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

[PublicHealth]

Nothing new. Of course there are psychiatrists who disagree on this issue. Let me point out that psychologists disagree as well. Case in point, a letter by the president of the American Association of Applied and Preventive Psychology in 2001, a suggested model letter for opposing RxP bills:

link: http://w3fp.arizona.edu/aaapp/

How long did it take you to find this obscure association? The people who head this association are dinosaur research psychologists (most are emeritus professors) who fear change in their profession. Have you ever heard the expression, "It's hard to teach an old dog new tricks?"

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[mdblue]

"I can't personally answer this question because I have not received RxP ed/training. However, the medical psychologist that went through the DoD project were evaluated to be at the level of a 3rd/4th year psychiatric resident. I presume that an RxP psychologist would probably feel as comfortable treating the case you presented as a 3rd/4th yr psych resident would"
Hey Sasevan, they talked about MSIII/IV level-not resident level MDs.
Just FYI,
I am currently seeing pts in a community clinic, where the norm for the MDs is the 15 mn med-ck. Given the complexity of the problems, it is just not possible for anyone just to review the chart in 15 min. However, some of the pts are also seeing PhD level therapists who I supposed would be more knowledgable about their pts because they are seeing them for 45 min qwk. Interestingly, all I am seeing a kind of generic tx plan w/o any specific intervention/reco. The clinical notes really fail to jsutify why the pt is seeing their therapist qwk. Even the supporting staff seems to be negligent to the point of being dangerous( e.g. not F/U w/ bood draws, rescheduling etc).
This AM I saw a pt who is a diabetic/hyperchol/CAD/HTN along w/ his MDD for which the best med which worked for him is Elavil. Now I don't know how comfortable any NP or med-psych will feel prescribing it to this pt, which incidentally I did and only after cking the h/p, ekg and labs. Does it make me different? Not really. The newer trainees have realized the follies of their senior colleagues, who in the 60s and 70s tried to demedicalize the specialty and tried to segregate MH from the rest of medicine. Most of them are aware of the medical issues and the only reason they don't do physicals because of the lack of infrastructure and support staff. And the current managed care is also promoting this.

 

[PublicHealth]

This AM I saw a pt who is a diabetic/hyperchol/CAD/HTN along w/ his MDD for which the best med which worked for him is Elavil. Now I don't know how comfortable any NP or med-psych will feel prescribing it to this pt, which incidentally I did and only after cking the h/p, ekg and labs.

These statements have been made ad nauseum above. Do we need an evaluation of "medical psychologists'" clinical skills above and beyond clinical psychopharmacology? I was under the impression that psychologists had to consult with each patient's primary care physician prior to writing a prescription.

Why do the psychiatry-backers/medical fundamentalists in this forum keep insisting that psychologists want to be physicians!? They're simply trying to acquire the knowledge and skills needed to prescribe psychotropic medications safely and effectively with the approval of each patient's licensed medical doctor.

 

[purpledoc]

Why do the psychiatry-backers/medical fundamentalists in this forum keep insisting that psychologists want to be physicians!? They're simply trying to acquire the knowledge and skills needed to prescribe psychotropic medications safely and effectively with the approval of each patient's licensed medical doctor.

See my earlier post regarding this issue. We are simply making the point that prescribing is, in fact, practicing medicine. To acquire the "knowledge and skills needed to prescribe psychotropic medications safely and effectively," with or without approval from another MD, go to medical school or nursing school, like thousands of other people.

With regard to the "obscure reference," I might add that the editorial you posted is similarly not the majority view of MDs. I am only pointing out that MDs and PhDs have disagreements among themselves as well.

Alas, I will be unable to post until next Monday. Enjoy the freedom of posting unhampered by some of us pesky physicians.

Peace,
Purpledoc

 

[mdblue]

"Why do the psychiatry-backers/medical fundamentalists in this forum keep insisting that psychologists want to be physicians!? They're simply trying to acquire the knowledge and skills needed to prescribe psychotropic medications safely and effectively with the approval of each patient's licensed medical doctor."
1. There is an easier and safer way of acquiring that knowledge. It's called med-school. You can not treat psychiatric conditions w/o looking at other parts of the body. To know why, you have to complete 4 yrs. of med school.If you can not get into one, lobby for opening up more schools or go to those off-shore institutions. If you really want to prescribe, be a MD.
If saying that makes me a med-fundamentalist I am OK w/ that

2. God bless the pt who have a NP/PA as his PCP and a med-psych as his psychiatrist. May be I'll really make that million from my testimonies as expert witness.

 

[Anasazi23]

....Those clinical rotations -- very similar to other psychiatry programs -- can occur in any order. Some residents start with psychiatry, some with internal medicine, etc., and the clinical rotations themselves may even be broken down into smaller blocks, say, spending two months of internal medicine at one hospital, and another two at a different hospital.

Exactly....I don't do internal until the end of the year. Right now I'm on inpatient psych. Despite this, today alone I performed a minor I&D, evaluated and treated a drug-induced rash, auscultated someone's heart, and even had a suspicion of Wilson's syndrome in a patient, for which I did a pared-down ophthalmological exam. The rash I mentioned made me think of varicella, for which I ordered titers.

