor quality of existing postdoctoral psychopharmacology programs, which lack emphasis on general medicine (e.g., http://www.cps.nova.edu/programs/PostdocMasterPsychopharmC7.html), why don't psychologists seeking to prescribe become PAs or NPs? Granted, these programs will require more time, but they will provide psychologists with more comprehensive medical training that is recognized in virtually every state, and that will allow them to function as psychotherapists and psychopharmacotherapists under the supervision of trained psychiatrists. Problem with this for psychologists is that they will have to be supervised and reimbursements will be less. However, malpractice will likely be less of an issue in this case as opposed to having psychologists prescribe on their own.

Interesting post, PH.

It's disheartening at best, and frightening, at worst to see that the complex issues related to cardiac disease, pulmonary manifestations, skin conditions, blood dyscrasias and related disorders, genetic susceptibilities, the neurological patient, and of course, the ever complex obstetrical patient will all be covered in the course entitled: "Introduction to Physical Assessment & Laboratory Exams."

Wow.

What also bothers me is the arrogance of the American Psychological Association in allowing said Master's degrees in psychopharm to be conducted without a universal acceptance for this model not only within its own profession, but the assumption that this coursework is sufficient for psychologists in these states to prescribe based on their preconceived course outline.

It gets worse...

http://www.alliant.edu/cspp/postdocmsppharm.htm

http://www.alliant.edu/download/2003/pubs/CA_RxP_Brochure0403.pdf

How are psychologists that aren't trained in Physical diagnosis, reading EKG's, Labs, etc., etc., going to function without seriously hurting or killing people? Just look at the side effects and potential lethality of TCA's, Lithium for example.
.


Today I pulled 3 NP's, 4 3rd year FP residents (getting ready to be done here), 4 psych residents (3y) and 2 PA's into my clinic office early this morning on a whim and gave them 4 EKG strips, 6 sets of CBC/CHEM25's, a couple RIA's and UA's. They all agreed to be part of a VERY small test sample and I did not "select" these folks. They happened to be near one another in the hallway and lounge.

All these from 4 separate patients.

Number of diagnoses: 5. Number correct: 0 Number of correct recomendations: 3 All of the FP's correctly read the EKG.

Number of the cases that that could have *easily* been correct from the lab data alone: 100%.

What am I trying to prove with this - exactly what you think I'm trying to prove. We have a pretty big problem with inter-rater reliability.

By the way, the most embarrasing problem: ALL of the psychiatric residents missed the cardiac arrthymias in all 4 cases and 2 misidentified the problems with the labs so completely that I'm calling a meeting with the training directors. Only one person correctly put together all of the data correctly, even though the ultimately conclusion was incorrect (I was still please with her thinking and she would have gotten to the correct diagnosis quickly. She was an FP.)


S

"Prejudice againsts osteopaths (or allopaths), FMGs (US or otherwise), or allied healthcare profesionals, in my opinion has no place in medicine.
It's actually a little bit disconcerting that someone who is so prejudiced is a physician since it reveals very poor scientific reasoning. Anyway, enough about that."

I can't tell if you think I am the prejudiced one or not. If so, Ill point out that my post was actually in condemnation of that attitude, and that I actually am an IMG (see sig). If not, well then I'm agreement with you.

In either case there are plenty of mental health workers at the hospital I'll be working at.

Today I pulled 3 NP's, 4 3rd year FP residents (getting ready to be done here), 4 psych residents (3y) and 2 PA's into my clinic office early this morning on a whim and gave them 4 EKG strips, 6 sets of CBC/CHEM25's, a couple RIA's and UA's. They all agreed to be part of a VERY small test sample and I did not "select" these folks. They happened to be near one another in the hallway and lounge.

All these from 4 separate patients.

Number of diagnoses: 5. Number correct: 0 Number of correct recomendations: 3 All of the FP's correctly read the EKG.

Number of the cases that that could have *easily* been correct from the lab data alone: 100%.

What am I trying to prove with this - exactly what you think I'm trying to prove. We have a pretty big problem with inter-rater reliability.

By the way, the most embarrasing problem: ALL of the psychiatric residents missed the cardiac arrhymias in all 4 cases and 2 misidentified the problems with the labs so completely that I'm calling a meeting with the training directors. Only one person correctly put together all of the data correctly, even though the ultimately conclusion was incorrect (I was still please with her thinking and she would have gotten to the correct diagnosis quickly. She was an FP.)


S
With due respect, Dr. Svas what' s your point?
There are good doctors and there are bad docs. Also there are good therapists and there are bad therapists. This AM I was in a group tx for DD substance users w/ a Clinical psychologist(a PhD). She was unable to answer my questions about the nature/goal/intervention techniques about the so-called therapy session. And I've seen multiple of therapists like her. It hardly proves that in general, therapists are incompetent and/or unsafe for clinical work.
Today psychiatry is another medical specialty and all residents should be trained in medicine and neuro to be board-certified. If someone lacks skills in these fields it reflects personal and/or training program deficit, and they should work to improve that. However, I do think it's a legacy from 60s and 70s in psychiatry wrt psych-med dichotomy. It's unfortunate but I've seen it in a lot of senior attendings who emphasize mind over body and gets carried over to the extent that they refuse to do a physical.
Just my 0.02c.

"Prejudice againsts osteopaths (or allopaths), FMGs (US or otherwise), or allied healthcare profesionals, in my opinion has no place in medicine.
It's actually a little bit disconcerting that someone who is so prejudiced is a physician since it reveals very poor scientific reasoning. Anyway, enough about that."

I can't tell if you think I am the prejudiced one or not. If so, Ill point out that my post was actually in condemnation of that attitude, and that I actually am an IMG (see sig). If not, well then I'm agreement with you.

In either case there are plenty of mental health workers at the hospital I'll be working at.

Hi Stephew,
No, I didn't mean you; on the contrary.
I am in complete agreement with your post and in fact have found many of your previous posts both here at StudentDoctorNetwork and at ValueMD to be very informative and balanced.
I believe you are very open minded physician and a credit to St. George's program.
Best of luck on completing your residency. :luck:

I think the prejudice thing was directed at me. My parents are foreign (muslim) and my dad's name is muhammed, but I was born in America. I apologize if I affended anyone with the Muhammed, Muhammed, and Muhammed comment. I guess I thought it was funny since I am muslim and so many muslims are named Muhammed. Poor taste, sorry. Anyways, my point was that residency status can easily be evaluated by the number of FMG's in a program. I work with and hang out with many FMG's everyday and the ones that are here definitely earned their ways here they are usually very, very intelligent. I am not prejudice. But I think that midlevel providers are just that, midlevel providers. They are not the real deal. There is no substitute for a US trained MD/DO. Anyways I have given a lot of thought to psychologist get prescription writing priviledges and after a year of busting my ass in my first year of residency saving lives. Yes it's true psychologist we spend the night in the hospital every 3rd or 4th night, usually working 80 hours a week sometimes more despite the new laws and attend many lecture and do dozens of presentations. I realize that there is very little that can be done to stop the political machine and the downward spiral of Mental Health Care. I was offered a EM residency spot today and will be jumping ship to emergency medicine. I would love to be a psychiatrist, but I feel the fight to save the integrity of psychiatry is already lost. I know I am not the only young physician to leave to field of psychiatry secondary to concerns about the future of psychiatry. It seems there are many more psychologist on this post than psychiatrist. Psychiatry has taken a bashing on this and other posts which is unfortunate considering psychiatrist tend to be the most compassionate and intelligent physicians with the least interest in power and financial gain. Psychiatrist probably helped created this problem by trying to educate psychology so that we could work side by side, hand in hand. Unfortunately some psychologist took advantage of this commadarie and are trying to gain more power than they have earned. Ultimately patient care will suffer. I believe my psychiatric training will serve me well in EM. If you knew me you would know that I have many friends of many colors and races and that I work hard every day with a smile on my face because I love medicine. It is sad to see psychiatry start to fall a part the way it is, this could have been handled much more professionally. Not with the speed and haste in which the Louisiana bill was passed. That bill was handled in a wreckless, sleazy fashion. As a young physician with a beautiful wife and a $200,000 debt I can not afford to take a chance on the future of psychiatry. Food for thought, On call last night a patient came in with nausea and vomiting and no chest pain. An EKG was ordered. The patient was admitted to the hospital thus I went to the ED to do the admission. So I was looking at this diabetics labs and then the EKG before I went to see the patient. The EKG had a slight ST segment elevation in the inferior leads that was missed by the EM physician. I called the cardiologist and sent the pt straight to the cath lab. That patient had bypass surgery that night. How bout that a diabetic with a silent MI diagnosed by a psychiatry resident or now a EM resident.

Hi Stephew,
No, I didn't mean you; on the contrary.
I am in complete agreement with your post and in fact have found many of your previous posts both here at StudentDoctorNetwork and at ValueMD to be very informative and balanced.
I believe you are very open minded physician and a credit to St. George's program.
Best of luck on completing your residency. :luck:
In that case I admire your fine insights :laugh:

Also I dont think its surprising for a psychiatrist to dx other physiologic conditions- heck you went to med school.. hopefully the ER doc can note psychiatric condintions on occasion in return...

Svas, re. your ad-hoc experiment:

I felt extremely uncomfortable reading your post about your real-life "experiment" involving junior trainees in the hospital you are currently working in.

I truly hope that your experiment idea using real-life trainees who are under your supervision was not generated by an individual impulse to try to "prove a point" dear to you, but rather by a desire to teach and/or devise methods for improving your supervision and the overall teaching quality on your service. And that such impromptu "grillings" are just not exceptional or generated impulsively and infrequently, but are just part of other routine teaching methods that you employ as part of your job, as a teacher/attending in that hospital, if indeed you are their direct supervisor in the course of their training.

What I actually fear that may have happened sounds much worse: if you just pulled aside randomly some unsuspecting trainees who are not even under your direct supervision and "forced" them to participate unwittingly in an impromptu experiment devised by you impulsively just to "prove a point to yourself" or to us here, knowing that they couldn't even refuse because you are somehow in a superior position of "power" in that hospital, moreover, penalizing and singling out the psych. residents who "failed" your little test by "reporting them" to their program director(what about the other participants who failed too?)...then you have crossed an important boundary and have acted out inappropriately and unethically by USING trainees which are in an inferior position of power to you...in order to satisfy your own needs and ideas.

Please clarify this VERY important point here and re-assure us about the exact circumstances of your described "experiment".

Svas, re. your ad-hoc experiment:

I felt extremely uncomfortable reading your post about your real-life "experiment" involving junior trainees in the hospital you are currently working in.

I truly hope that your experiment idea using real-life trainees who are under your supervision was not generated by an individual impulse to try to "prove a point" dear to you, but rather by a desire to teach and/or devise methods for improving your supervision and the overall teaching quality on your service. And that such impromptu "grillings" are just not exceptional or generated impulsively and infrequently, but are just part of other routine teaching methods that you employ as part of your job, as a teacher/attending in that hospital, if indeed you are their direct supervisor in the course of their training. .

This method is part of our regular training activities. I simply added the NP's and PA's because they were around. We grill our residents constantly. Further, the opportunity is not designed to humiliate, but to provide teaching opportunities. I suppose that I could loan them my computer and let them tell you about the experience. But I am certain that all of them experienced it as positive, but given your concerns, I'll raise it with them on Monday when they are all there again and I'll let you know what they thought of the exercise.

Given my "senior status" and that I have been reasonably frequently awarded the "favorite instructor/professor" awards here, I can promise you that I did not engage in any activity that would have either been inappropriate or demeaning to the trainees (or frankly that different from what I do on a weekly basis). It did, however, expose some weaknesses in our training model for them.

BTW, the above issue aside, would you have been concerned about their performance if you had been the proctor?

S

From AAMC

Educational Strategies
Modification of Existing Pedagogy

During the clinical years, the questions asked on ward rounds must proceed
beyond the usual recollection of known facts (i.e., ?What are seven causes of atrial fibrillation?? ?What are the Ranson Criteria??), and should ideally incorporate questions of mechanism and of investigative approach (i.e., ?Why might infection have led to atrial fibrillation in this patient, and how would you study this?? or ?Why should this patient with pancreatitis exhibit hypperglycemia, and how could this theory be tested??). While it may be more comfortable to stick with questions of fact, for which there are arguably pre-existing sets of ?correct? answers, such an approach ultimately does a great disservice to both student and patient.


Case Studies
Consideration of existing educational strategies suggests that, while ultimately
an experiential approach is best, an effective way to familiarize students with the power and range of clinical research is through case studies.
A broad and diverse range of case-studies must be developed, highlighting a
range of approaches (from DNA analysis through population-based studies), a
range of medical disciplines, a range of research quality (from exemplary to deeplyflawed), and should ideally include both historical and contemporary examples, from industry as well as academia. Cases should focus on research that resulted in:

1. the development of a new diagnostic or therapeutic approach
New diagnostic approaches might include the use of CT imaging to diagnose
pulmonary embolus, and the use of MRI in stroke. New therapeutic approaches
might include GnRH for premature puberty, and thrombolytic therapy for strokes.
2. a change in practice Examples include how the approach to myocardial infarctions has evolved over the last several decades, from bed rest for 6 months to diagnostic tests then home with rehab in a day. Another example includes the use of routine screening colonoscopy as part of good primary care/preventive medicine.

3. an ethical dilemma
Examples can include the implications associated with most genetic testing,

e.g., testing healthy people for Huntington?s or hemochromatosis.

4. the introduction of a new experimental approach or study design

The use of gene chips and the application of knowledge about population
genetics.

5. the introduction of a new technological innovation Examples include cardiac catherization, laproscopic surgery, and artificial skin
for burn victims.

6. the development of a new outcome measure or surrogate marker

An example is looking at troponin to assess myocardial infarctions.
The case studies are expected to introduce students to the ?process? of developing questions, as well as to illustrate the range of questions possible for a given clinical conundrum. The case studies will enable students to develop and hone their critical appraisal skills, and learn how to formulate and frame ethical, scientifically useful questions. Case studies will also emphasize the role of the patient as partner in discovery, and will highlight the role of communication as an essential aspect of both medical practice and clinical research.

Svas, thank you for clarifying. I'm not against "grilling" as a method within the regular teaching activities. (I was just getting anxious about the way the first post sounded to me, but now that you've clarified the situation, I understand what you mean.)

Re. concern about performance...yes...I do have concerns about the quality of Academic Medicine too, and the way Academic Medicine's influence and respectability has also diminished; in Psychiatry, especially, Pharma encroachement via $$$ is, IMHO, exceeding proper levels. Basically, it seems that there is no "independence"/boundary from corporate influence, and/or that boundary has been breached quite severely, in both Academic Medicine and even national research...see NIH "scandals". http://www.biomedcentral.com/news/20031210/06 is just one of the "examples".

But to me it seems, and correct me if I am wrong...that you might be coming from the approach "if you can't beat 'em, join 'em", or the "change from within" strategy. Or "this is the way things are evolving"...just jump on the bandwagon and try to be a Player in the system at all cost". I'm not sure if this is the RIGHT way to go, ethically or even practically. The thing is, within this corporate-influence system of funding for Academia and Research, where the major players are basically Insurance co's, and Pharma co's...with their very powerful lobbies, and agendas, and clout...I just see this slippery slope getting more slippery by the minute, and us tumbling down on this path. Even the most well intentioned ones among us. Physicians seemingly HAVE NO SAY re. administrative/funding/policy issues...horror of horrors...even in Academic Medicine! But maybe this is an OLD conflict...and I'm just seeing it now. It just seems pretty blatant nowadays...almost like there's no checks and balances in Medicine anymore. That's mostly what I worry about. But I confess...this is a PERSONAL view, and I admit, I AM biased. I just can't help it. But I do try to be VERY careful about what I post in a public forum frequented by my younger colleagues and doctors to be.

What do we teach our students then? Do we even have a duty re. educating re. policy matters, which are political more than medical? How do we encourage students to learn to make their own decisions, WITHOUT introjecting our own biases and prejudices into the mix? HOW do we DO that?

Since it is obvious that some of the participants in this forum are not just residents but "older" physicians in practice too...personally I would like to hear from the "older" and presumably more experienced participants, but I also think that there is a responsibility here towards our younger colleagues in training.

Hi folks,
I'm really glad that so many here are beginning to be less vitriolic and more constructive; in line with that I'd like to share some random thoughts on the points raised by Svas and Sanman and the proposals suggested by PublicHealth and Dentite001 as well as to make some suggestions of my own.

Svas and Sanman, :)

I believe we're all on basically the same page: we can't find any reasonable arguments against RxP for psychologists and sufficient evidence that non-medical professionals can be trained to be safe and effective autonomous pharmacotherapist as demonstrated by psychologists in the DoD and NPs in 11 states and DC; not to mention, dentists, optometrists, and podiatrists.

I think the question that many have, who while being open-minded are honestly concerned about extending RxP to PhD/PsyDs, is: how can the DoD or the NP model be translated for psychlogists not in the DoD who want to extend their scope of practice into psychopharmacotherapy?

PublicHealth, :)

Like you, when I first saw various post-doc psychopharm program curricula, I become very concerned; at first glance, anyway. For example:

Prepare for your Future
Earn Your MS in Clinical Psychopharmacology in South Florida at the NSU Bimonthly (Fly-In) Program
Five Extended Weekends Per Year For Two Years

When I read "fly-in...five...weekends," I was :eek:

But I continued to read. :idea:

This model is designed to meet the needs of Licensed Psychologists who would like an opportunity to receive training from an ongoing University-based facility offering a Master of Science Degree in Clinical Psychopharmacology. This curriculum has been successfully used in our ongoing campus-based program since 1999 and meets all of the requirements of the APA model curriculum. It is now being slightly modified to match criteria proposed in the New Mexico Prescriptive Authority legislation
We are now expanding the program to welcome any licensed psychologist seeking to expand his/her knowledge of Clinical Psychopharmacology.

So, it is based on the APA model curriculum which is based on the DoD model.

The Fly-In Program is currently a 31.5 credit hour program curriculum spread out over two years. Classes meet only FIVE times a year on Thursday, Friday, Saturday, Sunday, Monday and Tuesday, from 9 AM to 5 PM.

31.5 credit hour program actually exceeds the DoD model 30 credit hour program. The weekend is actually Thurs-Tues, in other words longer than the regular work week.

In addition to the classroom activities, chat room and other distance learning techniques will be utilized. Most states allow CE credits for these learning activities. A candidate is expected to complete the Postdoctoral Master's Program in Clinical Psychopharmacology within five years. (SO FAR ALL BUT ONE HAVE COMPLETED IT IN TWO)

So, completion of this program generally takes 2 years while the DoD one took only 1.

Faculty is drawn from the Nova Southeastern University Schools of Psychology, Pharmacy, and Medical Sciences and is supplemented by adjunct professionals with special skills. Quality Intensive Learning in a Relaxed Atmosphere.

Speaks for itself.

Clinical Training

The clinical portion of the program provides students with assessment and intervention experience in a practicum setting. Students residing close to the Nova Southeastern's Community Mental Health Center may take their practicum at the clinic. Distance students may arrange acceptable practicum arrangements closer to their home.

This is in addition to the 31.5 credit hour didactic training. More below:

The practicum is one of the most important elements of the curriculum. This comprehensive program provides each student with practical experience with patients of various ages and varied diagnoses. The curriculum requires a minimum of two; 100-hour intensively supervised clinical experiences, ordinarily scheduled in the summer terms, where a minimum of 50 patients is seen during each practicum. To comply with APA recommended standards, each student should have a minimum of two hours per week of individual supervision.

Students are expected to spend 100 hours or more with their qualified mentor, usually a boarded psychiatrist or an otherwise qualified medical practitioner. The student observes the psychiatrist/patient interaction, his/her clinical evaluation; treatment (medication) prescribed and understands the justification for the treatment protocol. It is preferred that the supervisee is able to follow patients over time to observe long-term effects. In general, each student should spend sufficient hours each week with a supervising psychiatrist (or other accepted provider) to complete his or her practicum hours in a reasonable time frame (usually 8-12 weeks). The specific hours per week are arranged between the student and the approved practicum mentor.

A case seminar overseen by a qualified proctor is scheduled for clusters of students in the summer of the second semester. As part of the practicum training process, students are expected to present clinical cases. Seminar hours are considered part of the required 100 hours. We are currently scheduling four days for a case-based seminar: June 17, 18, 19, 20 2005. However, if students are interested we could extend the seminars for two additional days.

In review, the clinical rotation will consist of two, approximately 100 hours practica, including observation and clinical discussion of fifty patients. The goal is for students to observe a diverse group of patients with a variety of symptoms over the course of several weeks of treatment and to be able to observe the clinical effects of psychotropic medications developing over time.

Students must keep a complete log of their clinical activities as part of the record of their training. The log should include, but is not limited to: each patient?s concise biopsychosocial history; medical and psychiatric history; medications that the patient is currently taking; allergies; foods and beverages that might suggest negative drug interactions; current DSM diagnosis; indications and counter-indications regarding the psychotropic medication(s) currently prescribed and; drug-drug interactions. Each patient?s log will conclude with a one-paragraph summary.

It is our intention for students to develop appropriate practicum arrangements that rival supervision in our own clinical facilities, if it is not practical for them to arrange their schedule to receive supervision at our clinic.We will work with each student to help him/her locate training supervision from a qualified mentor at a site closer to heir residence that can be approved by the director.

Prerequisites for Practicum I and Practicum II are successful completion of all prior courses.

Again, I think it speaks for itself.

So, program length all together, didactic and practicum, is at least four years.

Grading Policy

Grades for course work are assigned according to the following system: P, F or PR (in progress). A grade of I (incomplete) is given only with instructor's approval and under exceptional circumstance. Our goal is to have our students complete the program successfully. Faculty and the director will make every reasonable accommodation to accomplish this goal.

From my understanding many med schools use this grading system; please correct me if I'm mistaken.

I know that this sample program when taken by itself still compares unfavorably with medical school as far as length of training.
HOWEVER, the post-doc psychopharm program is just that, a post-doc program that builds on psychology school training.
In other words, students admitted to this 4 year program already have at least 6 years of grad psych education and probably at least 1 year of licensed psych practice.

Another point is whether med school length of training is necessary for psychopharmacotherapy.
In other words, are 8 years of training necessary to become a competent and ethical psychotherapist/psychopharmacotherapist.
DoD psychologists had far less med training than that and still were impartially evaluated to be so considered; same for psych NPs.

So, maybe, just maybe, it is not the length of training that matters but the depth; not QUANTITY but QUALITY of training. ;) Just maybe ;)

To be continued...

Continued

PublicHealth, :)

You mentioned the possibility of PhD/PsyDs becoming NPs in order to gain RxP. Some psychologists are going that route but while it solves some problems it creates some others, such as:

1. PhD/PsyDs would be prescribing as NPs thus keeping psychology as a discipline on the periphery of the healthcare field; this is unacceptable to the big APA because it is very committed to expanding psych presence from academia to healthcare, including primary as well as specialty care beyond mental health.
2. NPs have RxP in all 50 states but only autonomous authority/full formulary in 11 states and DC; big APA is committed to the DoD model which is independent practice.
3. Psychologists entering nursing school for the sole purpose of becoming prescribers presents obvious ethical challenges as I'm sure you can envision.

PublicHealth and Dentite001, :)

I'm running out of time here so instead of commenting on your respective proposals I'd rather echo Svas' evaluation of them which I think is very well thought out and he is someone who is much better informed and articulate than I. :)

Instead, I'd rather share some reflections and ask for your and others' responses.

Should med psych be:

1. a clinical psych spec, such as neuro psych, health psych, forensic psych, etc, or
2. should it be a hybrid of med school and psych school training?

The big APA supports the former, the little APA opposes both, and I am open to either. I also believe that both of your respective proposals tend to lean towards the latter so I'd like to begin a discussion on that.

First some history, :cool: and then a rumor. :laugh:

HISTORY

PhD-to-MD Program

The PhD-to-MD Program was a special program started by the University of Miami School of Medicine in 1971. It was an innovative and extremely selective program in which students holding the PhD degree could earn the MD degree in just two years.

The program was discontinued in 1987 at the request of the Liaison Committee for Medical Education. Since this organization accredits all medical schools in the United States and Canada, there are no other programs like the PhD-to-MD Program in North America.

RUMOR

psych PhD/PsyD entering a shortened DO program resulting in a psychologist-psychiatrist practitioner. :idea:

I presume that the AMA would be opposed just on the basis that the little APA is vehemently opposed to PhD/PsyD gaining RxP without going through an additional 8 years of training and most psychiatrists are MDs, but what about the AOA?

perhaps that shortened DO program could include 2 years of med science, 1 year of clerkship, and 2 years of psychiatry residency, including rotations in IM, neuro, and C-L as well as outpatient and inpatient mental health.

of course, this would be in addition to an also shortened PhD/PsyD program that could perhaps include 3 years of behavioral science and 2 years of psychology residency.

Any thoughts???

Peace to all. :)

RUMOR

psych PhD/PsyD entering a shortened DO program resulting in a psychologist-psychiatrist practitioner. :idea:

I presume that the AMA would be opposed just on the basis that the little APA is vehemently opposed to PhD/PsyD gaining RxP without going through an additional 8 years of training and most psychiatrists are MDs, but what about the AOA?

perhaps that shortened DO program could include 2 years of med science, 1 year of clerkship, and 2 years of psych residency, including rotations in IM and C-L as well as outpatient and inpatient mental health.

Any thoughts???

Peace to all. :)

Sign me up! Where did you hear about this rumor? I described something along these lines in previous posts. With several DO schools opening branch campuses across the country, and a national shortage of psychiatrists, I'm surprised that a program like this has not been implemented. Interesting posts...

SVAS and everyone else, do you believe psychiatrist should be replaced by psychologist? I have not heard SVAS say one positive thing about psychiatrist and you profess to be a psychiatrist. If not, what role do you see psychiatrist playing in the future if psychologist do everything done by current psychiatrist.

OK, I need some term definitions, and some clarifications here, because I am getting confused by your last post, sasevan.

I have never heard of the terms "big APA" and "little APA". I have to infer from the last post that Sasevan defines "little APA" as being the American Psychiatric Association, and to presume that the qualifying adjective "little" refers to the total number of members, which indeed is lower within the APA (as compared with the number of psychologists who are members of the A. Psychological Assoc.). Am I correct?

Sasevan also notes that several participants to this discussion forum (which is primarily a forum for Psychiatrists in training, although we have also some graduated Psychiatrists participating here as well) are "all on the same page" regarding the appropriateness of psychologists prescribing dangerous substances. Indeed this may be the opinion of a few participants, (Svan, Sanman, Public Health), however none of these posters are either Psychiatry residents nor Psychiatrists currently in practice, nor do they seem to be medical students or other specialists aspiring to apply for an ACGME accredited Psychiatry residency training program. Please correct me if I am wrong.

OK, I need some term definitions, and some clarifications here, because I am getting confused by your last post, sasevan.

I have never heard of the terms "big APA" and "little APA". I have to infer from the last post that Sasevan defines "little APA" as being the American Psychiatric Association, and to presume that the qualifying adjective "little" refers to the total number of members, which indeed is lower within the APA (as compared with the number of psychologists who are members of the A. Psychological Assoc.). Am I correct?

Sasevan also notes that several participants to this discussion forum (which is primarily a forum for Psychiatrists in training, although we have also some graduated Psychiatrists participating here as well) are "all on the same page" regarding the appropriateness of psychologists prescribing dangerous substances. Indeed this may be the opinion of a few participants, (Svan, Sanman, Public Health), however none of these posters are either Psychiatry residents nor Psychiatrists currently in practice, nor do they seem to be medical students or other specialists aspiring to apply for an ACGME accredited Psychiatry residency training program. Please correct me if I am wrong.

Hi PsychMD,

Sorry about the confusion :(
Here's the clarification:
1. Yes, big APA refers to the American Psychological Association and little APA to the American Psychiatric Association.
2. Yes, the adjectives are in reference to the number of members: the big APA has about 150,000 and the little APA has about 35,000.
3. The terms are not meant to be derogatory in the least; as I noted in the same post, at least for me, length of training is not as important as depth of training, quantity is not as important as quality, in other words I'm not using those terms in any way to degrade psychiatry as size is not that important to me; I think this sounds kind of funny :laugh: More importantly, though, I'm not in any way degrading psychiatry since I eventually want to be a psychiatrist myself though I will be a psychologist in about 3 months. In the med center where I am a number of providers are both psych PhD/PsyDs and psych MD/DOs.
4. It is really cumbersome to keep writing the full name of both associations every time I refer to them.
5. Big APA, little APA is used by some psychologists to differentiate in informal settings while APA (PhD/PsyD), Apa (MD/DO) is used in more formal ones.
6. I believe some psychiatrists do the inverse, please correct me if I'm wrong.

As far as Svas, Sanman, PublicHealth, etc. I believe they better than I should respond to your questions/comments about their respective disciplines.

My comment about being on the same page was directed to Svas and Sanman and not to anyone else on this forum.

Neither the moderators of the Psychiatry nor the Clinical Psychology forums have limited posts to the practitioners or students of those respective disciplines. Neither have any other moderator of any other forum.

Due to recent events there has obviously been an incredible desire to vent, celebrate, condemn, and more recently to dialogue among individuals very concerned about the future of both psychiatry and psychology. Thus, the increase number of cross-postings. If you go to the Clinical Psychology forum you will see plenty of posts from psychiatry residents and med students just as you've seen in the Psychiatry forum the inverse. I actually think its a good thing :)

SVAS and everyone else, do you believe psychiatrist should be replaced by psychologist? I have not heard SVAS say one positive thing about psychiatrist and you profess to be a psychiatrist. If not, what role do you see psychiatrist playing in the future if psychologist do everything done by current psychiatrist.


I've answered this before. I think that the current field described as psychiatry should probably evolve into behavioral neurology. I think that psychologists will ultimately replace psychiatry.

Then again, I could be wrong.

As to what my discipline is: I'm a psychiatrist (and before that I was a chemist for Dow).

S

SVAS

Where I'm from we are proud to be psychiatrist. I would hate to be in your residency program if you are indeed a psychiatrist, which I very much doubt. You are a psychiatrist that doesn't even believe in your own profession, your colleagues and residents would be embarassed if they knew your thoughts. Behavioral neurologist?!? way to recreate the wheel. Neurology, psychotherapy, research and medicine all in one program = psychiatry residency. There are no short cuts. I agree somethings could be tweaked but I think medical school is a great/necessary evil. Again, psychologist does not equal psychiatrist. You should not be working with residents if you don't believe in psychiatry. Any other residents think this?

Sasevan also notes that several participants to this discussion forum (which is primarily a forum for Psychiatrists in training, although we have also some graduated Psychiatrists participating here as well) are "all on the same page" regarding the appropriateness of psychologists prescribing dangerous substances. Indeed this may be the opinion of a few participants, (Svan, Sanman, Public Health), however none of these posters are either Psychiatry residents nor Psychiatrists currently in practice, nor do they seem to be medical students or other specialists aspiring to apply for an ACGME accredited Psychiatry residency training program. Please correct me if I am wrong.

Call the SDN Police! Non-psychiatry residents have invaded the Psychiatry Forum! Seriously, if you're so opposed to psychologists gaining prescription privileges, your time would be better spent writing your state politicians instead of policing online forums.

SVAS

Where I'm from we are proud to be psychiatrist. I would hate to be in your residency program if you are indeed a psychiatrist, which I very much doubt. You are a psychiatrist that doesn't even believe in your own profession, your colleagues and residents would be embarassed if they knew your thoughts. Behavioral neurologist?!? way to recreate the wheel. Neurology, psychotherapy, research and medicine all in one program = psychiatry residency. There are no short cuts. I agree somethings could be tweaked but I think medical school is a great/necessary evil. Again, psychologist does not equal psychiatrist. You should not be working with residents if you don't believe in psychiatry. Any other residents think this?


I'm attempting to answer the question of where I *think* psychiatry *will* evolve. I suspect that behavioral neurology is a larger umbrella. It's okay not to agree, Thrill. However, what you have suggested about psychiatrists being competent at neurology is way off base. Most psychiatrists are very weak at functional neurology and VERY weak in the required biochemistry for this field. The average psychiatrist is a very poor reader of MRI's and most can't get through an EEG without pulling Aminoff off their shelves (presuming they know where it is).

As to whether or not I'm a psychiatrist - well, that's silly. You've thrown a philosophical gauntlet down that is ridiculous & without much merit. What your essentially saying is : "Anyone who doesn't see the world my way is probably not what I am." The flaws to that argument are so apparent that I won't bite. That other trainees would agree with you is beside the point. After being out, practicing and teaching for this long, *I'm* pretty certain of what I see happening.

Now, do I think that my fellow psychiatrists like this position? No. Do I advertise that I'm in favor of this adaptation? Not really. Will I explain it in a public forum if asked. Sure, I've done this. However, I've got a couple of more years to put in here before I can be as vocal as I'd like to be regarding the changes that I think psychiatry needs to address in order to survive.

Are my resident's embarrassed? No. Would I teach in an MS Psychopharm program? Absolutely. Why? Because I can do a better job of insuring that their training is more complete if I (as a psychiatrist) actively train them versus their getting their training from someone who is NOT a psychiatrist.

BTW, I love what I do as well. I identify with being a psychiatrist, although I'm boarded in neurology too. It's readily apparent from my teaching and consultation practice. However, I'm also open to new ideas and professional opportunities.

Sounds to me that as the stigma of mental illness declines there will be an increased demand for assessment and treatment, possibly further taxing psychiatry's efforts to provide mental healthcare. The relief for this situation may well be psychology's procurement of RxP.
In the 1950s and 1960s psychiatry argued that psychology was an academic disciplined and social science and that as such it could not provide medical evaluations and interventions such as diagnosis and psychotherapy.
In the 1990s and currently psychiatry's arguments against the expansion of psychology's scope of practice into psychopharmacotherapy is much the same.
Maybe we can learn from history and combine our efforts not to fight with one another but rather to fight together to achieve parity in healthcare funding and to develope ever more effective means of primary, secondary, and tertiary prevention.
Psychology is just as concerned about patient care as is psychiatry and there are plenty of patients to go around, in fact, far too many who want services but can't afford them and/or can't find a provider.

Please see below. Peace. :)

APA POLL: MOST AMERICANS HAVE SOUGHT MENTAL HEALTH TREATMENT BUT COST, INSURANCE STILL BARRIERS

--------------------------------------------------------------------------------

WASHINGTON -- Nearly half of Americans have had someone in their household seek mental health treatment, but most still perceive cost and lack of insurance coverage as barriers according to national poll results released today by the American Psychological Association (APA). The poll also shows that stigma about seeking mental health treatment is increasingly less of a barrier to getting treatment. :thumbup:

Nearly half (48%) of American households have had someone see a mental health professional and nine out of 10 Americans say they are likely to consult or recommend a mental health professional if they or a family member are experiencing a problem.

Those polled say lack of insurance coverage (87%) and concerns about the cost of treatment (81%) are important reasons not to seek help from a mental health professional. More and more Americans (85%) think health insurance should cover mental health services, up from 79% when asked the same question in December 2000. And access to those mental health services is very important to 97% of those polled, although only 70% say they feel they have adequate access to mental health care.

The poll shows that only 30% of Americans say they would be concerned about other people finding out if they saw a mental health professional and only 20% believe there is any stigma associated with therapy. Nearly half (47%) say that the stigma surrounding mental health services has decreased in recent years, and the media gets the most credit for that (35%), although society in general (25%) seems to be more accepting as well.

?We?ve made progress in people?s attitudes toward getting mental health treatment, or seeking it for their loved ones,? said Russ Newman, PhD, JD, APA?s executive director for professional practice. ?But cost, lack of insurance, and access still can be barriers for people in getting the help they need.?

Lack of access can range from health care plans whose criteria make it nearly impossible to have adequate mental health treatment, to scarcity of qualified health care professionals. For example, in Louisiana, waiting time to see a psychiatrist averages as long as six months. That state?s governor last week signed a law allowing specially-trained psychologists to prescribe medication to people with mental health disorders in mental health treatment, thereby, expanding the pool of qualified medical professionals who can prescribe psychotropic medicines to those in need. :thumbup:

The survey of 1,000 Americans was conducted by Penn Schoen & Berland on January 26-27. All respondents were between the ages of 18 and 64 years old. The margin of error for the study is ? 3.1 at the 95th percent level.


--------------------------------------------------------------------------------

The American Psychological Association (APA), located in Washington, DC, is the largest scientific and professional organization representing psychology in the United States and is the world?s largest association of psychologists. APA?s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its 53 divisions and its affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science and profession, and as a means of promoting health, education, and human welfare.


--------------------------------------------------------------------------------

Call the SDN Police! Non-psychiatry residents have invaded the Psychiatry Forum! Seriously, if you're so opposed to psychologists gaining prescription privileges, your time would be better spent writing your state politicians instead of policing online forums.


From the FAQ page:

Organizational Relationships

SDN has regular contact with many organizations within the medical education community. However, SDN serves as an independent site and has no direct relationship with any school, professional organization, or company, other than its parent organization, The Coastal Research Group, a 501(c)(3) charitable educational organization.

The Student Doctor Network is an entirely volunteer resource. SDN is run by a small group of unpaid volunteers that are dedicated to providing students unbiased information. SDN is here to tell you the real story about the health professions and help you reach your goals.

I like these statements, but as we're learning . . . being unbiased is nearly impossible (in anyone).

S

Sign me up! Where did you hear about this rumor? I described something along these lines in previous posts. With several DO schools opening branch campuses across the country, and a national shortage of psychiatrists, I'm surprised that a program like this has not been implemented. Interesting posts...

Remember, its just a rumor :laugh:

What I've heard is that at a DO setting there have been some physicians exploring that possiblity with some psychologists very much involved in the RxP movement. (I have a psychologist friend who has been asked to give feedback about such a possibility).

Howver, in reality I doubt that given recent developments the big APA would be willing to go that route.
The incoming president of APA, Dr. Levant, has been one of the most committed proponents of RxP since even before the big APA and most PhD/PsyDs were in favor. The big APA wants psychologists to have RxP not to be psychiatrists.
As NM gets ready to go forth with implementation of its RxP legislation and as LA also goes forth with its own RxP legislation based on a model likely to be more acceptable to physicians and legislators (NM provides for independent practice, LA for collaborative) I believe the big APA views RxP as a train that has already left the station.
I also doubt if the AOA would be willing to develope a med specialty that would not be recognized by the AMA (because of the little APA) or if such a discipline would be recognized by the accreditation committee for med edu (both MD and DO) as evidenced by that committee putting an end to the University of Miami's PhD-to-MD program. :(

The answer to helping more mental health patients is to open more psychiatry residency spots. The government put a freeze on developing new residency spots back in 1997, it is high time to reverse that and open more psych residency spots. Also, sasevan your are right it is near impossible for individuals with mental illness to afford good healthcare and the government nowing this is not helping. If you fart sideways and go to the ER you will get a 3-5 day hospital stay and a million dollar work-up. But if you go crazy the government doesn't recognize this as a serious health issue and greatly limits the amount of money spent on the mentally ill. If you get a nose bleed and go the to ER you'll get a CT of MRI. But it is like pulling teeth to get any imagining on a new psych patient. The main reason the government wants to give psychologist rx priviledges is because they see psychologist as less expensive labor. The government will not reimburse psychologist the same as psychiatrist. SVAS, dude you are smoking down again, psychiatrist don't and shouldn't read EEG's, you need to be a trained neurologist to do that. If you are managing epileptics that is malpractice waiting to happen. Neurology and Psychiatry separated many years ago although our degree is giving as the board of Neurology and Psychiatry. There is no way to combine these fields again it is far too encompassing. These fields split for a reason. I do agree we need more neuro in Psych training, but to read EEG's let's get real.

. . . psychiatrist don't and shouldn't read EEG's, you need to be a trained neurologist to do that. If you are managing epileptics that is malpractice waiting to happen. Neurology and Psychiatry separated many years ago although our degree is giving as the board of Neurology and Psychiatry. There is no way to combine these fields again it is far too encompassing. These fields split for a reason. I do agree we need more neuro in Psych training, but to read EEG's let's get real.

My residents CAN read MRI's and EEG's by the time they are done. If the EEG's reflect seizure, they get consults. The consultant either remains a consultant or becomes a co-treating doc. EEG's are pretty simple (pattern recognition & we've proven that HS students can do it effectively). MRI's are more complicated . . . but it's amazing what you can do if you understand both structural and functional neuroanatomy. This really should be required knowledge now in psychiatry - but you may discover that your professors don't know the field very well.

There's NO way to combine these fields again? Surely you jest. You made a case earlier for the fact that psychiatry was already the perfect marriage of these fields.

I gotta go mow the lawn & think about how to help you see that the future is much brighter if you adapt more effectively. Otherwise, you're going to end up only reminding me of that famous line by Danny DiVito from "Other People's Money" regarding the making of buggy whips.

S

PART I



Commentary: The Prescription Jihad
by Ali Hashmi, M.D.
Psychiatric Times July 2001 Vol. XVIII Issue 7


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I was compelled to pen this piece after reading yet another opinion on the fierce psychologist-prescribing debate in the Feb. 3 issue of Psychiatric News.
Before I go any further, some disclosures are in order. I am a psychiatrist, employed by a community mental health center in Arkansas, in a 100% outpatient practice. I am one of four psychiatrists (three specializing in the treatment of adults and one in child psychiatry) employed by our center, and we serve a catchment area of seven counties with a combined population of approximately 200,000. Despite having trained in a traditionally psychoanalytic program at Baylor College of Medicine, I was always more comfortable with medication evaluations and with what today would be called the biological aspect of psychiatry. I do very little therapy per se, apart from supportive therapy, some crisis intervention and education. I do, therefore, have a vested interest in keeping prescribing privileges out of the hands of non-physicians.

Having said that, I find it more than a little amusing when I hear all kinds of high-minded arguments being bandied about over what is obviously an economic issue. To quote from the above-mentioned article by Jan Leard-Hansson, M.D., "To prescribe medication properly the physician must know the patient from head to toe?We, as psychiatric physicians, must maintain a steadfast commitment to protecting and providing high-quality patient care."

Admirable sentiments indeed, but when was the last time Leard-Hansson, or any of us, did a rectal examination on a patient? Or auscultated their chest? Or palpated their lymph nodes or liver? Even my colleagues who work in hospital settings routinely defer physical examination to their internal medicine or family practice consultants. The simple truth of the matter is that sub-specialization, by definition, means that most of us lose some of the skills that we learned in medical school, primarily those that we do not use on a regular basis. I know that I would have a tough time picking up a murmur on a chest exam or appreciating a subtle physical finding. It is, therefore, more than a little disingenuous to claim that we, as psychiatrists, know our patients from head to toe. The day-to-day practice of our art demands, in fact, that we concentrate on certain areas and de-emphasize others, referring patients to others with more expertise when necessary. Surely, I find it easier to examine a routine blood report and pick up obvious abnormalities or interpret the results of a computed tomography or magnetic resonance imaging scan, but those are skills that can be learned with time.

Coming back to the main topic of non-physician prescribing, the arguments being put forward by both camps (i.e., physicians and non-physicians--mainly psychologists but soon to be joined, I am sure, by social workers and other clinical personnel) are similar. Each side accuses the other of being petty and money-grubbing, while claiming the moral high ground for themselves.

The Psychiatrists

Psychiatrists claim that the whole psychologist-prescribing effort was born of the drive toward managed care. Managed care organizations are increasingly driving down the rates of reimbursement for both therapy and psychological testing, while farming out therapy to ancillary (read "cheaper") clinical staff such as licensed certified and master's level social workers and associate counselors, or even counselors with only a bachelor's degree.

The managed care trend has also put psychologists in the uncomfortable position of feeling like a fifth wheel relegated to doing psychological and neuropsychological testing, which may also one day be delegated to even less costly technicians. Prescribing ability would ensure a more reliable income stream for psychologists. In addition, prescribing is much less labor intensive than therapy or testing.

The psychiatric community claims, with some justification, that this is uncomfortably similar to the top of a slippery slope. What is next? Prescribing privileges for social workers, marriage, family and child counselors, case managers, and mental health technicians? Where does it stop?

