Medical Psychologists on path to getting prescribing privileges, AMA/APA oppose

[sean1]

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 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.


-----

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.

---

Members don't see this ad.

 

[sdude]

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?

 

[MacGyver]

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.

 

[mdblue]

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

 

[lazure]

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.

 

[mdblue]

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.

 

[lazure]

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 .....

 

[hurt]

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.

 

[lazure]

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

 

[PsychNOS]

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?

 

[PublicHealth]

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.

 

[Anasazi23]

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.

 

[16846]

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.

 

[DrFocker]

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.

 

[PsychNOS]

Dr Focker:

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

 

[hurt]

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."

 

[16846]

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

Information for Psychologists That Wish to Prescribe Psychotropic Medications

More Information for Psychologists That Wish to Prescribe Psychotropic Medications

 

[castaway]

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.

 

[hurt]

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

 

[DrFocker]

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.

 

[hurt]

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

 

[Svas]

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 . . .

 

[PsychNOS]

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.

 

[Svas]

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).

 

[hurt]

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.

 

[Anasazi23]

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.

 

[Svas]

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

 

[Anasazi23]

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.

 

[dentite001]

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.

 

[PublicHealth]

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.

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!.....

 

[PsychNOS]

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?

 

[PublicHealth]

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.

 

[Svas]

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.

 

[PsychNOS]

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.

 

[Anasazi23]

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.

 

[Anasazi23]

.....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.

 

[PublicHealth]

...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.

 

[GeddyLee]

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.

 

[Neuron]

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

Information for Psychologists That Wish to Prescribe Psychotropic Medications

More Information for Psychologists That Wish to Prescribe Psychotropic Medications

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.

 

[Anasazi23]

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?

 

[PublicHealth]

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?

 

[Anasazi23]

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

You'll be glad with your decision to go to med school. 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.

 

[Neuron]

As always, I enjoy reading your replies.

Oh, you're too kind. Thank you.

 

[PublicHealth]

Oh, you're too kind. Thank you.

 

[Svas]

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]

 

[mswphysician]

very sad and misguided.

 

[PsychNOS]

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.

 

[Svas]

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?

 

[dentite001]

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

 

[Svas]

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