In response to Sasevan's comments about not really thinking there would be clinical difference between the Rxps and physicians - it's situations like these that make me feel that there is a lot more to be done, if at least for conveniences' sake, that would make physicians more efficient in evaluating/treating psychiatric patients. I also think that Sasevan made a very interesting comment about the eventual outcome of this "relationship." It seems, if this webboard is any indication and from whom I've talked at the hospital, that there is animosity brewing between the two camps. At least 3-4 times this year alone the psychiatrists in rounds have made comments about a patient being seen by a psychologist that has held off on referral to a physician that resulted in severe psychiatric decompensation. From my days in graduate school, I also knows that the door swings both ways entirely.....psychologists often scoff at the recommendations made by psychiatrists and view them as insensitive.

Take care all....

 

[sasevan]

"I can't personally answer this question because I have not received RxP ed/training. However, the medical psychologist that went through the DoD project were evaluated to be at the level of a 3rd/4th year psychiatric resident. I presume that an RxP psychologist would probably feel as comfortable treating the case you presented as a 3rd/4th yr psych resident would"

Hey Sasevan, they talked about MSIII/IV level-not resident level MDs.

Hi mdblue,
Thanks for the clarification regarding the 3rd/4th year issue. Below is the direct quote from part of the DoD project evaluation.

FINAL REPORT

MAY 1998


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


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

American College of Neuropsychopharmacology (ACNP)

Evaluation Panel Report May 1998

Executive Summary

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

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

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

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

Findings and Conclusions

1. Effectiveness: All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed. It was striking to the Evaluation Panel how the graduates had filled different niches and brought unique perspectives to their various assignments. For example, a graduate at one site worked lull time on an inpatient unit with his supervising psychiatrist. The psychiatrist said he preferred working with the graduate rather than with another psychiatrist because the prescribing psychologist contributed a behavioral, nonphysician, psychological perspective he got from no one else. On posts where there was a shortage of psychiatrists, the graduates tended to work side-by-side with psychiatrists, performing many of the same functions a 'junior psychiatrist" might perform. In another location, a graduate was based in a psychology clinic but worked largely in a primary care clinic for dependents, thereby providing cost savings for care that otherwise would have been contracted out. Another graduate was the only prescriber for active duty sailors in a psychology clinic that was located near the ships at a naval base. Yet another graduate was to be transferred soon to an isolated base where he will be the only mental health provider. His medical backup will be primary care physicians.
2. Medical safety and adverse effects: While the graduates were for the most part highly esteemed, valued, and respected, there was essentially unanimous agreement that the graduates were weaker medically than psychiatrists. While their medical knowledge was variously judged as on a level between 3rd or 4th year medical students, their psychiatric knowledge was variously judged as, perhaps, on a level between 2nd or 3rd year psychiatry residents. Nevertheless, all graduates demonstrated to their clinical supervisors and administrators that they were sensitive and responsive to medical issues. Important evidence on this point is that there have been no adverse effects associated with the practices of these graduates! Thus, they have shown impressively that they knew their own weaknesses, and that they knew when, where, and how to consult. The Evaluation Panel agreed that all the graduates were medically safe by this standard. In a few quarters, the criterion for "medical safety" was equated with the knowledge and experience acquired from completing medical school and residency, and, of course, no graduate of the PDP could meet such a test.

You are right about the level of med knowledge of the DoD graduates; but please note that the report also acknowledges that the level of psych knowledge was higher, also that these med psychologists knew when to consult psychiatrists.

No one is arguing that med psychologists equal psychiatrists in med knowledge only that the level that med psychologists have is sufficient to assess/treat routine cases and to make appropriate referral of the more complex ones.

What is being argued is that med psychologists are safe and competent prescribers and that the perspective of these practitioners will serve as a complimentary and at times corrective one to that of other mh providers, including the primary prescribers, i.e., psychiatrists (note the first highlighted section).

Peace.

 

[Svas]

In fairness, mdblue, this was a "guess." There was no formal assessment of the level of functional expertise of the DoD graduates performed in such a way as to allow a reliable or valid comparison. It was rendered as a hunch.

I know, because I asked Dr. Morgan Sammons, one of the DoD grads.

Svas

"I can't personally answer this question because I have not received RxP ed/training. However, the medical psychologist that went through the DoD project were evaluated to be at the level of a 3rd/4th year psychiatric resident. I presume that an RxP psychologist would probably feel as comfortable treating the case you presented as a 3rd/4th yr psych resident would"
Hey Sasevan, they talked about MSIII/IV level-not resident level MDs.
Just FYI,
I am currently seeing pts in a community clinic, where the norm for the MDs is the 15 mn med-ck. Given the complexity of the problems, it is just not possible for anyone just to review the chart in 15 min. However, some of the pts are also seeing PhD level therapists who I supposed would be more knowledgable about their pts because they are seeing them for 45 min qwk. Interestingly, all I am seeing a kind of generic tx plan w/o any specific intervention/reco. The clinical notes really fail to jsutify why the pt is seeing their therapist qwk. Even the supporting staff seems to be negligent to the point of being dangerous( e.g. not F/U w/ bood draws, rescheduling etc).
This AM I saw a pt who is a diabetic/hyperchol/CAD/HTN along w/ his MDD for which the best med which worked for him is Elavil. Now I don't know how comfortable any NP or med-psych will feel prescribing it to this pt, which incidentally I did and only after cking the h/p, ekg and labs. Does it make me different? Not really. The newer trainees have realized the follies of their senior colleagues, who in the 60s and 70s tried to demedicalize the specialty and tried to segregate MH from the rest of medicine. Most of them are aware of the medical issues and the only reason they don't do physicals because of the lack of infrastructure and support staff. And the current managed care is also promoting this.