Psychiatrists argue that they oppose this effort purely for the sake of their patients and with the purest motives at heart. (I am exaggerating, of course, but you get the gist.) Psychiatrists are resistant to psychologist prescribing because non-physicians would have a greater risk of missing crucial side effects, drug interactions and co-existing medical conditions, thereby leading to increased morbidity and mortality. There is something to be said for this concern, but it requires a greater leap of faith. Have none of us psychiatrists ever had any patients with bad outcomes? Of course we have, but one learns and moves on and, presumably, non-physician prescribers could do the same.

PART II

The Psychologists

Psychologists, on the other hand, claim that managed care organizations are increasingly restricting access to psychiatrists, preferring that psychopharmacological management is done by primary care physicians.

Also, thanks to managed care, Medicare and the Health Care Financing Administration, recent graduates from psychiatric residency training programs are well-versed in medication evaluation and management but are increasingly unaware of, and uninterested in, therapy skills. This makes psychiatrists little more than "dispensers," diagnosing people through DSM-IV checklists and prescribing the recommended medications according to various algorithms--something that can be done by a simple computer program, and for much less cost than using human dispensers. The move away from trying to understand the inner lives of people and learning how their relationships, families and feelings impact their illness makes today's psychiatrists increasingly expendable and replaceable by family physicians who can do the necessary prescribing while also caring for day-to-day illnesses. Psychologists argue, with some justification, that psychiatrists are already obsolete or will be in short order.

Also, unlike oncological chemotherapy, invasive cardiology or neurosurgery, for example, psychopharmacology is hardly rocket science. There are a limited number of agents, with most belonging to two or three major classes with similar efficacy and side-effect profiles. The safety margins--especially for the newer agents--are wide, with even large overdoses rarely proving fatal. In addition, the proponents of the psychologist-prescribing effort point out that the recently discontinued U.S. Department of Defense program has demonstrated that non-physicians with appropriate training can be just as effective and safe as physicians.

However, psychologists argue that they want prescribing privileges not for the crass purpose of making more money, but because the result would be an increase in the availability of qualified psychopharmacologists in rural areas where the need is still great. This argument flies in the face of several recent papers that have pointed out that, traditionally, doctorate level psychologists tend to cluster in big cities usually in and around universities.

It is the psychologists and their supporters, some say, who are the noble warriors in this crusade, battling against those dastardly psychiatrists (again, I exaggerate, but you get the gist).

Conclusions

As can be seen, there are valid arguments from both sides, and both sides have a vested economic interest in the outcome, which is usually unacknowledged. From personal experience, I have spoken to a number of psychologists on this issue, none of whom were enthusiastic about prescribing. These are qualified, competent people who do therapy, psychological testing, disability evaluations and some administrative work and are well-satisfied with what is on their plate. Most of them were of the opinion that the added monetary benefits of prescribing were not worth the additional risks of making decisions about people's suicidality, proneness to violence and other issues of potential medicolegal consequence, such as the use of psychotropics in pregnancy. They were more than happy to defer such decisions to the physician.

An added disincentive is the attendant deluge of drug-seeking patients, such as those with ill-defined physical conditions (i.e., chronic back pain, fibromyalgia, chronic fatigue) or others with intractable personality disorders who demand benzodiazepines, pain medications and the like. I see a large proportion of such patients in my day-to-day practice, and they are usually the ones I dread.

There are others who are either on, or in the process of applying for, disability. There is, of course, no hope that any of them will ever improve, since substantial improvement would mean loss of benefits. It's like walking on a treadmill. No matter how long you walk, you stay in exactly the same place.

Of course, I practice in a rural area where there are generally more patients than qualified practitioners. The situation is likely different in larger cities where there may be a large number of practitioners and where competition for patients may be fierce.

On the other hand, I have at times wished that there were more of us, simply because the need appears so great. The number of people needing care, from nursing home patients to adults to schoolchildren, means that most of us are booked up to six weeks or more in advance, and at times some extra help would be welcome. Just as family practice doctors often have nurse practitioners or physician assistants who can prescribe under supervision, perhaps a similar system could be devised for non-psychiatric prescribers. The quality and knowledge base would likely vary widely, but in the long term, self-selection would eliminate those with obvious deficiencies.

I think prescribing privileges for non-physician personnel are inevitable at some point. If such practitioners would cost less than psychiatrists, you can be sure managed care will be the first to jump on the bandwagon. As psychiatrists, our choice is not between having or not having non-physicians prescribe psychotropics. Our challenge is to engage in this process in a way that is productive and non-confrontational. In the long term, as with managed care, we will gain more by being active and shaping the debate rather than being isolated behind the ramparts of our self-righteousness, firing off shots in the dark. :thumbup:

Dr. Hashmi is a board-certified psychiatrist practicing at Mid-South Health Systems, a community mental health center in Jonesboro, Ark.

I have a question (and I am NOT trying to be facetiously "naive"; I'm genuinely trying to find out, actually, from a Public Health perspective): why do you think that the demand for mental health treatment has seemingly skyrocketed in the last 2 decades? Is our nation suddenly growing profoundly unhealthy (mental health-wise)? (Understanding "health" as per the WHO definition of a state of physical and psychological balance and well-being). Epidemiologically, the major mental illnesses are still around the same rates, aren't they? I don't really know. I am not trained in public health issues nor in public health policy issues, so probably I don't even have the tools to either ask or answer this question in a meaningful way. I was hoping maybe for some brainstorming here, prompted by the last couple of posts which seem to advocate rx. privileges for psychologists based on this lack of access to much needed care.

I also wanted to observe that treatment for psychiatric disorders does not necessarily equal pharmacotherapy alone, as we all know; most often than not, it's a combination of biological, psychological, AND social treatments (you know, the "old" bio-psycho-social paradigm). Of course, now, with the tremendous advances in psychopharmacology, we have some better tools available, but overall it is indeed true: the demand ouweighs the resources by far, and there seems to be no end in sight. Not even an ARMY of psychologists armed with BOTH psychotherapeutic knowledge AND with rx. pads will satisfy this demand at this time, IMHO.

Maybe I'm just repeating a truism here, but, in my personal experience: most patients who are truly in need of mental health care are CHRONIC, lack any funds, any insurance, most are homeless, most have a multitude of co-morbid substance abuse, and possibly other illnesses as well (with no access to even the most basic primary care either, unfortunately). This is the most underserved patient population of all. Some pills may make them temporarily a little better, during an acute exacerbation maybe, but...what about the tx. setting? Most community hospitals are closing their psych. units in droves, the funding for Community mental health has been declinig precipitously; state hospitals beds are practically almost non-existent relative to the demand (we're talking about really sick people here); a large percentage of the mentally ill are now in the correctional setting, etc. Where are the public health solutions for this increasing demand relative to the meagerness of the resources?

That's why I was saying that this is NOT just about having MORE people able to rx. psychotropics (or even about people being BETTER trained re. psychotropic rx.). Now, especially now...when even most psychiatrists and most Family Practice docs are growing actually INCREASINGLY CAUTIOUS about rx'ing ANY psychotropics, especially antidepressants...because we are starting to learn that psychotropics are in many cases actually potentially detrimental or just don't help more than placebo...especially when it comes to depression, anxiety, that Pharma studies have had problems, etc.

I just wanted to throw this too on the table for further discussion, because the answer to the growing "crisis" in Mental Health tx. access does not seem to be as easy as just having more numbers of prescribers, IMHO.

And...overall...thinking from a historical perspective...psychiatric patients have always had a hard time, even in the pre-Pharma era...I don't really see that much has really improved re. quality of tx. or access to tx. or tx. resources at "mass level" since the Pharma era started either. (Other than Pharma making $ billions).

Are you guys (who are advocating the rx. privileges for non-physicians)...are you sure you're not playing into the hands of Pharma corporate interest, while thinking that you are advocating for better/improved mental health tx. solutions...?

Not to make light of the situation or distract from the main topic, but I thought this may bring a bit of much needed humorous relief (albeit somewhat bitter too!)
http://www.nytimes.com/2004/05/16/fashion/16DENT.html?ex=1085284800&en=2171dfc250b84b27&ei=5062&partner=GOOGLE

(It's about oral surgeons in CA trying to get privileged to do plastic surgery procedures, rendering the Assoc. of Plastic Surgeons "appoplectic", as quoted in the article!)

I have a question (and I am NOT trying to be facetiously "naive"; I'm genuinely trying to find out, actually, from a Public Health perspective): why do you think that the demand for mental health treatment has seemingly skyrocketed in the last 2 decades? Is our nation suddenly growing profoundly unhealthy (mental health-wise)? (Understanding "health" as per the WHO definition of a state of physical and psychological balance and well-being).

http://www.iop.kcl.ac.uk/iopweb/departments/home/default.aspx?locator=528

Is Psychiatry for Sale?: an examination of the influence of the pharmaceutical industry on academic and practical psychiatry

Joanna Moncrieff (foreword by Fuller Torrey)
Institute of Psychiatry, King's College, London

Foreword
Dr. Moncrieff's question has been answered in the United States, where it is clear that psychiatry has already been sold. The buyer was Big Pharma. The sale price has not been disclosed, but rumor has it that the pharmaceutical industry got a bargain.

The author is right on target in her descriptions of the compromise of individual psychiatrists and of drug trials. She is also correct in decrying the extension of psychiatric diagnoses so as to enlarge the markets for pharmaceutical products. It is, in fact, embarrassing to see colleagues who were once respected line up under the banner of limitless "social anxiety" or "subsyndromal depression," then collect their paychecks from pharmaceutical representatives.

Unfortunately, Dr. Moncrieff also throws out the baby with the bath water. Major depressive disorder, bipolar disorder, schizophrenia, and other major psychiatric disorders are brain diseases, and the evidence to support this is overwhelming. They are in exactly the same category as Parkinson's disease and multiple sclerosis. Social factors must be considered in the treatment of all such disorders, but changing social factors will not prevent or cure them. One can criticize the pharmaceutical industry and its compromise of the psychiatric profession without discarding the medical model. Indeed, I am impressed by the large number of truly brain-diseased individuals in the United States who are unable to afford to purchase the drugs they need, because the drugs cost so much. And one reason they cost so much is because the drug companies have purchased so much pizza for psychiatric trainees and so many perks for practicing psychiatrists.

But do not blame Big Pharma-they are just doing what companies are expected to do in a free enterprise society. They are selling their goods in any way they can. Instead, blame our psychiatric colleagues who are colluding in the process and who should know better. We need more young psychiatrists like Dr. Moncrieff to save the profession from degenerating into a pharmaceutical brothel.

Summary
Western society is consuming ever larger quantities of prescription drugs and many of these are for psychiatric complaints. Drugs are central to modern psychiatric practice and to much psychiatric thought about the nature and causation of mental disorders. Psychiatry has therefore become an important target for the large and powerful pharmaceutical industry. Drug companies direct lavish advertising and hospitality towards psychiatrists and provide funding for much medical education and some mental health service initiatives. The industry is now heavily involved in the organisation of research into psychiatric drugs and the dissemination of research findings. This raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. Drug companies also provide funds for pro drug patient and carer groups and address advertising or disease promotion campaigns to the general public. They exert influence at a political level through lobbying and direct funding of political bodies including drug regulatory agencies.

This influence has helped to create and reinforce a narrow biological approach to the explanation and treatment of mental disorders and has led to the exclusion of alternative explanatory paradigms. The coercive function of psychiatry has been strengthened by promoting the idea that psychiatric disorders are akin to medical conditions and that they are amenable to technical solutions in the form of drugs. In addition, alternative treatment approaches are neglected and it is likely that drugs are currently used for overly long periods and in excessive doses. The adverse effects of drugs are neglected.

Psychiatry provides fertile ground for pharmaceutical industry profits because it provides opportunities for expanding definitions of sickness to include more and more areas of social and personal difficulty. This paper gives examples of how the industry has been involved in promoting and expanding concepts such as depression, social phobia, attention deficit hyperactivity disorder and psychosis.

The current extent of drug company influence threatens the integrity of psychiatry and some suggestions are made about steps that could be taken to address this. The influence of the industry must be curbed for political reasons too. We are rapidly becoming a society that seeks a "pill for every ill;" one that looks for simplistic, technical solutions to complex social problems. This helps to divert attention away from the profound social and political changes that have occurred during the last few decades. Psychiatrists should not be colluding in this process.

Not to make light of the situation or distract from the main topic, but I thought this may bring a bit of much needed humorous relief (albeit somewhat bitter too!)
http://www.nytimes.com/2004/05/16/fashion/16DENT.html?ex=1085284800&en=2171dfc250b84b27&ei=5062&partner=GOOGLE

(It's about oral surgeons in CA trying to get privileged to do plastic surgery procedures, rendering the Assoc. of Plastic Surgeons "appoplectic", as quoted in the article!)


:laugh: :laugh: :laugh:

That was hilarious. Thanks for the link.

I have a question (and I am NOT trying to be facetiously "naive"; I'm genuinely trying to find out, actually, from a Public Health perspective): why do you think that the demand for mental health treatment has seemingly skyrocketed in the last 2 decades? Is our nation suddenly growing profoundly unhealthy (mental health-wise)? (Understanding "health" as per the WHO definition of a state of physical and psychological balance and well-being). Epidemiologically, the major mental illnesses are still around the same rates, aren't they? I don't really know. I am not trained in public health issues nor in public health policy issues, so probably I don't even have the tools to either ask or answer this question in a meaningful way. I was hoping maybe for some brainstorming here, prompted by the last couple of posts which seem to advocate rx. privileges for psychologists based on this lack of access to much needed care.

I don't know the answer to this question but I suspect that as the stigma of mental illness has declined there has been a proportional rise in patient recognition, reporting, and request for mental health services. As the big APA's article suggested, much of the decline in stigma has been due to media coverage which has perhaps helped to educate patients and their families as to the etiology of much of psychopathology lying not in Mother but in biochemical dysfunction and/or maladaptive cognitive and behavioral patterns.

I also wanted to observe that treatment for psychiatric disorders does not necessarily equal pharmacotherapy alone, as we all know; most often than not, it's a combination of biological, psychological, AND social treatments (you know, the "old" bio-psycho-social paradigm). Of course, now, with the tremendous advances in psychopharmacology, we have some better tools available, but overall it is indeed true: the demand ouweighs the resources by far, and there seems to be no end in sight. Not even an ARMY of psychologists armed with BOTH psychotherapeutic knowledge AND with rx. pads will satisfy this demand at this time, IMHO.

It may not satisfy demand at this time but it would make a dent. There are currently about 60,000 psychology students. Of course, not all or maybe even the majority of these will want to become med psychologists as there are numerous other cl psych spec, such as neuro psych, forensic psych, etc. and there are also many non-cl psych fields such as experimental psych, industrial-organization psych, etc. But some would be willing to undergo the additional training and then go and practice where there is a critical need/financial opportunity, i.e., rural areas and the inner city.

Maybe I'm just repeating a truism here, but, in my personal experience: most patients who are truly in need of mental health care are CHRONIC, lack any funds, any insurance, most are homeless, most have a multitude of co-morbid substance abuse, and possibly other illnesses as well (with no access to even the most basic primary care either, unfortunately). This is the most underserved patient population of all. Some pills may make them temporarily a little better, during an acute exacerbation maybe, but...what about the tx. setting? Most community hospitals are closing their psych. units in droves, the funding for Community mental health has been declinig precipitously; state hospitals beds are practically almost non-existent relative to the demand (we're talking about really sick people here); a large percentage of the mentally ill are now in the correctional setting, etc. Where are the public health solutions for this increasing demand relative to the meagerness of the resources?

I absolutely agree. Here's an issue that psychology and psychiatry could be jointly addressing, and funneling the needed resources to do so effectively, except that we're not able to do so now because we're engaged in a costly war with one another that makes cooperation on other issues difficult if not impossible. Its difficult to dialogue with, much less consider allies, those who state that psychologists are just not smart enough to learn how to prescribe for if they were they would have gone to med school and become psychiatrists in the first place.

That's why I was saying that this is NOT just about having MORE people able to rx. psychotropics (or even about people being BETTER trained re. psychotropic rx.). Now, especially now...when even most psychiatrists and most Family Practice docs are growing actually INCREASINGLY CAUTIOUS about rx'ing ANY psychotropics, especially antidepressants...because we are starting to learn that psychotropics are in many cases actually potentially detrimental or just don't help more than placebo...especially when it comes to depression, anxiety, that Pharma studies have had problems, etc.

Again, I absolutely agree. I believe that when psychologists discuss the biological dimension of mental illness and appropriate chemical intervention for it as well as when psychiatrist discuss behavioral treatments and poorly designed pharmaceutical research, we're seeing really good changes in both disciplines that I believe will lead to increased used of evidence-based medicine both by MD/DOs and PhD/PsyDs.

I just wanted to throw this too on the table for further discussion, because the answer to the growing "crisis" in Mental Health tx. access does not seem to be as easy as just having more numbers of prescribers, IMHO.

Thanks for a very positive post. We may not agree about RxP but we don't have to be disagreeable about it.

And...overall...thinking from a historical perspective...psychiatric patients have always had a hard time, even in the pre-Pharma era...I don't really see that much has really improved re. quality of tx. or access to tx. or tx. resources at "mass level" since the Pharma era started either. (Other than Pharma making $ billions).

I disagree with this. I do believe there have been some needed developments:
1. reduced stigma of mental illness,
2. the re-medicalization of psychiatry (not that I'm anti-psychodynamic, quite the contrary; I just see this as a needed correction to a time when psychoanalysis had a stranglehold on the field),
3. the biochemicalization of psychology (again, not that I'm anti-cogitive-behavioral), and
4. a growing appreciation for evidence-based practice in both disciplines.

Are you guys (who are advocating the rx. privileges for non-physicians)...are you sure you're not playing into the hands of Pharma corporate interest, while thinking that you are advocating for better/improved mental health tx. solutions...?

I believe that research has demonstrated that the best tx is in many cases a combination of both cog-behavioral and bio-chemical interventions.

As Dr. Sammons, one of the first of the DoD program's graduate, stated:

"Only if psychologists directly involve themselves in the prescription of psychotropics can they hope to play a more forceful role in issues such as overreliance on psychotropics, inappropriate use of psychotropic agents in special populations (e.g., children, elderly people), and the neglect of effective behavioral interventions. It represents a surrender to the status quo if psychologists do not intervene and bring a fundamentally different orientation to the prescription of psychotropics-and there is much to suggest that the status quo is not very good." :thumbup:

Just thought I would add a short comment. I think the comment about the media is right on target. Prior to psychotropics being advertised on TV the average person didn't know what many of these disoders were and/or that they even existed. I also agree that this has been influential in reducing the stigma attached to mental illness.

One additional point that should not be overlooked is access to mental health services. You mention the work of psychologist, but how about social workers. MSW's make up a large number of our mental health professionals today. They are often more accessible and equally attractive to managed care panels. Not to mention that many of them are "altruistic" and don't charge the alarmed fees that psychiatrists charge so they are much more accessible to the average person.

I am actually a clinical social worker working in an HIV/AIDS clinic in Manhattan. Someone visiting our clinic from abroad (Nigeria) asked this very same question. Kind of interesting :) . She too was alarmed at the rate of mental illness seen in the clinic...granted this is a rather unique population and many factors contribute to the comorbidity. Anyway, I think I am rambling....

...got to this thread a little late...

SVAS (you have been quite civil, but nevertheless some things must be said),
Concerning your little experiment, I completely agree with MDBLUE's response. Also, the inability by the psychiatric residents missing the cardiac arrhymias in all 4 cases and 2 misidentifying the problems with the labs may be indicative of a problem in your residency program (and perhaps in your ability as a teacher if you are indeed a psychiatrist- you did say they where third years- what exactly have you been teaching them all this time-perhaps that they have no future as a psychiatrist!). Where I am, we are taught to look at EKG and labs when prescribing- simply secondary to all the potential side effects. As for your residents telling you that it was a positive experience- what exactly did you expect- that you're an a**hole? Not many residents are going to tell their attending anything but how positive their teaching is.
To thethrill- i'll back you up. I pray to god that SVAS is not going to be teaching me when I start my residency in July.

...got to this thread a little late...

SVAS (you have been quite civil, but nevertheless some things must be said),
Concerning your little experiment, I completely agree with MDBLUE's response. Also, the inability by the psychiatric residents missing the cardiac arrhymias in all 4 cases and 2 misidentifying the problems with the labs may be indicative of a problem in your residency program (and perhaps in your ability as a teacher if you are indeed a psychiatrist- you did say they where third years- what exactly have you been teaching them all this time-perhaps that they have no future as a psychiatrist!). Where I am, we are taught to look at EKG and labs when prescribing- simply secondary to all the potential side effects. .


Silbenny,

I understand your frustration when looking ahead to residency now, particularly in light of the political climate. Post again in 4 years & let us/me know how things look (in retrospect) Good luck. Depending upon where you go, your psychiatric residency will be challenging and probably an eye-opener.

I don't get the psych residents until they hit their 3rd and 4th years. I'm going to ask my colleagues/residents about the task I presented and get their feedback regarding it's appropriateness - as I already stated I'd do. I'll inform them of the negative reaction you and MDBlue had to it. The task I presented is not different than what I've been doing for the past decade. It *was* unusual for not being attended by a couple of neurology residents who are usually floating through and that I included the PA's and NP's (I have a joint appointment in both departments). Additionally, it's not unusual to have other faculty members sit in on such events (as I do in their seminars, classes, etc.).

Unfortunately, I find that psychiatrists' abilities to understand and engage in "medicine" diminishes badly by the time 2 or 3 years go by after residency, and I think that the problem is perpetuated by our current residency training structure (nationwide). I think that medicine can be a use it or lose it phenomenon. I grow weary of looking at board-certified psychiatrists' eyes glazing over when I begin to lecture regarding pharmacokinetics, and in hearing their stories of "treatment refractory" conditions that were actually produced by drug-drug, drug-food interaction effects or pathophysiologies that I KNOW they should know. I think that re-medicalizing (to quote from a different thread) our psychiatric residencies is one of the changes that will have to be made for psychiatry to survive if it is to remain in its *current* form. It is also why I have generally supported increasing the amount of behavioral neurology that should be required of the residents - and it's why I drill and continue to educate them regarding the value of labwork.

Psychiatry struggles with being an ignored stepchild of medicine. It's a position poorly deserved. I think, though, that psychiatrists are their own worst enemy in that we ended up (for so long) accepting people who could not get any other residencies and for not confronting the pathological narcissism that was a byproduct of compensating for feeling one-downed by our medical colleagues. Now that neurology and psychiatry are clearly beginning to apparently blend (via behavioral neurology), revitalizing the field through increased attention to functional neuroanatomy, biochemistry, imaging, etc., is critical to carry us through this phase. What we CURRENTLY think of as "psychiatry" must change and, yes, I think that medical psychologists are probably going to take over the CURRENTLY perceived model. (I say, let them have it.)

Anyway, my behaviors aren't sadistic, but geared toward making sure that our psychiatrists don't lose touch with being physicians first.

(Now, don't get me started with regard to how little training psychiatrists are getting in terms of psychotherapy. I'm also strongly convinced that psychiatric residents should all be IN individual psychotherapy and group for at least 6 months (each), but that's a personal belief that I would not force-feed to anyone.)

You know, that's a great question: How often are current psychiatric residents encouraged to seek out psychotherapy for themselves for the purpose of self-review and growth (if not for working through some real psychological/characterological issues)? My sense is "not frequently." Does anyone know where I could get stats on such a question?

S

Ah- still civil- one of the redeeming qualities of psychiatrists.
SVAS, I have no problem with your test. It's good to scut a little- best way i remember things. The issue I have is how you were trying to prove your point of the incompetencies of psychiatrists- equating them with the knowledge base of PA, NPs, etc...
As for the training- yes there are inadequacies. However, this is due to the nature of the profession and the residency itself as you have noted. For the 'medicine' part- the question should be- what knowledge is required for the current scope of our profession- many psychiatrist would agree that our knowledge base if sufficient for what is required within this scope. What this scope should encompass is debatable.

The current trend suggests that the scope is getting increasingly small- hence the ability by psychologist to eat away at the things we may not want (therapy). Prescribing privileges has always been within the core of our scope, but that is now being threatened. In my opinion it is being threatened by psychologist and fought by psychiatrist largely for economic issues. (yes I do agree that the patient will suffer in the long run) All professions have to deal with multiple changes and threats and all have the right to fight these changes. In our case, for psychologists, social workers (yes, i always hear them mumbling to themselves that they can do the job of a psychiatrist easily) the saying 'if you can't beat em, join em' doesn't work. We have set a limit on the number of psychiatry residencies and have done little to remedy the shortage. Who really didn't see these things coming- there will always be people who will take advantage of an opportunity if one is presented so clearly- can't blaim the psychologists for trying. Can't blaim the managed care companies for lovin' this- after all, their poor compensation and limits on psychotherapy are driving us away from this element of psychiatry. Now they and others have their eyes set on the prescription element of psychiatry. I have laypeople telling me they only want to go to a medical doctor if they had a mental illness. However, remove the insurance coverage and they'll probably sing another tune. Does this all mean we just lay down and take the beating? Absolutely not- we need to protect what is ours to lose. I for one plan on being actively involved. I can only hope others will be doing the same. For some reason, I get the feeling that you (SVAS) have already moved on- for better or worse- only time will tell.

Just Curious, everyone is quoting the DOD study as if it is god's justification for allowing Psychologists to prescribe. Am I wrong, but didn't this study have a very limited sample size (like 10 psychologists) and it took place in a military setting versus civilian? These seems flawed in many ways: Limited sample size is obvious, but can results in a military setting expect to be translated to results in civilian life? Also, it's only ONE STUDY so it seems the book is still way out on the safety and efficacy of Psychologists to Rxp. Obviously, Psychologists who lobby politicians without a science background can quote the study to lead credence to their arguement and it appears to be working. After all, how many governors have learned to look critically at scientific studies? Anyway, I guess I'm curious as to the specifics of the DoD study since it's brought out all the time in favor of Psychologists Rxp.

You question the generalizability of the DoD results; that's only good scientific reasoning BUT how do you answer the question of whether PhD/PsyDs can be safe and effective prescribers unless studies such as these are funded. The little APA lobbied hard against the extension of the DoD project, resulting inadvertantly in the DoD Final Report being the sole example of empirical evidence re medical psychologists. Ironic. ;)

FINAL REPORT

MAY 1998


Prepared for: LTC Thomas J. Williams, USA, MS Program Director, External Monitoring of Graduates of DoD Psychopharmacology Demonstration Project Chief, Department of Psychology Walter Reed Army Medical Center Washington, D.C. 20307


Prepared by: American College of Neuropsychopharmacology 320 Centre Building 2014 Broadway Nashville, TN 37203

American College of Neuropsychopharmacology (ACNP)

Evaluation Panel Report May 1998

Executive Summary

The Psychopharmacology Demonstration Project (PDP) was undertaken by the Department of Defense (DoD) to determine the feasibility of training military clinical psychologists to prescribe psychotropic drugs safely and effectively. The first class entered the PDP in the Summer of 1991, and the last of four classes graduated in the Summer of 1997. The PDP produced a total of 10 prescribing psychologists who undertook post-graduate assignments at military posts scattered throughout the United States.

In January 1998, the DoD contracted with the ACNP to monitor and to provide an independent, external analysis and evaluation of the program and its participants. The ACNP Evaluation Panel was the chief mechanism for performing those functions throughout the program's lifetime. The ACNP Evaluation Panel did its work chiefly by means of frequent, periodic visits to training sites to observe, to interview significant participants, to collect data; providing external assessment of effectiveness and implementation of the PDP program.

In March and April 1998 the Evaluation Panel site visited all graduates of the program. Some had completed their formal PDP training almost four years earlier, and some were only nine months into the post-graduate period. This report includes much detail about the 10 graduates, the 10 sites of their assignments, and the 10 positions they filled. Our Findings and Conclusions, however, have reached beyond the individual. We examined the PDP as one particular training program and correlated its characteristics with its outcomes, as represented in the collective performances of the cohort of graduates.

After the Findings and Conclusions section below, an Introduction and a Brief History of the PDP provide short, detailed accounts of the PDP and the role, influence, and history of the ACNP and the ACNP Evaluation Panel. Next, is a Methodology of the 1998 ACNP Evaluation. Last, is a lengthy section that comprises the bulk of the report, 1998 Practice Profiles of the 10 Graduates. These Profiles report in detail the observations and findings of the 10 site visits. They are presented in sequence by service beginning with Air Force (three graduates), followed by Army (three graduates), then Navy (four graduates). Although there were three female graduates, only masculine pronouns are used to protect identity.

Findings and Conclusions

1. Effectiveness: All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed. It was striking to the Evaluation Panel how the graduates had filled different niches and brought unique perspectives to their various assignments. For example, a graduate at one site worked lull time on an inpatient unit with his supervising psychiatrist. The psychiatrist said he preferred working with the graduate rather than with another psychiatrist because the prescribing psychologist contributed a behavioral, nonphysician, psychological perspective he got from no one else. On posts where there was a shortage of psychiatrists, the graduates tended to work side-by-side with psychiatrists, performing many of the same functions a 'junior psychiatrist" might perform. In another location, a graduate was based in a psychology clinic but worked largely in a primary care clinic for dependents, thereby providing cost savings for care that otherwise would have been contracted out. Another graduate was the only prescriber for active duty sailors in a psychology clinic that was located near the ships at a naval base. Yet another graduate was to be transferred soon to an isolated base where he will be the only mental health provider. His medical backup will be primary care physicians.

2. Medical safety and adverse effects: While the graduates were for the most part highly esteemed, valued, and respected, there was essentially unanimous agreement that the graduates were weaker medically than psychiatrists. While their medical knowledge was variously judged as on a level between 3rd or 4th year medical students, their psychiatric knowledge was variously judged as, perhaps, on a level between 2nd or 3rd year psychiatry residents. Nevertheless, all graduates demonstrated to their clinical supervisors and administrators that they were sensitive and responsive to medical issues. Important evidence on this point is that there have been no adverse effects associated with the practices of these graduates! Thus, they have shown impressively that they knew their own weaknesses, and that they knew when, where, and how to consult. The Evaluation Panel agreed that all the graduates were medically safe by this standard. In a few quarters, the criterion for "medical safety" was equated with the knowledge and experience acquired from completing medical school and residency, and, of course, no graduate of the PDP could meet such a test.

3. Outstanding individuals: One indicator of the quality and the success of this group of graduates was that eight out of 10 were serving as chiefs or assistant chiefs of an outpatient psychology clinic or a mental health clinic. Two of these chiefs completed their PDP training less than a year earlier. Other indicators of quality and achievement that characterized this cohort were present when they entered the program. They all had not only a doctorate in clinical psychology but also clinical experience that ranged from a few to more than 10 years. All but two had military experience. The characteristics that led to these accomplishments showed again in that this cohort overcame their limited background in traditional scientific prerequisites for medical school. They certainly suggested that the selection standards should be high, indeed, for candidates for any future prescribing psychologist training, be it military or civilian. The opinion of the Evaluation Panel was that the history of the PDP has established that any program with comparable aims must be a post-doctoral program.

4. Should the PDP be emulated? There was discussion at many sites about political pressures in the civilian sector for prescription privileges for psychologists. Virtually all graduates of the PDP considered the "short-cut" programs proposed in various quarters to be ill-advised. Most, in fact, said they favored a 2-year program much like the PDP program conducted at Walter Reed Army Medical Center, but with somewhat more tailoring of the didactic training courses to the special needs, and skills of clinical psychologists. Most said an intensive full-time year of clinical experience, particularly with inpatients, was indispensable. The Evaluation Panel heard much skepticism from psychiatrists, physicians, and some of the graduates about whether prescribing psychologists could safely and effectively work as independent practitioners in the civilian sector. The usual argument was that the team practice that characterized military medicine was an essential ingredient in the success of the PDP that could not be duplicated in the civilian world. The Evaluation Panel urged the graduates collectively to produce their own consensus view on what would constitute an optimal program.

5. Relationships with psvchiatry: Six graduates worked in close, gratifying, and harmonious partnerships with psychiatrists, one in an inpatient setting and the others in outpatient units. A seventh graduate had a similar, but more business-like pattern. The psychiatrists in these partnerships were very competent pharmacotherapists. The remaining three graduates were somewhat isolated from psychiatrists with psychopharmacological expertise. One graduate was an independent provider who directed a military division clinic, and, while the clinic had a staff psychiatrist, he was less experienced in psychopharmacology than the graduate--and openly admitted this. Their relationship also was somewhat strained. The other two graduates worked in very busy settings with other psychologists in one case and with primary physicians in the other. Each treated many patients with medication. Each had an expert proctor who was available by phone, page, and e-mail, but not first hand. Although both were only nine months out of the PDP, and they were doing excellent work by all accounts, the Evaluation Panel believed as a matter of principle that they would benefit more from the experience of closer daily liaison with an expert practitioner.

To be continued:

Continued:


6. Scope of practice and formulary: The practice of pharmacotherapy was restricted to adults age 18-65 for all graduates.. Six graduates had no significant formulary restrictions even though there were slight formulary variations among them. The Navy was most restrictive: One graduate who was completing a third year of proctorship could not prescribe lithium or a number of new agents. Another prescribing psychologist was the most restricted of all graduates. He could treat only active duty patients even though dependents and retirees attended his clinic, and he could not prescribe lithium, depakote, and some newer antipsychotics. The Evaluation Panel considered his restrictions unfounded and unreasonable. A few graduates' formularies comprised lists of specific agents instead of drug classes, and it was difficult to effect changes. The MAOIs were the most common exclusions, being included on only one graduate's formulary. It seemed to the Panel that most of the exclusions derived from someone's untoward local experience, and not from judgments about the graduate's competence. Most graduates regarded the current formulary restrictions as no more than minor nuisances.

7. Psvchologist extenders: The PDP was not designed to replace psychiatrists or produce mini-psychiatrists or psychiatrist extenders, and it did not do so. Instead, the program "products" were extended psychologists with a value-added component prescriptive authority provides. They continued to function very much in the traditions of clinical psychology (psychometric tests, psychological therapies) but a body of knowledge and experience was added that extended their range of competence.

8. Psychopharmacology educators: An unexpected benefit of the PDP was the extent to which the graduates contributed to the training of psychology interns. At every site where graduates were in contact with interns, they had initiated teaching sessions, seminars, or courses in psychopharmacology. At two sites the comments emphasized that the teaching was far better than that provided by psychiatry which tended to be either too abstruse or too glib about the subject. The graduates knew better where to pitch the level of discourse because they better understood the perspective of the psychology interns. Several of the graduates were active in teaching clinical psychopharmacology to residents and other physicians.

9. Career impact: Unfortunately, many graduates appeared likely to leave the service in the near future because of being passed over for promotion. The career impact of the PDP was complex and hard to evaluate. Promotion odds seemed to depend in part on whether one joined the PDP shortly before or well in advance of promotion opportunities. Whatever the reason, departure from service terminates further assessment of outcome (within the service). Those who remain in the service should be monitored annually to maximize the information which can be obtained from the PDP.

10. Variety vs. restriction of caseload: Three graduates had practices that included 90-100% active duty personnel, two had 15-20%. Two graduates treated 60-80% dependents. Three graduates saw no retired personnel, two saw 20-30%, and one had 75% retirees or spouses in his practice. With the exception of one graduate who treated inpatients exclusively, the large majority of the pharmacotherapy patients of the others had disorders in the adjustment, anxiety, and depression disorder spectra. Not surprisingly, the medicines they used were mostly the newer antianxiety and antidepressant agents, especially the SSRIs. On another dimension of practice, the proportion of the caseload treated with pharmacotherapy, there also were wide individual differences: Four graduates treated more than 50% of their patients with medication, and three treated 25% or less. The graduates who saw only active duty patients were exposed to the least depth and breadth of psychopathology, and they gained less experience with medications because of pressures against their use with the active duty group. The diagnoses made and the medications prescribed by the graduates were functions of the military outpatient sample. They essentially mirrored what psychiatrists did with the same population, and, in fact, they differed little from the private practices of the psychiatrists on the Evaluation Panel. The Evaluation Panel believed that the clinical and administrative supervisors should make efforts, whenever possible, to help the graduates maintain and sharpen their clinical skills by expanding the diagnostic breadth of their caseload. The increased diversity and range of severity found on the inpatient service make it an important potential site for additional experience. Family and primary practice medical clinics provide other options.

11. Independent provider vs proctored status: All graduates were initially proctored by psychiatrists. Half of them had advanced to independent provider status, with its standard minimum review of 10% of medication cases. Interestingly, all members of Group C and one from Group D-the last two classes to complete the PDP-were independent. Two other graduates were de facto independent providers. The clinical supervisor in one case and a department head in the other as a matter of principle and philosophy would not propose independent provider status for any prescribing psychologist. These two graduates were members of Groups A and B-one Navy, one AF-and each had been proctored for three years. Both were soon to attain "independence by transfer" through reassignment to sites that had no on base psychiatric oversight or backup. The Evaluation Panel viewed these two graduates as no less effective or safe than their peers. They were caught up in the problem of a lack of a DoD-wide agreed upon set of clearly defined steps from 100% supervision to independent practice.

12. A final comment: As the preceding synopsis and the following detailed report indicate, the PDP graduates have performed and are performing safely and effectively as prescribing psychologists. Without commenting on the social, economic, and political issues of whether a program such as the PDP should be continued or expanded, it seems clear to the Evaluation Panel that a 2-year program-one year didactic, one year clinical practicum that includes at least a 6-month inpatient rotation-can transform licensed clinical psychologists into prescribing psychologists who can function effectively and safely in the military setting to expand the delivery of mental health treatment to a variety of patients and clients in a cost effective way.

We have been impressed with the work of the graduates, their acceptance by psychiatrists (even while they may have disagreed with the concept of prescribing psychologist), and their contribution to the military readiness of the groups they have been assigned to serve. We have been impressed with the commitment and involvement of these prescribing psychologists to their role, their patients, and the military establishment. We are not clear about what functions the individuals can play in the future, but we are convinced that their present roles meet a unique, very professional need of the DoD. As such, we are in agreement that the Psychopharmacology Demonstration Project is a job well done.

Source: ACNP Bulletin, Volume 7, Number 3, Summer 2000 :)

CRITICAL ARGUMENTS THAT SUPPORT RxP

1. Many non-psychiatric physicians and other health care providers are prescribing psychotropic medications for their patients and actually prefer to refer those individuals to psychologists for treatment, including assessment, possible psychotropic medication prescription, and treatment.

a. The number of visits to general physicians in which psychotropic medications were prescribed increased from 32.7M to 45.6M from 1985 to 1994. (The proportion of such visits increased from 5.1% to 6.5%). Should general physicians prescribe in this way? Do they have adequate training to diagnose mental illness? Are they spending sufficient time with patients who present with psychological distress?

b. The federal government, aided by medicine and the pharmaceutical industry, has been advocating for medicating as the primary treatment for mental and emotional disorders by primary care physicians. These physicians have little or no formal training in empirically-based mental health treatments, with the exception of continuing medical education about depression that is usually provided by drug companies.

c. By the year 2020, depression with psychological etiology will be the second leading cause of the non-fatal disabling effects of disease. (Depression currently accounts for 47% of the effects of physical disease and injury.)

2. Individuals usually seek help from primary care physicians when experiencing physical, social, or emotional changes and/or discomfort. Primary care physicians have limited training in psychiatric diagnosis and little training in modern psychological treatment strategies and techniques. Many are uncomfortable making psychiatric diagnoses and tend to ignore or minimize symptoms of mental distress. It is not uncommon for them to attempt to explain symptoms as being solely due to a physical problem.

3. Psychologists have extensive training in biopsychosocial assessment, standardized diagnostic procedures and a wide variety of techniques and skills for the treatment of mental and emotional disorders. Psychologists have learned these fundamentals for providing effective services through an intensive graduate program leading to a doctorate in psychology, as well as an internship and post-graduate experience. The depth and scope of training for psychologists in the mental health and the psychological aspects of disease exceeds that of other health professions.

4. Training in the physiological aspects of mental and behavioral disorders is a part of doctoral-degree programs in psychology; APA accreditation and the psychology state licensure examination require demonstrated baseline competence in the biological, psychological and social bases of behavior.

5. A 1992 survey of hospital-affiliated psychologists indicated that 64% of the respondents already collaborate with physicians regarding psychotropic medication dose, type or toxicity and 41% provide follow-up documentation on the efficacy of the psychotropic medications.

6. Many other non-physician providers who have the legal authority to prescribe include, for example, dentists, podiatrists, advanced nurse practitioners, nurse midwives, optometrists, and physician assistants. In 1997, there were over 160,000 Advanced Nurse Practitioners who were either prescribing or utilizing psychotropic medications in their practices in all 50 states. Psychologists are already prescribing in certain federal programs. They are prescribing informally in other non-governmental settings. This shows that one does not have to attend medical school to learn how to prescribe competently and successfully.

7. Because psychologists will have the ability to prescribe medication does not mean that medications will always be prescribed for their patients. The psychologist may determine that other treatments are more appropriate after she or he is able to complete a comprehensive assessment. Physicians, on the other hand, use medication therapy as their customary and primary treatment intervention. Therefore, if a depressed patient visits a primary care physician, they are likely to be prescribed an antidepressant. If this same patient visits a prescribing psychologist, other equally viable treatment options excluding, or in addition to, antidepressant therapy will be considered. It is important to remember thatthe authority to prescribe is also the authority NOT to prescribe.

8. Psychologists in health care are already practiced in recommending and monitoring psychotropic drugs and serve as an important resource for primary care physicians in their prescribing practices. It is logical to progress to the next level and train psychologists to prescribe independently.

CRITICAL ARGUMENTS AGAINST RxP

Many of the compelling arguments for the aggressive pursuit of RxP have been offered. Several arguments opposing RxP have also been advanced and they are detailed below. These opposing arguments have not been ignored or dismissed. Listed below are some of the common sentiments that have been expressed against RxP, as well as counterpoints to supplement the pro-RxP arguments already outlined in this document.

Argument #1:

?If psychologists want to prescribe medication, they should go to medical school.?

Counterpoints:

A. Psychologists are highly trained specialists in mental health who can be trained to prescribe psychotropic medications, thus utilizing the psychologist?s ability to deliver services that span the full range of mental health services.

B. Psychologists obtain a high level of competency through an extensive education and training process. This normally entails an average of seven years of education beyond the undergraduate degree in a comprehensive academic program that includes practical training experiences and didactics.

C. Almost all states require 1 to 2 years of supervised post-doctoral experience for the granting of licensure.

D. Clinical psychology students receive extensive training in the physiological aspects of mental disorders. In fact, APA accreditation standards require coursework and demonstrated competence in physiological bases of mental disease.

E. The Association of State and Provincial Psychology Boards, which monitors and oversees all state licensure examinations, requires knowledge of common physical disease symptoms and psychophysiology, as well as the effects of major psychotropic drugs and other commonly prescribed drugs on behavior and cognition.

F. Psychology?s recognized competence in the medical and psychological aspects of illness is exemplified by the fact that over 3,000 psychologists are employed on medical school faculties where they participate in a range of health psychology activities, including teaching psychopharmacology courses!

Argument #2:

?Psychologists will become greedy pill-pushers. Prescribing will change the nature of the profession, causing psychologists to quickly write prescriptions and abandon our important psychological model of treatment.?

Counterpoints:

A. Many psychologists are currently informally prescribing medications when they consult with physicians and psychiatrists about the treatment regimens of mutual patients, which includes the use and effects of psychotropic medication.

B. Psychologists have demonstrated that their expertise in treatment allows patients to regain functioning with fewer medications and lower dosages of medication, thus dispelling the fear that psychologists will ?forget their skills? and become ?pill-pushers.?

C. Training in RxP is reserved for licensed psychologists who have been practicing for a minimum of 5 years after the granting of their degree and license. This is to ensure that the new psychologist has sufficiently solidified their professional identity, operating from a well-developed psychological model of intervention.

D. RxP clearly supports a psychological model of prescribing, not a medical model of prescribing. Practice and prescribing according to these two models is philosophically and fundamentally distinct. Psychology views the individual and prescribing from a biopsychosocial framework, whereas medical practice and prescribing focuses on identifying disease and eradicating it.

