And we're at it again -- psychologist prescribing in Oregon

[Beezlebub]

Sure, but you'd want to rule out other, more serious conditions first. Also, this strawman is still besides the point.

I respect your opinion, and I suspect you may disagree w/ my assessment based on your occupation. However, from your honest opinion, do you think a psychologist should be able to prescribe Rx w/ the contemporary training they undergo?

There are countless Rx adverse effects ranging associated w/ polypharmacy, patient's history, risk factors, etc. Do you think a psychologist is qualified to take such responsibility given what's at stake?

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[MLT2MT2DO]

Sure, but you'd want to rule out other, more serious conditions first. Also, this strawman is still besides the point.

The example was in reference to behavioral disturbances, you changed it to suit your need.
As you have most of this thread and now have me doing the same....so I'll end this here.



As far as psychology prescribing as mentioned by many others there isn't really a need and I'd feel 100 times over more comfortable with an FP prescribing. Even though that can be scary in and of itself.

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[WisNeuro]

I respect your opinion, and I suspect you may disagree w/ my assessment based on your occupation. However, from your honest opinion, do you think a psychologist should be able to prescribe Rx w/ the contemporary training they undergo?

There are countless Rx adverse effects ranging associated w/ polypharmacy, patient's history, risk factors, etc. Do you think a psychologist is qualified to take such responsibility given what's at stake?

The training as it is currently set, no. I've never advocated that particular position. However, I reject the notion that medical school and a full medical residency are necessary to do basic med management. There's simply no evidence to support that. So, in theory, I believe it could be done.

 

[WisNeuro]

The example was in reference to behavioral disturbances, you changed it to suit your need.
As you have most of this thread and now have me doing the same....so I'll end this here.

If it helps you sleep at night.

 

[Beezlebub]

The training as it is currently set, no. I've never advocated that particular position. However, I reject the notion that medical school and a full medical residency are necessary to do basic med management. There's simply no evidence to support that. So, in theory, I believe it could be done.

No evidence b/c it's illegal to prescribe and manage clinical patients w/o a medical license.

Do you honestly think that it's safe for someone w/o medical training to treat patients and prescribe them medications?

Would you let someone w/o medical training prescribe you Rx?

 

[WisNeuro]

No evidence b/c it's illegal to prescribe and manage clincial patients w/o a medical license.

RxP has existed in two states for over a decade, I believe.

 

[smalltownpsych]

I am ambivalent about RxP for various reasons, but some of the statements posted here are a bit hyperbolic and somewhat insulting to the skill set of a psychologist which does include diagnosis of mental disorders and differentiating and understanding the complex interplay of various medical conditions with cognitive and emotional affects.

 

[Beezlebub]

I am ambivalent about RxP for various reasons, but some of the statements posted here are a bit hyperbolic and somewhat insulting to the skill set of a psychologist which does include diagnosis of mental disorders and differentiating and understanding the complex interplay of various medical conditions with cognitive and emotional affects.

not intended to offend anyone at all - though it's clearly obvious why it could be misconstrued by people in the psychology field. first off there's a difference betwn dx and tx (specifically rx management). RxP, which is highly controversial and barely legal in 1 or 2 states, in limited areas - hardly a debate, requires additional training postdoc level or clinical psychpharma w/ supervision of clinicians. So i dont even understand why some of you are bringing this up bc it has nothing related to psychology as this is more of a "specialty". Fact of the matter is that an individual who is a psychologist, without advanced training, is not legal to prescribe in any US states.

 

[WisNeuro]

So i dont even understand why some of you are bringing this up bc it has nothing related to psychology as this is more of a "specialty". Fact of the matter is that an individual who is a psychologist, without advanced training, is not legal to prescribe in any US states.

Of course it isn't. That's kind of the point of the RxP stuff, some sort of advanced training and a limited scope of practice. I don't think we're talking about the same thing.

 

[wolfvgang22]

Lol, I've actually been consulted a handful of times to evaluate inpatients where the residents thought something was going on, usually schizophrenia or WKS, and it was just plain old delirium. I do this better than MDs already.

Edit...never mind. Somebody already said what I wanted to say.

 

[WisNeuro]

But not better than a psychiatrist.

I imagine that one could be argued. I get plenty of referrals from psychiatry diagnosed with Bipolar, who have never had a manic/hypomanic episode, who really just have borderline PD or something else. I have not been particularly impressed with diagnostic skills, generally, with some select exceptions.

 

[smalltownpsych]

not intended to offend anyone at all - though it's clearly obvious why it could be misconstrued by people in the psychology field. first off there's a difference betwn dx and tx (specifically rx management). RxP, which is highly controversial and barely legal in 1 or 2 states, in limited areas - hardly a debate, requires additional training postdoc level or clinical psychpharma w/ supervision of clinicians. So i dont even understand why some of you are bringing this up bc it has nothing related to psychology as this is more of a "specialty". Fact of the matter is that an individual who is a psychologist, without advanced training, is not legal to prescribe in any US states.

I wouldn't prescribe medications without extensive additional training. It would be quite unethical. I don't like to advise other docs about medications even when they ask because that is almost like the blind leading the blind. Now if I had two years of medical training and a year or two of supervised practice, I would probably feel much more comfortable.