 

[mdblue]

"In fairness, mdblue, this was a "guess." There was no formal assessment of the level of functional expertise of the DoD graduates performed in such a way as to allow a reliable or valid comparison. It was rendered as a hunch.

I know, because I asked Dr. Morgan Sammons, one of the DoD grads.

Svas"

Sure Dr. Svas. However the study itself was methodologically flawed which has been posted here in earlier posts. I presume it was an educated " guess"
Regards

 

[Svas]

What is methodologically flawed in "no adverse events?" There's a difference between nomothetic and ordinal data.

We have to be very precise about what is methodologically flawed about the study, particularly if the ecological value of our comments and criticisms don't (or won't) hold water.


S

"In fairness, mdblue, this was a "guess." There was no formal assessment of the level of functional expertise of the DoD graduates performed in such a way as to allow a reliable or valid comparison. It was rendered as a hunch.

I know, because I asked Dr. Morgan Sammons, one of the DoD grads.

Svas"

Sure Dr. Svas. However the study itself was methodologically flawed which has been posted here in earlier posts. I presume it was an educated " guess"
Regards

 

[Anasazi23]

We've mulled this concept over a few times now and I've been thinking about it for the last day or so. The reviewers of the DoD project guesstimate that their medical knowledge was that of a 3rd or 4th year medical student....

I've had a couple of medical students - both third years since the start of my residency. Both were really great and truly surprised me at their levels of knowledge of both general medicine and psychiatry. In fact, I found myself asking them a couple of medical questions since (and residents/attendings know this often to be true) they are closer to the more general and basic science medicine than specialists, which lose some of the info as they focus on their respective disciplines. In reviewing the coursework for the prescribing program, there is simply no way that the amount of information obtained in 1st/2nd or 1st, 2nd and third years of medical school are obtained through that system. Most 3rd/4th year med students have passed the US medical licensing exam - at least step I, and many or most, step II. Before making a ridiculous and unscientific comment such as "judged as on a level between 3rd or 4th year medical students," have them sit down, and take step I, and II of the USMLE. If the scores are comparable to the average, THEN make the comment that they are judged to be equal. I, like Svas, would bet the larger part of my massive salary that the scores would not be comparable.

To say that a psychologist knows the full protocol for a Tuberculosis workup, for example (which we experienced on the floor), along with pitfalls to treatment and expected outcome, I simply cannot believe. And why should we expect them to know this? It is not their formal training, no more than that of psychiatrists knowing how to perform a type of therapy to which they have had no exposure. Some keep stating that psychologists do not WANT to be physicians, but as was corrected, prescribing brings with it certain responsibilities and assumptions of knowledge. Just my .02

 

[PublicHealth]

Some keep stating that psychologists do not WANT to be physicians, but as was corrected, prescribing brings with it certain responsibilities and assumptions of knowledge. Just my .02

Exactly.

Have you met or worked with any prescribing psychologists? If so, what are your impressions of their knowledge and skill level in medicine and psychiatry? Is their level of medical knowledge enough to know when to refer?

As stated above, according to the DoD report, psychologists' psychiatric knowledge was equivalent to that of a 2nd or 3rd year psychiatry resident, while their medical knowledge was equivalent to that of a 3rd or 4th year medical student. This level of medical knowledge appeared to be enough for psychologists to know when to refer to or consult with a medical doctor.

Keep in mind, however, that the DoD curriculum is different from the M.S. in Clinical Psychopharmacology curriculum (see above), so the level of medical and psychiatric knowledge gained through M.S. programs remains to be determined.

Svas, what would you say is the level of medical and psychiatric knowledge and skills of the psychopharmacology-trained psychologists that you met?

 

[PublicHealth]

What is methodologically flawed in "no adverse events?" There's a difference between nomothetic and ordinal data.

We have to be very precise about what is methodologically flawed about the study, particularly if the ecological value of our comments and criticisms don't (or won't) hold water.


S

I agree. What is so "methodologically flawed" with the DoD project?

Will the psychiatric epidemiologists and biostatisticians step to the plate?

 

[Anasazi23]

As stated above, according to the DoD report, psychologists' psychiatric knowledge was equivalent to that of a 2nd or 3rd year psychiatry resident, while their medical knowledge was equivalent to that of a 3rd or 4th year medical student. This level of medical knowledge appeared to be enough for psychologists to know when to refer to or consult with a medical doctor.

Allow me to be more blunt....

There's no way in HELL that these psychologists knew as much medicine as 3/4th year med students, and that they knew as much psychiatry as a third year psychiatry resident.

We all keep stating that we want proof and statistics....fine. Sit down a DoD psychologist and give them the PRITE and USMLE step III. Then get back to me. I hope their ob/gyn knowledge is real good, cuz there's a hell of a lot of it on the boards.....

A good point is made by PublicHealth that perhaps the knowledge base is good enough to know when to refer. Problem is, with course descriptions in one of the Master's programs that was posted, it mentioned auscultating heart sounds and other very "medical" examinations. This will undoubtedly lead to a psychologist thinking that they can put a stethescope up to someone's chest and hear the subtle S4. If this isn't "trying to become a junior physician," I don't know what it. I think that's concerning to people.