E. Psychology has a strong identity and it can withstand and flourish with this additional tool for practice.

Argument #3:

?Liability insurance premiums will increase drastically and those who do not prescribe will have to pay higher rates to compensate for those who do prescribe. Doesn?t the likelihood of mis-prescribing increase when psychologists, not physicians, prescribe??

Counterpoints:

A. Over 70% of psychotropic medication in the United States is currently prescribed by non-psychiatric physicians who have minimal training in the detection and management of mental and emotional problems. Psychologists are much better trained and equipped to accurately diagnose and treat mental disorders.

B. Insurance premiums are rated based upon experience. The prescribing experience of Optometrists, Advanced Nurse Practitioners and Physician Assistants demonstrates that non-physician prescribers are as safe as physicians. Therefore, their premiums have not increased and are currently less expensive than the present liability rates for psychologists. Psychologists who oppose RxP fear substantial increases in liability insurance premiums. When medication is prescribed judiciously, as Optometrists and other non-physician prescribers have shown, there is no significant increase in premiums.

Argument #4:

?The education community has not been sufficiently consulted about the RxP scope of practice expansion. Are there going to be mandates to change core psychology curricula to adjust for RxP? Will the fundamentals of graduate psychology training suffer, or will more core courses be added, thus extending the duration of doctoral education??

Counterpoints:

A. The following education/training constituency groups have provided specific input in the development of the RxP movement: Board of Educational Affairs, Board of Scientific Affairs, Division 12 (Clinical), Division 22 (Rehabilitation), Board of Professional Affairs, Committee for the Advancement of Professional Practice, Board of the Advancement of Psychology in the Public Interest, National College of Professional Psychology, APA Council of Representatives, and the APA Board of Directors. Additionally, RxP issues have been included on several cross-cutting agenda items during many sessions of consolidated meetings where several APA constituency groups gather simultaneously to conduct their business meetings.

B. The overall quality of current education of psychology students is valued, important and will not be compromised. However, in some academic settings, the training is dated and practitioner students are not being adequately trained to thrive in the current marketplace. Education should evolve as the field evolves, while preserving the fundamentals of psychology education.

Argument #5:

?Are we just adding RxP because we fear that psychology is losing its distinctive identity to master?s trained individuals? Why should psychologists prescribe if we already have a good relationship with, and accessibility to, psychiatrists and physicians? Will the field begin to devalue psychologists who do not prescribe, thus phasing these psychologists out of the field??

Counterpoints:

A. RxP is an additional tool for psychologists use and it is not intended to replace the unique services that psychologists already deliver.

B. Psychologists already specialize with different populations, diagnoses and treatment approaches, and each specialty area is a respected sub-field of psychology.

C. Certification, not licensure, for RxP extends the current scope of psychological practice. It does not replace it.

D. Psychiatry has historically attempted to obstruct the evolution of psychology. For example, between 1950 - 1970 psychiatrists argued that it was unsafe to permit psychologists to practice outpatient psychotherapy without medical referral or medical supervision. Psychiatry also attempted to prevent psychologists from access to specialized training in psychoanalysis. They also opposed the psychologists? ability to treat patients in hospital settings and Skilled Nursing Facilities. And, psychiatrists unsuccessfully fought to defeat measures that now allow the elderly direct access to psychological care under the Medicare program (OBRA).

I was on call last night, hence my absence from this form. I still firmly believe the bill passed in louisiana was well beyond the scope of what psychologist should be allowed to do. Furthermore, the fashion in which that bill was passed was sleazy at best. The DoD like I have said in the past is a very, very small study of very selective psychologist and should not be extrapolated to include all psychologist. The study is not significantly powered and if it were a medical study would be at best lightly regarded. Furthermore, the military is biased and the study should only be taken with a grain of salt. Argue what you may, but even in the study psychologist were at best at the level of a 2nd or 3rd yeat resident. We had our residency meeting today and out of 7 attendings and 18 residents not one agreed with psychologist gaining prescription writing priviledges. We all have grave concerns and are currently composing a letter to the APA, governor Blanco, and everyone else who will listen. Argue what you may, but you have to agree the bill in Louisiana was poorly written and goes to far to fast. Let's also agree that psychiatrist have much more clinical training than psychologist, on averge psychiatrist graduate with a minimum 35,000 clinic hours. A good psychologist will be lucky to obtaing 1/8 of that in their training. Once again there is a great need for psychologist, but perscribing is a mistake. Again I am not naive and I am aware of turf wars and I am greatly concerned about the dumbing down of what is already considered fringe medicine. Furthermore, I am very aware that when psychologist start prescribing the will be much cheaper then the real deal those driving down reimbursements to psychiatrist. I can not afford to make much less then what current psychiatrist make. I did not go through all of this to have my family and I to struggle, we have struggled long enough. I always be very generous with my time and money, but I am not a martyr. Thankfully I worked very hard through medical school and performed extremely well academically making it easy to obtain an emergency medicine residency. Thus I will be switching as I am sure other psych residents will. The decision to grant psychologist prescription priviledges will have extreme detrimental effects on psychiatry in the near future. I believe psychologist gaining prescription priviledges is inevitable not because they are good at it but because they will be much cheaper at it. This move may be heavily dictated by healthcare costs as opposed to need. This is truly sad, the worst part is listening to people (psychologist) bash psychiatrist who are usually some of the lowest paid most altruistic physicians. Again there is no comparision between the level of a psychiatrist training and that of a psychologist. Finally, SVAS I don't believe you are a psychiatrist. I am not arguing with you and you don't have to defend yourself. If you are a psychiatrist I am sure you don't feel the need to prove it to a 1st year resident like myself that just switched to EM. I agree some changes need to be made to the psychiatry residency format, but for the most part I think psychiatry residencies are appropriately structured. Overwhelming every resident I talk to whether it be IM, Neuro, EM, etc... don't see psychologist writing scripts autonomously as the answer. Everyone one would like to see more psych spots open up and the residency freeze to be lifted by the governement. There are better ways to get help for rural areas then provideing substandard care. Finally, I am proud to be a physician. I ran a code last night in which the patient was awake talking to me in V-tach, then V-fib losing conciousness. And yes SVAS I can read a 12 lead and rhythm strip. I ran the code shocking him multiple times as well as ordering amiodarone and epi, as I intubated this poor 51y.o dude. He survived and is alive without cognitive deficit and went to bypass this AM. I also admitted 5 patients (light night) and had to deal with a DKA, several low BP's and low Hgb's as well as the usual agitation. I am a well trained physician and I can confidently say there is absolutely no comparision between a psychologist and a physician.

Argue what you may, but even in the study psychologist were at best at the level of a 2nd or 3rd yeat resident.

What level of resident status would a psychiatric NP achieve? Are you willing to say that NP's are functioning at at 4th year level? 3rd year? 2nd? Do psychiatric NP's have a clinical psychologists background, training, experience, and skill at making mental health diagnoses?


Just random thoughts.


S

Great posts everyone. I'm curious though. Someone mentioned that even if all psychologists were granted prescription, demand would still outweigh supply. I assumed we were just talking about the clinical psychologists becoming medical psychologists. Don't forget, that there are many sub-divisions within psychology, with clinical accepting the fewest each year. Would the clinical psychologists even make a dent in the current demand? Should other psychologists be granted that kind of power?
One final thought. I can see their being an entire backlash against white collar professions and higher education in general. What's the point of entering into a profession with no guarantee to be rewarded for all of your hard work and financial investment. It seems that way in the health profession and others such as the legal profession too. I know many people who went to University and then went back to college or entered into a trade. My landlord, who owns 12 houses was a mechanic. He is retired and enjoying everyday. My neighbour, a doctor still works 12 hours a day at the age of 70 (amazing), and has finally payed off his house. What the hell is going on here?

Interesting website:

http://www.rxp.info/

This one made me laugh out loud at least 5 times:
It's a good example of how the RxP psychologists are thinking...

http://home.fuse.net/schafer/prescrib.html

The TRUTH

About AAAPP

--------------------------------------------------------------------------------

The American Association of Applied and Preventive Psychology is a scientific Association with over 500 members worldwide. :laugh: The purpose of the Association is to promote, protect and advance the interests of clinical and preventive psychology in science, professional application, and other means of improving human welfare. We strongly value a research orientation toward clinical as well as preventive work, and placing the consumer and public interest above guild or personal interests. The Association publishes the Journal Applied and Preventive Psychology: Current Scientific Perspectives.

The AAAPP is a fringe group in psychology due to views so extreme that they became a spinoff of the American Psychological Society (APS), which in turn separated in 1988 from the APA in order to promote the academic-research dimension of psychology as the APA began to promote the clinical-applied dimension.

As the APS and the APA reconciled through the 1990s the more extreme element, increasingly losing acceptance in psychology (both in academic-research and clinical-applied circles) became the AAAPP.

AAAPP: 500 members
APS: 13,500
APA: 150,000

The GOOD NEWS

Finally, we can ALL agree that at least some psychologists (AAAPP) should not get RxP :p

I will post a very personal post now, so take it with a grain of salt...it is just a skewed and biased personal perspective.

I am utterly depressed (except by your youthful energizing optimistic enthusiasm, Anasazi! I really wish there would be more of you in the real-world practice, but since there are so few psychiatrists around anyway, the chances are pretty slim to find the rarely optimistic one around!). This whole discussion, many of the propagandistic links posted (either pro or con) reveal such corruption and such disregard for public safety, for the very "primum non nocere" concept, that it almost seems to be either institutionalized or even maybe done purposefully...the only conclusion that a casual observer will derive is that the "learned people" are arguing with one another like pompous fools over money while the patient is dying. This is nothing new, of course. I thought the age of Moliere in Medicine/Health-care was dead. But no...it's well and still alive, albeit somewhat dumbed-down, because more people actually want to wear the pompous fool hats too and fight over money and a piece of the pie. Not that I blame anyone. The incomes have realistically gone down across the board and it is increasingly difficult to maintain an income level via private Practice or even via a salary (compared to the late 80's, early '90's) by practicing ethically and judiciously. You either practice the "high quality way", the old fashioned way by allowing LOTS OF TIME for both evaluating/treating patients and reading/continued education for yourself, or you don't. The high-quality way (the artisan way) will clearly be unable to "compete" income-wise with the low-quality-mass production way...since it seems that this concept is now FULLY applied to health-care. The proponents of the assembly line model say that they are "modernizing" the field. The opponents say that this means "death for Medicine as we know it".

Personally, I am one of the ones who are still struggling, with great difficulty, to make a living as one of the artisans. It is quite evident to me that I don't earn even the median income by my way. I just earn enough to support myself and my daughter who is in college. I will continue to work the artisan way because it's the way that makes me feel the most comfortable, ethically and personally, and allows me to be in control and have a life too. But THIS IS increasingly a very "unproductive" way to earn a living, in the current health-care market situation, within this health-care system. My patients are mostly poor/impoverished themselves, by virtue of their illness, so I don't really expect to get loads of money from them. The VERY few patients who do have the ability to pay have long been already "captured" by my "older" more established colleagues. Plus the economy is pretty bad. Who has the money to pay me my current rates? Practically no one.

So, in a depressing way, SVAS, who has joined the mass-production "forces", may be actually right. You want mass psychiatry, you want to earn a living, to support a family, to pay your debts...that's what you get. The artisan skills are seemingly of no value in today's marketplace. This is why IT IS depressing. And I'm not getting into the subject of how bad the PATIENTS have it. The overall quality of care from the point of view of the patients is abysmal. There is no access, there are no services, there are no competent/well-trained professionals available for them. And the saddest part is that our patients, especially the children, are really disenfranchised. They have the least of voice, of clout, of power... to be heard.

From a personal point of view, I have made my peace with myself, I recognize my limitations, I only take on as much work as I can handle, I don't have grandiose aspirations that I can solve the "state of Psychiatry" or of "public Health". It's a hard and rather arduous road. I wouldn't necessarily recommend it to my child...not that she was ever even interested in any field of Medicine.

I TRULY HOPE THAT I AM WRONG. I TRULY HOPE THAT THIS DEPRESSING POINT OF VIEW IS JUST A SKEWED and BIASED INDIVIDUAL ONE. My personal experience does NOT necessarily describe well the current reality. You know why I even came here? JUST TO GET SOME HOPE, from younger colleagues, like Anasazi. And Anasazi, I want to thank you, because your posts have been like cool water to a fevered brow to me. YOU ARE INDEED A HEALER, WORTHY OF YOUR PROFESSION. If I ever needed a psychiatrist for myself, I would choose Anasazi and I would pay him whatever money I had just to be treated by him. Because SVAS, although he may be "right" from a business point of view, or even a Public Health point of view, has stopped being a healer a long time ago. And I can fully understand why. I don't blame Svas. But he DID DEPRESS ME. And he says he is a TEACHER too. Most depressing.

Hi PsychMD,

Change is often very scary for both patients and those who treat them.
Change represents a loss of the familiar, even when what was familiar was impoverishing in some ways.
A loss that is interpreted as self-diminishing may lead to depression.
With patients suffering due to loss and struggling with depression I attempt to help them overcome polarizing and catastrophizing patterns of thinking; to see in change not just loss but also opportunity for gain.
I agree that current changes in mental health (psychologists gaining RxP) will result in status and financial losses to psychiatrists.
I believe that the unjustifiable discrepancy between psych PhD/PsyDs earning about 40% of what psych MD/DOs earn (in Miami, median income for psychologists is 55K and for psychiatrists 135K) is coming to an end.
I also believe that the artificial division in mental health between psychiatrists providing med mgm and psychologists doing testing and therapy is also coming to an end.
For psychiatry these are losses BUT they are also opportunity for gains.
Maybe psychiatrists will once again truly become psychotherapists as well as psychopharmacotherapists.
Maybe they will no longer adhere to the 30 minute psychiatric med eval and 15 minute med check every 30-60 days.
Maybe this change can become the catalyst for psychiatrists to again practice as artists-scientists and not as minions of mangled healthcare.

Maybe I'm naive, but I see a bright future for mental health.
A future where clinical psychiatrists and medical psychologists both make a reasonable living but where making money is not the driving force of their practice; where both are providers of biomedical and psychosocial interventions; where both can champion the biopsychosocial model with physicians and other practitioners; where both work collaboratively with neurologists and neuropsychologists in an increasing understading of the mind-brain connection; where guild monopolies and turf wars are replaced by genuinely compassionate, comprehensive, and collaborative patient care.

Its a future that is possible. Its up to us to make it so. Peace. :)

Because SVAS, although he may be "right" from a business point of view, or even a Public Health point of view, has stopped being a healer a long time ago. And I can fully understand why. I don't blame Svas. But he DID DEPRESS ME. And he says he is a TEACHER too. Most depressing.

I really do understand your frustration. I apologize for making your experience about practice more difficult. That's not my intent. It is, however, my intent to attend to the sweeping numbers of patients that we are *not* treating. We are caring for a minute percentage of the mentally ill population and we can't pat ourselves on the back for that.

Psychiatrists, in general, provide good care. But we provide good care for such a small fraction of the mentally ill that we often forget that there is a massive tidal wave of people NOT being treated, or being treated by people with only a 6 week rotation through psych. The mentally ill are procreating just like everyone else, resulting in an ever increasing number of people with psychological difficulties. We are, in contrast, a diminishing number, with residency number paling in comparison with the task of taking care of such a wave. We have to do something different.

This is not about my making an adaptation so that I can make more money. (Personally, that suggestion is insulting, but I know that your comment was not borne from that attempt, but a reflection of your frustration. At least that's what I'm hoping.) My suggestions to adapt to psychology's desire to add prescriptive authority comes from my belief that psychologists are doctors too. They've got high level skills and can be trained to prescribe within a limited formulary safely.

The impact of adding such a large contingent of knowledgeable providers to care for a broader range of mental health conditions is very exciting. To ignore the suffering of the tidal wave I've discussed above while standing on our very unstable soapbox . . . now that's depressing.

S

4. Should the PDP be emulated? There was discussion at many sites about political pressures in the civilian sector for prescription privileges for psychologists. Virtually all graduates of the PDP considered the "short-cut" programs proposed in various quarters to be ill-advised. Most, in fact, said they favored a 2-year program much like the PDP program conducted at Walter Reed Army Medical Center, but with somewhat more tailoring of the didactic training courses to the special needs, and skills of clinical psychologists. Most said an intensive full-time year of clinical experience, particularly with inpatients, was indispensable. The Evaluation Panel heard much skepticism from psychiatrists, physicians, and some of the graduates about whether prescribing psychologists could safely and effectively work as independent practitioners in the civilian sector. The usual argument was that the team practice that characterized military medicine was an essential ingredient in the success of the PDP that could not be duplicated in the civilian world. The Evaluation Panel urged the graduates collectively to produce their own consensus view on what would constitute an optimal program.

It seems that the new law in LA requiring only 380 hours of classroom time on weekends without an intensive year of full time clinical experience falls far short of what the Psychologists in the DoD went through. Let's not forget the sample size was only 10! :scared: And only a limited number worked "de facto" independently while most had oversight with a limited formulary. The LA law gives an almost unlimited formulary (exceptions being narcotics I believe). And, that link that Anasazi posted where Dr. Schafer brought up a good point: The variability in the quality of PhD graduates. I received a spam email today advertising my new PhD in Psychology or Engineering, or whatever. Who's to prevent them from attaining RxP? :eek:

I'll be entering Psych residency in June and was pretty "psyched" about it. My question to some that are going through residency now or have finished and are practicing, what would you do in my position? I'm seriously considering entering FP or IM after my PGY1. I really wanted to do Psychiatry but I have massive loans, and a new wife that would like to start having kids before she's 40. All the hard work and sacrifice we've gone through, is it worth risking spending the next four years in Psych residency with the potential of not being able to make enough to pay back my loans? :(

I'm seriously considering entering FP or IM after my PGY1. I really wanted to do Psychiatry but I have massive loans

So, this is one person confirmed to be quitting his psychiatry residency, and another who is considering leaving.

I'm glad to see that the psychologists' push for Rx privilages is resulting in "increased access to mental health care."

Please stick with it. Be a good physician. Be a good psychiatrist. Psychiatry has endured worse and will remain despite this. The money will come if you're doing what you truly love and what you're best at.

Good luck.

Thank you for your input and optimism Anasazi. I hate sounding like it's all about the money, but obviously I need it to survive, pay loans, and start a family. I do have to wonder how Psychologists will make it when the mal-practice lawsuits start rolling in. Maybe economics will control what naive politicians can not. Unfortunately, some unlucky patients will suffer or die from this "experiment", but it's out of our hands.

Dr. Focker

I presume Mr. Gaylord Focker :-). There are many phenomenal fields of medicine. Ultimately you have to love what you do. I truly love medicine and can't imagine doing anything else. But my number one priority is my wife, family and friends. No matter what I do in medicine it will never be as important or as fun as what I do in my personal life and free time. I can not imagine entering a field with so much uncertainty. I am $200,000 in debt. With my wives optometry school debt we will be almost $350,000 in debt. I can not afford to make less than $100,000/yr, especially since my wife and I are going to start a family soon and she will be taking a lot of time off. I am 30 y/o, drive a 92 ford ranger, and haven't been on vacation in over 2 years. I grew up in the hood and I am still struggling today. I am not complaining because I truly have a great life. My wife is an angel and I am surround by many amazing friends, I have truly been blessed. However, you get the point, I need and want to start living my life and that requires a certain amount of financial freedom. I bought new furniture last week for the first time, pretty exciting. If I am one of the top earning physicians I am doing something wrong, either working too much or commiting fraud. My advice is to look around and find something you'll love. My fear with psychiatry is that the field is much my financial strained than other fields because crazy people don't make money and nobody wants to pay for them. Psychologist can rationalize it how they want but they don't have appropriate training to prescribe medications. Rememer all the tough classes you took as an undergrad always getting the best grades, studyig for that God forsaken MCAT, and all those interviews. I had a double major in Bio and Chem 3.85, scored a 28 on the MCAT and didn't get accepted the first time I applied. Got a masters degree, retook the MCAT scored a 31 and then got accepted. Then went through the rigors of medical school. Don't let anybody kid you the vast majority of psychology programs are not nearly as rigorous as medical school. Remember the 3 sets of boards you had to pass I find it insulting to here psychologist compare themselves to psychiatrist. Truth be told there are some bad physicians that skated through medical school, so there is that tail end on the class, but the tail in psychology is much, much, much longer. Soon enough psychologist will get what they ask for and then they will misdiagnose and kill patients. Medicine is very difficult, prescribing medications is very difficult. Mentally ill patients get pregnant, have renal failure, cardiac dz, are diabetic, etc... all of this has to be taken into consideration when prescribing. Without indepth medical training you can not truly appreciate the complexities of medicine. Medicine is changing and all fields have pro's and con's, I wish I had good advice for you but everything is uncertain at this point. If anyone offers "good advice" be suspicious. Do what's best for you. Ultimately I felt emergency medicine would be best for my wife and I, I still get the oppurtunity to help people in a meaningful way while earning a comfortable living with a nice lifestyle. Although that my change soon as well.

So, this is one person confirmed to be quitting his psychiatry residency, and another who is considering leaving.

I'm glad to see that the psychologists' push for Rx privilages is resulting in "increased access to mental health care."

Please stick with it. Be a good physician. Be a good psychiatrist. Psychiatry has endured worse and will remain despite this. The money will come if you're doing what you truly love and what you're best at.

Good luck.

Two states give psychologists RxP and the entire field of psychiatry is now doomed. Is it really that bad? Psychiatry has been the bastard stepchild of medicine for years, and only recently, with increased medicalization and reliance on psychopharmacology, has the field become more integrated with other areas of medicine. Keep in mind that most psychologists have stated that they will NOT seek RxP (time will tell). As Anasazi opines, psychiatry will survive, and psychiatrists will continue to treat a range of patients, perhaps even collaborating or sharing practices with "medical psychologists." Arguments about "patients will die!" and "it's not safe!" aside (who's to judge?), maybe allowing psychologists to prescribe under the supervision of psychiatrists may actually be a good move for psychiatry insofar as it will increase the numbers of patients who will have access to behavioral healthcare, reduce time to appropriate evaluation and treatment (indirect suicide prevention in some cases), and ultimately foster the development of integrated pharmacotherapeutic and psychotherapeutic treatments?

Hmm, it seems to me that giving psychologists prescribing privledges won't really reach out to the people who are really underserved. I'm talking about the chronically mentally ill, who flood the state system, and whose medication needs (psychiatric AND medical) are probably too complicated for most psychologists, and maybe even psychiatrists who don't have a strong medical background.

Most of the psychologists I know work with fairly monied "clients...." Do we really need to give more prozac to these people???

Dr. Focker, I can empathise with your concerns. Psychiatric practice is hard. But, as I've said before somewhere, this is most likely just a tip of the iceberg or a mirror re. other systemic problems re. health-care in our country. I will post here a copy from a colleague surgeon's post (from another website dedicated to interaction among practicing physicians from different specialties; it is a site with restricted access for MD/DO only which requires licensure verification for access, and it is amazingly good re. interaction with colleagues from different specialties...quite amazing, considering that today we are pretty "fragmented" among different specialties, and inevitable turfs, in the "real-world"):

"...don't despair afterall, it is not just psychiatry that is in a mess. I believe, all of medicine (include surgery) is in a mess. Surgery has splintered off in multiple diretions. Volumes of procedures falling to new interentional procedures and GI and other medical therapies. Many a times it is purely a turf war rathr than what is really good for the patient. Gimmicks have replaced well founded accepted practices. News flashes and Media reporting counts more than peer reviewed works. Many many academicians (use the word loosely) have chosen to go to their local TV station rather than their respective society journals for publiction of their work no matter how terrible it may be. Oh well, I have to run off to the O.R enough of my rant for today".

Dr. Focker, even if you are not inclined towards a surgical specialty, the "grass" is not always "greener" for other specialist colleagues either. It is hard not only for recently graduating residents, but also mid-career physicians who are primarily doing ANY clinical work at this time, especially hard for FP, IM, Peds too, not just Psych. or Surgery.

Obviously, as an individual, your primary "duty" is towards your own well-being and your family's well being. (see theTHRILL's post; BTW, theTHRILL, I personally think you are and will be a wonderful physician; your posts reflect the exact qualities which make our profession proud: well trained, compassionate, motivated, inquisitive, pro-active, always keeping the patient's best interest in mind; be proud of your training and career, no matter what specialty you will choose, you will do great; this is quite evident from your posts).
Most physicians, by virtue of their tradition and training, also feel great responsibility towards their profession AND toward their colleagues, AND their teachers as well, REGARDLESS of specialty. This is the old "Hippocratic" way, I think. This is the primary bond which still unites physicians at this time, in spite of the economics of health-care, or health-care policy/politics. The more recent "acute" conflict is occuring, it seems, since physicians who once exerted (or at least thought they could exert) some degree of control/influence over the profession, or over health-care policies, in general, feel at this time that they no longer have this degree of control/influence, at least not at national level. It was bound to happen, historically, at some point or another. So these are most likely historical/economical trends. But if the Hippocratic "message" has survived for so many centuries, and has apparently survived MUCH worse "Academic" infighting that we see now, it has survived scourges, plagues, wars, revolutions, economic downturns, the industrialization era, etc....I sincerely believe that it won't go down the drain so soon, at least not during our lifetimes, and will most likely survive beyond the "corporatization of health-care" era as well, I hope! So the ESSENTIAL message is POSITIVE. :)

Thanks for the insightful perspectives Psych MD, quixote, and thethrill. Obviously, the overriding theme is that all of medicine is changing for better or worse. I, like thethrill, have $200,000 in debts and about all I have to show for it is the clothes on my back and a 98 Honda with almost 200,000 miles on it. I can't conceivably pay off that debt, start a family, and buy a house/car without making over $100,000/year either. I guess I'll have to just stick with Psych in the hopes that everything will work out for the best. Psych is what I want to do and there seem to be similar problems happening in all the specialties. I'll hope for the best, but if worse, comes to worse and I can't make a living as an MD, there is always law school. :eek:

Damn...everyone took off their gloves. Have we debated all the issues related to psychologist RxP?

Anyone have information regarding which other state(s) besides New Mexico and Louisiana are closest to allowing psychologists to prescribe? I have heard that New England will be toughest because of persistent lobbying by the AMA and American Psychiatric Association in this region. Is the same true of other regions of the country?

"Rememer all the tough classes you took as an undergrad always getting the best grades, studyig for that God forsaken MCAT, and all those interviews. I had a double major in Bio and Chem 3.85, scored a 28 on the MCAT and didn't get accepted the first time I applied. Got a masters degree, retook the MCAT scored a 31 and then got accepted. Then went through the rigors of medical school. Don't let anybody kid you the vast majority of psychology programs are not nearly as rigorous as medical school. Remember the 3 sets of boards you had to pass I find it insulting to here psychologist compare themselves to psychiatrist. Truth be told there are some bad physicians that skated through medical school, so there is that tail end on the class, but the tail in psychology is much, much, much longer."

Could you psychiatrists on this list please distinguish the issue of whether psychologists should have the right to prescribe from your illusory beliefs of psychologists as a lesser species that is by definition less intelligent than someone in psychiatry!!! It is actually quite difficult to get into a quality graduate program in psychology (I am ignoring the psychology paper mill schools here), since the good schools will accept 3 to 8 applicants from a pool of 500. We get far superior training in research methods than psychiatry residents do. Based on reading this thread I could conclude that psychiatrists are defensive and have a superiority complex, but I won't given the small and selected sample you represent. I am not surprised that you have difficulty relating to other non-physician mental health professionals given the preconcivied notions you hold onto so strongly.

Alright! Lazure put his gloves on! Any psychiatrists care to get in the ring?

Ok I'll bite.

Could you psychiatrists on this list please distinguish the issue of whether psychologists should have the right to prescribe from your illusory beliefs of psychologists as a lesser species that is by definition less intelligent than someone in psychiatry!!!
No, silly us...
We feel that you should prescribe after undergoing training in medical school and residency where you learn about human disease, pharmacology (not just psychopharm but those other annoying drugs from about 700 other classes) and other nonsensical things like pathology, microbiology, ob/gyn, cardiology, pulmonology, gastroenterology, etc, etc, etc. By your definition, everyone who is intelligent should be mailed a prescription pad and DEA number to better society.


...We get far superior training in research methods than psychiatry residents do.

That's nice.

...and psychiatrists get far superior training in things that directly effect patient outcome - knowledge of medicine.

You state that psychiatrists have a superiority complex. Perhaps.

I propose that psychologists are attempting to expand their scope beyond its britches due to what I perceive as their inferiority complex (which I strongly feel it is). If the answer to this is also "perhaps," then that is very, very bad for patients.

Psychologists serve an important role on the mental health care team. No one disputes that. That role, however, has been refined over time and was filling a niche that suited them, and patients, well. They are attempting to blur the lines between physician and psychologist. This is about their financial greed, personal greed, attempt to solidify the future of the profession, and desire for parity - not patients.

To believe otherwise, I feel, is naive.

http://pn.psychiatryonline.org/cgi/content/full/38/8/1-a

http://www.psych.org/news_room/press_releases/20040506APADeploresLouisianaGovsDecisiontoSignPPBi ll.pdf

http://pn.psychiatryonline.org/cgi/content/full/39/10/3

http://pn.psychiatryonline.org/cgi/content/full/39/10/1

I used to oppose the idea of any psychologists prescribing medication, but I'm sorry to say I've changed my mind after my (unfortunately somewhat extensive) experience with med-school faculty psychiatrists.

I know there are exceptions, but the intelligent and well-regarded psychiatrists I have seen for depression (and many I have heard about from contacts) seem to have learned everything they know about statistics and neurochemistry from drug company reps. (or Stahl's psychpharm comic book, which is almost as bad).

Ph.D psychologists have extensive statistical training, and would be able to recognize that most of the "studies" done by drug companies are clinically meaningless. They have real research training and would likely demand real, independent studies of drug efficacy and side-effects.

Surpassing most psychiatrists' knowledge of psychpharm and neurochem is simply a matter of reading *The Molecular Basis of Neuropharmacology* by Nester et. al. I don't think it's uncommon for Ph.D psychologists to study much harder books like Cooper and Kandel.

In short, I feel that psychiatrists have dropped the ball in a big way. The closer one looks, the more painfully obvious it is that the profession is merely a distribution channel controlled by the pharmaceutical industry.

Unless psychiatry raises its standards, establishes scientific credibility, and regains its professional independence, it will become increasingly irrelevant to the real business of caring for the mentally ill.

I think everyone would be better off if they just decriminalized marijuana. Seriously, these wonder drugs are hype. 3% above placebo. Junk. I felt depressed once and Celexa did nothing. A little marijuana worked wonders. From what I hear the various sacred cacti(mescaline) can really heal the soul too. Those Indians were WAY ahead of their time.

Ok I'll bite.
Quote:
Originally Posted by lazure
Could you psychiatrists on this list please distinguish the issue of whether psychologists should have the right to prescribe from your illusory beliefs of psychologists as a lesser species that is by definition less intelligent than someone in psychiatry!!!
"No, silly us...
We feel that you should prescribe after undergoing training in medical school and residency where you learn about human disease, pharmacology (not just psychopharm but those other annoying drugs from about 700 other classes) and other nonsensical things like pathology, microbiology, ob/gyn, cardiology, pulmonology, gastroenterology, etc, etc, etc. By your definition, everyone who is intelligent should be mailed a prescription pad and DEA number to better society."


And of course, you missed my point entirely. I am objecting to the continued insults to the intelligence of the members of my profession by psychiatry residents on this thread. You have the full right to disagree with psychologists obtaining prescription rights given the inadequate training required. I agree with you and as a psychologist I will not seek prescription rights since if I wanted to I would have gone to med school. You and I talked about this already. But I insist that you and others here state your views without putting down the ability and intelligence quotient of doctoral level professionals. We worked our ***** off to get where we are as well....

The psychiatry folks here (or many of them at least) seem to be doing a very good job of alienating other mental health professionals by dismissing them as idiots. And then you wonder why psychiatry is no longer respected....

Ph.D psychologists have extensive statistical training, and would be able to recognize that most of the "studies" done by drug companies are clinically meaningless. They have real research training and would likely demand real, independent studies of drug efficacy and side-effects.

In short, I feel that psychiatrists have dropped the ball in a big way. The closer one looks, the more painfully obvious it is that the profession is merely a distribution channel controlled by the pharmaceutical industry.

Unless psychiatry raises its standards, establishes scientific credibility, and regains its professional independence, it will become increasingly irrelevant to the real business of caring for the mentally ill.

All excellent points. All the more reason to work together, aint it?

I agree with you that to insult the intelligence of psychologists (or any other member of a health care team) in general terms is wrong. You'll notice that I never, in any of my previous posts, made a comment about psychologists' 'intelligence quotients.' In turn, I take it upon myself to apologize for any psychiatrist who has insulted your intelligence.

Next:

I grow weary of saying this, but the above posts beg it again....
Psychopharmacology does not exist in a vacuum. Comorbid medical conditions are not, from the course outlines I've seen, adequately covered (how in the world could they be?) in these masters programs. Public Health posted a curriculum that left me wide-eyed in a previous post. It's worth checking out.

Last point: I'm not sure where the lot of other folks on this thread work or have worked - making comments like "psychiatry is the red-headed, 12-toed bastard stepchild blah blah....," "psychology is no longer respected, etc. I wish all of you could have done the neuropsychiatry rotation I completed as a 4th year med student. The knowledge level, clinical complexities, respect level and most importantly, the level of healing was incredibly outstanding. And in other psychiatric or medical institutions, if I bothered to ask, I always gained medical insight into why treatment regimens were undertaken, and for what specific purposes. On the other hand, if a glut of foreign medical grads, or some other blameable happenstance caused the psychiatrists to become what you perceive as insensitive pill pushers at your respective institutions, then I have a challenge for you.

If one were to look more closely at what psychiatrists are doing, or bother to ask why they are treating in a particular manner, you may be surprised to find that medications are not chosen via the help of a magic 8 ball or roulette wheel with SSRIS replacing red and black numbers. You may not even notice that psychiatrists have comprehensively reviewed charts, interviewed the patient, and are making what they feel are the best decisions based on their respective medical profiles, past medication trials, laboratory abnormalities or predictions, cardiac history, endocrine and kidney functioning, or any other such relevant collateral data.

Don't assume (I'm speaking generally) that because you undertook extensive training in psychological theory, testing, statistics, and the like that this entitles you to make medical decisions via the completion of weekend coursework in hotel lobbies. I challenge you to take the time to inquire as to the treatment plan with this psychiatrist. Find out their thinking. Ask for details. You may be surprised at what you hear.

All excellent points. All the more reason to work together, aint it?

That's just the point. The reading I've done on this subject indicates that it indeed "ain't" about working together, but is a battle for increased respect, autonomy, and parity.

To me, psychologists wishing to work together would have made a collaborative effort with psychiatrists to gain the ability to collaboratively prescribe psychoactive medications. They failed to do this, and to the contrary, fought against said collaborative efforts by psychiatry to oversee rxp approval. They failed to agree to prescribe in only the oft-touted mantra "underserved areas," they failed to agree to a "limited formulary." That's right, in LA, psychologists will now prescribe medications completely unrelated to the field of psychiatry. Think I'm wrong? Think that psychologists will be above this reprehensible behavior? I can't wait for the data. I'll bet my life that some psychologist will, out of ignorance or in a legitimate attempt to help a patient, attempt to prescribe a refill of a medication, or even worse, blatently prescribe a medication not considered to be within a psychiatric formulary. Perhaps they'll take data 10 years from now stating that of the 11,000 beta blocker refills they gave, there were only 16 adverse reactions. Therefore, of course, they should be allowed to prescribe all medications without supervision as long as they undergo additional training courses. After all, they ARE "medical psychologists" - another vaguely defined and misleading term meant to confuse both patients and legislators.

Be honest....how do you expect psychiatrists to react? What type of reaction would you expect from what is generally seen as a disrespectful attack on physicians that worked so incredibly hard to become the most comprehensive healer to the medical/psychiatric patient? Psychologists did not react well (and rightfully so) when psychiatric social workers gained therapy reimbursement parity or when bachelors level psychologists make a push for medicare reimbursement. Psychologists are speaking with forked tongues. They are preaching increased access to mental health care, while at the same time attempting to undermine a profession, and are using sinister tactics to obtain rights through legislation rather than education.

Psychiatric patients are not solely psychiatric patients. They are medical patients whose disease is manifesting psychiatrically. Psychiatrists are not solely psychiatrists. They are physicians trained in the specialty of psychiatry. Is this the medical model? Is it different from the psychological model? Yes. It is also the model that has been the most successful and accepted in modern treatment of both medical and psychiatric patients thus far.

To say that psychiatry needs to "establish scientific credibility" is utter idiocy. Psychiatry is what it claims to be and has been.
Medical fundamentalism? You bet. It is also the most logical and effective way to treat medical patients - which psychiatric patients are.

Psychologists are speaking with forked tongues. They are preaching increased access to mental health care, while at the same time attempting to undermine a profession, and are using sinister tactics to obtain rights through legislation rather than education.

:luck: Quote of the month. :luck:

I posted a response to non-physician groups seeking more medical privileges here:

http://forums.studentdoctor.net/showthread.php?p=1487059#post1487059

I seriously doubt about their own vested interest when people talk of about psychiatry being neglected in current medical environment. This year from my instituition 17 students matched in psych. If it's an indication of anything, psych is one of the "happening" specialties these days.
And I don't know about the "pill-popping" blame on the psychiatrists. If a certain pill can make a patient better in days rather than going thru 5d/wk therapy sessions continued over month, it should be appreciated not discouraged. That's why psychologists themselves are asking for the scripting power. ;)
And w/ all due respect to statistical training to the clinical psychologists, firstly as MDs we do get training in basic statistical methods, and in some countries to be a board-certified psychiatrist you have to complete a full paper on EBM(e.g. critical review in MRCPsych). The same thing holds true for ABPN, however not to that extreme. To what extent one needs to be knowledgable in bio-stat after graduating is a matter of personal choice and it should be left as such.
Also being educated by the drug-rep is like listening to the sales-pitch of your car dealer. Ultimately you decide what's good for you and for the patient(I heard this analogy at APA). To me it makes a lot of sense.
And these days people feel by going thru few webpages or reading a psychopharm text they can be as competent as a fully trained psychiatrist(or a cardiologist/GI whatever for that matter). They just ignore the decision making process which lies behind the med-checks. This is bad for the profession as well as the patients. There was a truth in "Your doc know better". Maybe it has gotten old-fashioned, but it did a lot of good to the people. Atleast I would not be bothered by 2 people who landed in my PES today w/ these horrible experiments of self-medication.
Just my 0.02c.

And I don't know about the "pill-popping" blame on the psychiatrists. If a certain pill can make a patient better in days rather than going thru 5d/wk therapy sessions continued over month, it should be appreciated not discouraged.

You know that there are evidence based therapies that have been reliably demonstrated to improve the functioning of patients with depression, anxiety etc. CBT ring a bell? IPT? Similarly, CBT has been used to increase med compliance in individuals with bipolar disorders. While I respect the need for pharmacological treatment for some individuals, I believe that psychiatrists such as you discount psychotherapy while ignoring the empirical evidence.

we do get training in basic statistical methods

yet the concept of effect size appears to elude you when you read the results of drug company studies .... It is easy to show a significant difference between group means with a sample size of 2000.... you know that a small but significant difference is not necessarily clinically significant. The suicidal patient on drug X now thinks of suicide 9 times per day rather than 10. Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????

Ultimately you decide what's good for you and for the patient(I heard this analogy at APA). To me it makes a lot of sense.

But what is the quality of the science you use to make the decision?

Evidence based psychotherapy such as CBT teaches skills to prevent and/or manage future re-occurances of a given disorder as well the ability to assess when further treatment should be sought. Is there evidence that pharmacological treatment alone will prevent or decrease the severity of future relapses? Or do the drug companies not sponsor long term follow up?

These are real questions and not sarcastic comments (before you jump at me).

I know we've been down this road . . . but in contrast to what psychologists are having to take to become eligible . . . I found the following description of a law in one state that enables an NP to prescribe legend drugs. This is a tad scary:

25-23-1-19.5
Advanced practice nurses; authority to prescribe legend drugs
Sec. 19.5. (a) The board shall establish a program under which advanced practice nurses who meet the requirements established by the board are authorized to prescribe legend drugs, including controlled substances (as defined in IC 35-48-1).
(b) The authority granted by the board under this section:
(1) expires on October 31 of the odd-numbered year following the year the authority was granted or renewed; and
(2) is subject to renewal indefinitely for successive periods of two (2) years.
(c) The rules adopted under section 7 of this chapter concerning the authority of advanced practice nurses to prescribe legend drugs must do the following:
(1) Require an advanced practice nurse or a prospective advanced practice nurse who seeks the authority to submit an application to the board.
(2) Require, as a prerequisite to the initial granting of the authority, the successful completion by the applicant of a graduate level course in pharmacology providing at least two (2) semester hours of academic credit.
(3) Require, as a condition of the renewal of the authority, the completion by the advanced practice nurse of the continuing education requirements set out in section 19.7 of this chapter.

S

You know that there are evidence based therapies that have been reliably demonstrated to improve the functioning of patients with depression, anxiety etc. CBT ring a bell? IPT? Similarly, CBT has been used to increase med compliance in individuals with bipolar disorders.
Sorry, I can also provide data as compared to IPT, CBT has not shown to be terribly effective. And statistical manipulations are not only limited to drug-rep studies, it is also seen in studies involving psychotx.
Also as you commented about the quality of psychiatrists, I've had my share of bad Phds-that really means nothing about the specialty in general.


yet the concept of effect size appears to elude you when you read the results of drug company studies .... It is easy to show a significant difference between group means with a sample size of 2000.... you know that a small but significant difference is not necessarily clinically significant. The suicidal patient on drug X now thinks of suicide 9 times per day rather than 10. Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????

Plz see my above response. Assuming you are not naive, people make careers out of research work, that's why they get published(and often the team involves PhDs). Again my analogy of buying cars hold true. You make an informed decision based on YOUR appraisal of the study not what the salesman says.

But what is the quality of the science you use to make the decision?
The same quality of science people using to glorify the DoD study in this forum and extrapolating their results in the community setting. It works either way.
BTW, when talking about the scripting power of psychologists, please don't give this crap of bad psychiatrists vs good Psychologists. If psychotherapy was really working miracles for pts, you guys would not have lobbied for scripting power. The pills are making $$, and you want a share of the pie. It's as simple as that, and let's keep it that way. The only loser in the game is the patient. Hopefully after few -ve outcomes(read death/disability) the lawmakers will listen to the dissenting voices.

You have the full right to disagree with psychologists obtaining prescription rights given the inadequate training required. I agree with you and as a psychologist I will not seek prescription rights since if I wanted to I would have gone to med school.

Hi Lazure, :)

Why "inadequate training required"? What is adequate training, and why?

Why associate prescription rights with med school?

The DoD project demonstrated that psychologists could be trained to function as effective and safe prescribers without going to med school.

In all 50 US states nurse practitioners function as effective and safe prescribers without having gone to med school (and in at least 11 states and DC, NPs do so with full autonomy and full formulary).

Other non-physicians that also prescribe include dentists, optometrists, and podiatrists. All do so without having gone to med school.

From your posts I gather that you highly value being a psychologist, i.e., a scientist and a clinician. Regardless of your own lack of interest in personally pursuing RxP I believe that you could contribute much to this unfolding development in the US (and soon enough, Canada). I invite you to join with those who are promoting what has been empirically demonstrated to be a safe expasion of the clinical skills of psychologists and other non-physicians and not to lend an unjustifiable air of scientific credibility to medical fundamentalism.

Peace.

That's just the point. The reading I've done on this subject indicates that it indeed "ain't" about working together, but is a battle for increased respect, autonomy, and parity.

To say that psychiatry needs to "establish scientific credibility" is utter idiocy. Psychiatry is what it claims to be and has been.
Medical fundamentalism? You bet.