 

[PsyDr]

You do see the point is that anyone can write down a N=1 case and it provides absolutely nothing to the discussion. You do see that I demonstrating that point, right?

I agree that stories are not evidence.

Your initial point was an ancedote about how you caught a cause of hyponatremia which you used to question psychologists acumen. That's an anecdote.

I provided a counter anecdote.

You responded with another anecdote and then said anecdotal reports are insufficient. In the same post.

So which is it?

 

[erg923]

I really do not see this as a "thing"...at least within the psychologist community.

Its not why most anyone gets into clinical psychology (that would be inefficient and dumb), its not widespread even in the states where where its permitted, and the "financial benefits" are (for the vast majority of psychologists) not worth it given certain market issues, market demands, geographics, liability, and the alternative of more appealing work (forensics, industry, research managed care, business, MH programming leadership, etc.).

It does speak to the erosion of scope within psychiatry and to the public's appetite for "magic" pills for problems in living. And I think that's the real/core problem, frankly. Let's face it, prescribing psychologists are not managing refractory patients on clozaril, or acute inpatient units...nor should they be.

 

[Beezlebub]

I really do not see this as a "thing"...at least within the psychologist community.

Its not why most anyone gets into clinical psychology (that would be inefficient and dumb), its not widespread even in the states where where its permitted, and the "financial benefits" are (for the vast majority of psychologists) not worth it given certain market issues, market demands, geographics, liability, and the alternative of more appealing work (forensics, industry, managed care, business, MH programming leadership, etc.).

It does speak to the erosion of scope within psychiatry and to the public's appetite for "magic" pills for problems in living. Let's face it, prescribing psychologists are not managing refractory patients on clozaril, or acute inpatient units...nor should they be.

US is overmedicated. Psychology is more therapy-based which reduces the amount of Rx- I'm in favor of this.

 

[st2205]

A great turn this thread has taken. A person is acutely encephalopathic with behavioral issues and we're arguing who they should go see? Everyone's penis size aside, the correct answer is you send them to the ER to be evaluated by someone who knows jack **** about anything we're discussing but will at least attempt to ensure they're not dying before passing it up the chain. But I guess you could send them to someone for an eval to expand that differential and perhaps recommend they "correct their metabolites," but in the meantime...

I reject the notion that medical school and a full medical residency are necessary to do basic med management. There's simply no evidence to support that. So, in theory, I believe it could be done.

You are correct. Their isn't evidence for that. I suppose one (not I) could reject the notion that a PhD and post-doc are necessary to administer and interpret neuropsychological testing. There's no evidence to support that.

 

[erg923]

You are correct. Their isn't evidence for that. I suppose one (not I) could reject the notion that a PhD and post-doc are necessary to administer and interpret neuropsychological testing. There's no evidence to support that.

Administer? No, that takes a trained monkey (sometimes an I-pad). Individuals with BAs do it all the time-"psychometrists."

Standardized administration is half the battle though, right? There is still half that needs to be fought. Hopefully by those actually trained in translating psychometric test data into behavioral/neurological/psychiatric functioning and reality in the context of complicated histories, presentations, and symptoms. But, if you have the training to do so? Sure. Behavioral neurologists have demonstrated this for decades. Psychiatry/psychiatrists? Not so much.

I agree, lets stop the pissing match. It gets embarrassing to both professions. Mostly because both professions have a history of abusing or perverting the interpretations. We have little excuse in this regard, but it happens, I admit.

 

[FlowRate]

The training as it is currently set, no. I've never advocated that particular position. However, I reject the notion that medical school and a full medical residency are necessary to do basic med management. There's simply no evidence to support that. So, in theory, I believe it could be done.

Psych NP's are already doing this.

(addressing the thread at large, not WisNeuro below)
We can throw around anecdotes of people from various professions doing boneheaded things. It's sort of like throwing out a single -2 SD measurement to support an assertion, whereas the mean is actually decent. Most psych NP's probably do an adequate job of assessing patients and managing basic psych meds, despite some of the really stupid decisions I've seen specific psych NP's make. Clin psych with a year of training might even do a better job, on average, IMO.

 

[Beezlebub]

I wouldn't prescribe medications without extensive additional training. It would be quite unethical. I don't like to advise other docs about medications even when they ask because that is almost like the blind leading the blind. Now if I had two years of medical training and a year or two of supervised practice, I would probably feel much more comfortable.

may as well become a psychiatrist with the extra years of training

 

[Crayola227]

Sorry, you do need a medical degree and then at least one if not 3-5 years of clinical training to prescribe drugs. Period.

I don't care we're mostly talking psychological needs and psychiatric diseases.

The fact that a psychologist caught a not that difficult to make diagnosis (most physicians would order a chem 7 in someone with acute AMS, even if the differential of hyponatremia didn't even occur to them) over RESIDENTS that are NOT EVEN IN PSYCHIATRY --

sorry, not giving out the badge that you're smarter than MDs and here's an Rx pad. This just underscores why there's residency training beyond the MD. The fact that someone in one instance can do it better than trainees working a little outside their typical comfort level - doesn't argue for less training.