 

[PublicHealth]

A good point is made by PublicHealth that perhaps the knowledge base is good enough to know when to refer. Problem is, with course descriptions in one of the Master's programs that was posted, it mentioned auscultating heart sounds and other very "medical" examinations. This will undoubtedly lead to a psychologist thinking that they can put a stethescope up to someone's chest and hear the subtle S4. If this isn't "trying to become a junior physician," I don't know what it. I think that's concerning to people.

Agreed. But this logic suggests that when nurses or even medical assistants (e.g.,http://www.richmond.cc.nc.us/MedicalAssistingTechnology/MedicalAssisting/handbook.pdf) auscultate heart sounds, they also want to be "junior physicians." Much of what MDs and DOs are trained to do is all too often done by other healthcare professionals. Just because psychologists are being trained in the basics of medical diagnosis does not mean that they want to become junior physicians. Given the inevitability of psychologist prescribing, would you not prefer that psychologists know at least the basics of medical diagnosis in order to provide more extensive information to consulting physicians or even to detect an emergency?

Here come the "Now psychologists want to be ER docs" comments.

 

[Svas]

What impresses me most is the level of assumption being made on the part of physicians on this list. We are trained, no . . . DRILLED REPEATEDLY to avoid assumption. We are scientists. Educated men and women. Let's stop assuming and do some basic research regarding what psychologists know and what they don't. We look ridiculous on the current path. We can do better.

Let's spend some time with the MS trained psychologists and find out what they know and what they don't. Then let's talk about this, together; knowledgeably. Until then, the often vitriolic diatribe is tiresome and has all the water holding value of a colander.

S

Agreed. But this logic suggests that when nurses or even medical assistants (e.g.,http://www.richmond.cc.nc.us/MedicalAssistingTechnology/MedicalAssisting/handbook.pdf) auscultate heart sounds, they also want to be "junior physicians." .

 

[PublicHealth]

What impresses me most is the level of assumption being made on the part of physicians on this list. We are trained, no . . . DRILLED REPEATEDLY to avoid assumption. We are scientists. Educated men and women. Let's stop assuming and do some basic research regarding what psychologists know and what they don't. We look ridiculous on the current path. We can do better.

Let's spend some time with the MS trained psychologists and find out what they know and what they don't. Then let's talk about this, together; knowledgeably. Until then, the often vitriolic diatribe is tiresome and has all the water holding value of a colander.

S

Excellent point.

Could you start us off by providing a summary of your discussions with M.S.-trained psychologists? You did so briefly above, but would you mind describing knowledge areas in which these psychologists were well trained, and the areas in which they may need additional training? Which program(s) did these psychologists attend?

Though it's a specious comparison, to what level of medical training -- student, resident -- would you equate these psychologists' level of knowledge?

In defense of the medical doctors/students involved in this forum, I would imagine that their not having spoken to or worked with M.S.-trained psychologists may explain, at least in part, their frustration and ignorance toward these psychologists' level of knowledge and practical skill in prescribing psychotropic medications. What most of us do have access to with respect to M.S. psychopharmacology training is nothing more than curriculum outlines and secondary articles that are either supportive or disdainful of such programs. I would bet that more than 95% of the medical doctors/students who have come out in vehement opposition of M.S. training in psychopharmacology have never even met a psychologist who trained in one of these programs. Of course, this speaks equally to the inchoateness of these programs as it does to medical doctors'/students' not seeking out the opportunity to meet graduates of such programs before formulating their opinions of them.

 

[Svas]

Could you start us off by providing a summary of your discussions with M.S.-trained psychologists? You did so briefly above, but would you mind describing knowledge areas in which these psychologists were well trained, and the areas in which they may need additional training? Which program(s) did these psychologists attend?

Though it's a specious comparison, to what level of medical training -- student, resident -- would you equate these psychologists' level of knowledge?

I've already posted on this issue and don't know if there's any value to my restating my experience. I've met with several MS trained folks and spoke with 2 of the DoD graduates because I wanted to understand, first hand, what their level of training was.

In terms of my interaction with those people with whom I spoke:

In short, I'm comfortable that they will manage psychiatric patients well. I'm comfortable that their overall psychiatric skills FAR exceed the NP's considerably. Their psychiatric skills equally far exceed the average FP. I'm comfortable that they are thoughtful and are likely to refer complex cases.

Their PSYCHIATRIC diagnostic skills were all consistent with a seasoned psychiatrist.

Their psycholotherapy skills and knowledge appeared superior.

Their knowledge of labs was less than I would have hoped for.

They all had been trained by an MD or DO regarding physical exams and seemed to have a handle on basic components of the exam. The 2 neuropsychologists from the group had an excellent grasp of the exam AND could adeptly discuss a basic neurological exam. Their knowledge for neuroanatomy was superior to the psychiatrists I know. Most had worked with HARVEY (the cardiac instruction "dummy") and had passed a basic exam on heart tone evaluation. NONE of them had any intent on trying to become "junior cardiologists" and readily admitted to needing more time to learn this skill.

I was pleased with their understanding of neuropharm, pharmacological principles of therapeutics, and general pathophysiology. I think that they are weaker in the area of endocrine and renal dysfunction, although this weakness was not uniform. Their appreciation for cardiac, CNS and PNS pathology was uniformly good. I have NO clue how they would handle a physical crisis (do they know how to coadminister a stim & an MAOi with a severely treatment resistent depressed patient? I don't know. They would probably avoid attempting such a treatment. Then again, most psychiatrists don't know how to do this.).