Imagine, psychologists want increased respect, autonomy, and parity? Who do they think they are? :rolleyes:

Imagine, psychiatrists needing to establish scientific credibility? How idiotic! :rolleyes:

If it's medical fundamentalism to refuse to show respect for psychologists, to give them autonomy, to treat them as equals;
if it's medical fundamentalism to reject the need to establish scientific credibility for psychiatric interventions,
then I'm a MEDICAL FUNDAMENTALIST. :rolleyes:

Let me hear you all say it: Yes, YES, I'm a medical fundamentalist.
Clap those hands, stomp those feet, shout it out: YES, I'm a MEDICAL FUNDAMENTALIST!
Be gone psychologists! Stay in your place! Be gone! I said: BE GONE!!! Back to Louisiana. Back to New Mexico. Back to your therapy sessions, to your tests, to your research projects, to your university classes. BACK! BACK!!!

In the name of the APA (the little one) I said: BE GONE!!!
:laugh: :laugh: :laugh:

Enough said :(

Enough said :(

Hardly....

Imagine, psychologists want increased respect, autonomy, and parity? Who do they think they are? :rolleyes:

You miss the point entirely. Do you feel that psychologists should attack neighboring professions in order to achieve the increased respect, autonomy, and parity? If you do, then you're a psychological fundamentalist.


Imagine, psychiatrists needing to establish scientific credibility? How idiotic! :rolleyes:


I competely forgot, in the past 100 years, psychiatry has yet to publish a study demonstrating the clinical efficacy of the myriad medications, ect, fMRI findings, etc etc etc. The cat's out of the bag folks! The gig is up! We've been found out! Run!!!


If it's medical fundamentalism to refuse to show respect for psychologists, to give them autonomy, to treat them as equals;
if it's medical fundamentalism to reject the need to establish scientific credibility for psychiatric interventions,
then I'm a MEDICAL FUNDAMENTALIST. :rolleyes:


You continue to convieniently forget....the psychologists started this. Not the psychiatrists. It was they who wanted to increase their scope. Don't expect to be met with no opposition by the medical community.


Let me hear you all say it: Yes, YES, I'm a medical fundamentalist.
Clap those hands, stomp those feet................................ BACK! BACK!!!

In the name of the APA (the little one) I said: BE GONE!!!
:laugh: :laugh: :laugh:

Your cavalier attitude about anyone and their mother taking weekend internet coffee-shop Holiday Inn poolside classes with their grueling practicum of 100 patients being safe to prescribe will change when you get to med school. The scientific and clinical safetynet that is the FDA, clinical experience, medical knowledge and the like did not come to be with fly-by-night cowboy quick "accept anything new and crazy" changes to American medicine. You'll find this out eventually.

p.s. You're not the only one who knows where the "laugh button" is:
:laugh: :laugh: :laugh:

Prescriptive Authority for Psychologists: A Matter of Professional Evolution
by Saul Lindenbaum, Ph.D. and Morgan Sammons, Ph.D.

[February 1996; Vol. 23 No. 1]

Dr. Lindenbaum is President of the Maryland Psychological Association. Dr. Sammons is a member of MPA and a graduate of the Department of Defense Psychopharmacology Demonstration Project. The opinions expressed by him in this article represent his views as a private citizen.

This article will focus on three main points. First, the idea is presented that prescriptive authority is an important step in the evolution of the profession of psychology. Second, an overview of other non-physician groups that prescribe is presented. Third, a case is made for a continuation of a respectful dialogue on the issues involved, based on the many areas of common interest and successful collaboration shared by psychiatry and psychology.

It has been about 125 years since the discipline of psychology began to differentiate itself from the field of philosophy, in whose departments it was housed in a number of European universities. This new experimental science soon moved across the ocean to the United States, and the American Psychological Association was formed just over 100 years ago by a small group of academicians. Over the next 50 years psychologists began to broaden their scope, moving out of their laboratories and into industry, child guidance centers and other settings. Psychological testing became a major occupation for many, and a brave few took the radical step of beginning to do psychotherapy.

The Second World War wrought great change in America, and psychologists were not immune to these changes. Thus, about 50 years ago the ideal of the psychologist as a scientist-practitioner was born, and the profession made a dramatic turn toward psychotherapy. About 40 years ago, psychologists began to be certified by the state of Maryland, and the Maryland Psychological Association was formed. Almost 25 years ago, the state recognized psychologists as independent practitioners, and about 15 years ago, certification changed to licensing.

Clearly, this is a profession that has been evolving for more than a century, and is continuing to evolve. To take another relevant example, a psychopharmacology subspecialty has existed within psychology for many years. At this time it is a research and teaching specialty, in which psychologists study the effects of psychoactive drugs, and teach others, including medical students, about them. Many believe that an important next step in the evolution of psychology is the right to prescribe psychoactive medications, as well.

History is clear that when qualified non-physician providers seek the right to independently provide pharmacotherapy, state legislatures have allowed them to do so. Dentists and podiatrists prescribe in all 50 states. The recent successful efforts of optometrists to obtain prescriptive authority is another such example. In all 50 states optometrists have the ability to prescribe diagnostic agents, and they now prescribe therapeutic agents in 46 states. Another example is the increasing discretion given to advanced practice nurses. Nurse practitioners have prescriptive authority in 47 states. In at least four states, psychiatric advanced practice nurses prescribe without physician oversight. Certified registered nurse anesthetists and nurse midwives prescribe in many states with extremely limited oversight, and physician assistants (often with less than a Bachelor's degree) have prescriptive authority in 40 states, with varying levels of physician oversight.

Understanding the successful efforts of other non-physician prescribers should help psychiatrists and psychologists reframe what some have called a turf war between the two professions. We need to keep in mind that the piece of turf in question is relatively small. If we engage in a fierce battle over this small piece of territory, any victories are likely to be Pyrrhic, in that both professions will be damaged and other groups will be more than willing to seek control over the same terrain. Would it not be better to work collaboratively to ensure that those psychologists who do gain prescriptive authority possess the proper training?

We are encouraged by recent developments in California, which illustrate the benefits of cooperation between two previously antagonistic groups, optometrists and ophthalmologists. Optometrists in California have been seeking therapeutic drug prescription authority, and had been engaged in a long, expensive battle with ophthalmologists. Our understanding is that legislators there grew tired of the incessant lobbying from both groups, and asked not to be bothered by members of either group. As a result, optometrists and ophthalmologists sat down together, and jointly drafted a bill which will be supported by both professions during the next legislative session. The bill allows for therapeutic drug prescribing by optometrists, but contains requirements for training sufficient to reassure the ophthalmologists.

We wish to assure our psychiatric colleagues that the decision to seek prescriptive authority is being made only after lengthy debate and with meticulous attention to proper training models. Training for prescriptive authority will be available only to doctorally trained, licensed psychologists. Training will be rigorous and thorough and will encompass studies in the relevant basic and applied sciences, as well as a medically supervised clinical training period. Passage of a standardized examination will be mandated before a psychologist is certified to prescribe psychoactive medications. Most psychologists probably will not seek prescriptive authority. We envision prescribing as a fellowship specialty in psychology with a limited number of practitioners, similar to other subspecialties such as neuropsychology or forensic psychology.

Finally, we must never lose sight of the vision common to both our professions: Ready access to continuity of high quality, affordable mental health services for all those who are in need of it. In private offices, in hospitals, in universities and in research facilities across the country, psychologists and psychiatrists work together every day in a respectful collaboration that is beneficial to both our professions and to the public. In a similar manner, we have worked together on complex legislative issues. It is our hope that the spirit of professionalism that has served us well in these contexts, will continue to guide us in the matter at hand.

How unfortunate that the initial overtures of psychology to work with psychiatry in the expansion of psychopharmacotherapy priviliges for PhD/PsyDs were rebuffed by medical fundamentalists in the little APA.
Psychology attempted to avoid a repeat of the battle that it had had with psychiatry over the expansion of psychotherapy privileges for PhD/PsyDs back in the 1950/1960s.
Unfortunately, 8 years after the publication of this article, we see (as evidenced by the short-sighted actions of the little APA in LA and the posts in this forum) that med fundas are still around. The battle lines are being set up once again. History is repeating itself.
:idea: FORTUNATELY, history repeating itself will lead to psychology expanding its scope of practice into psychopharmacotherapy just like it did with psychotherapy.
:idea: FORTUNATELY, history repeating itself will ensure that mental health patients will have increased access and improved treatments.
The model of medical psychology is NOT that of psychologists prescribing as psychiatrists.
Just like psychology helped to expand mid-century therapy from the constraints of psychoanalysis so too will it help to expand new century med mgm from its minimalistic and reductionistic tendencies.
:idea: FORTUNATELY, diversity in prescribing models will herald a new golden age of mental health, where both psychiatrists and psychologists will develope innovative psychopharmacotherapeutic interventions ever more evidence-based; just as 40 years ago diversity in psychotherapeutic models gave rise to Rogers, Beck, Ellis, etc.
:idea: FORTUNATELY, history is repeating itself.

You know that there are evidence based therapies that have been reliably demonstrated to improve the functioning of patients with depression, anxiety etc. CBT ring a bell? IPT? Similarly, CBT has been used to increase med compliance in individuals with bipolar disorders. While I respect the need for pharmacological treatment for some individuals, I believe that psychiatrists such as you discount psychotherapy while ignoring the empirical evidence.

No one is denying this. It is the psychologists that are apparently denying themselves by discounting this same evidence and seeking legislation-appointed prescriptive rights. I think you'd be hard-pressed to find a psychiatrist that truly believed therapy was useless.


Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????


Why does everyone who bashes psychiatry assume that pharma companies produce research on their medications, and then NOBODY, EVER does a follow-up study at some later date to verify, or replicate the results. Granted, these studies may take some time to come out or be published, but they DO come out. By the way, at my request, I was just mailed a published study by Abbott Laboratories on Depakote ER by a representative I met at the "little APA" convention, as sasevan so effectionately calls it. (Don't need to be a psychiatrist/psychologist to read into this by the way.) The study clearly showed that the use of Depakote ER was of no clinical value in bipolar manics. Like Mdblue states, I'll use that information how I'd like. I'm not a moronic slave to the pharmaceutical companies.


But what is the quality of the science you use to make the decision?

Do you think that psychiatry is the only field of medicine which suffers from "experience" treatment vs. EBM? All fields of medicine are undergoing a sort of EBM renaissance at this point. Some of these ideas are slow to change despite scientific discrediting. (Is it still necessary for NPO pre-surgery? New evidence suggests not. But find me a surgeon that won't write an NPO order for 12am prior to a cholecystectomy) But, these traditional thoughts and old-world experiences did have value for their time. Every health profession has had some treatments or theories not based in science - including psychology.

Psychiatry, like gastroenterology, like pulmonology, like hematology, etc is producing more EBM clinical studies which already have and will become the standard of care in the future. Therefore, to judge psychiatry as a lone horse by this alone is neither fair nor of value.

Hardly....

You miss the point entirely. Do you feel that psychologists should attack neighboring professions in order to achieve the increased respect, autonomy, and parity? If you do, then you're a psychological fundamentalist.

p.s. You're not the only one who knows where the "laugh button" is:
:laugh: :laugh: :laugh:

Fundamentalism is not restricted to medicine.
There are psychologists who absurdly assert that psych PhD/PsyDs are far better diagnostician and therapists than psych MD/DOs.
Notice, I said that this assertion is absurd.
Just like psychiatrists saying the inverse.
I oppose fundamentalism, period. Whether in medicine or in psychology, etc.
The point is that fundamentalism is contraindicated for any discipline that presents itself as scientific.
The problem is that when you and others express your opposition to RxP for psychologists you do it in a way that is patently offensive because of its unashamed embrace of med funda, i.e., that psychiatric ed, training, practice is superior to psychology and that consequently psychologists cannot be permitted to prescribe unless they attain that superior ed and training.
Medical fundamentalism is offensive to me both as a soon to be psychologist AND as a future psychiatrist. Likewise, psychological fundamentalism, etc.
The opposite of med funda is the acknowledgement and appreciation of alternative and complimentary healthcare models.
For me there is beauty in the clinical psychiatry model but also in the medical psychology one.
Because I'm not a psych nor a med funda I can tolerate...no...celebrate the different models.

P.S. I know you know where it is BUT I know how to use it well.
:laugh: :laugh: :laugh:

By the way, at my request, I was just mailed a published study by Abbott Laboratories on Depakote ER by a representative I met at the "little APA" convention, as sasevan so effectionately calls it. (Don't need to be a psychiatrist/psychologist to read into this by the way.)

Now that was funny. :laugh: :laugh: :laugh:

Psychiatrists are not solely psychiatrists. They are physicians trained in the specialty of psychiatry. Is this the medical model? Is it different from the psychological model? Yes. It is also the model that has been the most successful and accepted in modern treatment of both medical and psychiatric patients thus far.

To say that psychiatry needs to "establish scientific credibility" is utter idiocy. Psychiatry is what it claims to be and has been.


Psychiatrists are very, very necessary. That's why I'm so irritated about the general mediocrity in the field.

I have great respect for psychiatrists who are physicians in the best sense of the word, but the only one whom I've encountered (sadly not in person) has been the late Jerrold Bernstein, who's *Drug Therapy in Psychiatry* opened my eyes to really TREATING mental illness medically. His references are incredibly exhaustive, and he has whole chapters on how to use the MAOI's, the TCA's, how to safely COMBINE MAOI's and TCA's, use TCA's with SSRI's, use all with lithium--he simply refuses to give up. He even tried using Permax as an augmentor to Parnate in some resistant patients he suspected were responding to elavated dopamine, and noted that over half the patients reported a great or significant improvement in symptoms. He discusses side effects and their management in depth. There are pages of charts with tyramine content of common and exotic foods for MAOI patients.

I have never heard of another psychiatrist who was this attentive and aggressive in helping his or her patients recover.


And these days people feel by going thru few webpages or reading a psychopharm text they can be as competent as a fully trained psychiatrist(or a cardiologist/GI whatever for that matter). They just ignore the decision making process which lies behind the med-checks. This is bad for the profession as well as the patients. There was a truth in "Your doc know better". Maybe it has gotten old-fashioned, but it did a lot of good to the people. Atleast I would not be bothered by 2 people who landed in my PES today w/ these horrible experiments of self-medication.
Just my 0.02c.

"decision-making process?", "Your doc know better?"--please; I just ate. You mean prescribing the virtually-untested Zyprexa for every disorder under the sun--to the point that the expense of this drug alone was overwhelming medicaid?

I can't count the number of people I've had to reassure who had been prescribed Zyprexa for depression, anxiety, INSOMNIA, social phobia, etc. who read up on it and thought they had schizophrenia.

The fact that Zyprexa was subsequently shown to cause NMS and TDK, in addition to cool new tricks like orca-grade weight gain, hyperglycemia, and permanent type II diabetes (a stunt even Haldol couldn't pull) seems to have done little to blunt psychiatrists' puzzling enthusiasm for this drug.

You mean dishing out (also virtually untested) Effexor like candy and letting years go by before acknowleding the horrible and disabling withdrawal effects experienced by at least 15% of patients, some of which persisted for more than a year?

You mean ignoring the fact that no study has shown the SSRI's to be effective in MAJOR depression, and that numerous studies show these drugs to have little or no superiority over placebo in treating mild depression?


After 10 years of being a good, crippled patient, I'm afraid I've given up on "Your doc know better." If I still believed that, tomorrow I would obediently take my Effexor and Zyprexa, waddle to the 7-11 for breakfast, and then stare at the TV while waiting for my SSI check.

Instead, I'm popping a couple Parnate and going surfing.

P.S. I know you know where it is BUT I know how to use it well.
:laugh: :laugh: :laugh:

Am I correct in asserting that because you are a psychologist, you are better trained to know when to appropriately place laughing smiley face thingys? You are a smiley laughing face fundamentalist!

Seriously though, the main point about the fundamentalism thing is this:

You either believe that psychiatric patients are medical in nature or you do not. In medicine, you take the worst case scenario and work downwards in your differential. This is the time-proven logic-driven technique that ensures patient safety.

[simplification] If you assume psychiatric patients are completely environmentally-created, then you do not need medical intervention. Conversely, if you believe all psychiatric patients are medical and not in any way affected by the environment, you do not need therapy (again I'm simplifying).

The safest way to approach this quandry is to assume the worst - that all patients have medical etiologies and comorbidities until proven otherwise. Psychology training programs are looking to skip this step and move straight to psychopharmacological intervention. What might appear to you as dogmatic medical fundamentalism is really a top-down differential approach to the patient as a whole.

[QUOTE=lazure][B]
yet the concept of effect size appears to elude you when you read the results of drug company studies .... It is easy to show a significant difference between group means with a sample size of 2000.... you know that a small but significant difference is not necessarily clinically significant. The suicidal patient on drug X now thinks of suicide 9 times per day rather than 10. Furthermore, the fact that these studies are sponsored by drug companies doesn't bother you in the least? You don't suspect that null results or contradictory results just failed to be published????
QUOTE]

http://jama.ama-assn.org/cgi/content/short/291/20/2457

Empirical Evidence for Selective Reporting of Outcomes in Randomized Trials: Comparison of Protocols to Published Articles
An-Wen Chan, MD, DPhil; Asbj?rn Hr?bjartsson, MD, PhD; Mette T. Haahr, BSc; Peter C. G?tzsche, MD, DrMedSci; Douglas G. Altman, DSc
JAMA. 2004;291:2457-2465.
Context Selective reporting of outcomes within published studies based on the nature or direction of their results has been widely suspected, but direct evidence of such bias is currently limited to case reports. Objective To study empirically the extent and nature of outcome reporting bias in a cohort of randomized trials. Design Cohort study using protocols and published reports of randomized trials approved by the Scientific-Ethical Committees for Copenhagen and Frederiksberg, Denmark, in 1994-1995. The number and characteristics of reported and unreported trial outcomes were recorded from protocols, journal articles, and a survey of trialists. An outcome was considered incompletely reported if insufficient data were presented in the published articles for meta-analysis. Odds ratios relating the completeness of outcome reporting to statistical significance were calculated for each trial and then pooled to provide an overall estimate of bias. Protocols and published articles were also compared to identify discrepancies in primary outcomes. Main Outcome Measures Completeness of reporting of efficacy and harm outcomes and of statistically significant vs nonsignificant outcomes; consistency between primary outcomes defined in the most recent protocols and those defined in published articles. Results One hundred two trials with 122 published journal articles and 3736 outcomes were identified. Overall, 50% of efficacy and 65% of harm outcomes per trial were incompletely reported. Statistically significant outcomes had a higher odds of being fully reported compared with nonsignificant outcomes for both efficacy (pooled odds ratio, 2.4; 95% confidence interval [CI], 1.4-4.0) and harm (pooled odds ratio, 4.7; 95% CI, 1.8-12.0) data. In comparing published articles with protocols, 62% of trials had at least 1 primary outcome that was changed, introduced, or omitted. Eighty-six percent of survey responders (42/49) denied the existence of unreported outcomes despite clear evidence to the contrary. Conclusions The reporting of trial outcomes is not only frequently incomplete but also biased and inconsistent with protocols. Published articles, as well as reviews that incorporate them, may therefore be unreliable and overestimate the benefits of an intervention. To ensure transparency, planned trials should be registered and protocols should be made publicly available prior to trial completion.


Our problem with research, in general . . . goes beyond effect size.

S

Seriously though, the main point about the fundamentalism thing is this:

You either believe that psychiatric patients are medical in nature or you do not. In medicine, you take the worst case scenario and work downwards in your differential. This is the time-proven logic-driven technique that ensures patient safety.



Anasazi, this is nothing more than ideological reductionism. You appear to be attempting to reduce a very complex matrix down to a least common denominator. From your point of view, medicine (or the physiologic domain) explains the greatest number of variables. Many people do not agree with you.

This reductionism, I think, is part of the serious problem we're facing. The U.S.'s 60+ year movement/love affair with rampant objectification is partly to blame (despite the very positive impact the movement has made, it sometimes throws the baby out with the bathwater). We look for only those measureable aspects of behavior and forget that it IS the complex matrix of person-ness that we're treating - not just the physiological reaction. We forget that WHAT we're measuring might be "beside the point."

HAM-D scales are a perfect example of this. Anyone know what year the HAM-D's were developed and for what? (Hint . . . you'll have to go back 43 years to get to the publication date . . . and then farther to understand the basis upon which they were developed. ) Our understanding of depression/anxiety is more complex now than is was in 1960. Another ugly example is the tendency for drug companies to simply make up a behavioral scale that suits their need and to report the outcome/publish it AS THOUGH it had been adequately peer assessed. This happens so much within the child psychopharm literature as to be very distressing. As psychiatric professionals, trained (at least basically) in statistics, we should be leading our own revolt against such a ridiculous practice. But, by and large, we're tacit.

The unfortunate consequent of the common psychiatric approach (NOT what is seen in medical school, residency, or at research institutes, but that which is present in most private practices) is that the psychiatrist will use the interview to isolote "Psychopharmacologic Responsive States" or PRS. The, the diagnosis (a topic for another day, but these reliable labels have very serious validity problems) is defined by the clustering of the PRS and a drug is prescribed. The prescription is administered in the sincere belief that as the symptoms are reduced, the patient's debilitating condition will be abated.

The above method is so reductive that it often necessarily ignores what may be bothering the patient most;the psychosocial aspect of the patient's condition. My perception of what commonly goes on in the "real" world looks something like "BIOpsychosocial" as though the psychiatrist is treating the most important aspect. The number of times I've seen children psyciatrically diagnosed with ADHD/ODD being treated with the myriad of available chemicals we have in our toolbox, but their parents HAVE NOT BEEN REFERRED FOR PARENTING TRAINING is astounding. What have we been reading? Are we not aware of the impact this makes to the entire family system? The same is true for patients with depressive/anxious disorders, bipolar disorders, etc., many of whom get treated for their biological "needs" but the psychotherapeutic tools we have available to us are either discounted or ignored.

(As a teacher, I find myself asking, "What are we not doing when we train you? What are we missing? ")

Don't get me wrong, I LOVE diagnosing and treating primarily biological/neurological disorders that present as "behavioral dysfunction." But, for the most part, in the day-to-day practice world, these cases are VERY few in comparison to those that have MUCH greater psychosocial issues. (BTW, I have always wondered why we don't add spiritual to that matric, as in biopsychosocialspiritual, since so many patients seem to struggle with this as well - and NO, I'm not a religious fundementalist . . . at all).

Off to work now. You guys figure this out and let me know the anwers . . . I'll be back later in hopes that these problems have been solved.

:) :p :laugh: :laugh: :laugh: (How'd I do?)

I'm actually going to quote myself for contextual purposes:

[simplification] If you assume psychiatric patients are completely environmentally-created, then you do not need medical intervention. Conversely, if you believe all psychiatric patients are medical and not in any way affected by the environment, you do not need therapy (again I'm simplifying).


What Svas states is correct, in that this indeed IS reductionism. This is also a simplified view of the patient, (which I pointed out twice). Indeed, medical school and residency goes to great lengths to teach doctors to reduce a complex presentation of symptoms and findings to create a reasonable differential. In this sense, the entire medical educational system is to blame if you find this disagreeable. However, I myself have never subscribed to the notion that patients themselves were reductionist in nature. While I feel that the term "biopsychosocial" is a "feel good" overused garbage-term clinicians and institutions tout to appear comprehensive, it may still have meaning. Any clinician with common sense knows that patients are complex beings, which should be approaced in a "biopsychosocial" manner. To do less than this would to be not fully treating the patient.

I agree that many psychological rating scales are laughable in what we perceive as the changing face and understanding of pathology and wellness. Do I read mechanics magazines? Does it really matter? To the MMPI (copyright 1942) it certainly does. But, an invalid score on a personality test versus a missed medical diagnosis are not one inthe same. Psychology, rather than psychiatry, has the luxury of not having to worry about the gamut of medical conditions manifesting psychiatrically. No one expects a psychologist to pick up a melanoma-inducing depression. If a psychiatrist misses this, the possibility of a malpractice suit exists. Does this make psychiatrists "better" than psychologists? Of course not. The professions each have their strengths and are valuable in the treatment of the psychiatric patient.

Ideological reductionism may be intellecutally unappealing, but in the current mode of practice, given time, money, and knowledge constraints, it may be that which has "survived" or evolved from the primordial soup which is modern medical practice. In a perfect world, psychiatrists would be able to approach the patient in a manner in which Svas describes - biopsychosocialspiritually. As he points out, however, this is often difficult. Following the thread's original purpose then.....if psychiatrists have difficulty approaching psychiatric patients in this fully comprehensive manner, given the knowledge they have of biology, medicine, and psychiatry, then for what purpose are psychologists being given Rx rights? Is this effectively eliminating (despite training courses) the "bio" part of the biopsychosocial? This to me seems like further treatment quality dilution.

If a psychiatrist misses this, the possibility of a malpractice suit exists. Does this make psychiatrists "better" than psychiatrists? Of course not.

Hmm.....oversight or Glucksbergian metaphor?

more like overzealous use of cut & paste...I have a tendency to do that. ;)

more like overzealous use of cut & paste...I have a tendency to do that. ;)

Of course...I just wanted to use the adjective "Glucksbergian," so it seemed like an appropriate opportunity. ;)

You mean this guy?

http://www.princeton.edu/~psych/PsychSite/fac_glucksberg.html

I have a feeling he's not going after prescription privilages.
:laugh:

Psychiatrists are very, very necessary. That's why I'm so irritated about the general mediocrity in the field.

I have great respect for psychiatrists who are physicians in the best sense of the word, but the only one whom I've encountered (sadly not in person) has been the late Jerrold Bernstein, who's *Drug Therapy in Psychiatry* opened my eyes to really TREATING mental illness medically. His references are incredibly exhaustive, and he has whole chapters on how to use the MAOI's, the TCA's, how to safely COMBINE MAOI's and TCA's, use TCA's with SSRI's, use all with lithium--he simply refuses to give up. He even tried using Permax as an augmentor to Parnate in some resistant patients he suspected were responding to elavated dopamine, and noted that over half the patients reported a great or significant improvement in symptoms. He discusses side effects and their management in depth. There are pages of charts with tyramine content of common and exotic foods for MAOI patients.

I have never heard of another psychiatrist who was this attentive and aggressive in helping his or her patients recover.



"decision-making process?", "Your doc know better?"--please; I just ate. You mean prescribing the virtually-untested Zyprexa for every disorder under the sun--to the point that the expense of this drug alone was overwhelming medicaid?

I can't count the number of people I've had to reassure who had been prescribed Zyprexa for depression, anxiety, INSOMNIA, social phobia, etc. who read up on it and thought they had schizophrenia.

The fact that Zyprexa was subsequently shown to cause NMS and TDK, in addition to cool new tricks like orca-grade weight gain, hyperglycemia, and permanent type II diabetes (a stunt even Haldol couldn't pull) seems to have done little to blunt psychiatrists' puzzling enthusiasm for this drug.

You mean dishing out (also virtually untested) Effexor like candy and letting years go by before acknowleding the horrible and disabling withdrawal effects experienced by at least 15% of patients, some of which persisted for more than a year?

You mean ignoring the fact that no study has shown the SSRI's to be effective in MAJOR depression, and that numerous studies show these drugs to have little or no superiority over placebo in treating mild depression?


After 10 years of being a good, crippled patient, I'm afraid I've given up on "Your doc know better." If I still believed that, tomorrow I would obediently take my Effexor and Zyprexa, waddle to the 7-11 for breakfast, and then stare at the TV while waiting for my SSI check.

Instead, I'm popping a couple Parnate and going surfing.

I do think you and me are talking from the same viewpoint. Psychotropic meds are not to be used like candies. SSRI are not the answer to everything. Unfortunately "ask your doc" campaigns minimizes the risks associated w/ these psychotropics. That's why I feel these meds should be prescribed by psychiatrists. These days bulk of the SSRIs and SGAs are prescribed by people who work primarily as PCPs w/o any particular psych experience. The same holds true for stimulants in kids.
The point is it is extremely risky for the untrained to experiment w/ the drugs(be it the pt him/herself, PhDs or no-psych MDs for that matter).
BTW, there are psychiatrists who for whatever reasons restrict themselves to 15-min medcks. If anyone has any experience w/ those sessions they will realize what sub-standard care might creep thru those pt-encounters. This is sub-optimal care of the pt and nothing else. I am afraid w/o addressing the safety issue the PhDs for their own vested interest are arguing for their scripting rights and will provide the same sub-optimal care to the pt(because that's what the 3rd party payors will mandate).
And it's interesting when people have their own interests at heart, how callous they can be to other's safety.
http://pn.psychiatryonline.org/cgi/content/short/39/10/1

You either believe that psychiatric patients are medical in nature or you do not. In medicine, you take the worst case scenario and work downwards in your differential. This is the time-proven logic-driven technique that ensures patient safety.

The safest way to approach this quandry is to assume the worst - that all patients have medical etiologies and comorbidities until proven otherwise. Psychology training programs are looking to skip this step and move straight to psychopharmacological intervention. What might appear to you as dogmatic medical fundamentalism is really a top-down differential approach to the patient as a whole.

Hi Falwell23...ooops...I mean...Anasazi23 :laugh:

In response to your comment as to whether I believe that psychiatric patients are medical in nature, I say

In the words of "Sex & the City's" Mr. BIG: :laugh:

ABSO-------LUTELY!!!

One of the main reasons why I want to become a psychiatrist is because I highly value the biochemical dimension of mental illness.
I don't see how any mental health provider could possibly purport to dx or tx mental illness unless he/she has a functional knowledge of say, medical conditions that present as mood disorders, medications that may elicit depressive sx, and substance abuse impact on affective state.

One of the best arguments for psychologists gaining RxP is that as mental health providers they must be fully educated and trained in a functional knowledge of the biomedical dimension less they end up trying to assess and intervene with an exclusively psychosocial modality due to ignorance of the biomedical.

HOWEVER, to paraphrase Svas: they are also psychosocialspiritual in nature.

In my opinion, both psych PhD/PsyDs and psych MD/DOs need to be fully ed/trained in both the biochemical and psychosocialspiritual dimensions.
Short cuts, whether due to mangled healthcare pressure or some other pressure, are unethical.

How can a psychiatrist or a psychologist abide by the dictum "DO NO HARM" and at the same time pretend to be able to dx and/or tx mental illness without contextualizing said dx/tx within the biopsychosocialspiritual model????

Do you believe that the BPSS model is just (or mostly) political correctness???
If so, then you may be a medical fundamentalist AND an ideological reductionist. :laugh:

Seriously, if its really all about patient care, then we should ALL be insisting that psychologists be fully ed/trained in the biochem dim and psychiatrist in the psychosocialspiritual.

There will still be a difference between the two disciplines, with each emphasizing one or the other dimension, but with each also sufficiently prepared to dx/tx in a genuinely comprehensive and caring manner.

Psychology, to its credit, is acknowledging this and insisting on increasing incorporation of the biomedical dimension in its pre-doc as well as its post-doc ed/training models.

FYI, medical psychology ed/training is not just psychopharm (See Following Posts).

P.S. If you prefer, I can affectionately refer to
the little APA :laugh:
as the APA that came first :laugh:
Then again, is being premature any better than being small???
:laugh: :laugh: :laugh:

Psychology is NOT trying to circumvent appropriate ed/training for RxP.
Proposed medical psychology programs provide appropriate AND adequate ed/training for psychologists to become safe and effective psychopharmacotherapists. :thumbup:


Psychopharmacology Training Program

--------------------------------------------------------------------------------

The following description of the required courses and the content therein may be subject to changes necessitated by more current needs and/or other factors. The "content areas" listed below are the 10 knowledge-based segments included in the APA Psychopharmacology Examination for Psychologists (PEP)
I. NEUROSCIENCES: Didactic courses in the fields of neuroanatomy, neurophysiology, and neurochemistry are taught by faculty members with appropriate training and experience in these disciplines. Each course is 1.5 credit hours, and the course content is outlined below for each subject.

Neuroanatomy/Neuropathology:

Neuroanatomy:

Will include basic human neuroanatomy, with an emphasis on categorization of tracts by neurotransmitter systems. Categorization by neurotransmitter function will allow an early introduction to pharmacological agents and how they interact with the various anatomical pathways. The anatomy of the brain, spinal cord, and sympathetic and parasympathetic nervous systems will be important to the study of psychopharmacology. Brain regions studied will include cerebral cortex, frontal cortex, hippocampus, basal ganglia, thalamus and hypothalamus, brain stem (with particular attention to locus coeruleus and dorsal raphae nuclei). Involvement of particular anatomical regions in certain mental illnesses and relevant neurological illnesses will be introduced: Including appropriate items from APA Content Area 2

Content Area 2:Neuroscience

Refers to the anatomy, physiology, and biochemistry of the nervous system and its interfaces with other major body systems

0201 Knowledge of the structure and function of nervous system cells

0202 Knowledge of the structure and function of the central and peripheral nervous systems

0203 Knowledge of the major neuronal pathways and their functions

0204 Knowledge of the vascular supply of the brain, and the blood-brain and placental barriers

Neuropathology

The neuropathology section will include cognitive, movement, developmental, and seizure disorders, chronic pain, traumatic brain injury, and other nervous system pathology. Basic neurodiagnostic markers of pathology and mechanisms of extrapyramidal and dysfunction will be included, as well as discussion of the hypothesized neuropathological basis of psychological disorders. Appropriate APA Content Areas will be included

Content Area 3: Nervous system pathology

Refers to disorders of the nervous system resulting in abnormal function or behavioral/mood disruption. Includes biochemical, structural (congenital or acquired), or neurophysiological abnormalities and their impact on other body systems.

0301 Knowledge of etiological factors and diagnoses of dementia, delirium, and other cognitive disorders

03O2 Knowledge of etiological factors and diagnosis of chronic pain, including headache (e.g., differentiation of pain syndromes with primarily nervous, musculoskeletal, and tension-related etiology)

0304 Knowledge of etiological factors and diagnosis of movement disorders (e.g., including Parkinson's, Huntington's, and Tourette's syndromes)

0305 Knowledge of etiological factors and diagnosis of mental retardation

0306 Knowledge of etiological factors and diagnosis of neurodevelopmental disorders (e.g., fetal alcohol syndrome, pervasive developmental disorders, Fragile-X syndrome)

0307 Knowledge of etiological factors and diagnosis of central nervous system vascular disorders (e.g., cerebral vascular accidents [CVAs], transient ischemic attacks [TIAs])

0308 Knowledge of etiological factors and diagnosis of seizure disorders

0309 Knowledge of traumatic brain injury

0310 Knowledge of other nervous system pathology (e.g., multiple sclerosis, infectious diseases, neoplasms)

0311 Knowledge of neurobehavioral/psychological disorders that have an hypothesized neuropathological basis (e.g., schizophrenia, affective disorders, anxiety, ADHD)

0312 Knowledge of basic neurodiagnostic markers of neurobehavioral disorders (e.g., as found on EEG and diagnostic imaging, and in neuropsychological assessment)

0313 Knowledge of the mechanism of extrapyramidal dysfunction (e.g., dystonic reactions and tardive dyskinesia)

Neurophysiology:

Physiological concepts underlying central and peripheral nervous system function will be presented. Cellular neurophysiology concepts such as the resting potential, action potential and basic ion channel kinetics will be introduced. An integrated view of the electrical functioning of the brain, with an introduction to electroencephalographic concepts, will be introduced. Neurotransmitter receptor function, second messengers and neural plasticity with an introduction to cellular theories underlying learning will be included. Appropriate APA Content Areas be covered

0205 Knowledge of cellular and molecular nervous system biology and regulatory processes and second messenger systems

0208 Knowledge of the endocrine system and the interface of various hormones and other neurotransmitters

0303 Knowledge of etiological factors and diagnosis of sleep disorders as related to the nervous system and psychopathology

0312 Knowledge of basic neurodiagnostic markers of neurobehavioral disorders (e.g., as found on EEG and diagnostic imaging, and in neuropsychological assessment

Update in Neurochemistry and Biochemistry

This course will provide students with a brief review of those aspects of chemistry, organic chemistry and biochemistry which are needed for the study of pharmacology. For instance, in the field of general chemistry the instructor will review the general concepts of chemical compounds and bonds, and atomic theory. In the field of organic chemistry the instructor will review the concepts of organic compounds, bonds and valences. In the field of biochemistry the instructor will review biomolecules of proteins, carbohydrates, nucleic acids and lipids, as well as chromosomal theory and the genetic code, enzymes and metabolism. The assumption will be that all students have had previous coursework in chemistry, but that many students will have taken the courses many years previously. This 2 day course will provide 1 credit.

Professional, ethical, and legal issues:

Informed consent as it relates to prescribing psychotropic medications will be emphasized, including issues of drug side effects such as tardive dyskinesia. Informed consent in drug research protocols. Confidentiality and compliance issues, including involvement of family members in informed consent and treatment sessions. Continuing education requirements. The difficult patient, including the chronically noncompliant patient will be addressed. Second opinions, limitations of practice by psychologists and situations in which referral to psychiatrists or other medical specialists are indicated. Clinical decisions to initiate inpatient versus outpatient treatment with medication. Electroconvulsive therapy, indications and legal/ethical considerations. This course will be approximately 0.5 credits. APA Content Area 10

Content Area 10: Professional, legal, ethical, and interprofessional issues

Refers to knowledge of ethics, standards of care, laws, and regulations relevant to the practice of psychology involving Psychopharmacology.

1001 Knowledge of ethical codes and standards as they pertain to pharmacological practice and research (e.g., the APA Ethical Principles of Psychologists and Code of Conduct, APA Standards for Providers of Psychological Services, AERA/APA/NCME Standards for Educational and Psychological Testing, ASPPB Code of Conduct, Joint Commission on the Accreditation of Healthcare Organizations [JCAHO] Standards)

1002 Knowledge of practice guidelines and standards of care for prescribing psychotropic medications (e.g., documentation requirements, nomenclature for writing prescriptions, written and verbal orders, elements of informed consent, patient education, institutional formulary restrictions, chemical restraints, Agency for Health Care Policy and Research [AHCPR] guidelines, National Institute of Mental Health [NIMH] consensus panel protocols, health care organization rules)

1003 Knowledge of federal and state laws and statutes for prescribing psychotropic medication (e.g., FDA regulations, Medicare, controlled substance laws, specifics of psychologists' licensing laws, patient's rights)
1004 Knowledge of issues involved in collaboration and consultation with other health care providers who are also prescribers and/or psychotherapists (e.g., "ownership' of patients, when to refer or seek consultation, differences in theoretical orientation, triangulation, appropriate levels of disclosure)

1005 Knowledge of provision of psychotropic medications within specific environments (e.g., structured and unstructured environments, classroom and home, correctional institutions. military, substance abuse facilities)

1006 Knowledge of patient's rights (e.g., informed consent, right to refuse treatment, right to treatment within the least restrictive environment, duty to warn, and privileged communication)

1007 Knowledge of issues regarding relationships with pharmaceutical companies (e.g., acceptance of gifts, revealing sources of funding and affiliations)

Note: The complex of factors influencing human functioning noted in Content Area 1, i.e., biological (e.g. genetic, sex, age, disease), psychological (e.g, cognitive, emotional, dynamic, motivational, behavioral), psychosocial (e.g., gender, cultural/ethnicity, interpersonal), and ecological/environmental factors should be considered as they apply across all knowledge areas.

Neurochemistry

This course will emphasize the various neurotransmitter systems relevant to modern psychopharmacological practice. These include but are not limited to: serotonin, norepinephrine, dopamine, acetylcholine, glutamate, GABA, opiods, and Substance P. The interaction of these neurotransmitters with their receptors will be emphasized, as will the mechanism of action of the various receptor systems. The biochemical mechanisms of action of prototypical drugs used in modern psychopharmacological practice will be introduced in this course. Including appropriate APA content areas.

0206 Knowledge of major neurotransmitter and neuromodulator synthesis, storage, release, distribution throughout the brain and the rest of the body, action, reuptake, and degradation

0207 Knowledge of neuropeptides (e.g., enkephalin, endorphin, substance P)

II. CLINICAL AND RESEARCH PHARMACOLOGY AND PSYCHOPHARMACOLOGY:

Approximately ten credit hours will be devoted to courses in general pharmacology, psychopharmacology, developmental psychopharmacology, and chemical dependency and pain management, as outlined below. In addition, review of the general principals involved in the conduct of research on psychoactive substances as itemized in APA Content Area 9

Content Area 9: Research

Refers to the methodology, standards, and conduct of research on psychoactive substances. The knowledge base facilitates research design and implementation, accurate data interpretation and communication, effective utilization of findings, the accumulation of scientific knowledge, and the improvement of the practice of clinical psychopharmacology.

General pharmacology:

This core course, consisting of approximately four credit hours, will cover basic science and clinical concepts fundamental to the subject of general pharmacology. This will be presented to introduce genera! principles (such as pharmacodynamics and pharmacokinetics) which will be expanded upon in the psychopharmacology courses, and to provide students with knowledge of general pharmacological agents used in general medical practice. This will introduce the important concept of drug interactions, which will be reemphasized throughout later course work. General principles including routes of administration, half-life, protein-binding, lipid solubility and the blood-brain barrier will be included. General pharmacology principles will include drugs such as antibiotics, cardiovascular agents, analgesics and drugs affecting the renal, pulmonary, gastrointestinal, and urological systems. Drug interactions will be emphasized in each section. Developmental pharmacology will be covered with special emphasis on pharmacokinetic and pharmacodynamic differences in the very young and very old patients. APA Content Area 7 will be covered

Content Area 7:Pharmacology

Refers to the interactions of drugs with biophysiological systems; encompasses pharmacokinetics, pharmacodynamics, pharmacogenetics, and the epidemiology of various medications such as psychotropics, adjunctive agents, and other medications used in the practice of medicine, as well as substances of abuse, OTC products, and food and dietary supplements. The influence of cultural/ethnic factors, environmental factors, and responses of special populations are considered.

0701 Knowledge of drug classifications for psychotropic and adjunctive medications (e.g., stimulants, sedatives, antidepressants, anticholinergics), other drugs used in the practice of medicine, OTC medications, and substances of abuse

0702 Knowledge of biological factors effecting pharmacokinetics and pharmacodynamics

0703 Knowledge of absorption (e.g., delayed-release preparations, rates of absorption after oral dosing or parenteral injection, area under the curve, timing with food intake)
0704 Knowledge of distribution (e.g., plasma protein binding, influence of lipophilicity)

0705 Knowledge of metabolism (e.g., drug metabolism, understanding of the substrate and inhibitors and inducers of the "family" of P450 enzymes, other enzymes outside the liver)

0706 Knowledge of excretion (e.g., renal filtration rate, clearance of drugs)

0707 Knowledge of importance of biological half-life in determining steady-state drug concentrations, dosing schedules, accumulation

0708 Knowledge of drug properties and characteristics (e.g., therapeutic index, therapeutic blood levels/prescription doses, potency, bioavailability, efficacy, cognitive and behavioral manifestations of toxicity, dose-response relationships)

0709 Knowledge of types of drugs and other agents interacting with receptors(e.g., direct and redirect agonists, antagonists, and inverse agonists)

0710 Knowledge of drug-induced cellular adaptation (e.g., cellular signaling ion channels, second messengers, neurotransmitter release, sensitivity, supersensitivity)

0711 Knowledge of drug effects on genetic expression (e.g., down-regulation)

0712 Knowledge of specific neurotransmitters, receptors, modulators, and neuropeptides

0713 Knowledge of mechanisms of action of a range of therapeutic agents with particular focus on psychotropic and adjunctive medications

0714 Knowledge of theoretical relationships thought to exist between neurotransmitter systems and psychopathological conditions based on known mechanisms of action and clinical observations (e. g., roles of serotonin in depression, dopamine in psychosis and substance abuse)

0715 Knowledge of drug-drug and drug-food interactions for a range of medications as well as substances of abuse, and supplements and other OTC products

0716 Knowledge of drug-induced disease, dysfunction, and adverse reactions (e.g., hepatotoxicity, agranulocytosis, dystonias)

0717 Knowledge of genetic polymorphisms (e.g., ethnic and gender differences, differences in cytochrome P450 isoenzymes in drug metabolism)

0718 Knowledge of familial patterns of drug response and toxicity

0719 Knowledge of pharmacoepidemiology (e.g., epidemiology of psychotropic drug use)

0720 Knowledge of tolerance, dependence, and withdrawal

0903 Knowledge of the FDA drug development process (i.e., Phase I: Human Pharmacology; Phase Il: Therapeutic Exploratory; Phase III: Therapeutic Confirmatory; Phase IV: Therapeutic use)

0908 Knowledge of current status of research regarding specific medications

Clinical Psychopharmacology:

This four-credit core course will cover the general principles underlying the use in modern practice of drugs to treat the major classes of mental illness. This will include antipsychotics (conventional and atypical), antidepressants, anxiolytics, mood stabilizers, and special topics. Mechanism of action, drug interactions, pertinent aspects of differential diagnosis will be discussed. Psychiatric aspects of general medical conditions, with particular attention to the diagnosis and treatment of delirium will be presented. APA Content Area 8 will be covered.