The problem when you have less education, is it's easy to look at someone else's job and say you can do it.

Hm, the people with the education say you can't properly do the job with0ut it.......
the people without the education wonder why you need so much education...

Do we see what's wrong with this?

 

[nexus73]

I think I'd rather see a Neurologist.

You really want an internist first.

 

[Crayola227]

Every drug taken by mouth acts systemically.

Every systemic illness has the ability to affect one's psychiatric presentation.

Therefore, I believe that only one who has had a complete medical education covering all the organ systems and specialties should have prescribing rights.

You can "get away" with throwing a lot of drugs at a lot of things. We know this is a bull**** way to practice medicine, so why act like it's OK? There's what the human body will "let" you do, and there's good care. Not the same.

There's a NP in my town, I'm sure she does fine with uncomplicated UTIs and vaccinations, Pap smears, etc. Except for the stories I hear, fever of unknown origin that goes on for over a year, turned out to be undiagnosed leukemia, then the patient dies. Story after story. They call her Dr. Death in my town, despite her not being a doctor.

I remember catching her mistakes when she was my PCP in high school. It didn't make me think I could do her job. Didn't make think the level of education I should have should be hers. It made me think I should have an MD so I could understand it all, from a basic molecular level on up.

Even in 3rd year med school, working side by side with students from the PA program, it became clear to me the limited exposure they have to pathophys compared to MD affected their ability to correctly think through certain problems as a result.

This has continued on, where I have NPs or PAs say to me, "I don't understand X," "I don't understand why the doc did X," and they know enough that I can teach them.

But it's very clear to someone with an MD what the limitations are for NPs and PAs in a 10 minute conversation on medicine.

 

[Beezlebub]

But it's very clear to someone with an MD what the limitations are for NPs and PAs in a 10 minute conversation on medicine.

"You can see the trees but not the forrest"

P.S. Oregon? lol this state generally does not cause drama!

 

[nexus73]

I wouldn't prescribe medications without extensive additional training. It would be quite unethical. I don't like to advise other docs about medications even when they ask because that is almost like the blind leading the blind. Now if I had two years of medical training and a year or two of supervised practice, I would probably feel much more comfortable.

Simple solution there is to become a PA. Get actual medical training, but you probably won't be able to do it while continuing to work...as it should be. Medical training is difficult and demanding. The NPs are lazy bastards.

 

[Beezlebub]

We need someone to step up and reform the medical system. Need a 21st century medical revolution.

 

[Salpingo]

You can actually get SSRIs over the counter in some countries, which makes more sense in terms of lethality compared to aspirin, acetaminophen, ibuprofen, etc.

Medications aren't hard to manage in psychiatry, but the patients who ask for them are. The biggest advantage we have in our training is the sheer amount of clinical exposure; were expected to handle psychiatric emergencies in our sleep (or close to it). While psychology interns may provide therapy 2-3x/week to the hospitalized borderline patient, it's the psych resident who has to manage the staffs splitting, orchestrate dispo, handle behavioral outbursts overnight when on-call. its exhausting, but it makes you a better doctor.

Whenever someone complains about 60 hour work weeks, or weekend call, I want to show them these threads, and show them that we're not entitled to the letters after our name because we graduated medical school, but because we have to work our butts off to be relevant.

 

[Crayola227]

the fact that certain medicines are over the counter in other countries says nothing about whether or not it's good medical practice
I don't think it is

I also think psychiatric meds ARE much harder to manage than is realized
I also think psychiatrists can take regular "medicine" for granted.

People who have not gone to medical school have no business writing scripts.

I see so much improvement needed all around that the idea of less training easier to access scripts makes me psychosomatically ill - sick to my stomach at the thought

 

[smalltownpsych]

You can actually get SSRIs over the counter in some countries, which makes more sense in terms of lethality compared to aspirin, acetaminophen, ibuprofen, etc.

Medications aren't hard to manage in psychiatry, but the patients who ask for them are. The biggest advantage we have in our training is the sheer amount of clinical exposure; were expected to handle psychiatric emergencies in our sleep (or close to it). While psychology interns may provide therapy 2-3x/week to the hospitalized borderline patient, it's the psych resident who has to manage the staffs splitting, orchestrate dispo, handle behavioral outbursts overnight when on-call. its exhausting, but it makes you a better doctor.

Whenever someone complains about 60 hour work weeks, or weekend call, I want to show them these threads, and show them that we're not entitled to the letters after our name because we graduated medical school, but because we have to work our butts off to be relevant.

Maybe you have some places where residents are the experts at managing patients and staff, but that is not what I have seen. That has been my job. Anyway, you are not making a very good point against psychologists because we tend to have excellent training and experience in those areas. Medications? Not so much. Medical training in general? None at all.

the fact that certain medicines are over the counter in other countries says nothing about whether or not it's good medical practice
I don't think it is

I also think psychiatric meds ARE much harder to manage than is realized
I also think psychiatrists can take regular "medicine" for granted.

People who have not gone to medical school have no business writing scripts.