I have NO clue as to whether they'd pass the USMLE. I'm certain that one of the folks could probably pass anything we threw at him. He's exceptionally bright and I think that he could teach in any US med school.

Now a disclaimer: None of these people knew when I met them that I was quizzing them. I'm sure that all of them thought I was just being a jerk in checking out what they knew and what they didn't. Was it a fair assessment? Probably not. I was probably experienced as a tad on the hostile side of the spectrum and this could certainly have lead to a less than fair review of their actual skils.

Perhaps this answers your questions. However, interesting my responses, more psychiatrists will have to interact with these folks. I'm hoping that several here will try to do this before espousing further opinions.

 

[PublicHealth]

Thank you for sharing your impressions, Svas.

Here are some articles on the psychologist RxP issue from this month's issue of Psychiatric News:

http://pn.psychiatryonline.org/cgi/content/full/39/15/8

http://pn.psychiatryonline.org/cgi/content/full/39/15/1?etoc

http://pn.psychiatryonline.org/cgi/content/full/39/15/44

http://pn.psychiatryonline.org/cgi/content/full/39/15/3

 

[PublicHealth]

Thank you for sharing your impressions, Svas.

Here are some articles on the psychologist RxP issue from this month's issue of Psychiatric News:

http://pn.psychiatryonline.org/cgi/content/full/39/15/8

http://pn.psychiatryonline.org/cgi/content/full/39/15/1?etoc

http://pn.psychiatryonline.org/cgi/content/full/39/15/44

http://pn.psychiatryonline.org/cgi/content/full/39/15/3

Anyone care to comment on these articles?

 

[PublicHealth]

Sure has been dead around here.

According to this article(http://pn.psychiatryonline.org/cgi/content/full/39/15/44), psychologists have to pass a national certification exam before they can prescribe legally. Does anyone know if any psychologists in New Mexico and Louisiana are already prescribing?

 

[PublicHealth]

Support from the "opposition:"

http://www.managedcaremag.com/archives/0205/0205.ethics.pdf

 

[PublicHealth]

New Mexico Psychologist RxP:

Final Report: http://www.nmpsych.org/report_hb_170.htm

PMANM Recommendations: http://www.nmpsych.org/pmanm_recommendations_for_psychologist_prescribing.htm

 

[purpledoc]

New Mexico Psychologist RxP:

Final Report: http://www.nmpsych.org/report_hb_170.htm

PMANM Recommendations: http://www.nmpsych.org/pmanm_recommendations_for_psychologist_prescribing.htm

Re: "Support from the opposition." I would say it was an extremely cautious "let's see," not support. You'll note that he points out a number of flaws in psychologists' arguments and the real risks of allowing psychologists to prescribe.

As for the New Mexico stuff, thanks for the links. I've reviewed the final report. The minority report, at the end, is perhaps the best argument one could make against the NM law. The PMANM website also has a great chart comparing number of hours spent by other non-MD prescribing professionals to the requirements of the NM law.

I do still find it amazing that RxPs pull out the DoD experiment so much when the proposed training is barely comparable to what those docs did, and when the state laws have no age restrictions and provide for minimal oversight.

 

[PublicHealth]

I do still find it amazing that RxPs pull out the DoD experiment so much when the proposed training is barely comparable to what those docs did, and when the state laws have no age restrictions and provide for minimal oversight.

Correct me if I'm wrong, but the Final Report from NM states that prescribing psychologists will, for a conditional two-year period, only treat individuals age 14 to 65 under the primary supervision of Board-certified psychiatrists. This supervision includes psychologists' meeting face-to-face with their primary supervisors each week and with their secondary supervisors every two weeks for the duration of the two-year conditional period. If a psychologist wants to prescribe to individuals less than age 14 or more than age 65, s/he needs to submit a formal application that details a supervisory plan (see below). Moreover, if a psychologist fails the two-year peer review process, s/he must repeat the didactic portion of the program and reapply for a conditional certificate.

Your comment that "the state laws have no age restrictions and provide for minimal oversight" does not appear to reflect the facts.

According to the report:

"9. A prescribing psychologist who, after obtaining a prescription certificate, intends to extend his or her scope of prescribing practice to patient populations under the age of 14 or over 65 shall make formal application to the psychopharmacology applications committee that includes:

a) A supervisory plan, as outlined in ? V. N., shall be submitted to treat an additional 100 patients from the age populations to which the scope of practice is being extended.

b) The same rules and regulations applicable to the previous supervisory period will apply with the exception of the time period which will not exceed (one) 1 year and not be shorter than six (6) months.


10. Prescribing psychologists who prescribe to children under the age of 14 or to adults over the age of 65 without the additional required hours during either their two-year conditional prescription certificate period, as described in ?VI, or subsequent to the additional supervision, described in ? V. C. 9, shall be subject to disciplinary action by the board of psychologist examiners."

 

[Anasazi23]

purpledoc may be referring to the LA law.....it provides no age restriction, or limit to formulary; which means that psychologists will inevitably prescribe outside their moral jurisdiction and to patients that even psychiatrists feel should usually be treated with an additional year of post-residency training .

 

[purpledoc]

Your comment that "the state laws have no age restrictions and provide for minimal oversight" does not appear to reflect the facts.

According to the report:

"9. A prescribing psychologist who, after obtaining a prescription certificate, intends to extend his or her scope of prescribing practice to patient populations under the age of 14 or over 65 shall make formal application to the psychopharmacology applications committee that includes:

a) A supervisory plan, as outlined in ? V. N., shall be submitted to treat an additional 100 patients from the age populations to which the scope of practice is being extended.