Content Area 8: Clinical Psychopharmacology

Refers to the application of pharmacology to the management of psychological/behavioral disorders. This includes indications, contraindications, dosing, adverse effects and toxicities of psychotropic and adjunctive medications, interactions with other medications (including other drugs used in medicine, for recreational purposes, and available for OTC purchase) as well as the management of adverse reactions, overdoses, and toxicities.

0801 Knowledge of indications, contraindications, and off-label uses of various psychotropic and adjunctive medications

0802 Knowledge of rational for psychotropic medication selection, taking into account target symptoms, patient and family history premorbid personality, demographics, comorbid medical conditions, existing medication regimen and potential for interactions, and differences among medications within classes off drugs

0803 Knowledge of dosing, time course of therapeutic action and adverse effects; and patient factors that influence dose (e.g., weight, gender, ethnicity, age, concurrent disease)

0804 Knowledge of therapeutic monitoring, augmentation strategies, and dose adjustment (e.g., titration, cross-taper, discontinuation)

0805 Knowledge of routes of administration (e.g., oral, intramuscular, intravenous, inhalation) and differential response

0806 Knowledge of specific drug toxicities, management of adverse reactions, including overdose, and indications for referral for appropriate medical care (e.g., acute allergic reaction, extrapyramidal symptoms, hypertensive crisis)

0807 Knowledge of interactions of psychotropic and adjunctive medications with other medications (including other drugs used in medicine, for recreational purposes, and available for OTC purchase)

0808 Knowledge of relapse prevention, maintenance, and prophylaxis (e.g., strategies for sustaining remission of substance abuse, ensuring treatment compliance, preventing recurrence of depression)

0809 Knowledge of drug effects in special populations e.g., developmentally disabled, elderly, pregnant or lactating women)

0810 Knowledge of pharmacological implications for comorbidity of age-related and disability-related disorders (e.g., overanxious disorder comorbid with ADHD)

0811 Knowledge of potential psychological and physiological manifestations of (medications including OTC drugs, supplements, and herbal substances) used for nonpsychological purposes (e.g., beta blockers, steroids)

0812 Knowledge of psychological and physiological manifestations of various recreational substances and treatment of intoxication or addiction, including strategies for assisted withdrawal, maintenance, and relapse prevention.

0813 Knowledge of tolerance, cross tolerance, dependence and withdrawal, sensitization/cross-sensitization with respect to specific medications, and the management strategies used to treat them.

0814 Knowledge of drug-seeking behavior, and potential for abuse of prescription medications.

0815 Knowledge of culturally appropriate educational techniques to inform patients about drug utilization, risks, benefits, potential complications, and alternatives to pharmacotherapy (e.g., procedures to enhance compliance, techniques to teach appropriate attribution and self-monitoring).

Developmental Psychopharmacology:

This 1.5 credit course will supplement the general psychopharmacology course by emphasizing the treatment of disorders of childhood and old age. Disorders in children will include ADHD, anxiety disorders, depression, and others. Differences between the treatment of these disorders in children and adults will be pointed out. Treatment of comorbid conditions in children with conduct disorder, mental retardation, and learning disabilities will be discussed. In the geriatric population, treatment of dementia and delirium will be emphasized. Common medical conditions presenting with psychiatric manifestations, and the treatment of depression, psychosis, anxiety, and insomnia in the elderly will be topics of discussion. Again, drug interactions will be emphasized.

Chemical dependency and pain management:

Substance abuse and its treatment will be discussed in this 1.5 credit course. Major classes of substances of abuse, including alcohol, cocaine, marijuana, opiates, hallucinogens, stimulants, caffeine, and nicotine will be discussed. Diagnosis, evaluation and treatment of intoxication and withdrawal states will be emphasized. Abuse of commonly prescribed psychotropics and drugs used to treat pain will be topics for discussion. The treatment of chronic pain with opiates, antidepressants, mood stabilizers, and other adjunctive treatments will be discussed

III. PATHOPHYSIOLOGY:

This section consists of one four-credit core course, which covers the following topics fundamental to modern pharmacological practice: Normal physiology and pathophysiology (disease states) of the various organ systems of the human body (cardiovascular. renal, endocrine, gastrointestinal, urological, sex organs, organs of special senses, musculoskeletal.) Psychological manifestations of general medical conditions will be emphasized. Interactions of drugs used to treat general medical conditions with those commonly used in psychopharmacological practice will be discussed. Effects of general medical conditions on drug pharmacokinetics and pharmacodynamics as well as effects of age, sex, and ethnicity will be discussed. This section will include APA Content Area 4

Content Area 4: Physiology and Pathophysiology

Refers to normal physiology and pathophysiology across the life span, and to their impact on psychological functioning and psychopharmacology.

0401 Knowledge of indications for referral to other health care providers for treatment or additional assessment

0402 Knowledge of basic cardiovascular system physiology and pathophysiology across the life span (e.g., rhythm and rate disorders such as prolonged QT interval)

0403 Knowledge of interrelationships between cardiovascular functioning and: psychopharmacology (e.g., EKG changes secondary to TCAs, blood pressure changes secondary to psychotropics, beta blockers, and depression), and psychopathology (e.g., mitral valve prolapse related to panic disorder, tachycardia related to generalized anxiety disorder)

0404 Knowledge of basic pulmonary system physiology and pathophysiology across the life span

0405 Knowledge of interrelationships between pulmonary functioning and psychopharmacology (e.g., theophylline and anxiety, beta blockers and asthma), and psychopathology (e.g., hypoxia versus dementia)

0406 Knowledge of basic renal/genitourinary system physiology and pathophysiology across the life span (e.g., effect of electrolyte imbalance on mental status)

0407 Knowledge of interrelationships between renal/genitourinary functioning and (a) psychopharmacology (e.g., effect of psychotropic substances on urinary/sexual functioning), and (b) psychopathology (e.g., urinary tract infection and mental status change in the elderly)

0408 Knowledge of basic hepatic system physiology and pathophysiology across the life span (e.g., first-pass metabolism, disorders affecting first-pass metabolism)

0409 Knowledge of interrelationships between hepatic functioning and (a) psychopharmacology (e.g., the interaction between psychotropics and liver enzymes, such as the cytochrome P450 system), and b) psychopathology (e.g., metabolic encephalopathy and delirium; carcinoid tumor and anxiety)

0410 Knowledge of basic endocrine system physiology and pathophysiology across the life span (e.g., relationship between thyroid function tests and hypothyroidism and hyperthyroidism)

0411 Knowledge of interrelationships between endocrine functioning and (a) psychopharmacology (e.g., elevated prolactin and antipsychotic medications), and b) psychopathology {e.g., hormonal disequilibrium and perimenstrual dysphoria, depression and Cushing's disease)

0412 Knowledge of basic hematological system physiology and pathophysiology across the life span

0413 Knowledge of interrelationships between hematological functioning and psychopharmacology (e.g., agranulocytosis and clozapine, thrombocytopenia and carbamazepine), and psychopathology (e.g., anemia and depression) 0414 Knowledge of basic muscular/skeletal/dermatologic system physiology and pathophysiology across the life span (e.g., hypercalcemia and depression)

0415 Knowledge of interrelationships between muscular/skeletal/dermatologic functioning and psychopharmacology (e.g., alopecia and valproic acid), and psychopathology(e.g., OCD and trichotillomania)

0416 Knowledge of basic immunologic/rheumatology system physiology and pathophysiology across the life span (e.g., systemic lupus erythematosus (SLE).

0417 Knowledge of interrelationships between immunologic/rheumatologic functioning and (a) psychopharmacology, and b) psychopathology (e.g., SLE and depression, fibromyalgia and depression, AIDS-related dementia)

0418 Knowledge of interface of psychological, physiological, and behavioral factors and their relationship in complex behaviors and processes involving multiple body systems (e.g., psychoneuroimmunology, sexual functioning)

0419 Knowledge of relationship of complex behaviors involving multiple body systems with (a) psychopharmacology (e.g., sleep disruption secondary to antidepressant medication), and (b) psychopathology (e.g., sexual dysfunction and depression)

IV. INTRODUCTION TO PHYSICAL ASSESSMENT, LABORATORY EXAMS & DIFFERENTIAL DIAGNOSIS

This three-credit course will introduce the topics of basic history and physical examination, as they are pertinent to prescribing of medication. The goal of this course will be to allow the practitioner to gain the knowledge necessary to interpret reports of medical histories, physical examinations, and laboratory studies. Laboratory studies will include basic blood chemistry panels, complete blood counts, thyroid and other endocrinological tests, urinalyses, basic radiological studies computed tomography scans, magnetic resonance imaging studies of the brain, electrocardiogram reports, and electroencephalogram reports. The monitoring of psychotropic medications with blood levels where appropriate and required concomitant general laboratory tests (e.g.: liver function tests with Depakote, thyroid function tests with lithium, etc.) will be emphasized. The ability to distinguish between side effects of medication versus signs and symptoms of general medical conditions, as they are manifested in the history, physical exam, and laboratory studies, will be emphasized also. This area will include APA Content Area 5 and Content Area 6

Content Area 5: Biopsychosocial and pharmacological assessment and monitoring

Refers to a range of biopsychosocial (psychological, neurological, behavioral, physical, biomedical) and pharmacological assessment techniques and procedures for baseline and ongoing evaluation of the individual's physical and psychological health status as well as the assessment of therapeutic efficacy, adverse effects, contraindications for usage, drug interactions, and appropriateness for medication continuation, modification, or discontinuation.

0501 Knowledge of psychological assessment and history taking procedures (e.g., comprehensive individual and family mental health history, dietary habits, mental status, and behavioral assessments)

0502 Knowledge of basic physical and neurological examination procedures

0503 Knowledge of normal laboratory values in screening, assessment, and monitoring techniques, and the implication of disease states, sample timing, and medications on those values

0504 Knowledge of laboratory tests and assessment procedures indicated for general assessment (e.g., basic screening panel), appropriate for use with special populations (e.g., females, individuals experiencing first psychotic break), or before prescribing particular medications (e.g., lithium)

0505 Knowledge of medication-specific therapeutic drug monitoring, and indications for monitoring of clinical laboratory values (e.g., TCA levels, renal functioning in lithium use)

0506 Knowledge of behavioral assessment methods (e.g., rating scales, direct observation of behaviors, parent/teacher/self report) in baseline and ongoing monitoring of therapeutic effectiveness, quality of life, and adverse effects of psychopharmacological agents (e.g., tardive dyskinesia with antipsychotics, sexual dysfunction with antidepressants)

0507 Knowledge of techniques for differential diagnosis and indications for referral to other health care providers based on identification by abnormal biopsychosocial or pharmacological evaluation measures

0508 Knowledge of intellectual and neuropsychological assessment as it pertains to aiding diagnosis (e.g., depression versus dementia), indications for medication regimens, and ability to provide informed consent

Content Area 6: Differential Diagnosis

Refers to the use of comprehensive diagnostic information about a patient to establish an accurate diagnosis from among possible medical and psychological diagnoses in order to select appropriate treatment modalities and determine appropriateness of referral to other heath care providers.

0601 Knowledge of medical disorders that present as psychological disorders (e.g., ADHD versus PKU versus autism, anxiety versus Graves' disorder)

0602 Knowledge of psychological disorders that present as medical disorders (e.g., factitious disorders, somatization disorders)

0603 Knowledge of psychological signs and symptoms (e.g., mental status changes, memory dysfunction, depression, psychosis) secondary to substances of abuse, prescribed and over-the-counter [OTC] medications, supplements, and alternative treatments (e.g., St. John's Wort, steroids)

0604 Knowledge of varied presentations of psychological disorders in different populations (e.g., depression versus dementia in the elderly, ADHD versus anxiety in children, mania versus paranoid schizophrenia in African Americans)
0605 Knowledge of the use of psychological testing, physical and laboratory assessment, and medication response to clarify diagnostic dilemmas (e.g., mania versus cocaine abuse versus hyperthyroidism versus theophylline overdose)

0606 Knowledge of psychopharmacological implications for mental health disorders with overlapping symptomatology (e.g., major depressive disorder with psychotic features, anxious depression)

0607 Knowledge of dual diagnosis and co-morbid conditions (e.g., double depression, alcoholism and schizophrenia, depression with Parkinson's disease)

0608 Knowledge of iatrogenic effects of medication versus primary symptoms of disease progression (e.g., akathisia versus anxiety; depression versus negative symptoms of schizophrenia; anticholinergic reactions versus dementia; medication-induced tremor, dystonic reaction, or tardive dyskinesia versus primary movement disorders)

V. SPECIAL ISSUES IN PHARMACOTHERAPEUTICS:

Psychotherapy/pharmacotherapy interactions:

This one credit course will examine the single practitioner model, in which one practitioner provides therapy and medication prescription services, versus a split treatment model in which these functions are divided among two practitioners. Literature studies of synergistic interactions between psychotherapy and pharmacotherapy will be introduced. Will include APA Content Area 1

Content Area 1: Integrating clinical psychopharmacology with the

practice of psychology

Refers to the implementation of clinical practices of biopsychosocial assessment, multiaxial diagnosis, and treatment, including pharmacotherapy, in the context of a complex of factors influencing functioning. These factors include biological (e.g., generic, sex, age, disease), psychological (e.g., cognitive, emotional, dynamic, motivational, behavioral), psychosocial (e.g., gender, cultural/ethnic, interpersonal), and ecological/environmental factors.

0101 Knowledge of biopsychosocial variables as determinants of medication effects (c.g., family history, differential familial medication response, patient belief systems, economics, social support, current environmental circumstances)

0102 Knowledge of relative effects of psychopharmacological and psychological interventions as sole, additive, or interactive treatment, for given disorders

0103 Knowledge of limitations and value of single-treatment modalities, combined interventions (i.e., medication employed alone or ha conjunction with a psychological therapy), and patient perceptions (e.g., attributions of therapeutic and adverse psychological meaning of medication, motivations, treatment expectations)

0104 Knowledge of timing and sequencing of interventions to achieve maximum treatment effectiveness, including importance of patient instruction

0105 Knowledge of practitioner-patient relationship, including its impact on medication adherence, efficacy, adverse effects, and response to side effects, and implications for the relationship when physical and pharmacological interventions are utilized

0106 Knowledge of the development and implementation of a coherent and organized treatment plan of psychological and pharmacological intervention

0107 Knowledge of case and medication management techniques to enhance adherence to treatment plan (e.g., biological and psychological principles relevant to adherence, communication skills, patient education techniques, cultural competence)

0108 Knowledge of pharmacoeconomics/cost issues in treatment planning

Computer based practice aids:

Use of computer databases such as Medline literature searches will be introduced. On-line resources such as the National Library of Medicine database and drug interaction databases will be introduced. Computer networks used to receive laboratory and radiology reports, and to communicate with pharmacies will be covered. This course will consist of one-half credit hour.

Pharmacoepidemiology/Literature review and critique:

This one credit hour course will examine the literature relating to treatment of various disorders with psychotropic medication: for example, the literature on maintenance and discontinuation of antidepressant medication. Literature studies of abuse of prescribed and illicit drugs will be included. Attention to research protocols will be emphasized.

0901 Knowledge of psychopharmacological retrieval systems and databases

0902 Knowledge of research designs and analytic techniques used in psychopharmacological research (e.g., double-blind, drug washout, control groups, dose-response relationships, intent-to-treat analyses, endpoint analyses, within-subject and group designs, cross-over, use of "rescue" medications, and concurrent administration of other drugs [including OTC, and nonpsychotropic medications])

0904 Knowledge of measurement issues in psychopharmacological research (e.g., sample heterogeneity; sample size; random assignment of participants to treatment conditions; drug levels; outcome measures; standard monitoring procedures for side effects, adverse effects, and drug levels; interpretation issues; and interobserver reliability)

0905 Knowledge of community and participatory research strategies to enhance the relevance of studies on ethnic/cultural and other undeserved populations (e.g., use of community advisory boards, community involvement in research planning)

0906 Knowledge of regulatory issues in psychopharmacological research (e.g., FDA regulations, informed consent, research ethics, Institutional Review Board [IRB], safety, abuse liability, follow-up, compassionate care)

0907 Knowledge of how to critically review clinical research data and use the information for making treatment decisions.



--------------------------------------------------------------------------------

Center for Psychological Studies NSU


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This page is maintained by: Eduardo Magalhaes and Diane Karol, Dean's Office.
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sasevan,

Do you know if clinical psychologists in Florida are pushing for RxP? If so, how much longer before they obtain them?

Anasazi,

That's him! :D Be careful. He may actually want to obtain rights to prescribe psychotropics to improve our comprehension of metaphors.

Anasazi,

That's him! :D Be careful. He may actually want to obtain rights to prescribe psychotropics to improve our comprehension of metaphors.

LOL :laugh:

I don't discount anything anymore....

P.S. For God's sake, you can post links in posts so that you don't have to sort through a mile of spam

I do think you and me are talking from the same viewpoint. Psychotropic meds are not to be used like candies. SSRI are not the answer to everything. Unfortunately "ask your doc" campaigns minimizes the risks associated w/ these psychotropics. That's why I feel these meds should be prescribed by psychiatrists. These days bulk of the SSRIs and SGAs are prescribed by people who work primarily as PCPs w/o any particular psych experience. The same holds true for stimulants in kids.
The point is it is extremely risky for the untrained to experiment w/ the drugs(be it the pt him/herself, PhDs or no-psych MDs for that matter).
BTW, there are psychiatrists who for whatever reasons restrict themselves to 15-min medcks. If anyone has any experience w/ those sessions they will realize what sub-standard care might creep thru those pt-encounters. This is sub-optimal care of the pt and nothing else. I am afraid w/o addressing the safety issue the PhDs for their own vested interest are arguing for their scripting rights and will provide the same sub-optimal care to the pt(because that's what the 3rd party payors will mandate).
And it's interesting when people have their own interests at heart, how callous they can be to other's safety.
http://pn.psychiatryonline.org/cgi/content/short/39/10/1


I'm afraid you may be right about the psychologist issue. For me, the whole point of letting trained Ph.D's prescribe would be that patients usually see these doctors much more frequently, which would increase the chance that an adverse psychological (and hopefully physical) reaction might be detected. If psychologists just turned into marginally-trained drug dispensers (which as you say, is what 3rd party payors would demand)--patients would not benefit in the least.

My concern has been that many psychiatrists' medical education isn't doing their ambulatory patients much good in the current practice environment. Your standards appear to be much higher, and I admire that, but "on the other side of the fence"--so to speak--the 15 min. med handout of whatever-the-drug-rep-brought-in-that-day seems to be the way most office physicians (psychiatrists and others) operate.

Ultimately, the ball is still in the psychiatrists' court. Somehow you guys need to demand really good, independent research into drug efficacy and side effects. Drug company research is often quite sketchy--particularly when it comes to side effects. Among other things, doctors and patients need serious studies on treatment for severe, resistant depression. New drugs should be compared not only to placebo, but also to established treatments. (I seriously doubt any SSRI manufacturer would want their flagship to go head to head with a MAOI or Elavil for MDD!)

I also think the strong (and completely undertandable) preference doctors have for "safe" drugs like the SSRI's, Depakote, etc. over "dangerous" drugs like Lithium, MAOI's, TCA's, benzos etc. often acts against patients' interests. It should be difficult to impossible to hold a doctor liable for a patient's misuse of medication. Dangerous diseases sometimes require dangerous drugs--whether the condition is cardiovascular or psychiatric--and tort law should reflect this.

Empirical Evidence for Selective Reporting of Outcomes in Randomized Trials: Comparison of Protocols to Published Articles
An-Wen Chan, MD, DPhil; Asbj?rn Hr?bjartsson, MD, PhD; Mette T. Haahr, BSc; Peter C. G?tzsche, MD, DrMedSci; Douglas G. Altman, DSc
JAMA. 2004;291:2457-2465.

Thanks so much for the reference....things are worse than I thought.....how can one insist that doctor knows best after reading such articles is beyond me......as a psychologist in training, I see 'clients' not 'patients' and I prefer it that way. I think of myself as providing a service not 'the right answer'.

On a separate thought, some of the psychiatry folks here are proud medical fundamentalists, others have good grasp of problems in interpreting research, others yet are more concerned with psychiatry neglecting the psychosocial aspects of mental illness (these aren't necessarily exclusive categories). What I'd like to know is whether it is realistic to argue for a 'super' mental health professional who is equally at ease in medical/biological, environmental and empirical aspects of psychopathology? In a sense, that's the image that psychologists who want prescription rights are trying to sell....but again, is that realistic or is there a limit to how much the human brain can do.....

What I'd like to know is whether it is realistic to argue for a 'super' mental health professional who is equally at ease in medical/biological, environmental and empirical aspects of psychopathology? [/B] In a sense, that's the image that psychologists who want prescription rights are trying to sell....but again, is that realistic or is there a limit to how much the human brain can do.....

Great point. I think it is less an issue of "how much the human brain can do," as it is a reflection of (mis)managed care. I am sure psychiatrists and psychologists would love to spend more time with their patients in order to understand the myriad medical, psychosocial, and environmental factors that impact their health. Unfortunately, they also have to play by the rules outlined by insurance companies and generate enough paper to pay off school loans, mortgages, and car payments. Increasingly, the healthcare profession as a whole seems to be focusing more on quantity of patients seen, and less on quality of patient care. This is especially true in psychiatry, where over-medication appears to be commonplace, and pharmaceutical companies reign supreme. Why do you think most psychiatrists don't even do psychotherapy any more? As I am sure you know, business runs medicine, not physicians and patients.

"Medical psychologists," if such organisms ever come into form, will likely not be "super mental health professionals." They will be more like "pseudo-psychiatrists," non-physician psychologists who prescribe psychotropic medications and provide psychotherapy. Time will tell whether this will work out with respect to patient safety and treatment effectiveness. Until then, we debate!

sasevan,

Do you know if clinical psychologists in Florida are pushing for RxP? If so, how much longer before they obtain them?

Anasazi,

That's him! :D Be careful. He may actually want to obtain rights to prescribe psychotropics to improve our comprehension of metaphors.

Medications may be necessary since talking appears not to have done much to reduce limited patterns of thinking; in fact, cognitive errors seem to be spreading...maybe the two of you are getting too close...not that there's anything wrong with that...(as Jerry Seinfeld said). :D :laugh:

LOL :laugh:

I don't discount anything anymore....

P.S. For God's sake, you can post links in posts so that you don't have to sort through a mile of spam

OK, I'll give it to you the way you want it: short and quick :laugh:

For goodness sake, why do you get so upset by BIG things, i.e., the big APA, big posts,...? :D :laugh:

"Medical psychologists," if such organisms ever come into form, will likely not be "super mental health professionals." They will be more like "pseudo-psychiatrists," non-physician psychologists who prescribe psychotropic medications and provide psychotherapy. Time will tell whether this will work out with respect to patient safety and treatment effectiveness. Until then, we debate!

To say that medical psychologists who prescribe will be akin to being "pseudo-psychiatrists" is like saying that academic psychiatrists who do behavioral research are akin to being "pseudo-psychologists."

(Is medication going to be needed for similes as well as metaphors?) :D :laugh:

Medical psychologists will be a specialization of clinical psychology. They will not be pseudo-psychiatrists anymore than neuropsychologists are pseudo-neurologists.

Medical psychologists will prescribe medication but this will be based on the psychology model, i.e., psychopharmacotherapy will be an adjunctive intervention. Med psychologists like all psychologists will continue to differentiate themselves from psychiatrists in that their primary tools will be psychological assessments (psychometric instruments) and psychological interventions (psychotherapy and cognitive-behavioral therapy).

For goodness sake, do I have to post the ENTIRE evaluation :D :laugh: of the DoD project to once again demonstrate that medical psychologists can be and have been (and continue to be so, BTW) safe and effective prescribers?

[QUOTE=sasevan]
Medical psychologists will prescribe medication but this will be based on the psychology model, i.e., psychopharmacotherapy will be an adjunctive intervention. Med psychologists like all psychologists will continue to differentiate themselves from psychiatrists in that their primary tools will be psychological assessments (psychometric instruments) and psychological interventions (psychotherapy and cognitive-behavioral therapy).

WTF?
:rolleyes:

OK, I'll give it to you the way you want it: short and quick :laugh:

For goodness sake, why do you get so upset by BIG things, i.e., the big APA, big posts,...? :D :laugh:

Must have something to do with the way my mother treated me as a child...


Med psychologists like all psychologists will continue to differentiate themselves from psychiatrists in that their primary tools will be psychological assessments (psychometric instruments) and psychological interventions (psychotherapy and cognitive-behavioral therapy).

*Begin Dr. Evil voice*

Riiiiiiiight

:laugh:

Oh, and about the DoD study:

First quote (from my old friend Hurt)":

Of note; psychologists who graduated from the 3-year Department of Defense prescribing training program did not earn independent prescribing privileges. These ?pharmacopsychologists? were not allowed to either start or stop a medication without direct supervision from a physician. They were not allowed to even independently monitor any individual with ?concomitant unstable medical conditions,? or those younger than 18 or over 65.


At the conclusion of the study, the Gonvernmental Accounting Office (GAO) stated: ?given PDP?s substantial costs and questionable benefits . . . we see no reason to reinstate this demonstration project.?

Then the public is supposed to be impressed with the lack of adverse effects?
Talk about confounding variables...funny I don't see psychologists complaining about the poor study design of this project. :rolleyes:
As if that's not enough, now we're supposed to generalize this to the GENERAL POPULATION with LESS supervision and a LARGER formulary? Wow.

In every medical school curriculum, you take classes in study design and some basic statistics. No, we're not computing MANOVAs by hand. There isn't time. USMLE step I, II, and III incoroprate either direct or implied knowledge of basic medical statistics. During your psychiatry residency, you have multiple lectures, classes, speaking events about interpreting the medical literature, and are often required to publish a clinical study in a peer-reviewed journal yourself. Many psychiatry residencies offer research electives. Required continuing medical education classes offer courses, either basic, refresher, or advanced seminars on statistical design and research literature.

If you're a psychiatrist and don't know how to interpret basic medical literature, it's your own fault. Try coming to most of the psychiatric team meetings I've been to and tell the psychiatrist they don't know how to read medical literature. Good luck. Whenever anyone ever speaks of psychiatrists on this forum who are non (and even are) psychiatrists, they seem to speak only of the worst-case psychiatrist who has no interest in therapy, doesn't know an ANOVA from a hole in the ground, uses about 3 different psychiatric medications indiscriminately, doesn't do ECT, has no idea about general medicine, and can't tell an EKG from an EEG. These generalizations are getting tiresome. The door swings both ways...I know more than a handful of psychology Ph.D.s (never mind PsyDs) from various universities that would be lucky if they could calculate a mean, let alone tear apart minute manipulations in study design, statistical analysis or interpretation.

If we're going to decide now that those that can best interpret clinical studies are the ones that should be treating, I look with worry to the day that mathematical scientists, statisticians, and actuaries are running medicine.

P.S. I saw "The Day After Tomorrow" today, err, yesterday. It was shockingly cool and ridiculously stupid at the same time.

At the conclusion of the study, the Gonvernmental Accounting Office (GAO) stated: ?given PDP?s substantial costs and questionable benefits . . . we see no reason to reinstate this demonstration project.?



Anasazi,

Everyone is cherry-picking data. Your quote above reflected an island of information in a sea of data that supported the project. It also ignores that the Navy and Air Force are continuing to train psychologists to prescribe and are commissioning graduates from the already existing programs (rather than sending them through the original DoD program).

For the time being, psychologists will advertise the data they choose, psychiatrists will emphasize the data they like . . . and until we get a large enough data pool, this will be how it goes.

There will be dooms-day sayers that will pose that psychologist will kill hundreds of people with the meds they use. Fear-mongering is a great technique and it's worked for thousands of years. Will the American Psychiatric Association do the honest thing and simultaneously publish the adverse events causes by improper medication use by psychiatrists so that the public can rationally compare the data? Doubtful.

We do have an obligation. We've been prescribing medications for years. Our obligation is to teach, to warn, to inform, and to protect (in addition to continuing to provide care). However, our obligation is not to narrowly interpret reality so that it only reflects that with which we are internally or professionally comfortable. Efforts to do just that have been eroding psychiatry for decades. We don't like something . . . we call it pathology. We don't like something .. . we call it dangerous. These reactions might be reasonable. However, in some situations, the reaction is either paranoid or economically defined turf protection.

What would happen if, instead of fighting this process, we embraced those psychologists with the 2 years of advanced training and assisted them to get licensure laws that enabled limited formulary rights . .. so long as they obtained some form of regular supervision from a board-certified psychiatrist? There is value in this from a patient care perspective AND we won't be wasting so much energy, time, and money fighting a battle that, in the end, isn't going to be that productive. These laws would SAIL through the legislatures, would be hailed as patient-care responsible, would save consumers a vast amount of money, and provide access to broader number of providers. Does all progress need to happen with self-injury?

At least that's my take on what psychiatry would do if it really wanted to take a strong leadership role in this issue.

S

Oh, and about the DoD study:

First quote (from my old friend Hurt)":


At the conclusion of the study, the Gonvernmental Accounting Office (GAO) stated: ?given PDP?s substantial costs and questionable benefits . . . we see no reason to reinstate this demonstration project.?

Then the public is supposed to be impressed with the lack of adverse effects?
:thumbdown

I knew you wanted it short and quick BUT I can't give it to you that way because, as obvious from your post, short, quick, and easy answers are also often very wrong.

I hope you don't develope a dx/tx style that follows that pattern.
Complex issues just like patients require painstaiking research and work and humble and honest reporting of the facts.
Please remember: DO NO HARM.

Here then is the ENTIRE GAO report: :thumbup:

Prescribing Psychologists: DOD Demonstration Participants Perform Well
but Have Little Effect on Readiness or Costs (Letter Report, 06/01/99,
GAO/HEHS-99-98).

Pursuant to a legislative requirement, GAO reviewed the Military Health
System's (MHS) Psychopharmacology Demonstration Project (PDP), focusing
on: (1) how PDP graduates have been integrated into MHS; (2) the quality
of care they provide to military personnel and beneficiaries; (3) their
effect on medical readiness; and (4) comparing the costs of the program
graduates to those of other military psychologists and psychiatrists.

GAO noted that: (1) the 10 PDP graduates seem to be well integrated at
their assigned military treatment facilities; (2) the graduates
generally serve in positions of authority, such as clinic or department
chiefs; (3) they also treat a variety of mental health patients;
prescribe from comprehensive lists of drugs, or formularies, and carry
patient caseloads comparable to those of psychiatrists and psychologists
at their same hospitals and clinics; (4) also, although several
graduates experienced early difficulties being accepted by physicians
and others at their assigned locations, the clinical supervisors,
providers, and officials GAO spoke with at the graduates' current and
prior locations--as well as a panel of mental health clinicians who
evaluated each of the graduates--were complimentary about the quality of
patient care provided by the graduates; (5) however, granting drug
prescribing authority to 10 military psychologists cannot substantially
affect the medical readiness of an organization staffed by more than 800
psychiatrists and psychologists; (6) according to military psychiatrists
and psychologists GAO talked to, it is unlikely that the graduates'
prescribing abilities and knowledge of psychotropic drugs would be
needed during wartime because these types of drugs are not generally the
treatment of choice in combat; (7) rather, in treating combat stress,
the preferred course of treatment is adequate rest, counseling, and a
quick return to the front lines; (8) nonetheless, clinic and hospital
officials told GAO that the graduates--by reducing the time patients
must wait for treatment and by increasing the number of personnel and
dependents who can be treated for illnesses requiring psychotropic
medications--have enhanced the peacetime readiness of the locations
where they are serving; (9) GAO projects that the Department of Defense
(DOD) will spend somewhat more on these 10 prescribing psychologists
than it would have spent to provide similar services without the
prescribing psychologists; and (10) primarily because of their high
training costs, GAO estimates that over the course of the PDP graduates'
careers, DOD will spend an average of about 7 percent more (or about
$9,700 annually) per PDP graduate than it would spend on a mix of
psychiatrists and psychologists who would treat patients in the absence
of the PDP graduates.

In conclusion, GAO (like ACNP) concluded that medical psychologists were effective and safe prescribes. The decision not to continue the DoD project was due to the cost of ed/training psychologists (or rather, manipulation of cost figures).

While the DoD project was discontinued, the med psychs were permitted to continue to exercise RxP in the DoD and some still do so to this day. Additionally, last year the DoD accepted to ed/train another psychologist in order to become a prescriber.

For those who can handle it :meanie: , the GAO report is in the following posts.

--------------------------- Indexing Terms -----------------------------

REPORTNUM: HEHS-99-98
TITLE: Prescribing Psychologists: DOD Demonstration Participants
Perform Well but Have Little Effect on Readiness or
Costs
DATE: 06/01/99
SUBJECT: Health care personnel
Performance measures
Military personnel
Human resources utilization
Medical education
Human resources training
Health services administration
Drugs
Cost effectiveness analysis
Mental health care services
IDENTIFIER: DOD Psychopharmacology Demonstration Project
DOD Medical Readiness Strategic Plan
DOD Military Health Services System

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Cover
================================================== ============== COVER

Report to the Chairman and Ranking Minority Member, Committee on
Armed Services, U.S. Senate

June 1999

PRESCRIBING PSYCHOLOGISTS - DOD
DEMONSTRATION PARTICIPANTS PERFORM
WELL BUT HAVE LITTLE EFFECT ON
READINESS OR COSTS

GAO/HEHS-99-98

DOD Prescribing Psychologists

(101619)

Abbreviations
================================================== ============= ABBREV

ACNP - American College of Neuropsychopharmacology
DOD - Department of Defense
MHS - Military Health System
MRSP - Medical Readiness Strategic Plan
PDP - Psychopharmacology Demonstration Project
USUHS - Uniformed Services University of the Health Sciences
VRI - Vector Research, Inc.

Letter
================================================== ============= LETTER

B-280869

June 1, 1999

The Honorable John Warner
Chairman
The Honorable Carl Levin
Ranking Minority Member
Committee on Armed Services
United States Senate

The Military Health System (MHS) provides for the mental health care
needs of the approximately 8 million active-duty members, retirees,
and their dependents. To meet these needs, MHS employed 431
psychiatrists and 430 clinical psychologists in fiscal year 1999.
Some functions of psychiatrists and clinical psychologists overlap.
As physicians, however, psychiatrists are trained in and licensed to
practice medicine and are permitted to prescribe medication for the
treatment of both mental and physical conditions. Because no medical
training is required to practice clinical psychology, clinical
psychologists--whether in the military or the civilian
sector--historically have not been permitted to prescribe drugs. In
1991, however, MHS instituted the Psychopharmacology Demonstration
Project (PDP), which was designed to train and use military
psychologists to prescribe psychotropic medications.\1 By June 1997,
when the project was terminated, 10 psychologists had completed the
training and were subsequently assigned to various Air Force, Army,
and Navy military medical facilities across the country.\2

At the time of our review, 9 of the 10 program graduates were still
treating patients and prescribing medications at military hospitals
and clinics.

The Senate report accompanying the fiscal year 1999 National Defense
Authorization Act directed us to study the results of this program,
including the use and performance of the PDP graduates. Based on the
Senate report and subsequent discussions with your offices, our
evaluation (1) describes how PDP graduates have been integrated into
MHS, (2) provides information on the quality of care they provide to
military personnel and beneficiaries, (3) discusses their effect on
medical readiness, and (4) compares the costs of the program
graduates to those of other military psychologists and psychiatrists.
To address these issues, we talked with all 10 PDP graduates and
other providers and officials at the facilities where the graduates
were practicing or had practiced. Although one graduate left the
military during the course of our review, our evaluation includes
information about this graduate's service as a prescribing
psychologist before leaving the military to reflect the full range of
information available on the performance of the graduates. We also
reviewed the PDP graduates' credentials files,\3 performance reviews,
and relevant reports.

Our work was performed from June 1998 through May 1999 in accordance
with generally accepted government auditing standards. Further
information on our scope and methodology is included as appendix I.

--------------------
\1 These drugs affect psychic function, behavior, or experience.

\2 In April 1997, we issued a report on PDP, Defense Health Care:
Need for More Prescribing Psychologists Is Not Adequately Justified
(GAO/HEHS-97-83, Apr. 1, 1997).

\3 The credentials files contain information on education, licenses,
performance evaluations, and other information, as well as a record
of any quality problems that resulted in adverse outcomes.

RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The 10 PDP graduates seem to be well integrated at their assigned
military treatment facilities. For example, the graduates generally
serve in positions of authority, such as clinic or department chiefs.
They also treat a variety of mental health patients; prescribe from
comprehensive lists of drugs, or formularies;\4 and carry patient
caseloads comparable to those of psychiatrists and psychologists at
the same hospitals and clinics. Also, although several graduates
experienced early difficulties being accepted by physicians and
others at their assigned locations, the clinical supervisors,
providers, and officials we spoke with at the graduates' current and
prior locations--as well as a panel of mental health clinicians who
evaluated each of the graduates--were complimentary about the quality
of patient care provided by the graduates.

However, granting drug prescribing authority to 10 military
psychologists cannot substantially affect the medical readiness of an
organization staffed by more than 800 psychiatrists and
psychologists. Moreover, according to military psychiatrists and
psychologists we talked to, it is unlikely that the graduates'
prescribing abilities and knowledge of psychotropic drugs would be
needed during wartime because these types of drugs are not generally
the treatment of choice in combat. Rather, in treating combat
stress, the preferred course of treatment according to service
readiness officials and field commanders is adequate rest,
counseling, and a quick return to the front lines. Nonetheless,
clinic and hospital officials told us that the graduates--by reducing
the time patients must wait for treatment and by increasing the
number of personnel and dependents who can be treated for illnesses
requiring psychotropic medications--have enhanced the peacetime
readiness of the locations where they are serving.

We project that the Department of Defense (DOD) will spend somewhat
more on these 10 prescribing psychologists than it would have spent
to provide similar services without the prescribing psychologists.
Primarily because of DOD's higher training costs, we estimate that
over the course of the PDP graduates' careers, DOD will spend an
average of about 7 percent more (or about $9,700 annually) per PDP
graduate than it would spend on a mix of psychiatrists and
psychologists who would treat patients in the absence of the PDP
graduates.

--------------------
\4 As used here, "formulary" refers to the set of prescription drugs
that a provider is permitted to prescribe to patients when treating
illnesses.

BACKGROUND
------------------------------------------------------------ Letter :2

The principal mission of MHS is medical readiness. As defined by
DOD, medical readiness encompasses both wartime and peacetime
components. The wartime mission is primary, according to DOD's
Medical Readiness Strategic Plan (MRSP), requiring MHS to provide
top quality health services, whenever needed, in support of military
operations.\5 In peacetime, according to MRSP, the military medical
departments are to maintain and sustain the well-being of the
fighting forces in preparation for war. Finally, MRSP states that
the military may provide care to dependents or retirees in peacetime,
when not employed in preparation and training for the wartime role.
The Army, Navy, and Air Force all use military and civilian health
care providers to meet their readiness needs.

PDP was established by DOD in response to a conference report dated
September 28, 1988, which accompanied the fiscal year 1989 DOD
Appropriations Act (P.L. 100-463). The report directed DOD to
establish a demonstration pilot training program in which military
psychologists may be trained and authorized to issue appropriate
psychotropic medications under certain circumstances."

This training program began in August 1991 with four participants.
Training for the initial class consisted of 2 years of classroom
training at the Uniformed Services University of the Health Sciences
plus 1 additional year of clinical training. For subsequent classes,
however, the training was modified to consist of 1 year of classroom
training and 1 year of clinical training. PDP participants obtained
their clinical experience on inpatient wards and at outpatient
clinics at Walter Reed Army Medical Center in Washington, D.C., or at
Malcolm Grow Medical Center located at Andrews Air Force Base in
Maryland. During the clinical part of the training, participants
were trained to take medical histories and incorporate them into
treatment plans and to prescribe medication for patients with certain
types of mental disorders.

Two prescribing psychologists graduated from the initial training
class in 1994. The three subsequent graduating classes included 1
prescribing psychologist in 1995, 4 in 1996, and 3 in 1997--for a
total of 10 graduates.\6 These 10 graduates--three women and seven
men\7 --represented each of the three services: 4 from the Navy and
3 each from the Air Force and Army. In 1995, as part of the program,
guidelines were issued on the graduates' roles, including a suggested
drug formulary that they would use, a scope of practice limited to
patients between the ages of 18 and 65, and the level of supervision
or proctoring of graduates for 1 year after graduation.

Several evaluations of the program have been completed since its
inception. The American College of Neuropsychopharmacology (ACNP),\8
under contract to DOD, conducted six annual assessments of PDP and
issued a final report on the program in 1998. In conducting these
assessments, an ACNP evaluation panel interviewed PDP participants
and graduates, program officials, classroom instructors, clinical
supervisors, and others. Vector Research, Inc. (VRI), also under
contract to DOD, conducted an evaluation of the program to determine
its cost-effectiveness and feasibility. VRI's report was issued in
May 1996 and concluded that PDP was cost-effective.\9 In our April
1997 report, we expressed concern about VRI's analysis because in our
view it was based, in part, on unrealistic assumptions.

Additionally, as required by the National Defense Authorization Act
for fiscal year 1996 (P.L. 104-106), GAO conducted a study of PDP,
which included (1) an assessment of the need for prescribing
psychologists in MHS, (2) information on the implementation of PDP,
and (3) information on PDP's costs and benefits. In our resulting
1997 report, we concluded that training psychologists to prescribe
medication was not adequately justified because MHS had not
demonstrated a need for prescribing psychologists, the cost of the
program was substantial, and the benefits were uncertain.

In response to the same act, PDP was terminated in June 1997.
However, those psychologists who had graduated from or were currently
enrolled in the program were permitted by the legislation to continue
prescribing psychotropic medication.

--------------------
\5 See DOD, Medical Readiness Strategic Plan (MRSP) 1998-2004
(Washington, D.C.: Aug. 1998), p. 22.

\6 Three participants left the program during the training.

\7 To safeguard the graduates' privacy, we use only masculine
pronouns in this report.

\8 ACNP is a professional association of about 600 scientists from
disciplines such as behavioral pharmacology, neurology, pharmacology,
psychiatry, and psychology.

\9 VRI, Cost-Effectiveness and Feasibility of the DOD
Psychopharmacology Demonstration Project: Final Report (Arlington,
Va.: May 17, 1996).

PDP GRADUATES ARE WELL
INTEGRATED INTO MHS
------------------------------------------------------------ Letter :3

PDP graduates are well integrated into MHS. They hold positions of
responsibility, such as clinic or department head, and treat a broad
spectrum of patients, including active-duty personnel, retirees, and
dependents. They can prescribe medication from comprehensive drug
formularies and have patient caseloads that are comparable to those
of psychiatrists and other psychologists who practice at their
clinics and hospitals. Although the graduates were initially
supervised closely, all but two have been granted independent status,
meaning that they are subject only to the same level of review as
psychiatrists at their locations. However, although the graduates
are currently well integrated, several experienced early difficulties
being accepted at their locations.

PDP GRADUATES HOLD POSITIONS
OF RESPONSIBILITY, AND MOST
TREAT A MIX OF PATIENTS
---------------------------------------------------------- Letter :3.1

The nine program graduates remaining in the military at the time of
our visits are serving as the chief of a clinic or department,
suggesting the high professional esteem in which they are held. For
example, one serves as the chief of an Army division mental health
clinic, one as the commander of an Air Force mental health clinic,
and another as the chief of a Navy hospital's mental health
department. Serving as clinic or department chief includes
performing administrative duties, such as supervising other mental
health providers and managing the day-to-day operations of the
clinic. The one graduate who left the military did not serve as
clinic or department chief during his year of post-PDP service.