I see so much improvement needed all around that the idea of less training easier to access scripts makes me psychosomatically ill - sick to my stomach at the thought

Couldn't agree more with this sentiment. We have a school here that cranks out licensed counselors like you wouldn't believe and I guarantee you that they know not what they do. What is even funnier is how often academic psychologists argue that these folks are just as good. Now there is a movement by counselors to intentionally keep psychologists out of the education and training process altogether. I guess they are following the NP playbook. I really think psychologists and psychiatrists might be better suited if we stayed in our own lanes and supported each other as the experts in our respective arenas. I work with psych NPs and family NPs who like to prescribe psych meds and it is a travesty. I think that the argument is that psychologists would be better than that, but that kind of thinking also makes me ill. I didn't go to school for 10 years with three years of practicums and an internship and a postdoc just to be a second rate "prescriber".

 

[Crayola227]

Maybe you have some places where residents are the experts at managing patients and staff, but that is not what I have seen. That has been my job. Anyway, you are not making a very good point against psychologists because we tend to have excellent training and experience in those areas. Medications? Not so much. Medical training in general? None at all.

Couldn't agree more with this sentiment. We have a school here that cranks out licensed counselors like you wouldn't believe and I guarantee you that they know not what they do. What is even funnier is how often academic psychologists argue that these folks are just as good. Now there is a movement by counselors to intentionally keep psychologists out of the education and training process altogether. I guess they are following the NP playbook. I really think psychologists and psychiatrists might be better suited if we stayed in our own lanes and supported each other as the experts in our respective arenas. I work with psych NPs and family NPs who like to prescribe psych meds and it is a travesty. I think that the argument is that psychologists would be better than that, but that kind of thinking also makes me ill. I didn't go to school for 10 years with three years of practicums and an internship and a postdoc just to be a second rate "prescriber".

Some states will let MDs with no residency training, no other training, get a license to act as a counselor. More proof, just because the state is doing something or giving a license, doesn't mean jack ****.

Now, I always say I'm a professional advice giver by trade (that's what an MD boils down to), I'm certainly a jack of all trades master of none type, and I think in the rendering of one-size fits-most primary care I have some decent wisdom to give about relationships and other stuff....

but no. Just no.

I'm going to use Youtube to teach myself how to do some electrical work around my house.
I don't think I'm going to use enough internets to go around acting like everyone's new electrician next door.

 

[Salpingo]

Maybe you have some places where residents are the experts at managing patients and staff, but that is not what I have seen. That has been my job. Anyway, you are not making a very good point against psychologists because we tend to have excellent training and experience in those areas. Medications? Not so much. Medical training in general? None at all.

Thats interesting, I probably don't appreciate the regional variation.

My general point was that our training is setup to provide thousands of patient hours over a short duration of time. Whats actually performed in those hours will vary by institution, but when you say you graduated a psych residency, you're implying you've taken call, spent hours on the inpatient unit, seen hundreds of patients in several treatment modalities. My sense is that psychology training is time intensive, but with a focus more on research and writing. Broadly speaking (and correct me if I'm wrong), while I was up all night working with ED staff to get a patient under control or discharged, the psychology postdoc was up writing a grant.

I'm sure psychologists could gain the experience over an extended period of time through their career. Obviously, a seasoned clinical psychologist will be a better clinical leader than a psychiatry intern. But taking a psychologist and psychiatrist immediately post-graduation, I have little question who has spent more time in the clinic or hospital.

 

[Merovinge]

I imagine that one could be argued. I get plenty of referrals from psychiatry diagnosed with Bipolar, who have never had a manic/hypomanic episode, who really just have borderline PD or something else. I have not been particularly impressed with diagnostic skills, generally, with some select exceptions.

That makes total sense. I can see how seeing, at best, 1/10th the number of patients during training, rarely seeing them during acute crisis, rarely if ever seeing them on a medical floor, having little to no experience with medical mimics or comorbidity, little to no experience ordering/interpreting labs would lead to better diagnostic skills.

While you may be a hospital-based, purely clinical neuropsychologist who is very good at these skills it completely boggles my mind you think this is the norm for the average psychologist. Just by nature of having the extra training of being a neuropsychologist alone puts you in a tiny percentage of total psychologists.

 

[MedJosh]

I imagine that one could be argued. I get plenty of referrals from psychiatry diagnosed with Bipolar, who have never had a manic/hypomanic episode, who really just have borderline PD or something else. I have not been particularly impressed with diagnostic skills, generally, with some select exceptions.

And I have seen several psychologist who think everything is a personality disorder, when if fact the patient has NMDA encephalitis, substance induced cognitive impairment precipitated by fluctuating levels of benzos ect. So your arguments are anecdotal and I have yet to meet a MD who is insecure because they are not a psychologist, but there is plenty of evidence on this thread of the reverse....

 

[Seroquelled]

I imagine that one could be argued. I get plenty of referrals from psychiatry diagnosed with Bipolar, who have never had a manic/hypomanic episode, who really just have borderline PD or something else. I have not been particularly impressed with diagnostic skills, generally, with some select exceptions.