Mea culpa. You are correct, at least for NM.

However, I have to say that I find a requirement for seeing 100 supervised patients in order to treat children under the age of 14 to be plain nonsense. I spent months on an inpatient unit treating children and adolescents, as most psychiatry residents do, and I'm sure I saw 100 patients along the way. However, not only do I not treat children under 14 years old in my practice, I don't treat anyone under 16 -- and even 16 and 17-year-olds I treat only if they have incredibly simple psychiatric problems. As my pediatrics professor used to say, "Children are not simply small adults." A child/adolescent fellowship in psychiatry is two years, a full year longer than most other fellowships.

As for extension into the over-65 age range, most folks in that range have multiple medical issues and multiple medications. When even regular physicians don't always prescribe appropriately for older folks -- hence the development of the board-certified specialties of geriatric medicine and geriatric psychiatry -- it is certainly not safe for non-medically trained folks to do it.

It seems to me there is a simple solution to part of this. Have the RxPs take the board certification exams in general psychiatry. If they pass, they can then take the board exams in the specialty area (child/adolescent, or geriatric) that they want to enter. If they can't pass general psych, they certainly shouldn't be attempting to prescribe for children or geriatric populations who are much, much harder to treat medically. Note that passing the general psych boards is a requirement for MDs to take the subspecialty boards, as well.

I honestly do not think that is an unreasonable requirement for those who wish to prescribe for those populations. I do know that the children and elderly in New Mexico should not be made into guinea pigs when no one has even studied the competence of RxPs with extremely limited training (not the DoD folks) in treating general adult patients.

Just my opinion.

Peace,
Purpledoc

P.S. Just diagnosed spinal stenosis in a geriatric patient with "anxiety" and "perseveration" about leg pain (confirmed on MRI), and sleep apnea in a middle-aged woman (confirmed by sleep lab), both of whom have primary care doctors. How many more examples do I need to give to convince people that (a) psychiatrists know primary care, because that's a minimum prerequisite knowledge base for prescribing medications, and (b) "coordinating treatment" with a primary care doc does not mean the patient has no medical issues? And these are private patients with insurance. Now just imagine what it's like in the remote clinics and state hospitals.

 

[JRB]

I do know that the children and elderly in New Mexico should not be made into guinea pigs when no one has even studied the...

Purpledoc,

I'm interested in hearing your thoughts on the practice of empiric medicine. It seems to be the mode of practice in psychiatry in my locale.

Regards,
JRB

 

[JRB]

Just diagnosed spinal stenosis in a geriatric patient with "anxiety" and "perseveration" about leg pain (confirmed on MRI), and sleep apnea in a middle-aged woman (confirmed by sleep lab), both of whom have primary care doctors. How many more examples do I need to give to convince people that (a) psychiatrists know primary care, because that's a minimum prerequisite knowledge base for prescribing medications, and (b) "coordinating treatment" with a primary care doc does not mean the patient has no medical issues? And these are private patients with insurance. Now just imagine what it's like in the remote clinics and state hospitals.

I?ve been following this thread, and I have to disagree with your argument that these psychologists will not be alert to medical issues. It?s not that the concern shouldn?t be raised; it?s just that (with all due respect) your recitation of personal accomplishments in catching medical problems is not making your point.

I just did the following? and only in this month.

1. Diagnosed Pick?s disease in a patient (confirmed on MRI) who was being treated by a psychiatrist for psychotic depression.
2. Contacted a PCP with concerns regarding a patient?s medication regimen? she was taking a non-therapeutic dosage of Wellbutrin, was on Synthroid as prescribed by another provider despite a history of normal thyroid studies, as well as an estrogen/progesterone compound? and Strattera. PCP did not know about any of this.
3. Contacted a PCP after review of lab data from medical records revealed that his patient had most likely not taken her Synthroid consistently.
4. Contacted a psychiatrist to inform him that his patient, whom he had cleared for elective surgery was, in fact, not appropriate because she was dissociating.
5. Diagnosed CO induced dementia; that may not have occurred had the ER doc paid better attention to the lab data upon admission.
6. Diagnosed sleep apnea (confirmed by sleep lab) in a 28 year old patient.

I am responsible and very thorough in my work. I am gathering that you are the same, and I would expect that you would have caught the above as well.

Perhaps I?m missing your point.

Peace,
JRB

 

[JRB]

...forgot to tell you.

I'm a licensed clinical psychologist, specializing in neuropsychology.

JRB

 

[PublicHealth]

I?ve been following this thread, and I have to disagree with your argument that these psychologists will not be alert to medical issues. It?s not that the concern shouldn?t be raised; it?s just that (with all due respect) your recitation of personal accomplishments in catching medical problems is not making your point.

I just did the following? and only in this month.

1. Diagnosed Pick?s disease in a patient (confirmed on MRI) who was being treated by a psychiatrist for psychotic depression.
2. Contacted a PCP with concerns regarding a patient?s medication regimen? she was taking a non-therapeutic dosage of Wellbutrin, was on Synthroid as prescribed by another provider despite a history of normal thyroid studies, as well as an estrogen/progesterone compound? and Strattera. PCP did not know about any of this.
3. Contacted a PCP after review of lab data from medical records revealed that his patient had most likely not taken her Synthroid consistently.
4. Contacted a psychiatrist to inform him that his patient, whom he had cleared for elective surgery was, in fact, not appropriate because she was dissociating.
5. Diagnosed CO induced dementia; that may not have occurred had the ER doc paid better attention to the lab data upon admission.
6. Diagnosed sleep apnea (confirmed by sleep lab) in a 28 year old patient.