Although PDP guidance limits graduates to seeing patients between the
ages of 18 and 65, most graduates see a mix of patients, including
active-duty personnel, retirees, and dependents. Two graduates serve
in clinics that treat only active-duty personnel, and one serves in a
clinic that treats primarily active-duty personnel but also treats
dependents when mental health providers are available. The remaining
seven treat a mix of active-duty personnel, dependents, and retirees.

PDP GRADUATES PRESCRIBE FROM
COMPREHENSIVE DRUG
FORMULARIES
---------------------------------------------------------- Letter :3.2

To guide medical facilities when granting prescribing privileges to
the program graduates, a suggested drug formulary listing
psychotropic drugs by name was created as part of PDP.\10 Six of the
10 graduates are assigned to facilities that granted the graduates
drug formularies that are at least as comprehensive as the drug
formulary recommended for them. The remaining four graduates have
formularies that lack some drugs listed on the suggested formulary
but contain additional drugs not listed on the suggested formulary.
Although these four graduates' formularies do not include all drugs
on the recommended formulary, none noted that this lack of some drugs
reduced their effectiveness in providing patient care.

Some graduates' authority to prescribe is broader than others'.
While four of the graduates have formularies consisting of lists of
specific drugs they can prescribe, five have formularies listing
classes of drugs from which they can prescribe. Formularies listing
drugs by class, rather than by name, allow the flexibility to
prescribe a new medication if it falls into a class of drugs already
authorized. Otherwise, the graduates have to petition to have the
new drug added to their authorized drug formulary. One graduate's
formulary is even more flexible, granting the graduate broad
authority to prescribe psychotropic drugs and their adjuncts.\11

--------------------
\10 Although all graduates received training in the use of
psychotropic drugs to treat mental disorders in patients, they may
not prescribe medications until granted prescribing privileges by the
medical facility where they are assigned. Each facility is
responsible for establishing the list of drugs, or formulary, from
which providers at the facility can prescribe.

\11 Adjuncts are drugs that are commonly used in the treatment of the
side effects of psychotropic medications.

PDP GRADUATES' AVERAGE
MONTHLY CASELOADS ARE
COMPARABLE TO COLLEAGUES'
---------------------------------------------------------- Letter :3.3

Eight of the 10 graduates' caseloads are comparable to those of
psychiatrists and other psychologists at the same location. (The
remaining two graduates practice at locations without psychiatrists
or other psychologists, so their caseloads could not be compared to
other mental health providers'.) For example, one graduate sees an
average of 47 cases per month--higher than both the average for other
psychologists at the same location (40 cases per month) and the
average for psychiatrists at the same location (30 cases per month).
Another graduate--the chief of the clinic in which he works--sees
between 60 and 70 cases per month. Although this is lower than the
average of 100 cases per month seen by the psychiatrist in the same
clinic, the graduate told us that 30 to 50 percent of his time is
spent on administrative duties associated with his position as chief.

Variation in the graduates' average monthly caseloads--which range
from 40 cases for one graduate to 185 cases for another--results in
part from the graduates' locations and responsibilities. For
example, the graduate with the lowest monthly caseload is stationed
overseas and treats only active-duty personnel and their dependents
who have been screened for suitability for overseas assignment. In
addition, this graduate is the chief of the mental health department
and of the hospital credentials committee and serves on the medical
staff executive committee. Conversely, the graduate with the highest
monthly caseload was the only graduate not serving as a clinic or
department chief, allowing this graduate more time to treat patients.

MOST GRADUATES HAVE BEEN
GRANTED INDEPENDENT STATUS
---------------------------------------------------------- Letter :3.4

Initially, all graduates received close supervision by psychiatrists,
in accordance with guidance issued as part of PDP. For example, each
graduate's supervisor reviewed the graduate's charts for patients
receiving medication. Other elements of supervision varied but
included observing patient sessions or meeting separately with
patients; holding formal weekly meetings to discuss cases; and
requiring written approval for either starting, stopping, or changing
the dosage of medications. The level of supervision was subsequently
reduced for all graduates, seven of whom were granted independent
status--meaning that they are subject only to the same level of chart
review as other providers at their location. Another graduate has
been granted independent status for treating outpatients--the bulk of
the graduate's caseload--but is supervised when treating inpatients.
Granting these graduates full or partial independent status indicates
hospital officials' belief that the graduates need no more
supervision than do other prescribing providers.

The remaining two graduates have not been granted independent status.
Officials stationed at one graduate's location told us that they had
anticipated granting him independent status; however, before
officials reevaluated his status, the graduate was transferred to a
new location.\12 The second graduate serves at a facility that has a
policy requiring continued supervision of all physician extenders
(such as prescribing psychologists, physician assistants, and nurse
practitioners) who prescribe medication, regardless of length of
service or level of performance.

--------------------
\12 According to the graduate, hospital officials at the graduate's
new location have not yet determined whether he will be granted
independent status.

SOME GRADUATES EXPERIENCED
INITIAL PROBLEMS WITH
ACCEPTANCE
---------------------------------------------------------- Letter :3.5

While ultimately well integrated at their locations, some graduates
experienced some initial difficulty in this regard. For example, a
graduate from one of the first PDP classes waited 10 months at his
initial location to receive prescribing privileges and waited another
3 months before treating a patient requiring medication. Another
graduate told us he learned that certain drugs on his formulary had
been eliminated only after being informed by a patient that the
hospital pharmacy had rejected a prescription written by the
graduate. However, both graduates have been reassigned to different
locations, and both have been accepted at their new locations.

Some of the graduates encountered initial skepticism from supervising
psychiatrists, primary care physicians, nurses, and hospital
officials who were uncomfortable with the idea of allowing
psychologists to prescribe drugs. For example, one graduate told us
that a physician at his location was so opposed to giving him
prescribing privileges that the doctor resigned from the credentials
committee after these privileges were granted. One psychiatrist at
another location told us that upon learning that he was assigned to
supervise a PDP graduate, he contacted the American Medical
Association to inquire about the ethical propriety of a psychiatrist
serving as a proctor for a prescribing psychologist. However, nearly
all of the physicians and others we spoke to told us that the
graduates' performance subsequently convinced them that the graduates
were well trained and knowledgeable. Several physicians also told us
that they came to rely on the graduates for information about
psychotropic medications.

GRADUATES ARE REPORTED TO
PROVIDE GOOD QUALITY OF CARE
------------------------------------------------------------ Letter :4

Overwhelmingly, the officials with whom we spoke, including each of
the graduates' clinical supervisors, and an outside panel of
psychiatrists and psychologists who evaluated each of the graduates
rated the graduates' quality of care as good to excellent. Further,
we found no evidence of quality problems in the graduates' credential
files.

The graduates' clinical supervisors have the most extensive knowledge
about the graduates' clinical performance because they have been
responsible for reviewing the graduates' charts, discussing cases
with the graduates, and observing the graduates' interactions with
patients. Without exception, these supervisors--all
psychiatrists--stated that the graduates' quality of care was good.
One supervisor, for example, noted that each of the graduate's
patients had improved as a result of the graduate's treatment;
another supervisor referred to the quality of care provided by the
graduate as phenomenal. The supervisors noted that the graduates
are aware of their limitations and know when to ask for advice or
consultation or when to refer a patient to a psychiatrist. Further,
the supervisors noted that no adverse patient outcomes have been
associated with the treatment provided by the graduates.

External evaluators also provided information on the graduates'
quality of care. In 1998, an ACNP panel composed of board-certified
psychiatrists and licensed clinical psychologists performed a final
evaluation of the graduates--interviewing the graduates, their
supervisors, and other officials, and reviewing a portion of each
graduate's patient charts. In its resulting report, ACNP described
each graduate's location and role, discussed the results of
interviews with the graduates' clinical supervisors and others, and
discussed the results of patient chart reviews. In its report, ACNP
stated that the graduates had performed well in all the locations
where they were assigned, that they had performed safely and
effectively as prescribing psychologists, and that no adverse
outcomes had been associated with their performance.\13

--------------------
\13 During our review, we received allegations regarding certain
graduates' performance from two individuals involved in overseeing or
evaluating the graduates. In all cases, we reviewed available
evidence and held discussions with relevant officials. In all but
one case, we found that there was not sufficient evidence to support
the allegations. In the one case, the hospital's chief of medical
staff considered the issue insignificant.

GRADUATES' EFFECT ON READINESS
IS MINIMAL
------------------------------------------------------------ Letter :5

Although the graduates have been well integrated and have been
reported to provide good care, their effect on DOD's medical
readiness could not be more than minimal. DOD has approximately 400
psychiatrists and 400 psychologists; granting prescribing privileges
to 10 psychologists is unlikely to affect combat readiness. Further,
because psychotropic drugs are not used extensively during combat,
the graduates, if deployed in combat, would likely have little effect
on readiness beyond their role as clinical psychologists. However,
evidence we gathered suggests that the graduates have modestly
enhanced the peacetime readiness of military personnel at their
current locations.

GRADUATES ARE UNLIKELY TO
NEED PRESCRIBING ABILITY IN
WARTIME
---------------------------------------------------------- Letter :5.1

Many officials--including service readiness officials and field
commanders--told us that the graduates would likely have little
effect on readiness in combat because psychotropic drugs are not
generally the treatment of choice in combat and thus prescribing
authority would not be in great demand. Because none of the PDP
graduates have been deployed to a combat zone, however, no data exist
on the actual use of the graduates in wartime situations.

According to many officials with whom we spoke, the preferred course
of treatment for combat stress is adequate rest, counseling, and a
quick return to the front lines. Soldiers who require medication are
generally evacuated to hospitals located away from combat areas.
Psychologists' counseling skills can be valuable front-line tools to
handle stress, although this can be accomplished without the special
training given to prescribing psychologists. A service-level medical
readiness official told us that the most effective techniques to
minimize combat stress are proactive--that is, counseling troops upon
their arrival in the combat zone to reduce their anxiety level before
combat. According to officials, the social workers, psychologists,
and psychiatrists who provide this type of proactive counseling have
a far greater effect on the well-being of the troops in battle than
those who treat personnel after combat stress has set in. This
proactive approach does not require prescribing authority.

GRADUATES CONTRIBUTE TO
READINESS AT THEIR LOCATIONS
---------------------------------------------------------- Letter :5.2

Although the PDP graduates' prescribing skills may not be needed in
combat situations, the graduates reportedly improve medical readiness
at their peacetime locations. According to officials, the graduates
improve readiness by reducing the time that patients must wait for
treatment or by increasing the number of patients who can be treated.

Before the graduates were stationed at their current locations, some
patients requiring mental health care received both psychotherapy
from a psychologist and drug therapy from a psychiatrist because
psychologists had not been permitted to prescribe drugs. Patients
who needed to see two providers for treatment could, according to
officials, wait up to 3 weeks to get an appointment with a
psychiatrist. Prescribing psychologists, however, can treat some
patients needing drugs who otherwise would require an appointment
with a psychiatrist. Since these patients see only one
provider--their prescribing psychologist--the time and effort needed
to receive treatment is reduced.

Other benefits may accrue as well. For example, one official told us
that when only a portion of the units in his division--which is
staffed with a psychologist and a psychiatrist--get an order to
deploy, the division has to consider which providers should remain at
the division's permanent location so that the division as a whole has
adequate medical support. In the past, if the division decided to
deploy its psychiatrist, the permanent location would be without a
prescribing mental health provider. Having a prescribing
psychologist enables the division to deploy one prescribing provider
while keeping another at the division's permanent location.

The graduates may also contribute to medical readiness through the
care of dependents. According to several officials with whom we
spoke, personnel who are worried about whether their family members
are receiving adequate care may be affected in their ability to carry
out their duties. One official told us that the PDP graduate in his
unit--who primarily treats dependents--contributes to readiness in
this manner. Because the facility did not have enough psychiatrists
to care for dependents before the graduate was assigned to this
location, those who needed to see a psychiatrist were referred to
civilian psychiatrists in a nearby city. According to this official,
many dependents did not seek care from these psychiatrists because
they could not afford the copayment. The PDP graduate gives the
facility the additional capability to provide care to dependents
without charging them. The official believes that, consequently,
more dependents seek and receive the care they need and fewer
active-duty personnel worry about their family members' treatment.

PDP GRADUATES ARE MORE COSTLY
THAN TRADITIONAL PSYCHOLOGIST
AND PSYCHIATRIST MIX
------------------------------------------------------------ Letter :6

We project that DOD will spend somewhat more on its 10 prescribing
psychologists than it would have spent on providing mental health
services using the traditional mix of psychologists and
psychiatrists. When all DOD expenditures for various mental health
care providers--including salaries and acquisition, training, and
retirement costs--are averaged over the length of time the providers
are expected to serve, the average yearly cost of a PDP graduate is
about 7 percent higher than that of the combination of psychologists
and psychiatrists who would have provided treatment similar to that
provided by the graduates.\14

Adapting a methodology developed by VRI,\15 we analyzed and compared
DOD's costs for providing salaries, training, retirement pay, and
other career-related benefits to military clinical psychologists,
prescribing psychologists, and psychiatrists. We found that mental
health providers' overall yearly costs to DOD are not identical. Of
the three types of providers we analyzed, the costs for military
psychiatrists are the highest--in part because psychiatrists receive
more yearly pay than military clinical psychologists or prescribing
psychologists. The PDP graduates' costs are the next highest and are
considerably more than clinical psychologists--primarily because the
costs involved in training the graduates and evaluating them
(including evaluations by ACNP and VRI) far exceed the training costs
for clinical psychologists.

Considering all career-related costs, we project that, on average,
the PDP graduates will each cost DOD about $9,700 per year--or about
7 percent--
more than the cost of the combination of psychologists and
psychiatrists that would be used to treat patients in their absence.
Appendix II describes our analysis in more detail.

--------------------
\14 Other physicians--such as family practice and internal medicine
doctors--also prescribe psychotropic medications. However,
psychiatrists are the only physicians included in our analysis.

\15 VRI previously evaluated PDP, under contract to DOD. We updated
VRI's model with more current information.
AGENCY COMMENTS
------------------------------------------------------------ Letter :7

In comments received April 26, 1999, responding to a draft of this
report, the Executive Director of DOD TRICARE Management Activity
stated that DOD agreed with the report and had no further comments.

Copies of this report are being sent to Representative Floyd Spence,
Chairman, and Representative Ike Skelton, Ranking Minority Member,
House Committee on Armed Services; and to the Honorable William
Cohen, Secretary of Defense. Copies will also be made available to
others upon request. If you have any questions about this report,
please call me at (202) 512-7101 or Ronald J. Guthrie, Assistant
Director, at (303) 572-7332. Other major contributors to this report
are Steve Gaty, Sigrid McGinty, and Arthur D. Trapp, Senior
Evaluators; and Timothy J. Carr, Economist.

Stephen P. Backhus
Director, Veterans' Affairs and
Military Health Care Issues

OBJECTIVES, SCOPE, AND METHODOLOGY
OF OUR REVIEW
================================================== ========= Appendix I

The objectives of our review were to

-- describe how the 10 Psychopharmacology Demonstration Project
(PDP) graduates have been integrated into the Military Health
System (MHS);

-- obtain information on the quality of care they provide to
military personnel, dependents, and retirees;

-- determine their effect on medical readiness; and

-- assess the cost-effectiveness of the PDP graduates.

To address the first two objectives, we visited the current or former
duty locations of nine of the graduates and contacted the remaining
graduate, who is stationed overseas, by telephone. At the locations
we visited, we also interviewed the graduates' clinical supervisors,
the hospital commander or designee, and various other clinicians and
personnel to obtain information about the graduates' performance and
level of integration.

Lacking a uniform definition of integration, we used several measures
of how the graduates were used in order to assess their integration.
We obtained information on each graduate's current position and role,
scope of practice, drug formulary, average monthly caseload, and
level of supervision received. We also reviewed the graduates'
credentials files and performance reviews. We contacted all the
members of an American College of Neuropsychopharmacology (ACNP)
panel that performed a 1998 review of the graduates to obtain their
views about the quality of care provided by the program graduates.
We analyzed ACNP's May 1998 report and the report's supporting
documentation, as well as prior ACNP evaluations of PDP.

To collect information on the PDP graduates' impact on medical
readiness, we spoke with officials from each of the services and from
the Office of the Assistant Secretary of Defense (Health Affairs), as
well as officials at the graduates' locations. In addition, we
reviewed DOD's Medical Readiness Strategic Plan to determine the role
of MHS in supporting DOD's medical readiness.

To assess the cost-effectiveness of the graduates, we used a model
developed by Vector Research, Inc. (VRI), under contract to DOD.
Using updated data and assumptions, we calculated the life-cycle
costs of the graduates, as well as those of other DOD psychologists,
psychiatrists, and other physicians, and compared the annual
life-cycle costs of these providers to determine the cost of the
graduates relative to that of other providers. Appendix II provides
a more detailed description of the model and the assumptions we used
in calculating life-cycle costs.

ANALYSIS OF PDP GRADUATES' COSTS
RELATIVE TO THOSE OF OTHER DOD
PROVIDERS
================================================== ======== Appendix II

This appendix presents the methodology, data sources, and principal
assumptions we used to calculate the career costs of military
psychiatrists, psychologists, and prescribing psychologists. It also
discusses how we compared the costs of prescribing psychologists to
those of these other mental health care providers. Our analysis
builds on a 1996 VRI study, in which VRI compared the cost of various
types of military health care providers to the cost of a prescribing
psychologist and assessed the relative cost-effectiveness of training
the psychologists to prescribe medication and having them deliver
this service in MHS.\16

For the purposes of this report, we have updated and extended the VRI
analysis, most notably by

-- revising the figures used by VRI to represent the costs involved
in training the prescribing psychologists and

-- estimating the career length of the graduates who currently
remain in the military, based on their career length to date,
and calculating their career costs.

Except where noted, the data we used--such as military pay rates and
health care costs--were provided by VRI. However, we did not verify
the accuracy of these data.

--------------------
\16 Other tasks in the study included identifying impediments to
integrating prescribing psychologists into MHS and evaluating the
potential roles and functions of prescribing psychologists in DOD.

COST ANALYSIS
------------------------------------------------------ Appendix II:0.1

DOD uses several types of providers to deliver mental health care,
including psychologists, psychiatrists, family practice doctors, and
internal medicine doctors. However, their career-related
costs--including salaries, training, and retirement pay--are not
identical and are generally lower for psychologists than for these
physicians. For example, psychologists are not eligible for all
special payments above salaries that physicians may receive.

We calculated the average career costs of the graduates and other
providers and compared them to one another, using costs based on the
anticipated career length and overall cost to DOD of the PDP
graduates and other providers. Most PDP graduates spent a part of
their military careers as clinical psychologists (before they entered
PDP) and part of their military careers as prescribing psychologists
(after they entered PDP). For comparison purposes, we assumed that
the mental health services provided by PDP graduates as prescribing
psychologists are comparable to those provided by psychiatrists\17
--that is, they are trained to perform a function (prescribing
psychotropic medication) that psychiatrists would have to perform in
their absence.\18

Because a PDP graduate's career, on average, is a combination of the
functions performed by psychologists and psychiatrists, we compared
the portion of a PDP graduate's career spent as a psychologist (that
is, before the graduate became a prescribing psychologist) to the
yearly cost of a military psychologist, and we compared the portion
of a PDP graduate's career spent as a prescribing psychologist to the
yearly cost of a military psychiatrist. For example, one PDP
graduate served about 10 years as a military psychologist before
entering PDP and, since then, has served about 4 years as a
prescribing psychologist--for a total of 14 years. Thus, the
graduate spent 71.4 percent (10 years) of his practicing career in
the military as a clinical psychologist and 28.6 percent (4 years) as
a prescribing psychologist. The yearly cost of the graduate could
then be compared to 71.4 percent of the yearly cost of a psychologist
plus 28.6 percent of the yearly cost of a psychiatrist.

Another PDP graduate served 3 years as a military psychologist before
entering PDP and has served 3 years as a prescribing psychologist,
for a total of 6 years. Thus, 50 percent of his practicing career in
the military was spent as a clinical psychologist and 50 percent was
spent as a prescribing psychologist. As a result, the yearly cost of
this graduate could be compared to 50 percent of the yearly cost of a
psychologist plus 50 percent of the yearly cost of a psychiatrist.

The 10 PDP graduates differed in the length of time they had served
as military psychologists before entering PDP, ranging from not
having served in the military to having served 10 years,\19 with a
mean average of about 4.5 years as military psychologists.
Similarly, the participants can be expected to differ in the length
of time each remains in the military as a prescribing psychologist.
We calculated the average length of their projected careers as
prescribing psychologists, based on the length of their military
service to date and the rates at which DOD psychologists have
historically left the military. Using these data, we project that
each program participant will serve an average of 6 years as a
prescribing psychologist after entering PDP (including service to
date as prescribing psychologists). Thus, we expect the participants
to serve an average combined career total of 10.5 years in the
military as clinical psychologists and subsequently as prescribing
psychologists: an average of 4.5 years (or 43 percent of their
careers) as clinical psychologists, plus an average of 6.0 years (or
57 percent of their careers) as prescribing psychologists. The
average yearly cost of the graduates can thus be compared to 43
percent of the yearly cost of a psychologist plus 57 percent of the
yearly cost of a psychiatrist.

Our estimates of the overall cost of the various types of providers
included

-- acquisition costs that DOD incurs when recruiting someone into
the military;

-- training costs to provide DOD-sponsored training to military
health care providers;

-- force costs, which cover basic pay and allowances (such as
allowances for housing), special pay, miscellaneous expenses,
and health care benefits over the course of an active-duty
career; and

-- retirement costs, which include retirement pay and retiree
health care benefits over the expected life of the retiree.

--------------------
\17 Some--including ACNP and the American Psychological
Association--have pointed out that the graduates are not intended to
replace psychiatrists. ACNP wrote, PDP was not designed to replace
psychiatrists . . . and it did not do so. Instead, the program
products' were extended psychologists with [the] value-added
component prescriptive authority provides.

\18 Other physicians--such as family practice and internal medicine
doctors--also prescribe psychotropic medications. However, their
annual life-cycle costs are higher than those of psychiatrists,
primarily because they serve shorter careers than psychiatrists and,
thus, their overall costs are larger on an annual basis. Because
psychiatrists' costs were the lowest of the physicians' costs
analyzed, we used their costs in order to provide the most
conservative comparison.

\19 Two PDP graduates entered PDP immediately upon joining the
military.

DATA AND ASSUMPTIONS
------------------------------------------------------ Appendix II:0.2

Although our analysis resembles VRI's--and in most cases relies on
VRI's data and assumptions--in several instances we used data or
assumptions that differed from VRI's. These differences reflect our
emphasis on incorporating data that reflect, to date, the actual
costs and experience of the program as it was implemented by DOD,
rather than VRI's projections of how the program might be
implemented. We discussed these changes with a VRI official, who
stated that while he disagreed with our estimate of the cost of
classroom training, the assumptions we used in our calculations were
reasonable given the history of the program. The remainder of this
appendix discusses the major assumptions we made in performing our
analysis and explains where and how our data or assumptions differed
from VRI's.

DIFFERENT SCENARIOS
---------------------------------------------------- Appendix II:0.2.1

In calculating the cost-effectiveness of PDP, VRI used two case
scenarios: start-up and optimal. Costs in the start-up scenario
included the nonrecurring, fixed costs associated with PDP
development and initial implementation, such as the cost of the
external evaluation by ACNP, as well as other costs that VRI believed
would diminish or disappear in the long run.

The optimal scenario represented PDP in a long-term, steady state
during which no nonrecurring costs associated with program start-up
would accrue. In this scenario, VRI set the cost of supplies and
training to levels that indicate long-term efficiency.

In contrast to VRI, we did not project different scenarios because
the program has been terminated. Instead, we used data that reflect,
to date, the actual costs and experience of the program as it was
implemented by DOD.

PRE-PDP SERVICE
---------------------------------------------------- Appendix II:0.2.2

VRI assumed that PDP participants would have at least 6 years of
experience as military clinical psychologists when they entered PDP.
However, we found that although the 10 PDP graduates served an
average of almost 7 years in the military before entering PDP, on
average only about 4.5 of those years were spent as a clinical
psychologist. We did not include nonpsychologist years in our cost
comparison.

VRI assumed that the yearly continuation rates--that is, the
probability that a given provider will stay within a given service
occupation during a given year--for program participants before
entering PDP were identical to those for military psychologists,
including some psychologists who leave the military each year after
the first 2 years of service. In contrast, based on the experience
of the program, we used yearly continuation rates that reflect the
fact that no participants left the military before entering PDP.\20

--------------------
\20 The continuation rate used affects the length of service
calculated by the model. Because annual costs depend in part on this
expected length of service, different continuation rates will result
in different annual costs.

PDP CHARACTERISTICS
---------------------------------------------------- Appendix II:0.2.3

VRI used two different estimates of class size, depending on the
scenario. In the start-up case, VRI assumed that, on average, 3.25
psychologists would enter each PDP class, from which 2.25 prescribing
psychologists would graduate. These numbers were based on the
program experience at the time of VRI's report: 13 psychologists had
entered the program and, according to a VRI official, it appeared
that 9 would graduate. VRI set the retention rate during the program
to reflect the assumption that 9 of 13 participants would graduate.

In the optimal case scenario, VRI assumed that, on average, 8.7
psychologists would enter PDP each year, while 6 prescribing
psychologists would graduate. The continuation rate during the
program was identical to that used in the start-up case.

However, of the 13 participants, 10--not 9--graduated from the four
PDP classes. Consequently, we used an average of 3.25 (that is,
13/4)
psychologists entering PDP each year and 2.5 (that is, 10/4)
graduating. We set the continuation rate during the program
accordingly. Further, in order to reflect the fact that 13
psychologists entered PDP--effectively leaving the services'
clinical psychologist force for cost-comparison purposes--we used a
continuation rate for clinical psychologists that differed slightly
from the historical DOD rate to account for these psychologists.

Our estimates of the cost of training the graduates also differed
from those used by VRI. For its cost model, VRI estimated the
overhead costs associated with the program to be $2,890,343.
However, based on ACNP's annual reports (some of which were not yet
published when VRI conducted its study) and our interviews with the
former PDP training director, we estimated the overhead costs to be
about 14 percent lower at $2,474,578.

While our estimate of overhead costs is lower than VRI's estimate,
our estimate of 1 year of classroom training at the Uniformed
Services University of the Health Sciences (USUHS) is markedly higher
than that used by VRI. VRI estimated the classroom training costs
(which do not include the PDP overhead costs it estimated) for
participants to be $39,969, based on its 1995 study of the costs of
graduate medical education and on a survey of the costs of graduate
medical education in the Washington, D.C., area. However, based on
our previous analysis of USUHS costs,\21

we estimated the classroom training costs to be $110,028--or about
175 percent higher than VRI's estimate.

--------------------
\21 Military Physicians: DOD's Medical School and Scholarship
Program (GAO/HEHS-95-244, Sept. 29, 1995).

POST-PDP SERVICE
---------------------------------------------------- Appendix II:0.2.4

To project how long the PDP graduates could be expected to serve as
prescribing psychologists, VRI assumed no graduates would leave the
military for the 2 years immediately following the program. VRI also
assumed that the rate at which the graduates leave the military
thereafter would be identical to the rate at which other clinical
psychologists leave.

In contrast, our projections of the graduates' post-PDP careers were
based on their actual length of service to date. Because all
graduates completed at least 1 year of post-PDP service, we set the
continuation rate for the first year after the program to 1.
However, the yearly rate for the second year was set to 0.9, because
only 9 of the 10 graduates completed a second year of post-PDP
service. To estimate how much longer the graduates who are still in
the military could be expected to remain in the military, we used
information gathered during our interviews with the graduates (such
as the graduates' future plans for military service) as well as
historical continuation rates for DOD clinical psychologists. Based
on these calculations, we estimate that the participants will serve
an average of about 6 years as prescribing psychologists, including
the productive portion of their training.\22 (We conducted a
sensitivity analysis, described at the end of this appendix, to
determine the effect this estimate had on our final cost estimates.)

VRI also assumed that the PDP graduates posed no more of a
malpractice risk to DOD than any other mental health providers
delivering the same treatment to the same types of patients.
Further, VRI assumed that PDP graduates did not receive the special
pay paid to psychiatrists and other physicians in the military,
assuming instead that the salary for PDP graduates was identical to
that for military clinical psychologists. We also used these
assumptions.

--------------------
\22 In accordance with VRI's estimate, we assumed that PDP
participants were not productive (that is, saw no patients) during
the classroom portion of their training and were 50 percent
productive (that is, were half as productive as fully trained
clinicians) during the clinical portion of their training.

SUPERVISORY TIME
---------------------------------------------------- Appendix II:0.2.5

VRI estimated that the PDP graduates would require 5 percent of a
supervisor's time for the remainder of their careers. However, based
on our fieldwork, we reduced that estimate to zero. Although two
graduates have still not been granted independent status, supervision
of the graduates in general has been reduced significantly. For
example, one graduate required about 1 hour per week (or less than 3
percent) of supervisory time during the first 18 months after the
program; during the subsequent 18 months, this graduate has required
about 0.5 hours per month (or less than 0.3 percent) of supervisory
time. Eight of the graduates currently require less than 1 hour per
week of supervisory time. However, not all supervisors were able to
quantify the amount of time they spent supervising the graduates.
Even when supervisors could quantify this time, it was often less
than 1 percent, and as a result we used an estimate of zero to
provide a conservative estimate of the cost of the graduates. Had we
used a percentage larger than zero, our estimate of the PDP
graduates' costs would have been higher. (We conducted a sensitivity
analysis, described at the end of this appendix, to determine the
effect this assumption had on our final cost estimates.)

RETIREMENT COSTS
---------------------------------------------------- Appendix II:0.2.6

Based on DOD figures, VRI calculated pension rates based on an
average service time for military retirees of 22.5 years. However,
our estimates of the graduates' expected length of service yield an
average service time for retirees in this group of 23.8 years. In
other words, the graduates who serve at least 20 years in the
military--and are thus eligible to earn a pension--will likely have
served an average of 23.8 years. We calculated retirement costs
accordingly.

Further, since only some of the graduates' years of service before
entering PDP were spent as military clinical psychologists and
because some of the retirement costs for the graduates are associated
with service as neither clinical psychologist nor prescribing
psychologist, we believe it is not appropriate to include this
portion of retirement costs in our cost comparison. As a result,
retirement cost estimates for the graduates were reduced.

UPDATED COSTS
---------------------------------------------------- Appendix II:0.2.7

The data used in VRI's earlier calculations were in 1996 dollars.
For our analysis, we updated the figures to 1999 dollars using the
most recent estimates of the DOD medical consumer price index.\23

--------------------
\23 Neither we nor VRI discounted the costs included in these
calculations. Discounting determines the present value of an amount
of money that will be spent in the future. For example, a dollar
paid by the government today is more costly than a dollar paid at
some future date because it increases the burden of making interest
payments on the national debt. See Office of Management and Budget,
Guidelines and Discount Rates for Benefit-Cost Analysis of Federal
Programs, Circular A-94 (Washington, D.C.: Office of Management and
Budget, Revised Oct. 29, 1992).

RESULTS OF ANALYSIS
---------------------------------------------------- Appendix II:0.2.8

Table II.1 shows the results of VRI's calculations and our
calculations.

Table II.1

VRI's Cost Estimates and GAO's Cost
Estimates

Yearly life-cycle cost
per full-time
equivalent (1999
dollars)
----------------------
Provider group VRI total GAO total
---------------------------------- ---------- ----------
Psychiatrist $188,472 $188,472
Psychologist 96,819 92,703
Psychologist and psychiatrist 136,895 147,532
combination
Prescribing psychologists (start- 133,942 \a
up case scenario; graduating
class size set to 2.25)
Prescribing psychologists (optimal 120,463 \a
case scenario; graduating class
size set to 6)
PDP graduates (based on program \a 157,226
experience)
----------------------------------------------------------
\a Not applicable.

VRI's estimates for the annual cost of the prescribing psychologists
in both the start-up case ($133,942) and the optimal case ($120,463)
were less than that of the combined psychologist and psychiatrist
cost ($136,895). VRI concluded that the program was cost-effective.
On the other hand, our estimate of the annual cost of prescribing
psychologists ($157,226) was higher than that of the combined
psychologist and psychiatrist cost ($147,532), by about $9,700.

Our estimate of the cost of the graduates is higher than VRI's
because of the different data and assumptions we used, our estimate
of the cost of the psychologists is lower than VRI's because we
adjusted the psychologist continuation rate slightly, and our
estimate of the combination of psychologist and psychiatrist costs is
higher than VRI's because our estimates of the length of time the
graduates served as military clinical psychologists and will serve as
prescribing psychologists differ somewhat from VRI's estimates.
Because the combination of psychologist and psychiatrist costs
depends on the proportion of time the graduates spend as clinical
psychologists and prescribing psychologists, differences in these
proportions will result in different estimates for the combination of
psychologist and psychiatrist.

SENSITIVITY ANALYSIS
---------------------------------------------------- Appendix II:0.2.9

To assess the influence that our assumptions of length of service and
supervisory time had on the results of our calculations, we performed
a sensitivity analysis on each of these assumptions. To perform each
analysis, we varied our assumptions about length of service or
supervisory time while holding all other values constant.

First, we performed a sensitivity analysis on our projections of the
length of time the graduates can be expected to remain in the
military. Using DOD's historical continuation rate for
psychologists, we projected that the participants will serve for
about 6 years as prescribing psychologists, including service to
date. This resulted in our estimate that the annual cost of the
graduates is about $9,700 more than the combined psychologist and
psychiatrist costs used for comparison. If the participants were to
serve for 7 years as prescribing psychologists, the estimated cost
differential between the PDP graduates and the combined psychologist
and psychiatrist costs is reduced to about $6,300. Projecting an
average length of service of 8 years as prescribing psychologists
reduces that differential to about $3,800; 9 years, to about $2,100;
and 10 years, to about $800. Thus, given this program's experience,
the graduates would not be less expensive than the combined
psychologist and psychiatrist unless they served as prescribing
psychologists for an average of more than 10 years.

In addition, because we could not precisely quantify the amount of
supervisory time required by the graduates, we assumed in making our
calculations that the supervisory time was zero. To determine the
effect that this assumption had on our final cost estimates, we
performed a sensitivity analysis using other estimates of supervisory
time. First, we used VRI's estimate that the graduates would require
5 percent of a supervisor's time throughout their career. This
assumption raised the estimated differential between the cost of the
graduates and the combined psychologist and psychiatrist cost from
$9,700 to about $11,800. Assuming 3 percent of a supervisor's time
raised the estimated cost differential to about $11,000 per year;
assuming 1 percent of a supervisor's time raised the estimated cost
differential to about $10,100 per year.

*** End of document. ***

Great point. I think it is less an issue of "how much the human brain can do," as it is a reflection of (mis)managed care. I am sure psychiatrists and psychologists would love to spend more time with their patients in order to understand the myriad medical, psychosocial, and environmental factors that impact their health. Unfortunately, they also have to play by the rules outlined by insurance companies and generate enough paper to pay off school loans, mortgages, and car payments. Increasingly, the healthcare profession as a whole seems to be focusing more on quantity of patients seen, and less on quality of patient care. This is especially true in psychiatry, where over-medication appears to be commonplace, and pharmaceutical companies reign supreme. Why do you think most psychiatrists don't even do psychotherapy any more? As I am sure you know, business runs medicine, not physicians and patients.

While we don't have managed care in Canada, that might not last very long given the current legislative changes :mad:

Another relevant issue here is one that was brought up by a psychiatrist that visited one of my psychopathology classes. The current focus in psychiatry is not to cure patients but to significantly improve their condition so that they can function. They are not one and the same.... will we ever have a treatment that will restore mental health? whether it's pharmacological and/or talk therapy?

LOL :laugh:

I don't discount anything anymore....

P.S. For God's sake, you can post links in posts so that you don't have to sort through a mile of spam


For goodness' sake, climb down from that ledge, put aside those pills (self-prescription? :D ) and sit down with a FL margarita or NY cosmopolitan and read the ENTIRE GAO report. It's not spam, it's information. It may change your entire perspective on this whole issue.

For my sake I'm taking Memorial Day off.
Posting the entire GAO report wore me out.
Hopefully you'll read it or at least stop citing it if you don't. :laugh:

As usual, Sasevan attempts to use gobs of "data," which by the way, reads less like science and more like a communist propaganda release, to overwhelm and convince readers that his is the only way. (can you say Fundamentalism?) As predicted, the highlighted red area stating that psychologists are "safe prescribers" is presented with no retort to the above variables I mentioned. Namely, that the oversight was so strong, the formulary so limited, and the patients so "pure," that generalization to the general population is impossible.

Island of data? Sure, but don't accuse just me of doing this. I didn't post the additional comments on military record delineating why many of the Rxp psychologists dropped out (to go to med school, dissatisfaction with the program, etc) - but I forgot.....only psychiatrists are the scientists publishing data that is convenient to them.

Here's the funny thing....I wouldn't be that against psychologists prescribing if it weren't for the underhanded and offensive way in which they approach the request. Svas keeps stating that we should embrace them and live happily ever after. I've stated numerous times that the psychologists DO NOT WANT OUR OVERSIGHT. As evidenced in their original bills, and by the opposition to the pleas for increased oversight, they want only completely autonomous practicing rights with an unlimited formulary, to be held responsible to a different (some say incompetent by definition) level of care by their OWN governing body, and the ability to take their practice to any area they want - not the "underserved areas" as they blatently lied about in order to for these bills to reach the legislature. Then they can't imagine why psychiatrists and other branches of medicine are upset at the underhanded techniques with which they procure these rights.

I'm not sure why any psychiatrist or other physician would put their necks on the line in Louisiana where psychologists have to (over the phone if they like), present their patient to the attending in order to secure medications for them. Any insuing lawsuit would bring not only the psychologist, but also the attending physician into the suit with them. How you could possibly defend yourself as a physician in this type of trial would be beyond me.

Svas correctly asserts that psychologists will publish data after some time claiming that their prescribing practices are safe. He then also states that psychiatrists should publish similar data in order to compare. Problem is....and contrary to the dearth of erroneous beliefs held in this forum, psychologists will publish data that is beneficial to THEM. At best, statistics will be manipulated in order to show no statistical difference in practice safety comparing the two groups. I've taken enough statistics and research design classes to know how this occurs. Psychiatrists are busy seeing patients, and by the nature of their profession, will publish less data and spend less time hemming over choosing the right multivariate stat possibly to its own detriment. This will be an unfortunate occurance.

For the time being, psychologists will advertise the data they choose, psychiatrists will emphasize the data they like . . . and until we get a large enough data pool, this will be how it goes.
Dr. Svas how to prevent adverse outcome in the process? If there is a psychiatrist overseeing the scripting process how radically it's going to change the current system and how much savings of resources will happen at the end? And I am not bringing up the issue of malpractice.

There will be dooms-day sayers that will pose that psychologist will kill hundreds of people with the meds they use. Fear-mongering is a great technique and it's worked for thousands of years. Will the American Psychiatric Association do the honest thing and simultaneously publish the adverse events causes by improper medication use by psychiatrists so that the public can rationally compare the data? Doubtful.
The same holds true for PhDs too.
Efforts to do just that have been eroding psychiatry for decades. We don't like something . . . we call it pathology. We don't like something .. . we call it dangerous. These reactions might be reasonable. However, in some situations, the reaction is either paranoid or economically defined turf protection.
Unless and until there is enough protection for the pt inbuilt in the system majority of the docs will be sceptical about it. Docs by nature are conservative and rightfully so because they have to conserve the most precious thing- a human life :)
What would happen if, instead of fighting this process, we embraced those psychologists with the 2 years of advanced training and assisted them to get licensure laws that enabled limited formulary rights . .. so long as they obtained some form of regular supervision from a board-certified psychiatrist?
Why is it necessary for an exceptionally trained "med Psychologist" to seek supervision if they supremely confident about their training? And if they are trained for this only one task they should be able to perform it by their own. There is no half-way in it. If you challenge the basic med model coming up w/ an alternative idea, it's you who have to face the music. You can't belittle the MD model and ask them for help at the same time.
These laws would SAIL through the legislatures, would be hailed as patient-care responsible, would save consumers a vast amount of money, and provide access to broader number of providers.
Are are that naive to belive that it's so simple. All it'll need is a single -ve outcome and a smart-ass lawyer to get these "non-MD providers scripting these mind-altering horrible drugs" out of the playground. People are not that altruistic and being a capitalistic society all of us are after $$. That's the issue here and not "broader access to pt-care." The PhDs are threatened by MSWs and college grads and they want to get a piece of the cake. There is no harm in trying, but why we should tolerate lowering the standard?
Will you feel comfortable in taking your loved ones to these "med PhDs" for tx-I wouldn't . If not why should I refer others to them?
At least that's my take on what psychiatry would do if it really wanted to take a strong leadership role in this issue.S[/QUOTE]
We are competitors, so by definition question of LEADING the team is not there. Why I've to take the risk of supervising "med PhDs" when I can see my pts w/o them? What's my incentive for that? And plz don't give me those altruistic ideas of pt care in the current US helath environment.
I do appreciate your concern about the sub-standard care provided by "SOME" psychiatrists, but I guess they are not the norm. And let's keep it that way. :thumbup:

Quoted from Svas:
For the time being, psychologists will advertise the data they choose, psychiatrists will emphasize the data they like . . . and until we get a large enough data pool, this will be how it goes

Good point, I wonder when "the big" APA will propose studies comparing the efficacy of using Social workers, Bachelor Psychs, or Chiropractors from performing "medical psychology"? After all, there isn't enough data out there to suggest they can't perform on par with the physician. Psychologists want expanded access to patient care, right? When, will the Psychologists stop this fundamentalism and demand social workers be trained in RXP? ;)

Quoted from Dr. Focker:

"Good point, I wonder when "the big" APA will propose studies comparing the efficacy of using Social workers, Bachelor Psychs . . ."

It's been done AND reported. IT wasn't particularly supportive of needing doctoral level training to perform psychotherapy well.

S

I think he meant the efficacy of psychiatric social workers and bachelors psychs prescribing.....(hence the "medical psychology" comment)

As usual, Sasevan attempts to use gobs of "data," which by the way, reads less like science and more like a communist propaganda release, to overwhelm and convince readers that his is the only way. (can you say Fundamentalism?) As predicted, the highlighted red area stating that psychologists are "safe prescribers" is presented with no retort to the above variables I mentioned. Namely, that the oversight was so strong, the formulary so limited, and the patients so "pure," that generalization to the general population is impossible. :eek:
SEE BELOW

Island of data? Sure, but don't accuse just me of doing this. I didn't post the additional comments on military record delineating why many of the Rxp psychologists dropped out (to go to med school, dissatisfaction with the program, etc) - but I forgot.....only psychiatrists are the scientists publishing data that is convenient to them. :eek:
UNBELIEVABLE!!!

Here's the funny thing....I wouldn't be that against psychologists prescribing if it weren't for the underhanded and offensive way in which they approach the request. Svas keeps stating that we should embrace them and live happily ever after. I've stated numerous times that the psychologists DO NOT WANT OUR OVERSIGHT. As evidenced in their original bills, and by the opposition to the pleas for increased oversight, they want only completely autonomous practicing rights with an unlimited formulary, to be held responsible to a different (some say incompetent by definition) level of care by their OWN governing body, and the ability to take their practice to any area they want - not the "underserved areas" as they blatently lied about in order to for these bills to reach the legislature. Then they can't imagine why psychiatrists and other branches of medicine are upset at the underhanded techniques with which they procure these rights. :eek:
YOU'RE RIGHT ABOUT THIS ONE; CRITICAL THINKERS DON'T WANT TO BE UNDER FUNDAMENTALISTS! However, mutual consultation/collaboration between psychologists and psychiatrists is welcomed as is even temporary supervision.

I'm not sure why any psychiatrist or other physician would put their necks on the line in Louisiana where psychologists have to (over the phone if they like), present their patient to the attending in order to secure medications for them. Any insuing lawsuit would bring not only the psychologist, but also the attending physician into the suit with them. How you could possibly defend yourself as a physician in this type of trial would be beyond me. :eek:
UNBELIEVABLE!!!