I don't understand what kind of craphole you're working in that psychiatrists lack very basic knowledge. I was not a great medical student and I'm not at a top program/school but everyone I know appears aware that opiates and anticholinergics are bad for the elderly. I admit I'm not going around quizzing my coworkers but this is often discussed and these meds are not often prescribed to this population without a very good reason. Also all of the psychiatry residents I know are aware of the commonly made error of confusing bipolar and borderline and will not diagnose someone with bipolar without any history of mania. This is another frequently discussed issue among students and trainees here. Your stories of physician ineptitude are almost unbelievable to me based on my personal experiences but I guess things are different in different places. Is an old diagnosis of bipolar disorder being carried forward in the medical charts? Are these "psychiatrists" day one interns? Or are they so aged that they may be losing touch? Are these bipolar diagnoses being reported by the patients? I've certainly seen numerous borderline patients reject the idea that they don't have bipolar disorder. I'm told you can get a disability check for having bipolar but not for having borderline.

I'm confused also about what your job is. Are you a psychologist that sees patients in the ED? I wish my hospital had those sort of resources. I've never seen that either. Maybe I'm in a different sort of craphole.

 

[Nasrudin]

I think there's an inverse corollary. That when we accept the role of psychopharmacologist. Without rigorous pursuit of understanding basic psychological theories and therapuetic techniques, much of our approach is superficial and even harmful. In my program we spend a couple of months training at a personality disorder clinic with blackbelt level psychologists running the the show. That was a game changing experience. Without it. I think I could see myself pscyhopharmacologizing the phenomenon more often.

Now that I'm pursuing basic psychology material with a passion. I can't believe how we've been allowed to segregate that aspect of approaching clinical situations to a minimal level of caseload an minimal outside reading and training.

I really think we should go all in and synthesize our training systems. The problem is we would have to attract a hybrid candidate. We'd have to have people who could knuckle through huge amounts of physiology and neurology and basic medicine AND have someone who is attracted to the subtle, patient, sophisticated process of talk therapy.

I really think this can only be done properly by the consummation of both perspectives. And I'm thrilled to be in a position to do it. For no other reason than it's the Truth. But... it's taking a mountain beyond mountain approach. And after undergrad, medical school, and residency, most don't have the drive or endurance. So... yes... we would need to cut the bull**** out of both perspectives to make it work.

I think it would be much easier to use the medical model as a basis and hybridize it. The psychology programs with medicine/psychopharm embellishment is a terrible idea.

And count me in the camp that has no sympathy for the cynical utilitarian approach of breaking down the encounter into it's cheapest possible parts. I'm a straight zealot for the purity of the total encounter. Medical/physiological/psychological one stop totality. And if it's not that it's total chicanery.

 

[smalltownpsych]

Thats interesting, I probably don't appreciate the regional variation.

My general point was that our training is setup to provide thousands of patient hours over a short duration of time. Whats actually performed in those hours will vary by institution, but when you say you graduated a psych residency, you're implying you've taken call, spent hours on the inpatient unit, seen hundreds of patients in several treatment modalities. My sense is that psychology training is time intensive, but with a focus more on research and writing. Broadly speaking (and correct me if I'm wrong), while I was up all night working with ED staff to get a patient under control or discharged, the psychology postdoc was up writing a grant.

I'm sure psychologists could gain the experience over an extended period of time through their career. Obviously, a seasoned clinical psychologist will be a better clinical leader than a psychiatry intern. But taking a psychologist and psychiatrist immediately post-graduation, I have little question who has spent more time in the clinic or hospital.

Actually, by the time I was licensed, I had obtained five years of clinical experience and that is probably typical. Two of those were almost completely on inpatient units and another year was at a VA with both inpatient and intensive outpatient experience with an SMI population. It is true that my level of exposure to severe mental illness is probably a bit more than average, but it is not that unusual. When you talk about sheer numbers of patients, I'm sure that you got me there and that is a strength of psychiatry and a limitation of psychology that I have experienced firsthand. I'm very competitive so I hate it when you spot something quicker because of that higher level of exposure. On the other hand, I have delved in to the individual patients perspectives much deeper and I often have a qualitatively richer understanding and intuition on how to use the relationship to effect change that is second to none. I think it really boils down to the fact that we both bring something vital to the table and we are better off working together against the systems that want us both to be replaced by cheaper less trained individuals.

 

[Nasrudin]

Actually, by the time I was licensed, I had obtained five years of clinical experience and that is probably typical. Two of those were almost completely on inpatient units and another year was at a VA with both inpatient and intensive outpatient experience with an SMI population. It is true that my level of exposure to severe mental illness is probably a bit more than average, but it is not that unusual. When you talk about sheer numbers of patients, I'm sure that you got me there and that is a strength of psychiatry and a limitation of psychology that I have experienced firsthand. I'm very competitive so I hate it when you spot something quicker because of that higher level of exposure. On the other hand, I have delved in to the individual patients perspectives much deeper and I often have a qualitatively richer understanding and intuition on how to use the relationship to effect change that is second to none. I think it really boils down to the fact that we both bring something vital to the table and we are better off working together against the systems that want us both to be replaced by cheaper less trained individuals.

Yes! This is exactly how I see it too.

I think as it stands now, with the current products of these training models at large, I think pairing or grouping into small close knit working teams would be best. We could meet weekly, I could get extra supervision in my therapy cases and we could consult each other and co-formulate when needed. I would feel more comfortable seeing people for brief med management if we had a close working dialogue and you could see them more often and illuminate the most therapeutic approach for psychopharm.