I am responsible and very thorough in my work. I am gathering that you are the same, and I would expect that you would have caught the above as well.

Perhaps I?m missing your point.

Peace,
JRB

JRB,

It's great to have you aboard.

Just curious...are you for or against psychologists gaining the right to prescribe? What are your thoughts regarding the current postdoctoral clinical psychopharmacology training programs for psychologists?

PH

 

[purpledoc]

I?ve been following this thread, and I have to disagree with your argument that these psychologists will not be alert to medical issues. It?s not that the concern shouldn?t be raised; it?s just that (with all due respect) your recitation of personal accomplishments in catching medical problems is not making your point. <<SNIP long list of impressive diagnostically skilled assessments here>>

Thanks for your recitation! You're obviously very good at what you do. But unlike some of those discussing this issue, I don't necessarily think you're an "exception to the rule." (Although, in terms of baseline IQ, I'm sure you're a few standard deviations away. ) Any good psychologist or psychiatrist should be asking enough questions to let a PCP know if the patient's not being compliant, or to diagnose dissociation. You're also trained as a neuropsychologist, and good neuropsychologists should indeed be able to diagnose Pick's disease, sleep apnea, and, if they're really good, carbon monoxide poisoning.

What bothers me the most in this whole debate is how often psychologists who want prescribing privileges promote the idea that psychiatrists are just "pill pushers," which feeds into the prejudice that other physicians have against psychiatrists, and the negative views of us in the general population, as popularized by the media (remember Eddie Murphy in Dr. Doolittle, where the evil psychiatrist graduated last in his class and was a closet transvestite?) When I point out to psychologists that psychiatrists are physicians, the response is always, "Well, you're an exception. Most psychiatrists I know wouldn't diagnose those things." ARGH. They seem to think that prescribing psychotropic medications is almost an aside, once the psychiatric diagnosis is made.

So I think it brings us back to a couple of points. One is that psychiatrists will diagnose medical issues that aren't related to mental status -- say, urinary tract infections, spinal stenosis, etc. -- but that may be impacting general health. That may or may not be important regarding the issue of RxP. I personally think it is important, because so many people with psychiatric problems do not get proper medical care or do not get properly evaluated by their PCPs because of their psychiatric problems. But as I said, it may or may not be directly relevant to RxP.

However, the other main point I would make is that yes, all good Ph.D.s should be able to at least suspect when there is a common organic syndrome or medical problem that is masquerading as a psychological problem. Psychiatrists should be able to definitively diagnose those things, barring normal human error with regard to some really uncommon disorders. Psychiatrists should also diagnose or suspect when there is a medical problem that is not related directly to mental status (e.g. diagnosing or suspecting spinal stenosis, rather than just pointing out the pain component to the patient's perseveration.)

The relevant issue is, who should treat these issues? A radiology tech with good training or years of experience will know by looking at a chest X-ray, prior to the "official reading" by a radiologist, that a person has congestive heart failure. A dermatologist may note a mild cyanosis of the face without finger clubbing, and know that the person has mitral stenosis. And a psychologist or psychiatrist may see cherry-red skin, evaluate labs, or see more subtle signs and know that the person has carbon monoxide poisoning. In none of these cases should the person who diagnosed the problem be the one to treat it.

I simply believe that the current system, of referring the person along to the correct medically-trained specialist, is the way things should work. Prescribing is practicing medicine, with all the enormous risks to the patient of any medical procedure, and hence all the legal liability as well, of course. I had all the training in various fields of medicine. I've seen far more than 100 patients in medical school, internship, and fellowship with cardiac problems (I even worked with a heart transplant team for 4 months), and I still see patients every day on medicines for hypertension, so I have a good basic knowledge of cardiology and can often predict what medicine their PCP or cardiologist will put them on. That knowledge has been invaluable to me. But I don't prescribe even simple diuretics, and I'm sure you could poll a hundred psychiatrists and they'd all tell you the same thing.

It seems to me that this is such an easy issue. I know a psychologist who is also a nurse practitioner. She chooses to do psychotherapy only, though she could prescribe. Any psychologist who wants to prescribe should simply follow that route. To say or imply that they don't want to waste time learning all about treating non-psychiatric illnesses that they'll never treat -- well, join the club. Lots of us would have preferred to skip dermatology, or surgery, but now we all understand why we did those things.

OK, back to work for me. Looking forward to hearing your thoughts.

Peace,
Purpledoc

P.S. I don't mean to denigrate transvestites, by the way; it's just the way it was used in the film.

 

[PublicHealth]

It seems to me that this is such an easy issue. I know a psychologist who is also a nurse practitioner. She chooses to do psychotherapy only, though she could prescribe. Any psychologist who wants to prescribe should simply follow that route. To say or imply that they don't want to waste time learning all about treating non-psychiatric illnesses that they'll never treat -- well, join the club. Lots of us would have preferred to skip dermatology, or surgery, but now we all understand why we did those things.

Great post, purpledoc!

You mention nurse practitioner programs as a possible alternative to the current postdoctoral Master's programs clinical psychopharmacology. Correct me if I'm wrong, but don't MSN/APRN programs require a BSN/RN + some nursing experience + an additional 1 to 2 years of MSN training before one can become a nurse practitioner?