Svas correctly asserts that psychologists will publish data after some time claiming that their prescribing practices are safe. He then also states that psychiatrists should publish similar data in order to compare. Problem is....and contrary to the dearth of erroneous beliefs held in this forum, psychologists will publish data that is beneficial to THEM. At best, statistics will be manipulated in order to show no statistical difference in practice safety comparing the two groups. I've taken enough statistics and research design classes to know how this occurs. Psychiatrists are busy seeing patients, and by the nature of their profession, will publish less data and spend less time hemming over choosing the right multivariate stat possibly to its own detriment. This will be an unfortunate occurance. :eek:
AGAIN, UNBELIEVABLE!!!


WOW!!! :mad:
You didn't read the full GAO report but still alluded to it. :mad:

I believed that your mind was already made up and you didn't want to be confused by the facts but your above statements provide evidence of this even beyond what I had expected.

BTW, the retorts to your points were ALL in the full GAO report. That's why I posted it.

You didn't find them. Why?

Three possibilities: :idea:

1. You're intellectually challenged,

2. You're lazy, and/or
3. You're being disingenuous.

I'm leaning to the latter two, given that:

1. You actually earned a masters degree in a psychology program so your actions cannot be excused under you being intellectually challenged.

2. However, you found that program to be boring and repetitive. Maybe what you consider "boring" was learning critical thinking skills and "repetitive" the routine application of those skills. I can see why you prefered the Asclepian model (look it up). But it's unfortunate if you believed that since a mind is a terrible thing to waste. :(

3. By contrast, you may actually be using your brain but in a destructive as opposed to a constructive way: you continue to make outrageous claims and when these are rebutted you then simply move on to making new ones. Maybe then, I should say a terrible mind, what a waste. :(

I'm now convinced that you're still intentionally contributing misinformation to this discussion making any attempts at genuine dialogue absurd. That's sad.

Anyway, I wish you the best in your upcoming residency. I hope you genuinely take good care of yourself and your patients.

what is it with the people on this thread that they take these internet discussions so damn personally? you have a right to disagree but don't take away from your previous thoughtful posts by posting personal attacks ..... these simply fuel the fury and don't accomplish anything...

And yes, the DoD study is promising. But at this point it is just one study and as such, it requires replication by independent researchers. I do not compromise research standards when examining psychologists' work either ;)

Hi Lazure, :)
Thanks for the advise. I appreciate it.
Usually I try to avoid characterizations but at times the evidence precludes any other course.
If you read through the >200 posts here you may come to similar conclusions.
I genuinely attempted to engage in a dialogue but was finally dissuaded from continuing to do so with those who consistently gave evidence that they weren't seeking common ground. :(
It's unfortunate because I initially thought that both a common background in psychology and a future in psychiatry would have facilitated such dialogue.
That wasn't the case so I've chosen to recognize reality and cut my losses by ending any further discussion.
Oprah Winfrey once said something to the effect that: when someone says something negative about themselves, believe it the first time; don't make them have to repeat it a second time.
I regret that I did not follow her counsel when I first came upon the infamous quotation in the signature. :(
Peace.

I will not attempt to continue any negative dialogue. Believe it or not, it was not my intention. We agree to disagree. I think that's about the end of it. As a final point, though, you should take a sincere look at your own intentions. Yes, I gave up psychology because I found it unfulfilling. I don't blame others for this. It was my own experience. If others find this insulting, then frankly, so be it. I recognized that the medical model was more in alignment with what I think is proper treatment of patients, and was simply more interesting to me.

After reading the DoD report years ago and more recently, I agree that to psychologists, the study is promising. But as a scientist, it is one tiny baby step in the "proof" that psychologists are so desparately seeking stating that they are as competent prescribers as physicians.

Sasavan, I bet that if we had a beer together at the local Irish pub, it would actually be quite fun and that we'd get along great. Unfortunately, I think the internet (particularly web boards) have a way of making what are often innocuous words seem more hostile and sarcastic. And, also allow people to say things that would be deemed socially inappropriate. In those respects, I may be a victim or such propagation.

I flew to visit my parents yesterday here in Florida and as chance would have it, sat next to a clinical psychologist on the plane - a very nice woman who is a professor at a small liberal arts college in the south. I asked her her opinion about prescription privilages....she stated, "Oh, I think that what psychologists and the APA are doing is inappropriate. If people want to be the best prescribers, they certainly should go to medical school." I can see people cringing in their computer chairs from here, but the salient point is this: Despite research that may or may not be generalizable, despite the fact that NPs or PAs may be prescribing, etc, there is a non-quantifiable component to healthcare in general, and psychiatric practice in particular. Lots of psychiatrists or prescribing psychologists can give medication and not hurt, but many not help much either. In these qualitative respects, people can disagree, and that's OK.

The fact that you're seeking medical school to pursue psychiatry after your PhD (congratulations, btw), tells me, and other readers, something. Perhaps after some time off and soul-searching, you'll find that you prefer the medical model as well, or will see the astounding complexities and information overload experienced in medical school to be eye-opening. You may see that to read about diseases in a book to be informative, but to SEE these same conditions on your clinical rotations and their subtle manifestations is actually disconcerting. Or perhaps not.

Either way, I wish you luck. We all have our passions and are willing to stick up for them. This same enthusiasm should serve our patients well, as long as they don't become dogmatic and destructive.

p.s. And as for my signature, I never intended it to bring so much angst to so many people. I explained myself more fully in another post, but suffice it to say that I'm simply a fan of the show, that's it.

To Sasevan,
glad you liked my response :) Good luck in med school and I'm sure you'll make a wonderful combined MD with great respect for psychology....I'll be happy to refer clients to you ;)


To Anasazi23,

I fully aggree with the right to disagree line. And yes it is extremely easy to freak out about what someone posted given the lack of physical, emotional cues (and the icons here don't help either). Perhaps that's why psychotherapy should never be conducted over the internet .......

Sasavan, I bet that if we had a beer together at the local Irish pub, it would actually be quite fun and that we'd get along great. Unfortunately, I think the internet (particularly web boards) have a way of making what are often innocuous words seem more hostile and sarcastic. And, also allow people to say things that would be deemed socially inappropriate. In those respects, I may be a victim or such propagation.



Anasazi23,
Cool...but no discussion of guild issues. ;)
Peace.
P.S. That woman on the plane will be hunted down...LOL :laugh:

Anasazi23,
Cool...but no discussion of guild issues. ;)
Peace.
P.S. That woman on the plane will be hunted down...LOL :laugh:


She said she was a member of APS....maybe you could start there :cool:

http://pn.psychiatryonline.org/cgi/content/full/39/10/1

Louisiana Lawmakers Hurriedly Pass Psychologist-Prescribing Law

Jim Rosack

Even though the new law calls for no specific medical oversight, state officials apparently didn?t believe patient safety was at stake.

On May 6 the state of Louisiana became the second state in the country to authorize psychologists to prescribe psychotropic medications to people with mental illness. The state joins New Mexico, which enacted psychologist-prescribing legislation in March 2002 (Psychiatric News, April 5, 2002).

APA?s reaction was swift and condemning. "[Louisiana] HB 1426 is a rush to judgment that puts politics above patients? lives and safety," said APA President Michelle Riba, M.D. "By enacting it, Gov. [Kathleen Babineux] Blanco and the Louisiana legislature have codified a dangerous, substandard level of care as legally acceptable in Louisiana. HB 1426 puts Louisiana well outside the medical mainstream in the United States and will jeopardize patients struggling with mental illnesses."

While "the lessons to be learned from Louisiana are far from clear" at this time, Riba emphasized that APA plans to undertake "a careful review" as a "key part of continuing to block such reckless laws." (See "From the President" on page 3.)

Blanco, a Democrat, signed HB 1426 after concerted efforts by APA, the Louisiana Psychiatric Medical Association (LPMA), the American Medical Association, and the Louisiana State Medical Association, along with local chapters of the National Alliance for the Mentally Ill and the Depressive and Bipolar Support Alliance, strongly urged the governor to veto the hastily passed legislation.

The original psychologist-prescribing bill was introduced on April 7, sponsored by Louisiana House Speaker Joe Salter (D). An identical bill was introduced on April 13 by Senate President Donald Hines, M.D. (D), who maintains a family practice while the legislature is not in session. With little discussion or debate and only minor amendments, the bill was passed by the House on April 19 by a vote of 62-31.

The next day the Senate received the House bill, and declaring it to be a duplicate of the Senate version, Hines deftly moved the House bill through the Senate chamber. On April 21 Hines used procedural privileges as Senate president to suspend the normal rules for considering legislation in an orderly manner.

When the president pro tempore, Diana Bajoie (D), attempted to offer an amendment that would have prohibited psychologists from prescribing to children, Hines dismissed the effort. He noted that as a physician himself, he could write prescriptions for children for the very medications in question, and he wasn?t required to have a master?s degree in psychopharmacology.

Hines called for a vote, and the measure passed the Senate by a vote of 21-16. In the end, only minor editorial changes and clarifying amendments were passed.

The bill went back to the House immediately, and, again with the rules suspended, representatives voted on it without any conference committee consideration. The House passed the bill by a vote of 68-30.

The final bill was signed by Salter on Thursday, April 22, and by Hines on the following Monday, April 26, starting a 10-day countdown for the governor?s action. In Louisiana the governor may sign passed legislation, veto it, or allow it to go into law without a signature.

Lobbyists for the state medical society and LPMA were so dismayed that they left the legislative chambers silently, shaking their heads.

No Regard for Patient Safety

In the ensuing 10 days, efforts were made with "warp speed," noted LPMA legislative representative Dudley Stewart Jr., M.D. The lobbyists, Stewart, and LPMA President Patrick O?Neill M.D., called in AMA President Donald Palmisano, M.D., who is from Louisiana, to advise the governor?s office of the significant patient-safety concerns that the legislation raised.

The new Louisiana statute will allow a "medical psychologist" to prescribe and distribute "agents related to the diagnosis and treatment of mental and emotional disorders." A "medical psychologist" is loosely defined as a "psychologist who has undergone specialized training in clinical psychopharmacology and has passed a national proficiency examination in psychopharmacology approved by the [psychologist examiners?] board and who holds from the board a current certificate of responsibility."

The only medications that the law specifically exempts are narcotics.

Blanco asserted in a prepared statement that she was "assured by the proponents [of the legislation], including the speaker of the House and the president of the Senate," that the new law?s "tight controls" and "tough" regulations she expects the board of psychologist examiners to promulgate will protect patients? safety. She noted that those who "do not abide" by the provisions of the law could lose their prescribing privileges and "face misdemeanor charges." Yet no such "tough rules" or any regulations are codified by the statute. In fact, complete oversight of psychologist prescribing is granted to the Board of Psychologist Examiners, and it is that same board that the law entrusts to create regulations and procedures to implement the law.

To be eligible to prescribe, applicants must hold a current license to practice psychology and must have "successfully graduated with a postdoctoral master?s degree in clinical psychopharmacology from a regionally accredited institution or equivalent to the postdoctoral master?s degree as approved by the board."

The law?s language describing educational requirements is vague, but it appears to be patterned after the American Psychological Association?s preferred curriculum for prescribing psychopharmacology.

The law requires a prescribing psychologist to "prescribe only in consultation and collaboration with the patient?s primary or attending physician and with the concurrence of that physician." However, Riba noted, "Bluntly, the vaguely defined consultative requirements cited by the governor as a safety measure do not pass muster: there is nothing in the law to ensure that a physician will ever lay eyes on the patient."

Patients Opposed Legislation

Riba said that patient advocacy groups and patients themselves were adamantly opposed to the legislation, and she had urged Gov. Blanco to protect them and their loved ones by vetoing the bill.

"[Psychotropic] medications," Riba emphasized, "impact the whole patient, not just the patient?s mental or emotional disorder, as the governor suggests." These "potent medications," she continued, "may interact with other medications and may impact other medical conditions. As behavioral scientists, psychologists are simply not trained for the medical complexities faced by psychiatrists and other physicians when they prescribe medications."

Riba stressed that APA?s focus must be on "action." As part of an action plan, she added, APA must "review how we respond to these assaults. We will undertake this review quickly, but we should not?unlike the Louisiana legislature?rush to judgment without the benefits of the facts."

Such an examination?determining what was successful in some states and what was unsuccessful in Louisiana?"is a key part of continuing to block such reckless laws," she continued.

Louisiana grants psychologists prescriptive authority
Louisiana psychologists' persistence pays off, and their state becomes the second to pass RxP legislation.

BY JENNIFER DAW HOLLOWAY
Monitor Staff

In a major victory for professional psychology, the Louisiana legislature voted in April to grant prescription privileges to trained psychologists.

The bill passed 62-31 in the Louisiana House and 21-16 in the state's Senate. And then on May 6, Governor Kathleen Blanco (D) signed the bill into law, making Louisiana the second state--New Mexico became the first in 2002--to give specially trained psychologists the authorization to prescribe certain drugs related to the diagnosis and treatment of mental health disorders.

Fueling the bill's passage was legislators' overall sense that it would boost mental health care while providing cost savings--a message communicated through strong relationships psychologists had forged with key politicians, observers say. The president of the Senate, Donald E. Hines, MD (D), and the speaker of the House, Joe R. Salter (D), sponsored the bill. In fact, Hines--a physician--spoke out before the vote in support of the training psychologists must receive in order to prescribe, noting that the 50 current Louisiana psychopharmacology graduates had gone to school every other weekend for two years to obtain their postdoctoral master's degree in psychopharmacology. He also pointed out that many primary-care or family physicians already refer patients to psychologists and that the bill would ensure greater coordination of care.

Applauding such support is James Quillin, PhD, president of the Louisiana Academy of Medical Psychologists (LAMP)--a group of 50 psychopharmacology graduates that has worked hand in hand with the Louisiana Psychological Association (LPA) on RxP issues. He explains the reason behind his praise: "As in most states, front-line treatment of psychological disorders is currently managed by nonpsychiatric physicians who largely welcome the role of psychologists in assisting in the management of these conditions."

In that spirit, the law requires consulation and concurrence between psychologists and physicians.

For example, if a physician refers a patient to a psychologist, and the psychologist determines that the patient is depressed and recommends an antidepressant, the physician and psychologist must agree on the course of treatment, and then the psychologist can write the prescription. This provision, says John Bolter, PhD, LAMP's treasurer, reduces what opponents of the bill often bring up--medical risk. "And it improves patient care because it creates a collaboration. Patients benefit from that," he adds. Echoing Bolter's point that patient care is the major winner is Russ Newman, PhD, JD, APA's executive director for professional practice: "Another state is now poised to improve access to care by enabling qualified psychologists to prescribe." Newman adds that Louisiana's achievement is important because it lays to rest any sense that New Mexico's victory was a fluke. "While two laws may not constitute a critical mass, the groundbreaking ones tend to be the most difficult ones to pass," he explains.

Steady progress

Indeed, Louisiana psychologists laid the groundwork for this success for years. To be exact, they first began the push for prescription privileges in 1995 and introduced their first bill in 1997. In fact, this victory marks their fourth RxP bill introduction. "It's been a multiyear process. Nothing was done in one year--this is a cumulative effect," says Bolter. Adds Quillin, "This has been an issue of educating legislators and you have to stick with it."

And the national RxP movement wasn't built overnight. Advocates base their efforts on the belief that with appropriate training, psychologists can improve patient services by providing psychological psychopharmacological care and by collaborating with primary-care providers, especially in states like Louisiana, where much of the territory is rural and access to services is a problem. So far, 18 states have introduced RxP legislation. In 1999, Guam passed legislation and then in 2002, New Mexico gave prescribing authority to trained psychologists. Combined with these earlier developments, the Louisiana win could pave the way for additional states to gain RxP victories, some observers speculate.

"The more laws we achieve, the more it may help invigorate other states that are advocating for prescriptive authority," Newman points out.

The fact that Louisiana is such a conservative state makes this victory even more stunning, adds Bolter. "It should raise the bar of hope for everyone else," he says.

Building support

Indeed, Louisiana can serve as a model for other states, says Michael Sullivan, PhD, associate executive director for state advocacy in APA's Practice Directorate. Cathy Castille, PhD, president of LPA, adds that the keys to success were "a combination of strategic lobbying, very dedicated and hardworking psychologists and grassroots efforts." The prescriptive authority bill enjoyed the strong support of the consumer advocacy organization known as Louisiana Families for Access to Comprehensive Treatment (LaFACT), a diverse group of families and individuals from all over the state. According to Bolter, LaFACT members were very active during critical periods leading up to the bill's passage.

"It's hard to get people to talk to legislators," he says. But LaFACT made it easy; the group put members in touch with their legislators. So why did so many consumers care enough to join LaFACT? Access to mental health services is a major issue in Louisiana, which has an extreme shortage of psychiatrists. In fact, there are only 518 psychiatrists in the entire state to meet 4.5 million people's needs--that equals about one psychiatrist for every 9,000 citizens, says Quillin. The state ranks 48th in the United States in social services. And to make matters worse, many of the psychiatrists have opted out of the state's Medicare and Medicaid systems. "So there are enormous wait times for an appointment and those who can't pay for services suffer," says Bolter.

As a result, properly trained psychologists can fill an unmet need in Louisiana, he says.

At the same time, these psychologists could even save the state money. According to Bolter, the state contracts for private psychiatric services at a large cost. "So this would be a way for psychologists who are accustomed to working in state hospitals to provide additional services," he says.

Indeed, the bill's benefits to health-care costs and quality were impossible for legislators to pass up, Quillin believes. "It's hard to argue against a bill that represents good, quality health care," says Quillin. "This [will] allow us to begin to address the problem of inadequate access. The alternative is to allow the powerful medical lobby to dictate all policy while they reject safe and meaningful alternatives that could address the present health-care needs."
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? 2004 American Psychological Association

Just out of curiousity, would you guys still be against it if Ph.D candidates were required to take the necessary pharmacolology and biochem classes and have a residency incorporated into their graduate training? I can't tell, because it really seems that some of you are more worried about medical school losing its percieved "right of passage" status than anything.

I was a Psych. major who has decided on med school instead of graduate school. The problem is it seems like anyone can prescribe lately Chiropractors (sp?), Nurse Practitioners, podatrists, optometrists...you get the picture. There are already too many people who don't go thorugh medical school who can prescribe medicine. But going to medical school shouldn't be the issue. Sufficient pharmocological training should be the issue here. After all, they call it "medical school" not "psychopharmacology school."

Then there's the reasons I'd support it. First off, it's pretty damn hard to get into a Clinical Psych. Ph.D. program. I'm talking around 3.8 - 4.0 for a decent program. So it's not like these people aren't smart enough. Second, according to the head of Pitt's Clinical Psych. admissions committee, there's a huge wait (4-6 months?) to see a Psychiatrist for medication unless we're talking participating as a subject in clinical trials or being an inpatient.

The only way I'd support prescribing rights for Ph.D's is if they went through what would amount to at least a year (straight through) of the necessary pharmacology and biochem classes that medical students go through, and a 6 month - 1 year residency involving the obvious patient contact and clinical application of prescribing the meds that psychiatry residents experience. Those conditions are what were outlined to our class as probable minimum training, so I'm surprised at the utter lack of vigorous training that would be included in the Louisianna bill.

Funny thing is, the average Clinical Psychologist goes through 6-7 years of graduate school. 1.5 - 2 more years training for prescribing rights equates to more schooling than psychiatrists go through! So what you would be looking at is the Ph.D's who already are practicing going through the extra schooling so they can prescribe, and everone else who would have gone that route would just go to medical school for psychiatry instead because it would take less time. So even if the bill passes, in 20 years there would be nobody taking advantage of it 'cause they'd all be in medical school working towards psychiatry anyways. More money, less time...think about it.

The only way I'd support prescribing rights for Ph.D's is if they went through what would amount to at least a year (straight through) of the necessary pharmacology and biochem classes that medical students go through, and a 6 month - 1 year residency involving the obvious patient contact and clinical application of prescribing the meds that psychiatry residents experience. Those conditions are what were outlined to our class as probable minimum training, so I'm surprised at the utter lack of vigorous training that would be included in the Louisianna bill.

Medical psychologists in Louisiana are required to complete a program such as the following, which is similar to the program you described in your post.

"The curriculum includes 395 hours of university-based didactic course work with an appropriately interspersed 200 additional hours of supervised clinical practicum. The program is completed in two years. Classes are usually held once per month on Friday, Saturday and Sundays for nine months. Practica are arranged individually during the summer months for training at the Nova Southeastern University Community Mental Health Center and other approved sites. Students upon completion of their practica will have had contact with a minimum of 100 patients who are on medication."

http://www.cps.nova.edu/programs/PostdocMasterPsychopharmC7.html

Dear rpost3,
good post and interesting ideas....but you'll get eaten on this thread ......

Dear rpost3,
good post and interesting ideas....but you'll get eaten on this thread ......

So what!?

rpost3 brings up a good point about clinical psychology. Considering the length of training in such programs, relative lack of jobs, and low salaries in this field, it's hard to imagine why it's so competitive to secure a spot as a grad student. Pretty much EVERY clinical psychologist that I have spoken to has advised to me to stay away from clinical psychology and to pursue psychiatry instead. They all cited poor compensation as the primary reason.

My son discussed this with me a year ago. His take on it is that psychology is fascinating and that their major professors are interesting. Psychology will never lose its following because studying human behavior is a blast. Being able to predict it .. . well, that's even better. Additionally many people like the study of the abstract much more than they enjoy massive memorization tasks. Generally speaking (and now after reading Paul Meehl's work I understand what he's been saying), it appears that psychologists tend to be more conceptual/abstract thinkers and we physicians are much more likely to be complex linear and technically adept. As a consequent, clinical psychology is more interesting and challenging for many of them.

It costs considerably less to get a doctorate in psychology than medicine. In expensive places, proabably about 1/3rd to 1/2.

Next year I'm going to offer to supervise my office associate (a psychologist going through one of these two year programs) during his practicum training. I believe that this is the only way I'm going to learn about what they really know.

Data before decisions.

S



So what!?

rpost3 brings up a good point about clinical psychology. Considering the length of training in such programs, relative lack of jobs, and low salaries in this field, it's hard to imagine why it's so competitive to secure a spot as a grad student. Pretty much EVERY clinical psychologist that I have spoken to has advised to me to stay away from clinical psychology and to pursue psychiatry instead. They all cited poor compensation as the primary reason.

So what!?

rpost3 brings up a good point about clinical psychology. Considering the length of training in such programs, relative lack of jobs, and low salaries in this field, it's hard to imagine why it's so competitive to secure a spot as a grad student. Pretty much EVERY clinical psychologist that I have spoken to has advised to me to stay away from clinical psychology and to pursue psychiatry instead. They all cited poor compensation as the primary reason.

Poor conpensation wasn't the primary reason for me, but the following are reasons I have decided on med school instead:

1) the fact that people with masters degrees are going to be granted licensure because they are favored by managed care (ie cheaper)...

2) grad school sucks. its 2 years of class, then 5 years of being in an office all day, with some teaching in between. I'd rather be in Gross Lab or something liek that, moving around and learning visually

3) research blows

4) there are already too many clinical psychologists because the professional school each churn out like 100 Ph.D's a year

5) more than anything, my TA's that are grad students told me to stay clear of grad school. All it is is stress. At least in med school, there's a quantitative cut-off determing whether you pass or fail. In grad school, you can do what amounts to A+ work, and the faculty will still dick with you over dissertations and defenses just so you can continue to work on their own research projects.

I'd much rather know my pass-fail status is quantitative and objective as a med student, as opposed to the qualitative, subjective crap Ph.D's have to put up with.

6) Did you ever meet a Clinical Psych. graduate student 5 or so years into their program? They are absolutely miserable. Med students don't seem that way to me.

7) I got sick of working with populations consisting of extreme psychology. As an undergrad I worked at an inpatient facility as a nursing assistant. All in one day, I got swung at by a 250 lb. schizophrenic who though I was an Irish Republican Army assasin, and had to break up a fight between two other schizophrenics who got into it because they were both claiming to be Jesus Christ. That was it for me :laugh:

Personally, I think that the inaccessibility to competent care and hence medication can be solved by the increased recruitment and training of psychiatrists (through the entire medical school and residency years) instead of bypassing the essential pharmacology and physiology.

I have the greatest respect for the psychotherapy that psychologists and social workers provide, but it's not enough to merit the writing of scripts.

Personally, I think that the inaccessibility to competent care and hence medication can be solved by the increased recruitment and training of psychiatrists (through the entire medical school and residency years) instead of bypassing the essential pharmacology and physiology.

I have the greatest respect for the psychotherapy that psychologists and social workers provide, but it's not enough to merit the writing of scripts.

Postdoctoral Master's Degree programs in Clinical Psychopharmacology DO provide training in the pharmacology and physiology relevant to the prescribing of psychotropic medications. Clinical psychologists seeking RxP must complete such a program and pass a licensing exam before they may prescribe. Even then, they must consult with a patient's physician before writing the script. Several of the posts above describe this process in greater detail. Please don't think that any clinical psychologist could just begin prescribing on his or her own simply because they're clinical psychologists.

:thumbup: :thumbup: Realistically, how much "medical supervision" does the average SSRI user get? Fifteen minutes with a psychiatrist once a month, or more likely even less frequent contact with a family practitioner?

The main danger of the newer AD's (which realistically, is all psychologists would probably dare to prescribe) is psychological, rather than physiological. A psychologist who is seeing a patient for 45 minutes once or twice a week is much more likely to notice a bad psychological rxn to an AD, such as derealization, suicidal ideation, etc.

Let's be honest here. The blockbuster success of the newer AD's and antipsychotics has mainly been due to the fact that they've been billed as drugs that can be prescribed without a PE, bloodwork, and with minimal concern about interactions.

The press release above makes it sound like psychologists are chomping at the bit to design MAOI/lithium/TCA cocktails for patients with BPD and Bipolar I! I seriously doubt that's the case. Psychologists don't want to get sued any more than M.D.'s, and they probably leave their psychopharmacology program scared to death of anything besides the established bread and butter benzos, SSRI's, and variants. I think they are also trained to make sure their patients have regular contact with an internist or FP.

I'm not taking a position on this issue--I just want to point out that it's a bit hypocritical to suggest that all patients on psychoactive drugs (particularly in underserved areas) are getting wonderful, regular care from medical specialists.

In practice, I suspect medical psychologists will be offering care to people who weren't getting it in the first place.

Is getting six refills of Zoloft from a busy FP you don't see for six months to a year really better than getting Zoloft from a psychologist with psychopharmicological training that you see every week?

Realistically, how much "medical supervision" does the average SSRI user get? Fifteen minutes with a psychiatrist once a month, or more likely even less frequent contact with a family practitioner?

The main danger of the newer AD's (which realistically, is all psychologists would probably dare to prescribe) is psychological, rather than physiological. A psychologist who is seeing a patient for 45 minutes once or twice a week is much more likely to notice a bad psychological rxn to an AD, such as derealization, suicidal ideation, etc.

Let's be honest here. The blockbuster success of the newer AD's and antipsychotics has mainly been due to the fact that they've been billed as drugs that can be prescribed without a PE, bloodwork, and with minimal concern about interactions.

The press release above makes it sound like psychologists are chomping at the bit to design MAOI/lithium/TCA cocktails for patients with BPD and Bipolar I! I seriously doubt that's the case. Psychologists don't want to get sued any more than M.D.'s, and they probably leave their psychopharmacology program scared to death of anything besides the established bread and butter benzos, SSRI's, and variants. I think they are also trained to make sure their patients have regular contact with an internist or FP.

I'm not taking a position on this issue--I just want to point out that it's a bit hypocritical to suggest that all patients on psychoactive drugs (particularly in underserved areas) are getting wonderful, regular care from medical specialists.

In practice, I suspect medical psychologists will be offering care to people who weren't getting it in the first place.

Is getting six refills of Zoloft from a busy FP you don't see for six months to a year really better than getting Zoloft from a psychologist with psychopharmicological training that you see every week?

The state of New Mexico says you are wrong.

NM enacted this legislation several years ago, under the SAME PREMISE that it would widen access in rural areas.

Guess how many psychologists went thru the training and are now providing care in rural areas?

ZERO.

Imagine that. Psychologists want to stay in the big cities just as much as the psychiatrists.

I am not sure how accurate you are but the more trained mental health individuals out there the better the chances of the public gaining adequate mental health care. It has been the argument that because psychologist never attended medical school they will not be able to prescribe adequately. This does not appear to be the case since other prescriping professionals have been prescribing as well as MD e.g. Optomitrists, Pharm D's, Nurse practicioners, PA, etc. The psychologists who are pursuing prescription rights are generally more educated then all whom have been mentioned above. Moreover, psychologist who are pursiuing prescription rights are obligated morally and ethically to DO NO HARM and I believe that they would not wellingly or unwillingly place thier patients/clients in a compromising position. Additionally, psychologist do become under the supervision of MD's for some time after gaining their Psychopharmacology Masters Degree to assure 100% patient care. Pyschologist will always refere to MD's for consultation and vice versa to assure comprehensive patient care. I hope that one day medical professionals accept the invitable of psychologist gaining Rx in order to, collectively, focus our energy in better treatment for our patients/client not in attempting to defeat eachother in a fruitless battle.

I've been watching and following this thread since it started. Before jumping on the bandwagon and calling Gov Blanco, I decided to look at the training being required by the American Psychological Association (ApA) and at the curriculum being required by two of the university-based training programs. I have to admit that the training looks pretty thorough and certainly more so that any FP gets. The science programs are run by Pharm.D.'s or Ph.D. in appropriate fields, not by psychologists. Both had classes taught by MD/DO's. Apparently the MD that supervised the DoD demonstration project has also gone on record saying that the psychologists performed very well and that the current programs above are sufficient for the purpose of the psychologists prescribing.

My spouse is an NP and admits that the clinical psychologists who get this training will have much more training than an NP in psychology AND psychopharm. The training is obviously more than PA's get. With the rigorous training they already get in psychology (far more than we get in our residencies, if we're honest), without data, can we honestly say that they will perform less effectively than FP's, NP's, or PA's? It doesn't seem to me that we have enough data to say that. Should we simply support their getting priv's with some sort of guaranteed collaboration so that we can continue to protect medically fragile patients?

Have you guys looked at what is being required for this post-doctoral degree they're required to get? Does anyone know anything about the national exam they are suppose to take (which is apparently already in existance)?

I'm thinking it might have been smarter to have taken a residency in neuro . . .

This is an excellent observation by you, which in my opinion has been offered by a level headed and rational professional.

You know . . . no amount of training in the world could adequately protect patients from the likes of yahoos like the following:



PORTLAND, Oregon (Reuters) - An Oregon doctor, who had sex with a patient and then charged the state about $5,000 for his "treatments," has been jailed for 60 days and stripped of his license, officials said on Friday.


Dr. Randall J. Smith, 50, told the woman that massaging her "trigger points" would ease her pelvic pain. The treatments led to sexual intercourse and Smith billed the Oregon Health Plan for the 45-minute sessions at the Adventist Health Medical Group clinic in Gresham, Oregon, near Portland.


Smith must also perform 200 hours of community service and pay $1,105 in fines and is on probation for 18 months as part of the plea agreement. He also turned in his medical license.

Though he pleaded guilty to submitting false health care claims, a felony, Smith maintained the sex with the 47-year-old woman was consensual.

Adventist repaid about $5,000 to the state, David Russell, clinic administrator for the hospital said.

Physicians are often their own worst enemy.

Thank you, raekelly, for getting a swing in. What happened to this thread? Has the "medical psychologist" issue died? Anyone care to provide an update on the status of psychologist RxP? Last I heard (in Psychiatric Times), Florida was entertaining psychologist RxP legislation and will likely be the next state to approve such legislation. According to one article, psychiatrist lobbying efforts were not slowing down the effort.

http://www.flsenate.gov/cgi-bin/view_page.pl?Tab=session&Submenu=1&FT=D&File=hb1583.html&Directory=session/2003/House/bills/billtext/html/

www.prescribingpsychologist.com

Pharmacists know MUCH MORE ABOUT DRUGS, ETC than a physician does. Remember they also come from a strong science and medical background. Also, their whole program is about drugs. I have often seen physicians turn to pharmacists for help when it comes to prescribing. A pharmacist prescribing drugs is in no way ridiculous as someone who is ambidextrous and therefore should do surgery. This is a ridiculous comparison.

Yes, pharms know more about drugs than docs do. So what? Prescribing drugs is just as much about pathophysiology as it is about pharmacology.

If I know the ins and outs of a drug, but dont know a damn thing about heart disease, how the hell am I going to be able to prescribe atropine in a professional manner?

Knowing about drugs is NOT enough to script them.

Pharms are NOT trained in diagnosis. They are NOT trained how to come up with a differential diagnosis list of a person presenting with chest pain. The ONLY DRUGS they would be qualified to give out are stuff where diff dx is not required (i.e. maybe birth control, viagra, and other elective medications that dont involve disease processes).

The short sightedness of the psychologists on this board is amusing.

Do you imbeciles REALLY believe that script rights is going to stop with only PhD-level psychs who have taken the relevant pharma training?

Thats INCREDIBLY naive, and only a fool would believe such a thing.

This is quickly turning into a "race to the bottom" to find the absolute MINIMUM training for script rights. The psychological society articles frequently refer to PAs and NPs and assert that since they are supposedly "lesser trained" than psychs that psychs should have equal if not greater script rights.

Let me tell you whats going to happen in 20 or 30 years:

1) PhD level psychs get script privileges in all states

2) PhD level psychs stay in teh SAME BIG CITIES where their urban psychiatrist counterparts reside.

3) Very few PhD level psychs go to rural/underserved areas, essentially abolishing the ENTIRE PREMISE for the legislation in the first place.

4) Bachelor level psychs and masters level social workers see a great opportunity for a piece of hte pie. They go to state legislatures and argue that they can treat underserved areas if given script rights.

5) Legislature (in their infinite stupidity) totally forgets about the "promise" of PhD level psychs treating underserved areas and says "Great, lets give the bachelors guys script rights too!"

You see where I'm going with this. I GUARANTEE YOU there will be "pilot" programs showing that bachelor psychs with extra pharma training can supposedly script just as well as PHD psychs or psychiatrists.

This is a race to the bottom. You psychologists are opening the floodgates. I hope you are happy in 20 years when your bachelor level colleagues gain the privs to do 100% of what you do, at a fraction of the cost.

What goes around comes around.

It is actually quite difficult to get into a quality graduate program in psychology

No its not. Yes, its difficult to get into the BEST psych PHD programs, but getting into A program is not hard at all. There are tons of little colleges out there that nobody has ever heard of which offer PhDs in psych.

(I am ignoring the psychology paper mill schools here),

Why are you ignoring them? Does the Louisiana law state that ONLY PhD grads from certain schools qualify for rx privileges? I dont think so. The new psych laws allow ANYBODY WITH A PHD IN PSYCHOLOGY to enter the training program and get rx privileges. Quit feeding us this bull**** that "only" the reputable PhD grads will be able to get script rights.

since the good schools will accept 3 to 8 applicants from a pool of 500.

What the "good" schools do is totally irrelevant. Somebody who graduates from podunk university graduate program in psychology is considered EQUIVALENT to a Columbia University grad, according to the New Mexico and Louisiana laws. There is NO REQUIREMENT that only graduates from teh "good" programs get the script rights.

We get far superior training in research methods than psychiatry residents do

Oh really? Even the diploma mill schools give superior training? What bull****. You are incredibly myopic if considering just the "good" schools. What the "good" schools do is irrelevant, becaue the state laws recognize ALL the PhD granting programs, not just some of them.

The "medical model" was mentioned above. Nurse practitioners are trained in the "nursing model" and are able to prescribe drugs. How are these models different?

They're not different at ALL!

This is a bull**** ploy used by the nurses/NPs to increase their scope of practice.

Each state gives a state nursing board the authority to define what "nursing" is. These state boards are liars and scoundrels. They defined "nursing" as scripting drugs, doing surgery, and god knows what else. By using these "definitions" the doctors on the state medical board have no say over their scope of practice.

Nurses used the term "nursing model" to effectively create a loophole for them to practice medicine. There is no difference between "nursing" and "medical" model, but the ONLY way for NPs to increase their scope was to deceive people and state legislatures with their idiotic semantic bull****.

Don't think that the psychologists don't have a plan. They will prescribe mostly benign SSRIs for 10 years or so, all the while, gathering data about how safely they prescribe. Then, they'll again introduce legislation in the remaining states citing this data, and will falsely be at a great advantage because the "real data" is seemingly in their favor.

Exactly right. Furthermore, not only will they use psyhotropic drugs, eventually they will try to expand into other drugs. They will claim that their patients have lots of other medical problems, and that by allowing psychologists access to the WHOLE FORMULARY, they could offer the patient more healthcare and reduce waiting times.

Trust me, this is an evolving scope of practice issue. Eventually, psychologists will want to script EVERYTHING, from schedule II narcotics to SSRIs to antibiotics to freakin Viagra.

No way in hell their ambition stops at just psychotropic drugs.

I have little question that psychologists can be taught to prescribe within a limited, but reasonable formulary in a safe fashion.

Why in the world do you think PhD psychs will be content to "limit" their formulary? Exactly what do you point to which backs this up AT ALL?

This is incredibly naive thinking. Eventually, the PhDs will start clamoring for a wide open formulary. You are fooling yourself if you think PhD psychs will be content to have access to a limited formulary.

The new psych laws allow ANYBODY WITH A PHD IN PSYCHOLOGY to enter the training program and get rx privileges. Quit feeding us this bull**** that "only" the reputable PhD grads will be able to get script rights.

Actually, it's not ANYBODY WITH A PHD IN PSYCHOLOGY, but rather State-licensed psychologists with health service provider designations. This includes PhDs, PsyDs, and EdDs who received their degrees in clinical or counseling psychology from APA-accredited institutions.

For current information on Psychologist RxP, check out these sites:

www.prescribingpsychologist.com
http://www.division55.org/

Tennessee looks to be making strides toward passing psychology RxP legislation: http://www.tpaonline.org/leg/id140.htm
http://www.tpaonline.org/leg/id139.htm

Actually, it's not ANYBODY WITH A PHD IN PSYCHOLOGY, but rather State-licensed psychologists with health service provider designations. This includes PhDs, PsyDs, and EdDs who received their degrees in clinical or counseling psychology from APA-accredited institutions.

For current information on Psychologist RxP, check out these sites:

www.prescribingpsychologist.com
http://www.division55.org/

Tennessee looks to be making strides toward passing psychology RxP legislation: http://www.tpaonline.org/leg/id140.htm
http://www.tpaonline.org/leg/id139.htm

Semantics. :sleep:

the point is that its totally foolish to dismiss "diploma mill" psych PhD programs, assuming that their grads cant get rx privileges. Thats a totally false assertion.

ALL DOCTORAL LEVEL PSYCH PROGRAM GRADS are eligible to become scripters, not just the ones from Stanford or Yale or the other top notch programs.

I noticed also there is a lot of funny math being cited in the psychologist's camp about saving money. They cite studies that show reduced use of drugs, and then claim that it means psychologists save money over psychiatrists.

What kind of BS logic is that? That idiotic conclusion IGNORES the cost incurred by spending time with the psychologist. It assumes that the psychologist doesnt charge the patient anything to visit with him every 2 weeks or whatever.

There's also a lot of hypocrisy in their camp as well. If masters level counselors showed data that they could get extra pharmacology training and script just like a psychologist, they'd be up at arms trying to quash the "rebellion."

Semantics. :sleep:

the point is that its totally foolish to dismiss "diploma mill" psych PhD programs, assuming that their grads cant get rx privileges. Thats a totally false assertion.

ALL DOCTORAL LEVEL PSYCH PROGRAM GRADS are eligible to become scripters, not just the ones from Stanford or Yale or the other top notch programs.

Wrong again. Psychology is a broad field with many DOCTORAL LEVEL experts, including social psychologists, developmental psychologists, environmental psychologists, educational psychologists, industrial-organizational psychologists, cultural psychologists, experimental psychologists, humanistic psychologists, health psychologists, rehabilitation psychologists, clinical psychologists, counseling psychologists, etc.(http://www.apa.org/about/division.html)

THERE ARE DOCTORAL LEVEL DEGREES OFFERED IN ALL OF THESE FIELDS. HOWEVER, ONLY LICENSED PSYCHOLOGISTS WITH HEALTH CARE PROVIDER DESIGNATIONS ARE ELIGIBLE TO GAIN PRESCRIPTION PRIVILEGES. IT'S NOT AN ISSUE OF SEMANTICS. SOCIAL PSYCHOLOGISTS, OTHER NON-CLINICAL/COUNSELING PSYCHOLOGISTS, AND NON-LICENSED CLINICAL/COUNSELING PSYCHOLOGISTS CANNOT PURSUE PRESCRIPTION PRIVILEGES.

The point made by people above was that clinical psychology PhD and PsyD programs are incredibly competitive, with only a handful of applicants gaining admission each year. Yale, for example, received 347 applications and accepted 5 students for the 2004-2005 incoming class (http://www.yale.edu/psychology/clinical_perfdata.html)
That's a 1.4% acceptance rate. Nevertheless, there are other PhD and PsyD programs out there who accept more students. Yes, graduates of these programs may eventually go on to gain prescription privileges. They still have to complete requirements for a doctoral degree, pass State licensing examinations to become healthcare providers, complete a postdoctoral Master's degree in clinical psychopharmacology, and pass the Psychopharmacology Exam for Psychologists (http://www.rxpsychology.com/PEP.htm). Once licensed to prescribe, they have to consult with each patient's primary care physician regarding medications. Haven't you read any of the above posts? Get off your high horse.

Your arguing that clinical psychologists from "diploma mill" schools will be less qualified than clinical psychologists from top clinical programs like Yale is akin to arguing that MD graduates from State medical schools are less qualified than MD graduates from top ten medical schools.

By the way, your "protests," as well as those of your colleagues, apparently aren't making much of your difference according to recent articles in Psychiatric Times: http://pn.psychiatryonline.org/cgi/content/full/39/12/1
http://pn.psychiatryonline.org/cgi/content/full/39/12/49-a

Psychology is a broad field with many DOCTORAL LEVEL experts, including social psychologists, developmental psychologists, environmental psychologists, educational psychologists, industrial-organizational psychologists, cultural psychologists, experimental psychologists, humanistic psychologists, health psychologists, rehabilitation psychologists, clinical psychologists, counseling psychologists, etc.(http://www.apa.org/about/division.html)

THERE ARE DOCTORAL LEVEL DEGREES OFFERED IN ALL OF THESE FIELDS. HOWEVER, ONLY LICENSED PSYCHOLOGISTS WITH HEALTH CARE PROVIDER DESIGNATIONS ARE ELIGIBLE TO GAIN PRESCRIPTION PRIVILEGES. IT'S NOT AN ISSUE OF SEMANTICS. SOCIAL PSYCHOLOGISTS, OTHER NON-CLINICAL/COUNSELING PSYCHOLOGISTS, AND NON-LICENSED CLINICAL/COUNSELING PSYCHOLOGISTS CANNOT PURSUE PRESCRIPTION PRIVILEGES.

I'LL SAY IT AGAIN: THIS IS SEMANTICS! There are many programs that offer PhDs in clinical psychology. For you to pretend that this is somehow and elite group of programs is just BULL****!

The point made by people above was that clinical psychology PhD and PsyD programs are incredibly competitive, with only a handful of applicants gaining admission each year. Yale, for example, received 347 applications and accepted 5 students for the 2004-2005 incoming class (http://www.yale.edu/psychology/clinical_perfdata.html)
That's a 1.4% acceptance rate.

so what? MIT's engineering acceptance rate is 5%, yet its EASY to get accepted into north dakota state university's PhD engineering program. Why do you persist in using faulty logic?

Nevertheless, there are other PhD and PsyD programs out there who accept more students.

Translation: on aggregate, its pretty easy to get accepted to A PhD clinical psych program. We're not talking Yale or Stanford specifically because talking about individual schools is IRRELEVANT! I dont recall ANYTHING in the rx bill stating that only Yale or Stanford PhD clinical psych grads are eligible for script privileges.