But.... that seems like maybe a fantasy. So absent that and because I want the total skill set anyway, I'm preparing to do it all myself.

 

[F0nzie]

Yes! This is exactly how I see it too.

I think as it stands now, with the current products of these training models at large, I thing pairing or grouping into small close knit working teams would be best. We could meet weekly, I could get extra supervision in my therapy cases and we could consult each other and co-formulate when needed. I would feel more comfortable seeing people for brief med management if we had a close working dialogue and you could see them more often and illuminate the most therapeutic approach for psychopharm.

But.... that seems like maybe a fantasy. So absent that and because I want the total skill set anyway, I'm preparing to do it all myself.

The type of working relationship you are describing isn't fantasy but it is difficult to come by. There are two ways of acquiring it: 1. Looking for it or 2. Creating it. Anybody thinking this will be a present waiting for them at the start of their first job is hanging their hopes on the improbable.


Sent from my iPhone using SDN mobile app

 

[Salpingo]

I think there's an inverse corollary. That when we accept the role of psychopharmacologist. Without rigorous pursuit of understanding basic psychological theories and therapuetic techniques, much of our approach is superficial and even harmful. In my program we spend a couple of months training at a personality disorder clinic with blackbelt level psychologists running the the show. That was a game changing experience. Without it. I think I could see myself pscyhopharmacologizing the phenomenon more often.

I think there's a key point there. In the early stages of training/career, we let treatment guide diagnosis.

You put one patient in a room.

1. If you've started with CBT, you will see more anxiety/depressive symptoms
2. If you're specializing in schema therapy you'll see personality disorder
3. If you're a "psychopharmacologist" (hate that term, but it seems like it's not going anywhere), you'll diagnose an affective disorder (like "bipolar spectrum").

Typically any treatment will improve SOME aspect of the patients life (at least temporarily) which confirms the bias. The more experienced experts eventually seem to see the limitations of their treatment and appreciation for alternative viewpoints, but that takes a lot of trial and error and not just book knowledge.

So maybe prescribing psychologists will have an expanded diagnostic framework by being able to prescribe. More likely, there diagnosis will be informed by treatment, and their choice of treatment will be informed by economics.

 

[Salpingo]

Actually, by the time I was licensed, I had obtained five years of clinical experience and that is probably typical. Two of those were almost completely on inpatient units and another year was at a VA with both inpatient and intensive outpatient experience with an SMI population. It is true that my level of exposure to severe mental illness is probably a bit more than average, but it is not that unusual. When you talk about sheer numbers of patients, I'm sure that you got me there and that is a strength of psychiatry and a limitation of psychology that I have experienced firsthand. I'm very competitive so I hate it when you spot something quicker because of that higher level of exposure. On the other hand, I have delved in to the individual patients perspectives much deeper and I often have a qualitatively richer understanding and intuition on how to use the relationship to effect change that is second to none. I think it really boils down to the fact that we both bring something vital to the table and we are better off working together against the systems that want us both to be replaced by cheaper less trained individuals.

Yeah, I tried to be as nonjudgmental in my post, but realize it still was a little obnoxious. I THINK psychiatrists are generally TRAINED to be more efficient, arrive at diagnoses and treatments faster, although that doesn't mean the end product is better.

But my feelings are if psychologists want to prescribe, at least make it a requirement to do x number of overnight or weekend calls during training. That would win over at least a few psych residents and attendings.

 

[FranzLO]

All doctors should be very concerned about psychologist prescriber legislation because unlike with nurses, PAs, CRNAs, or optometrists, psychologists are not medically trained. The aforementioned professions should have supervision by physicians. I do not agree with splik that psychiatrists have done this to themselves. Safety should be the primary concern and high standards need to remain for people who prescribe medications, which can be dangerous, to patients.

It is literally nuts to think psychologists prescribing is okay. A clinical psychologist is not a clinician. NP/PAs are one thing but this is a whole new level.

 

[Crayola227]

I think there's an inverse corollary. That when we accept the role of psychopharmacologist. Without rigorous pursuit of understanding basic psychological theories and therapuetic techniques, much of our approach is superficial and even harmful. In my program we spend a couple of months training at a personality disorder clinic with blackbelt level psychologists running the the show. That was a game changing experience. Without it. I think I could see myself pscyhopharmacologizing the phenomenon more often.

Now that I'm pursuing basic psychology material with a passion. I can't believe how we've been allowed to segregate that aspect of approaching clinical situations to a minimal level of caseload an minimal outside reading and training.

I really think we should go all in an synthesize our training systems. The problem is we would have to attract a hybrid candidate. We'd have to have people who could knuckle through huge amounts of physiology and neurology and basic medicine AND have someone who is attracted to the subtle, patient, sophisticated process of talk therapy.

I really think this can only be done properly by the consummation of both perspectives. And I'm thrilled to be in a position to do it. For no other reason than it's the Truth. But... it's taking a mountain beyond mountain approach. And after undergrad, medical school, and residency, most don't have the drive or endurance. So... yes... we would need to cut the bull**** out of both perspectives to make it work.

I think it would be much easier to use the medical model as a basis and hybridize it. The psychology programs with medicine/psychopharm embellishment is a terrible idea.

And count me in the camp that has no sympathy for the cynical utilitarian approach of breaking down the encounter into it's cheapest possible parts. I'm a straight zealot for the purity of the total encounter. Medical/physiological/psychological one stop totality. And if it's not that it's total chicanery.

This, 100%.

 

[Crayola227]

I said before but I'll say again shorter, the minute you add meds you're no longer mucking with a patient on a psychological level, but a fundamentally medical one. That takes someone with significant medical training.

 

[Armadillos]

These threads are an eyesore and seems with each year I have less interest in them, hopefully soon will manage to pass by without even opening.

 

[erg923]

These threads are an eyesore and seems with each year I have less interest in them, hopefully soon will manage to pass by without even opening.

I agree that the debate is tiresome, and I actually don't agree with the whole psychologist Rx thing, although for more varied reasons than than the average psychiatrist here.

Again, I just don't accept the fundamental notion that people need more, or more access to, psychotropic medications. In the absence of demonstrated SPMI (I do think alot of diagnoses can end up meeting that definition though), I observe that most are unnecessary garbage and counterproductive to overall healthy living/behavior. If you don't want to be depressed/anxious/compulsive etc., you have to do some work. And research demonstrates that we we have efficacious behavioral/psychological treatments for these issies for a wide spectrum of populations and circumstances. I also don't like the modern trend in psychiatric medicine of attempting to "rescue" people from their psychosocial stressors/environment with 50-100mg sertraline. I really dont think we need to give people an "out" from this reality if we are touting ourselves as "experts"in the area of mental health.

I do think there has been some really good points, ideas, and dialogue exchanged in this thread, however.

 

[jadedphysiotherapist]

US is overmedicated. Psychology is more therapy-based which reduces the amount of Rx- I'm in favor of this.

Ya. Conservative competition model for similar conditions giving positive outcomes is good.

Psych NP's are already doing this.

(addressing the thread at large, not WisNeuro below)
We can throw around anecdotes of people from various professions doing boneheaded things. It's sort of like throwing out a single -2 SD measurement to support an assertion, whereas the mean is actually decent. Most psych NP's probably do an adequate job of assessing patients and managing basic psych meds, despite some of the really stupid decisions I've seen specific psych NP's make. Clin psych with a year of training might even do a better job, on average, IMO.

No. My own program is based on med model training (didactic 22-23 months, 1 yr clinical. Optional specialty....at this time postgrad for us) and we go into a good bit of detail on mental disorders since they are so prevalent after someone has suffered trauma or debilitating disease leading to poor prognosis and ineffective tx time. Getting a good dx on a subjective and hx can be incredibly difficult due to overlapping symptoms and subjective perception from the patient.

NPs covering every neurotransmitter for a patient isn't exactly a good thing. There's a reason psych residents see people right in the morning as they wake and stay around to monitor responses to medications on a full care continuum before getting released to society. Unless you feel med residency is a complete waste of time.

Thats interesting, I probably don't appreciate the regional variation.

My general point was that our training is setup to provide thousands of patient hours over a short duration of time. Whats actually performed in those hours will vary by institution, but when you say you graduated a psych residency, you're implying you've taken call, spent hours on the inpatient unit, seen hundreds of patients in several treatment modalities. My sense is that psychology training is time intensive, but with a focus more on research and writing. Broadly speaking (and correct me if I'm wrong), while I was up all night working with ED staff to get a patient under control or discharged, the psychology postdoc was up writing a grant.

I'm sure psychologists could gain the experience over an extended period of time through their career. Obviously, a seasoned clinical psychologist will be a better clinical leader than a psychiatry intern. But taking a psychologist and psychiatrist immediately post-graduation, I have little question who has spent more time in the clinic or hospital.

Idk why more of you guys don't leverage the exact bold to defend your practice enough.

Actually, by the time I was licensed, I had obtained five years of clinical experience and that is probably typical. Two of those were almost completely on inpatient units and another year was at a VA with both inpatient and intensive outpatient experience with an SMI population. It is true that my level of exposure to severe mental illness is probably a bit more than average, but it is not that unusual. When you talk about sheer numbers of patients, I'm sure that you got me there and that is a strength of psychiatry and a limitation of psychology that I have experienced firsthand. I'm very competitive so I hate it when you spot something quicker because of that higher level of exposure. On the other hand, I have delved in to the individual patients perspectives much deeper and I often have a qualitatively richer understanding and intuition on how to use the relationship to effect change that is second to none. I think it really boils down to the fact that we both bring something vital to the table and we are better off working together against the systems that want us both to be replaced by cheaper less trained individuals.

You guys need a didactic and then a temp license for a few yrs under mentorship to not break the bank. Very poor avg reimbursement for the value you do imo. I cannot believe how long you have to spend before getting to mentorship and paying the bills.

Yes! This is exactly how I see it too.