I think it would be very enlightening for you to post a list of all PsyD and clinical psych PhD programs in the United States. If you dont, then I will. Everybody on this board will have a healthy laugh at that list. A good number of those institutions are places that nobody has ever heard of, and accept virtually everyone who applies to the program.

Yes, graduates of these programs may eventually go on to gain prescription privileges. They still have to complete requirements for a doctoral degree

Thats pretty damn trivial, depending on what grad school you go to.

pass State licensing examinations to become healthcare providers

Ditto.

By the way, your "protests," as well as those of your colleagues, apparently aren't making much of your difference according to recent articles in Psychiatric Times: http://pn.psychiatryonline.org/cgi/content/full/39/12/1
http://pn.psychiatryonline.org/cgi/content/full/39/12/49-a

whats your point here? That politicians know whats best?

Yeah, because state legislatures ALWAYS get it right. :sleep:

Look, if I showed data showing that people with a bachelors degree in biology could be trained to script drugs, the state legislature would probably fall for that too. Its very easy to mislead these people. they are not scientists, they are politicians. They will vote for almost ANYTHING that "increases access to healthcare." Those are magic words that they like to use in their political campaigns.

This also brings up the hypocrisy of the psychologists. If there was data showing that people with a bachelors degree in psych could be trained to script drugs, and that their outcomes were no worse than PhD psychs, the PhD psychs would be outraged and trying to block it at all costs. Your group is a bunch of hypocrites. They want increased scope of practice for their own protected group, but they will FIGHT TO THE DEATH to prevent "outsiders" from having the same privileges, EVEN IF THERE WERE SPECIFIC EVIDENCE contrary to their claims.

You guys are wolves in sheeps clothing. Dont give us that bull**** about how MDs are just trying to protect turf. Its incredibly disingenuous and hypocritical.

This also brings up the hypocrisy of the psychologists. If there was data showing that people with a bachelors degree in psych could be trained to script drugs, and that their outcomes were no worse than PhD psychs, the PhD psychs would be outraged and trying to block it at all costs. Your group is a bunch of hypocrites. They want increased scope of practice for their own protected group, but they will FIGHT TO THE DEATH to prevent "outsiders" from having the same privileges, EVEN IF THERE WERE SPECIFIC EVIDENCE contrary to their claims.

By that logic haven't you just proved the point that MD's are trying to protect their turf, since there is evidence that PhD's are just as effective in pharmacological treatment?

Why are you ignoring them? Does the Louisiana law state that ONLY PhD grads from certain schools qualify for rx privileges? I dont think so. The new psych laws allow ANYBODY WITH A PHD IN PSYCHOLOGY to enter the training program and get rx privileges. Quit feeding us this bull**** that "only" the reputable PhD grads will be able to get script rights.





I think that it would be wise for you to actually look at the application for psychologist licensure in Lousiana before commenting further.

Svas

Why in the world do you think PhD psychs will be content to "limit" their formulary? Exactly what do you point to which backs this up AT ALL?

This is incredibly naive thinking. Eventually, the PhDs will start clamoring for a wide open formulary. You are fooling yourself if you think PhD psychs will be content to have access to a limited formulary.


Psychologists with appropriate training arent' interested in treating cardiac disease, cancer, renal disorders, etc. They are interested in treating patients with psychological disorders. They are developing the skill to treat medically ill patients with psychiatric disorders. I don't think they are likely to want to treat non-psychiatric disorders anymore that you are to want to do neurosurgery (although, legally, you could).

You're obviously pretty stirred up by this and I can understand why. I would only caution you about how you use the term "naive." It's an animal with teeth on both ends of the body.

I'LL SAY IT AGAIN: THIS IS SEMANTICS! I dont recall ANYTHING in the rx bill stating that only Yale or Stanford PhD clinical psych grads are eligible for script privileges.

I think it would be very enlightening for you to post a list of all PsyD and clinical psych PhD programs in the United States. If you dont, then I will. Everybody on this board will have a healthy laugh at that list. A good number of those institutions are places that nobody has ever heard of, and accept virtually everyone who applies to the program.

Seriously, you need to do some research before you come onto these forums. First off, Stanford does NOT have a Ph.D. program in clinical psychology (http://www-psych.stanford.edu/grad_areas.html), so graduates of this program would NOT be eligible to pursue prescription privileges unless they complete a Respecialization Program in clinical psychology. Secondly, as requested, here are a couple lists of clinical training programs in the U.S. and Canada (for your "healthy laugh"): http://www.div40.org/pdf/npprogs_doctoral.pdf
http://www.socialpsychology.org/clinrank.htm
Third, your point about some institutions being places that "nobody has ever heard of" employs "faulty logic." Most pre-meds, medical students, practicing physicians, other healthcare professionals, and members of the general public have never heard of dozens of allopathic, osteopathic, and international medical schools. Moreover, some of these schools -- particularly Caribbean schools -- accept practically EVERY applicant, so long as they have a pulse and a loan. Graduates of these programs are fully eligible to become licensed physicians and practice the full scope of medicine. Chances are that a physician who graduated from one of these unrecognized/"healthy laugh" medical schools treated you at some point in your life!

Moral of the story...do some RE-SEARCH...READ articles and books, TALK to people in the field, and remain OPEN-MINDED. It'll serve you well as a medical fundamentalist.

Cheers,

PH

Pharms are NOT trained in diagnosis. They are NOT trained how to come up with a differential diagnosis list of a person presenting with chest pain. The ONLY DRUGS they would be qualified to give out are stuff where diff dx is not required (i.e. maybe birth control, viagra, and other elective medications that dont involve disease processes).

Wrong again.

http://healthcare.monster.com/pharm/articles/diseasemgmt/

CRITICAL ARGUMENTS THAT SUPPORT RxP

1. Many non-psychiatric physicians and other health care providers are prescribing psychotropic medications for their patients and actually prefer to refer those individuals to psychologists for treatment, including assessment, possible psychotropic medication prescription, and treatment.

a. The number of visits to general physicians in which psychotropic medications were prescribed increased from 32.7M to 45.6M from 1985 to 1994. (The proportion of such visits increased from 5.1% to 6.5%). Should general physicians prescribe in this way? Do they have adequate training to diagnose mental illness? Are they spending sufficient time with patients who present with psychological distress?

b. The federal government, aided by medicine and the pharmaceutical industry, has been advocating for medicating as the primary treatment for mental and emotional disorders by primary care physicians. These physicians have little or no formal training in empirically-based mental health treatments, with the exception of continuing medical education about depression that is usually provided by drug companies.

c. By the year 2020, depression with psychological etiology will be the second leading cause of the non-fatal disabling effects of disease. (Depression currently accounts for 47% of the effects of physical disease and injury.)

2. Individuals usually seek help from primary care physicians when experiencing physical, social, or emotional changes and/or discomfort. Primary care physicians have limited training in psychiatric diagnosis and little training in modern psychological treatment strategies and techniques. Many are uncomfortable making psychiatric diagnoses and tend to ignore or minimize symptoms of mental distress. It is not uncommon for them to attempt to explain symptoms as being solely due to a physical problem.

3. Psychologists have extensive training in biopsychosocial assessment, standardized diagnostic procedures and a wide variety of techniques and skills for the treatment of mental and emotional disorders. Psychologists have learned these fundamentals for providing effective services through an intensive graduate program leading to a doctorate in psychology, as well as an internship and post-graduate experience. The depth and scope of training for psychologists in the mental health and the psychological aspects of disease exceeds that of other health professions.

4. Training in the physiological aspects of mental and behavioral disorders is a part of doctoral-degree programs in psychology; APA accreditation and the psychology state licensure examination require demonstrated baseline competence in the biological, psychological and social bases of behavior.

5. A 1992 survey of hospital-affiliated psychologists indicated that 64% of the respondents already collaborate with physicians regarding psychotropic medication dose, type or toxicity and 41% provide follow-up documentation on the efficacy of the psychotropic medications.

6. Many other non-physician providers who have the legal authority to prescribe include, for example, dentists, podiatrists, advanced nurse practitioners, nurse midwives, optometrists, and physician assistants. In 1997, there were over 160,000 Advanced Nurse Practitioners who were either prescribing or utilizing psychotropic medications in their practices in all 50 states. Psychologists are already prescribing in certain federal programs. They are prescribing informally in other non-governmental settings. This shows that one does not have to attend medical school to learn how to prescribe competently and successfully.

7. Because psychologists will have the ability to prescribe medication does not mean that medications will always be prescribed for their patients. The psychologist may determine that other treatments are more appropriate after she or he is able to complete a comprehensive assessment. Physicians, on the other hand, use medication therapy as their customary and primary treatment intervention. Therefore, if a depressed patient visits a primary care physician, they are likely to be prescribed an antidepressant. If this same patient visits a prescribing psychologist, other equally viable treatment options excluding, or in addition to, antidepressant therapy will be considered. It is important to remember thatthe authority to prescribe is also the authority NOT to prescribe.

8. Psychologists in health care are already practiced in recommending and monitoring psychotropic drugs and serve as an important resource for primary care physicians in their prescribing practices. It is logical to progress to the next level and train psychologists to prescribe independently.

Source: http://www.apa.org/apags/profdev/prespriv.html

CRITICAL ARGUMENTS AGAINST RxP

Many of the compelling arguments for the aggressive pursuit of RxP have been offered. Several arguments opposing RxP have also been advanced and they are detailed below. These opposing arguments have not been ignored or dismissed. Listed below are some of the common sentiments that have been expressed against RxP, as well as counterpoints to supplement the pro-RxP arguments already outlined in this document.

Argument #1:

?If psychologists want to prescribe medication, they should go to medical school.?

Counterpoints:

A. Psychologists are highly trained specialists in mental health who can be trained to prescribe psychotropic medications, thus utilizing the psychologist?s ability to deliver services that span the full range of mental health services.

B. Psychologists obtain a high level of competency through an extensive education and training process. This normally entails an average of seven years of education beyond the undergraduate degree in a comprehensive academic program that includes practical training experiences and didactics.

C. Almost all states require 1 to 2 years of supervised post-doctoral experience for the granting of licensure.

D. Clinical psychology students receive extensive training in the physiological aspects of mental disorders. In fact, APA accreditation standards require coursework and demonstrated competence in physiological bases of mental disease.

E. The Association of State and Provincial Psychology Boards, which monitors and oversees all state licensure examinations, requires knowledge of common physical disease symptoms and psychophysiology, as well as the effects of major psychotropic drugs and other commonly prescribed drugs on behavior and cognition.

F. Psychology?s recognized competence in the medical and psychological aspects of illness is exemplified by the fact that over 3,000 psychologists are employed on medical school faculties where they participate in a range of health psychology activities, including teaching psychopharmacology courses!

Argument #2:

?Psychologists will become greedy pill-pushers. Prescribing will change the nature of the profession, causing psychologists to quickly write prescriptions and abandon our important psychological model of treatment.?

Counterpoints:

A. Many psychologists are currently informally prescribing medications when they consult with physicians and psychiatrists about the treatment regimens of mutual patients, which includes the use and effects of psychotropic medication.

B. Psychologists have demonstrated that their expertise in treatment allows patients to regain functioning with fewer medications and lower dosages of medication, thus dispelling the fear that psychologists will ?forget their skills? and become ?pill-pushers.?

C. Training in RxP is reserved for licensed psychologists who have been practicing for a minimum of 5 years after the granting of their degree and license. This is to ensure that the new psychologist has sufficiently solidified their professional identity, operating from a well-developed psychological model of intervention.

D. RxP clearly supports a psychological model of prescribing, not a medical model of prescribing. Practice and prescribing according to these two models is philosophically and fundamentally distinct. Psychology views the individual and prescribing from a biopsychosocial framework, whereas medical practice and prescribing focuses on identifying disease and eradicating it.

E. Psychology has a strong identity and it can withstand and flourish with this additional tool for practice.

Argument #3:

?Liability insurance premiums will increase drastically and those who do not prescribe will have to pay higher rates to compensate for those who do prescribe. Doesn?t the likelihood of mis-prescribing increase when psychologists, not physicians, prescribe??

Counterpoints:

A. Over 70% of psychotropic medication in the United States is currently prescribed by non-psychiatric physicians who have minimal training in the detection and management of mental and emotional problems. Psychologists are much better trained and equipped to accurately diagnose and treat mental disorders.

B. Insurance premiums are rated based upon experience. The prescribing experience of Optometrists, Advanced Nurse Practitioners and Physician Assistants demonstrates that non-physician prescribers are as safe as physicians. Therefore, their premiums have not increased and are currently less expensive than the present liability rates for psychologists. Psychologists who oppose RxP fear substantial increases in liability insurance premiums. When medication is prescribed judiciously, as Optometrists and other non-physician prescribers have shown, there is no significant increase in premiums.

Argument #4:

?The education community has not been sufficiently consulted about the RxP scope of practice expansion. Are there going to be mandates to change core psychology curricula to adjust for RxP? Will the fundamentals of graduate psychology training suffer, or will more core courses be added, thus extending the duration of doctoral education??

Counterpoints:

A. The following education/training constituency groups have provided specific input in the development of the RxP movement: Board of Educational Affairs, Board of Scientific Affairs, Division 12 (Clinical), Division 22 (Rehabilitation), Board of Professional Affairs, Committee for the Advancement of Professional Practice, Board of the Advancement of Psychology in the Public Interest, National College of Professional Psychology, APA Council of Representatives, and the APA Board of Directors. Additionally, RxP issues have been included on several cross-cutting agenda items during many sessions of consolidated meetings where several APA constituency groups gather simultaneously to conduct their business meetings.

B. The overall quality of current education of psychology students is valued, important and will not be compromised. However, in some academic settings, the training is dated and practitioner students are not being adequately trained to thrive in the current marketplace. Education should evolve as the field evolves, while preserving the fundamentals of psychology education.

Argument #5:

?Are we just adding RxP because we fear that psychology is losing its distinctive identity to master?s trained individuals? Why should psychologists prescribe if we already have a good relationship with, and accessibility to, psychiatrists and physicians? Will the field begin to devalue psychologists who do not prescribe, thus phasing these psychologists out of the field??

Counterpoints:

A. RxP is an additional tool for psychologists use and it is not intended to replace the unique services that psychologists already deliver.

B. Psychologists already specialize with different populations, diagnoses and treatment approaches, and each specialty area is a respected sub-field of psychology.

C. Certification, not licensure, for RxP extends the current scope of psychological practice. It does not replace it.

D. Psychiatry has historically attempted to obstruct the evolution of psychology. For example, between 1950 - 1970 psychiatrists argued that it was unsafe to permit psychologists to practice outpatient psychotherapy without medical referral or medical supervision. Psychiatry also attempted to prevent psychologists from access to specialized training in psychoanalysis. They also opposed the psychologists? ability to treat patients in hospital settings and Skilled Nursing Facilities. And, psychiatrists unsuccessfully fought to defeat measures that now allow the elderly direct access to psychological care under the Medicare program (OBRA).

Source: http://www.apa.org/apags/profdev/prespriv.html

I second with Svas and Public Health's posts. Given that you are so influenced by the medical model and MD training, shouldn't you seek the evidence first and diagnose second? Physician heal thyself....

Great point, lazure. :laugh:

From the above article:

"Psychiatry has historically attempted to obstruct the evolution of psychology. For example, between 1950 - 1970 psychiatrists argued that it was unsafe to permit psychologists to practice outpatient psychotherapy without medical referral or medical supervision. Psychiatry also attempted to prevent psychologists from access to specialized training in psychoanalysis. They also opposed the psychologists? ability to treat patients in hospital settings and Skilled Nursing Facilities. And, psychiatrists unsuccessfully fought to defeat measures that now allow the elderly direct access to psychological care under the Medicare program (OBRA)."

In the next few years, we'll be able to add: "Most recently, psychiatrists have also unsuccessfully fought to defeat psychologist prescribing legislation in several states." In fact, psychiatrists' OWN LITERATURE is stating this already: http://pn.psychiatryonline.org/cgi/content/full/39/12/1

Wrong again.

http://64.4.43.250/cgi-bin/linkrd?_lang=EN&lah=9407ddf883009c6990a4604012d1275f&lat=1089726877&hm___action=http%3a%2f%2fhealthcare%2emonster%2eco m%2fpharm%2farticles%2fdiseasemgmt

1) Your link doesnt work

2) You are delusional if you think pharms get sufficient training for scripting drugs. Like I said, there are exceptions for clear elective uses such as birth control or viagra, but for general prescription rights their training is TOTALLY INADEQUATE. Lets look at an example.

59 y/o post-menopausal white female comes in with LLQ abdominal pain. She describes pain as radiating from the left lower iliac crest to the umbilicus, with a dull/aching quality, 8/10 on the pain scale. Woman has had pain for previous 2 weeks, and it has intensified over the past 3 days. She reports no family/friends sick, no travels, and no restaurants or different foods recently. No allergies reported, no medications currently taken. No significant PMH or hospitalizations.

Physical exam: RR: 15, HR: 78, BP 140/90. Normal HEENT exam. Crackles in left lower lung field, no murmurs or gallops on cardiac exam. Liver span percussed at 6 cm. Light palpation resulted in LLQ resulted guarding and rebound tenderness. No masses palpated. Extremity/neuro exam normal.

Labs: ALT 2 U/L, AST 60 U/L, Crit 31%, blood cultures X 3 normal, FBG 100, FOBT positive

Given this info, the pharmacist would have NO CLUE how to proceed. It doesnt matter how much they know about drugs, you ahve to be able to DIAGNOSE FIRST before you can give drugs. They ARENT TRAINED FOR DIAGNOSIS, which is a prerequisite for drug scripting. The only things they could script for are those that dont involve pathophysiological differential diagnosis, such as viagra or birth control.

1) Your link doesnt work

2) You are delusional if you think pharms get sufficient training for scripting drugs. Like I said, there are exceptions for clear elective uses such as birth control or viagra, but for general prescription rights their training is TOTALLY INADEQUATE. Lets look at an example.

59 y/o post-menopausal white female comes in with LLQ abdominal pain. She describes pain as radiating from the left lower iliac crest to the umbilicus, with a dull/aching quality, 8/10 on the pain scale. Woman has had pain for previous 2 weeks, and it has intensified over the past 3 days. She reports no family/friends sick, no travels, and no restaurants or different foods recently. No allergies reported, no medications currently taken. No significant PMH or hospitalizations.

Physical exam: RR: 15, HR: 78, BP 140/90. Normal HEENT exam. Crackles in left lower lung field, no murmurs or gallops on cardiac exam. Liver span percussed at 6 cm. Light palpation resulted in LLQ resulted guarding and rebound tenderness. No masses palpated. Extremity/neuro exam normal.

Labs: ALT 2 U/L, AST 60 U/L, Crit 31%, blood cultures X 3 normal, FBG 100, FOBT positive

Given this info, the pharmacist would have NO CLUE how to proceed. It doesnt matter how much they know about drugs, you ahve to be able to DIAGNOSE FIRST before you can give drugs. They ARENT TRAINED FOR DIAGNOSIS, which is a prerequisite for drug scripting. The only things they could script for are those that dont involve pathophysiological differential diagnosis, such as viagra or birth control.

I love how you resort to name-calling in order to try to make a point. Your calling me "delusional" could get you in trouble with ethics boards should you be a licensed healthcare professional and should I learn your identity. Calling others "imbecilies," "idiotic," and "delusional" will not serve you well in your profession, whatever that may be.

Did you get a "healthy laugh" after reading through the lists of Ph.D./Psy.D. programs in clinical psychology and neuropsychology? What are your thoughts regarding the points made in the article above?

Here's the "link that didn't work:"

http://healthcare.monster.com/pharm/articles/diseasemgmt/

The pharmacist in that link is UNDER THE DISCRETION OF DOCTORS. She works under the protocol that they approved. Its the same setup with PAs.

The ONLY reason the doctors agree to it at all is because they make extra $$ billing for the scripts that the pharmacist writes. They give her a small kickback. I fault these doctors for their tremendous greed, trying to sell out the profession to make a quick buck.

BTW, NOTHING in that link contradicts my point. The pharmacist operates under specific guidelines approved by doctors. She doesnt independently diagnose and script drugs. She operates on a "cookie cutter" model approved by doctors. She's basically a functioning PA or NP.

You have the right to disagree with us if you wish. But do us a favour and come back with valid arguments as opposed to childish name calling... while I say a little prayer for your patients, collegues and superiors (in that order)...

You know it is possible to have a discussion with people, feel strongly about one's viewpoint, disagree with others and desist from immaturity at the same time...

I had a chance today to meet with 4 psychologists who have their MS in Psychopharm. Let me say, without hesitation, these people really have a very competent and uniform grasp of pharmacology, psychopharmacology, and certainly general psychiatry. Period. I've been teaching now for over 20 years and I have absolutely no question that they could easily be mistaken for psychiatrists. Having said that, there is an absense of experience in emergency situations that is troublesome, I don't think that they are comfortable with physical examinations, and I found them to need additional work with regard to reading labs. (Then again, I say this about a fair number of vetran psychiatrists.)

The most important aspect, though, was the strength of their diagnostic skills and proper recommendations & procedure for planning the treatment. This experience simply reinforced what I expected might be the case.

[BTW, *none* of them had any interest in ECT and, in fact, voiced considerable negativity toward it.]

So, I suppose I would challenge the psychiatrists and residents on this list to spend some time with one/some of these MS trained psychologists before commenting further on what they will or will not be able to manage. I was pleasantly surprised. We have a fair amount of work to do if we're going to suggest that they're not competent to prescribe psychotropic meds and family docs are. Legislators are going to see through this pretty easily if any of them testify.

S

I had a chance today to meet with 4 psychologists who have their MS in Psychopharm. Let me say, without hesitation, these people really have a very competent and uniform grasp of pharmacology, psychopharmacology, and certainly general psychiatry. Period. I've been teaching now for over 20 years and I have absolutely no question that they could easily be mistaken for psychiatrists. Having said that, there is an absense of experience in emergency situations that is troublesome, I don't think that they are comfortable with physical examinations, and I found them to need additional work with regard to reading labs. (Then again, I say this about a fair number of vetran psychiatrists.)

The most important aspect, though, was the strength of their diagnostic skills and proper recommendations & procedure for planning the treatment. This experience simply reinforced what I expected might be the case.

[BTW, *none* of them had any interest in ECT and, in fact, voiced considerable negativity toward it.]

So, I suppose I would challenge the psychiatrists and residents on this list to spend some time with one/some of these MS trained psychologists before commenting further on what they will or will not be able to manage. I was pleasantly surprised. We have a fair amount of work to do if we're going to suggest that they're not competent to prescribe psychotropic meds and family docs are. Legislators are going to see through this pretty easily if any of them testify.

S

Thank you for sharing this, Svas. This thread needed some more objective information about psychologists with RxP. In time, I imagine that data regarding the safety and effectiveness of psychologist RxP will emerge from New Mexico and Louisiana (once the medical psychologists in these states jump through the flaming hoops placed in their path by psychiatrists). Hopefully such studies will be done by independent scientists with no invested interest in this issue. Perhaps a study evaluating prescribing knowledge and practices of a number of medical psychologists and psychiatrists with independent scientists blind to the actual title (psychiatrist vs. medical psychologist) of each professional is in order?

Svas, have you considered going on record to describe the pros and cons of medical psychologists' training and level of expertise regarding RxP? Have you considered writing a letter to your State legislature or an editorial to a psychiatric or psychological journal or widely read newspaper in your state? I could imagine why you would not want to do this, but if you feel so strongly about medical psychologists' knowledge and level of training, wouldn't you want your state legislators and the general public to know about it? If the psychologist RxP is to gain approval in other states, people need to hear from professionals like you. It means a great deal to hear from a psychiatrist with decades of experience that psychologists with RxP are not as "dangerous and incompetent" as the American Psychiatric Association makes them out to be.

Update on psychologist RxP legislation:


STATES OR TERRITORIES THAT HAVE PASSED PSYCHOLOGIST RXP LEGISLATION :thumbup: :

. GUAM - BECAME LAW 12/98
. NEW MEXICO - BECAME LAW 3/6/02
. LOUISIANA ?BECAME LAW 4/9/04


STATES PENDING PSYCHOLOGIST RXP LEGISLATION:

. HAWAII, CALIFORNIA, GEORGIA, MISSOURI,
ILLINOIS, FLORIDA, ALASKA, CONNECTICUT, TEXAS, AND
TENNESSEE

I am a late contributor to this thread. I spent the last half hour reading through all the prior posts, so I hope I will be forgiven if I have missed a few details along the way.

I am a psychiatrist in private practice, doing some academic work and teaching. This discussion has been quite interesting. I'll bring up a couple of points:

(1) Those of you who are discouraged about choosing psychiatry, don't be too pessimistic. Psychiatry has indeed been ravaged by managed care, but I get to make a living talking with patients for 30 to 45 minutes at a time, which is far more pleasant than seeing a new patient every 8 minutes. If you need to repay debts, practice in a rural area for a few years; the recruitment packages pay well to make up for the lack of amenities in the community. You can always then move back to an urban area, if you so choose.

(2) The DoD experiment can be looked at many different ways. I choose to look at the fact that it cost as much per psychologist as it would to send them through medical school (over $100,000 each). They also spent far more hours in academic instruction (most had 712 hours, and the very first group had 1418 hrs) and far more hours in clinical experience (the first group had a 9 month *full time* inpatient training, plus 3 months of C/L, on-call admissions, and chart review before that; the later groups had 6 months full-time inpatient and 6 months full-time outpatient) than any proposed psychologist-prescribing program would provide. After all that, they were judged by the ACNP reveiwers to have medical knowledge comparable to that of a "3rd or 4th year medical student." While I know there are some very good 3rd and 4th year medical students, I think that patients deserve better.

(3) Someone mentioned the "super mental health professional" (sorry I don't remember who.) I don't know if this is "super," but I use empirically proven psychotherapy techniques such as CBT as well as interpersonal or psychodynamic techniques; I see patients for psychotherapy, psychopharmacology, or both combined; I diagnose physical illnesses masquerading as psychiatric conditions with regularity; I do, in fact, perform limited physical exams when needed (palpating thyroid glands, examining rashes or checking for edema) and I do order and evaluate lab tests and radiologic studies; and I am comfortable working with primary care docs, psychologists, and other therapists whenever needed.

(4) I disagree with the stereotyping on both sides about psychologists and psychiatrists. There are good and bad members of both fields. Most, but not all, psychologists are at least as intelligent as most, but not all, psychiatrists. Most, but not all, clinical psychologists are better trained in psychotherapy than most, but not all, psychiatrists. They spend far more time taking classes in psychotherapy in general than psychiatrists do, who spend part of that time learning medicine. However, psychologists also spend a great deal of time learning about theory, testing, and research, so the difference is not as tremendous as it otherwise could be.

(5) As for the use of medicine in psychiatry, let me offer a simple example. I got a phone call once from a patient who had recently started Buspar. She told me that it was upsetting her stomach, and asked if she could stop taking it. I asked her a couple of questions -- Where do you feel the pain, what kind of pain is it -- and followed up with just a few more, and told her two minutes later (correctly) that she had pyelonephritis, not a reaction to Buspar. Another patient complained of dizziness, and I correctly diagnosed her *before* ordering tests with an electrolyte imbalance rather than side effects of Serzone; hyponatremia was confirmed by the lab. No psychologist who has only had training in psychopharmacology will be able to diagnose correctly in that sort of situation.

(6) With regard to the safety factor of psychologists "working in collaboration with PCPs," I'll note that I regularly get referrals from primary care doctors. Despite this, I have diagnosed sleep apnea, Hashimoto's thyroiditis (despite the fact that the PCP had reviewed thyroid tests, and said they were "normal"), and hyperparathyroidism (based on history alone), among other problems. Primary care docs are underpaid, undervalued, and overworked, and sometimes have difficulty getting good histories from psychiatric patients. Two medical doctors are better than one.

OK, it's time to head home and catch a few zzzzzzs. :sleep: Hopefully people are still reading this thread.

Cordially yours,
Purpledoc

[COLOR=Purple]Your forgetting something. Pharmacists are familiar with heart disease, stroke, etc. They have a medical, pathophysiology background. The emphasis is drugs but they know medicine, too.

This is a lie.

Let me ask you something.

A person comes to your pharmacy and tells you they have chest pain.

What drugs do you give in that situation?

There are lay people checking with their pharmacists before taking PRESCRIBED MEDS, because their doctor gave them the wrong drug in the past. And it was the PHARMACIST that caught the error!!
[COLOR]

so what? The medication errors that pharmas catch are done with the benefit of diagnosis already being made.

For example, say a patient has CHD and the doctor ordered the wrong med. The pharma switches the med to another drug IN THE SAME CLASS as the original drug.

What they DONT DO is tell the patient, oh you dont have CHD you've got something else, therefore we're switching you over to a completely new class of drug that has nothing to do wiht CHD.

Like I said, pharmas can script ONLY for stuff like birth control, viagra, and stuff that is NOT part of a disease process. Pharmas are NOT CAPABLE OF DIAGNOSIS, AND THEREFORE ARE NOT QUALIFIED TO BE GENERAL SCRIPT WRITERS.

As for the use of medicine in psychiatry, let me offer a simple example. I got a phone call once from a patient who had recently started Buspar. She told me that it was upsetting her stomach, and asked if she could stop taking it. I asked her a couple of questions -- Where do you feel the pain, what kind of pain is it -- and followed up with just a few more, and told her two minutes later (correctly) that she had pyelonephritis, not a reaction to Buspar. Another patient complained of dizziness, and I correctly diagnosed her *before* ordering tests with an electrolyte imbalance rather than side effects of Serzone; hyponatremia was confirmed by the lab. No psychologist who has only had training in psychopharmacology will be able to diagnose correctly in that sort of situation.

I found myself generally in agreement with most of your comments, including the one above . . . almost.

Error is a complex thing. It's like a twin bladed sword that cuts both ways. If we pride ourselves on catching complex medical conditions, and suggest that psychologists won't catch them, we are talking about our having a smaller medical diagnostic error factor or rate than psychologists do. Seems reasonable, given our medical training. Unfortunately, if we engage in this, we have to ask "how often are we wrong?" How often do we miss medical diagnoses? How often do we misdiagnose (or miss altogether) psychiatric disorders? How often do we have to switch treatments midstream because we recognize that we've missed a condition because of our own bias (unconsciously or otherwise). How often would a advanced-trained psychologist miss these conditions and made the same kinds of errors? Unfortunately, we don't really know the answers to any of these questions.

On the face of it, I would tend to agree that psychologists would probably not recognize those conditions (above) as you did. However, I'm not sure that the average psychiatrist would. As you've pointed out, there are strong or talented members in each of these professional groups . . . and you're probably a member of that group.

In the midst of some of the more acrimonious posts, yours was a pleasure to read.

S

This is a lie.

Let me ask you something.

A person comes to your pharmacy and tells you they have chest pain.

What drugs do you give in that situation?


You're probably right that the pharmacists would NOT be able to diagnose the cardiac condition presented. However, they are more likely to correct the med error we/you make.

I suppose it's good that patients have both of us.

S

I found myself generally in agreement with most of your comments, including the one above . . . almost.

Error is a complex thing. It's like a twin bladed sword that cuts both ways. If we pride ourselves on catching complex medical conditions, and suggest that psychologists won't catch them, we are talking about our having a smaller medical diagnostic error factor or rate than psychologists do. Seems reasonable, given our medical training. Unfortunately, if we engage in this, we have to ask "how often are we wrong?" How often do we miss medical diagnoses? How often do we misdiagnose (or miss altogether) psychiatric disorders? How often do we have to switch treatments midstream because we recognize that we've missed a condition because of our own bias (unconsciously or otherwise). How often would a advanced-trained psychologist miss these conditions and made the same kinds of errors? Unfortunately, we don't really know the answers to any of these questions.

On the face of it, I would tend to agree that psychologists would probably not recognize those conditions (above) as you did. However, I'm not sure that the average psychiatrist would. As you've pointed out, there are strong or talented members in each of these professional groups . . . and you're probably a member of that group.

In the midst of some of the more acrimonious posts, yours was a pleasure to read.

S

We need DATA!

I found myself generally in agreement with most of your comments, including the one above . . . almost.

Error is a complex thing. It's like a twin bladed sword that cuts both ways. If we pride ourselves on catching complex medical conditions, and suggest that psychologists won't catch them, we are talking about our having a smaller medical diagnostic error factor or rate than psychologists do. Seems reasonable, given our medical training. Unfortunately, if we engage in this, we have to ask "how often are we wrong?" How often do we miss medical diagnoses? How often do we misdiagnose (or miss altogether) psychiatric disorders? How often do we have to switch treatments midstream because we recognize that we've missed a condition because of our own bias (unconsciously or otherwise). How often would a advanced-trained psychologist miss these conditions and made the same kinds of errors? Unfortunately, we don't really know the answers to any of these questions.

On the face of it, I would tend to agree that psychologists would probably not recognize those conditions (above) as you did. However, I'm not sure that the average psychiatrist would. As you've pointed out, there are strong or talented members in each of these professional groups . . . and you're probably a member of that group.

In the midst of some of the more acrimonious posts, yours was a pleasure to read.

S

Aw, shucks. *blush*

Actually, I have heard the same arguments you give on a number of occasions, either (1) psychiatrists are often wrong, too, or (2) most psychiatrists wouldn't catch these things. I would argue that yes, all psychiatrists miss medical diagnoses at times, since we're not perfect. On the other hand, in today's society where patients cannot afford doctor visits easily, and so don't see their PCP, or where the PCPs don't have enough time to catch everything, I find that I am doing more and more primary care. I often end up explaining diagnoses from patients' PCPs or, yes, catching things like UTIs or cholecystitis, which are things most psychiatrists would have a very hard time missing when the patient describes the symptoms, and which as doctors, we just automatically ask the right questions about (remember "pain, quality, radiation, symptoms, timing"?) So, just about all of us catch the basic stuff. We also all think about differential diagnoses routinely. We may not remember everything we learned in medical school or internship, but some of it is still dormant in our minds and can get triggered by just the right phrase (e.g., "Worst headache of my life.")

I agree that many psychiatrists wouldn't catch hyperparathyroidism, and I was just lucky that the patient mentioned an abnormal bone scan and family history of thyroid problems when I took a medical history, so that I could put the pieces together. But still, as I said above, two medical doctors are better than one. We may not be infallible, but that's not a reason not to say that yes, we are physicians, and we will diagnose medical conditions better than anyone who does not have training in medicine -- that's what we spent all those years in training for. We learned a style of thinking that always sets us apart, no matter how many little facts about anesthesiology or ophthalmology that we forget along the way. Courses in psychopharmacology will not change psychologists into physicians anymore than learning CBT turned me into a psychologist. (See my postings in the "scope of practice" thread in this forum.)

I think that psychiatrists fall into the same trap as liberals: Oh, we can't criticize conservatives for x, y, or z because we have our own flaws, too. Nonsense! There are bad doctors, just like there are bad psychologists. Nonetheless, the simple fact remains: We are physicians, and psychologists are not. Whether others think this is a good thing or a bad thing, well, that's for them to judge.

Aw, shucks. *blush*

Actually, I have heard the same arguments you give on a number of occasions, either (1) psychiatrists are often wrong, too, or (2) most psychiatrists wouldn't catch these things. I would argue that yes, all psychiatrists miss medical diagnoses at times, since we're not perfect. On the other hand, in today's society where patients cannot afford doctor visits easily, and so don't see their PCP, or where the PCPs don't have enough time to catch everything, I find that I am doing more and more primary care. I often end up explaining diagnoses from patients' PCPs or, yes, catching things like UTIs or cholecystitis, which are things most psychiatrists would have a very hard time missing when the patient describes the symptoms, and which as doctors, we just automatically ask the right questions about (remember "pain, quality, radiation, symptoms, timing"?) So, just about all of us catch the basic stuff. We also all think about differential diagnoses routinely. We may not remember everything we learned in medical school or internship, but some of it is still dormant in our minds and can get triggered by just the right phrase (e.g., "Worst headache of my life.")

I agree that many psychiatrists wouldn't catch hyperparathyroidism, and I was just lucky that the patient mentioned an abnormal bone scan and family history of thyroid problems when I took a medical history, so that I could put the pieces together. But still, as I said above, two medical doctors are better than one. We may not be infallible, but that's not a reason not to say that yes, we are physicians, and we will diagnose medical conditions better than anyone who does not have training in medicine -- that's what we spent all those years in training for. We learned a style of thinking that always sets us apart, no matter how many little facts about anesthesiology or ophthalmology that we forget along the way. Courses in psychopharmacology will not change psychologists into physicians anymore than learning CBT turned me into a psychologist. (See my postings in the "scope of practice" thread in this forum.)

I think that psychiatrists fall into the same trap as liberals: Oh, we can't criticize conservatives for x, y, or z because we have our own flaws, too. Nonsense! There are bad doctors, just like there are bad psychologists. Nonetheless, the simple fact remains: We are physicians, and psychologists are not. Whether others think this is a good thing or a bad thing, well, that's for them to judge.

I think you're ignoring a point made time and time again by psychologists. Psychologists seeking RxP DO NOT WANT TO BE PHYSICIANS. Through postdoctoral training in clinical psychopharmacology, they seek to provide their patients with an additional treatment option (with approval of the patients' PCP). As stated in the article linked above (Source: http://www.apa.org/apags/profdev/prespriv.html):

RxP is an additional tool for psychologists use and it is not intended to replace the unique services that psychologists already deliver. RxP extends the current scope of psychological practice. It does not replace it.

RxP clearly supports a psychological model of prescribing, not a medical model of prescribing. Practice and prescribing according to these two models is philosophically and fundamentally distinct. Psychology views the individual and prescribing from a biopsychosocial framework, whereas medical practice and prescribing focuses on identifying disease and eradicating it.

Many psychologists are currently informally prescribing medications when they consult with physicians and psychiatrists about the treatment regimens of mutual patients, which includes the use and effects of psychotropic medication.

Psychiatry has historically attempted to obstruct the evolution of psychology. For example, between 1950 - 1970 psychiatrists argued that it was unsafe to permit psychologists to practice outpatient psychotherapy without medical referral or medical supervision. Psychiatry also attempted to prevent psychologists from access to specialized training in psychoanalysis. They also opposed the psychologists? ability to treat patients in hospital settings and Skilled Nursing Facilities. And, psychiatrists unsuccessfully fought to defeat measures that now allow the elderly direct access to psychological care under the Medicare program (OBRA).

RxP clearly supports a psychological model of prescribing, not a medical model of prescribing. Practice and prescribing according to these two models is philosophically and fundamentally distinct. Psychology views the individual and prescribing from a biopsychosocial framework, whereas medical practice and prescribing focuses on identifying disease and eradicating it.

You have got to be ****ing kidding me. This is the same kind of idiotic logic that NPs and CRNAs use to justify their independent scope of practice thats not regulated by doctors.

When you give someone an SSRI, the method of action WORKS THE SAME, regardless of if you are a psychologist or psychiatrist. Dont feed us this bull**** that medications given by a psychologists are somehow different than when a psychiatrist gives them.

This is the same kind of bull**** logic that nurses use all the time. For example, when an NP does a lumbar puncture, its supposedly under a "nursing" model, whereas when an internist does it, its under a "medical" model and therefore there is some kind of magical distinction to be made. Of course this distinction is bull****, and it serves as an attempt to set up an artificial platform for nurses to do the same procedures as doctors, WITHOUT the doctors having any say over the scope of practice.

I think you're ignoring a point made time and time again by psychologists. Psychologists seeking RxP DO NOT WANT TO BE PHYSICIANS. Through postdoctoral training in clinical psychopharmacology, they seek to provide their patients with an additional treatment option (with approval of the patients' PCP). As stated in the article linked above (Source: http://www.apa.org/apags/profdev/prespriv.html):

RxP is an additional tool for psychologists use and it is not intended to replace the unique services that psychologists already deliver. RxP extends the current scope of psychological practice. It does not replace it.

RxP clearly supports a psychological model of prescribing, not a medical model of prescribing. Practice and prescribing according to these two models is philosophically and fundamentally distinct. Psychology views the individual and prescribing from a biopsychosocial framework, whereas medical practice and prescribing focuses on identifying disease and eradicating it.

Many psychologists are currently informally prescribing medications when they consult with physicians and psychiatrists about the treatment regimens of mutual patients, which includes the use and effects of psychotropic medication.

Psychiatry has historically attempted to obstruct the evolution of psychology. For example, between 1950 - 1970 psychiatrists argued that it was unsafe to permit psychologists to practice outpatient psychotherapy without medical referral or medical supervision. Psychiatry also attempted to prevent psychologists from access to specialized training in psychoanalysis. They also opposed the psychologists? ability to treat patients in hospital settings and Skilled Nursing Facilities. And, psychiatrists unsuccessfully fought to defeat measures that now allow the elderly direct access to psychological care under the Medicare program (OBRA).

Oh, I'm not missing the point that some (many? most? who knows) psychologists who want RxP don't want to be physicians. That's exactly why I said that we are physicians, and that "whether others think this is a good thing or a bad thing, well, that's for them to judge." Obviously the psychologists-who-don't-want-to-be-physicians keep using the arguments that physicians are bad, e.g. from your post earlier, "Physicians, on the other hand, use medication therapy as their customary and primary treatment intervention," or claiming that psychologists will somehow have a tendency to prescribe less than MDs do, or that they will have a more holistic approach. Unfortunately, these arguments simply don't hold water, though they are lovely theories.

With regard to the accusations about medical care, MDs are -- guess what? -- trained to know when to prescribe and when not to prescribe. We make these decisions based on diagnosis and cause, and not on symptoms (e.g., if someone has a stomachache, we find out why, we don't just give them an antacid.) If there's something we can do for someone with a medical problem that has equal or better efficacy and less risk than prescribing medications, we do that. For RxP to suggest otherwise is simply slander, not a scientific fact. There are psychologists who are adamantly against the use of medications, no matter what. However, MDs aren't going around -- at least, this one isn't -- claiming that PhDs are all "anti-medication." PhDs shouldn't accuse all MDs of being "pro-medication." It's simply not true.

My personal feeling is that RxP psychologists will prescribe precisely as much as psychiatrists do. Why? Several reasons. First of all, the PhDs who do this will obviously be a self-selected group who are interested in psychopharmacology. They will also have something to prove, namely, that they are able to prescribe as well as, or better than, MDs. And finally, these RxPers will be subject to the very same external incentives (more money, etc) that psychopharmacologists currently have. Am I right about this? Who knows. It's just my own theory.

Regardless of the RxP arguments, PhDs are not innately more generous, humanistic, and all around nicer people than MDs. Sorry. As far as that goes, I could argue that MDs spend 7+ years of training learning about and caring for extremely vulnerable people or people who are dying despite our best efforts, while making less than minimum wage and not sleeping. Does that make MDs "nicer"?

Anyway, I think I've made my point. People on both sides should stop accusing the other side of currently being stupid or bad providers. And if psychologists really think they'll prescribe less -- something I don't recall seeing in the DoD report, by the way -- they are free to think that, but it's not fact. It's just a theory, no different than mine. As for me, I do have the simple fact that MDs diagnose physical illnesses better than people who aren't trained in medicine. PhDs can feel free to tout the fact that they know more about psychotherapy. Everything else is just speculation.

Cordially,
Purpledoc

You have got to be ****ing kidding me. This is the same kind of idiotic logic that NPs and CRNAs use to justify their independent scope of practice thats not regulated by doctors.

When you give someone an SSRI, the method of action WORKS THE SAME, regardless of if you are a psychologist or psychiatrist. Dont feed us this bull**** that medications given by a psychologists are somehow different than when a psychiatrist gives them.

This is the same kind of bull**** logic that nurses use all the time. For example, when an NP does a lumbar puncture, its supposedly under a "nursing" model, whereas when an internist does it, its under a "medical" model and therefore there is some kind of magical distinction to be made. Of course this distinction is bull****, and it serves as an attempt to set up an artificial platform for nurses to do the same procedures as doctors, WITHOUT the doctors having any say over the scope of practice.
It's the question of having a share of the pie and nothing else. :rolleyes:
Doing therapy you make 125/h, scripting gives you 80/pt and you can see 3 of them in one hr. And I am talking of MD reimbursement. Do the math yourself and you'll understand the incentive behind this move. Forget about pt-care or safety. :(