I think as it stands now, with the current products of these training models at large, I think pairing or grouping into small close knit working teams would be best. We could meet weekly, I could get extra supervision in my therapy cases and we could consult each other and co-formulate when needed. I would feel more comfortable seeing people for brief med management if we had a close working dialogue and you could see them more often and illuminate the most therapeutic approach for psychopharm.

But.... that seems like maybe a fantasy. So absent that and because I want the total skill set anyway, I'm preparing to do it all myself.

Nope. Exists. I've benefited from it immensely.

It is literally nuts to think psychologists prescribing is okay. A clinical psychologist is not a clinician. NP/PAs are one thing but this is a whole new level.[/QUOTE]

I'm honestly under the impression that the NP/PA acceptance here is because they make private practice MD/DOs straight bank seeing their own patients but they are still held on a leash. Psychologists aren't. As someone who cares about the mental health field, I don't approve of RxP although I may not be in the best place to say that, but psychologists are legit in their training and the perceived consequence of RxP from physicians would be competition within a market and possible reimbursement cut to whoever is cheaper. If it's not on a leash then loss of control. I have psychologists and physicians in my family.

Oh, and the psychologists in this thread are straight studs

 

[FlowRate]

No. My own program is based on med model training (didactic 22-23 months, 1 yr clinical. Optional specialty....at this time postgrad for us) and we go into a good bit of detail on mental disorders since they are so prevalent after someone has suffered trauma or debilitating disease leading to poor prognosis and ineffective tx time. Getting a good dx on a subjective and hx can be incredibly difficult due to overlapping symptoms and subjective perception from the patient.

NPs covering every neurotransmitter for a patient isn't exactly a good thing. There's a reason psych residents see people right in the morning as they wake and stay around to monitor responses to medications on a full care continuum before getting released to society. Unless you feel med residency is a complete waste of time.

I am not sure what you're trying to argue or from what vantage point (I think you're saying you're an NP, but I'm otherwise lost.)

 

[Mad Jack]

I wonder why you think this is a bad idea? I know that there are lots of patients who can't access psychiatry care and may benefit from medication. Wouldn't psychologists be more knowledgeable about caring for mental health problems than Family Medicine doctors who already are trying to manage psych meds for patients who can't get an appointment with a psychiatrist? It seems to me this type of legislation would serve the common good.

I'd trust a family physician to prescribe infinitely more than a psychologist. They're trained in physical exams, differential diagnosis, drug-drug interactions, and lab interpretation enough to hopefully catch major side effects. The trouble with psychologists prescribing is that they have no ****ing clue about the 98% of non-psychiatric meds out there that the meds they are prescribing might interact with, not how the medications they prescribe affect various pathophysiological states. A psychologist-FM team working together is far from ideal, but in the absence of a psychiatrist, it's still 1,000 times more preferable than prescribing psychologists. And this it's all in addition to the whole ruling out organic disease thing, which psychologists are completely unable to do by training.

 

[Ceke2002]

Sorry, you do need a medical degree and then at least one if not 3-5 years of clinical training to prescribe drugs. Period.

I don't care we're mostly talking psychological needs and psychiatric diseases.

The fact that a psychologist caught a not that difficult to make diagnosis (most physicians would order a chem 7 in someone with acute AMS, even if the differential of hyponatremia didn't even occur to them) over RESIDENTS that are NOT EVEN IN PSYCHIATRY --

sorry, not giving out the badge that you're smarter than MDs and here's an Rx pad. This just underscores why there's residency training beyond the MD. The fact that someone in one instance can do it better than trainees working a little outside their typical comfort level - doesn't argue for less training.

The problem when you have less education, is it's easy to look at someone else's job and say you can do it.

Hm, the people with the education say you can't properly do the job with0ut it.......
the people without the education wonder why you need so much education...

Do we see what's wrong with this?

Agree with this entirely. Granted I've only just started my studies, and actually being a licensed as a clinical psychologist is some way off for me yet, but to me the whole prescribing issue shouldn't be about some sort of measuring of the proverbial contest to prove that one group of mental health practitioners is equal to the other and somehow now deserve the prescribing rights afforded to the group that has actually read the effing manual, so to speak. I don't want to be equivalent to an MD when I'm Licensed, I want to be able to complement the work they do with my own skills.

 

[WisNeuro]

Lot of Tl;Dr, I don't check this much on the weekends, but from my scanning, lot of hand wringing about patient safety, without anything of substance to back it up. Just call it what it is, turf protectionism, most of the upper level professionals engage it in at some level. If you want to make some kind of argument about what is the minimal level of training, get some data. Similar arguments came about in the early NP stuff, the sky didn't fall, some data (sparse) came out with similar outcomes, etc etc. I still personally think it's a bad thing, mostly because the industry will just push RxPs to be cheaper med managers if they become more widespread, but that's pretty much it. Way too many people have such an inflated idea about how hard their job really is, on both sides of this particular aisle.

 

[st2205]

If you want to make some kind of argument about what is the minimal level of training, get some data.

I suppose that would be one way of looking at it. It would also seem intuitive that if one were to advocate a legal change to the status quo that decreases the rigor with which something is obtained, that the burden of proof would be shouldered by the petitioner. Instead, we have an appeal to the expansion of access to care without any proof of how this would expand access or even proof that there's a shortage of psychotropics.