Also, what makes the nurse practitioner educational curriculum so different from the current MS in Clinical Psychopharmacology curriculum that you support this avenue of training for psychologists?

You bring up a good point about "learning all about treating non-psychiatric illnesses." Do you think the current psychiatric training system is flawed? Could you think of a more focused training path for psychiatrists?

 

[purpledoc]

Great post, purpledoc! <<SNIP>> You bring up a good point about "learning all about treating non-psychiatric illnesses." Do you think the current psychiatric training system is flawed? Could you think of a more focused training path for psychiatrists?

Hey, I finally got a thumbs-up!

Actually, I just got back from a psychotherapy conference in Aspen, CO. Three days of psychiatrists and psychologists interacting peacefully and sharing ideas and cases. Ahhhh. I hope those won't soon be the "good ol' days." Anyway...

Re: psychiatric training, I actually like the system. I wanted to be a doctor the second I left the womb, I think. My parents are doctors, and I used to point at pictures in medical journals and ask what they were. I never considered doing anything except medicine for longer than, oh, five minutes or so. So I may be a bit biased, I admit. I think that 4 yrs of medical school and a 4-yr residency -- a year longer than internal medicine, actually -- is just about right. I know there is at least one med school with a "fast track" program for psychiatry, but I would be a bit worried that this is a program that labels psychiatrists as "other" (a.k.a., not "real" MDs) even earlier in life. (Anyone who knows more about this, feel free to comment.)

If I have any complaints at all, it would only be that I wish we had more time to learn psychotherapy, not that we had less time on medicine or psychopharmacology. I would like to see some combined psychiatry residency/clinical psychology programs where theoretically you could finish in 5 yrs after med school for an MD-MA (no club drug jokes, please), or maybe 6-7 after med school for a MD-Ph.D., since a number of courses in residency and graduate school overlap.

Sigh. Well, right now I've got to get stuff together to write letters to PCPs, insurance companies, and patients on Monday morning. (All unpaid work, of course, as we all know.) Forensic psychiatry sounds very tempting, some days.

 

[Anasazi23]

I just did the following? and only in this month.

1. Diagnosed Pick?s disease in a patient (confirmed on MRI) who was being treated by a psychiatrist for psychotic depression.
2. Contacted a PCP with concerns regarding a patient?s medication regimen? she was taking a non-therapeutic dosage of Wellbutrin, was on Synthroid as prescribed by another provider despite a history of normal thyroid studies, as well as an estrogen/progesterone compound? and Strattera. PCP did not know about any of this.
3. Contacted a PCP after review of lab data from medical records revealed that his patient had most likely not taken her Synthroid consistently.
4. Contacted a psychiatrist to inform him that his patient, whom he had cleared for elective surgery was, in fact, not appropriate because she was dissociating.
5. Diagnosed CO induced dementia; that may not have occurred had the ER doc paid better attention to the lab data upon admission.
6. Diagnosed sleep apnea (confirmed by sleep lab) in a 28 year old patient.

I am responsible and very thorough in my work. I am gathering that you are the same, and I would expect that you would have caught the above as well.

Perhaps I?m missing your point.

Peace,
JRB

It's quotes like these that other pro-psychologist people love to see, and that only reinforce my point about how non-medical practitioners see only half the picture. First off, it's great that you 'diagnosed' these conditions. But to be frank, I'm skeptical. In fact, the vignette you describe about the person being essentially euthyroid and taking Synthroid and other meds disturbs me. Thyroid studies are not close to being near as simple as, "normal thyroid, no thyroid hormone needed." I'm not interested in taking the time to explain thyroid physiology or how to interpret T3, T3 uptake, free T4, T3/T4 ratio, Ath Ab, etc....suffice it to say that normal thyroid studies, depending on when you take them and how they've been taking any medications, can be normal, yet the person have a thyroid condition. I have a patient now that I'm keeping on Synthroid despite normal thyroid studies. I do not anticipate a psychologist calling me to tell me that the labs are normal.

Other examples such as the ER missing CO poisoning also makes me skeptical. It's easy to diagnose something in hindsight or when pathology has "settled in" and is presenting clasically. ER docs will be the first to tell you that most patients don't read textbooks. In order to have CO dementia acutely, you'd need low O2 sats, which are routine even in the triage. For this to be ignored is almost unbelievable to me.

You state you're missing the point. The point is that yes, psychologists will be privy to some medical conditions and will refer appropriately. However the more salient point is that psychiatrists are physicians, and will from now to the end, diagnose physical disease more than someone who is not a physician. This is not fundamentalism. It's just fact. People are arguing that psychologists prescribing will not be a lower standard of care. Yet, psychologists will practice some part of medicine without being physicians, and will miss many more physical diagnoses. This is by definition a lower standard of care. That's the point.

 

[JRB]

Anasazi,

I've sent you a private message.

JRB

 

[JRB]

In fact, the vignette you describe about the person being essentially euthyroid and taking Synthroid and other meds disturbs me. Thyroid studies are not close to being near as simple as, "normal thyroid, no thyroid hormone needed." I'm not interested in taking the time to explain thyroid physiology or how to interpret T3, T3 uptake, free T4, T3/T4 ratio, Ath Ab, etc....suffice it to say that normal thyroid studies, depending on when you take them and how they've been taking any medications, can be normal, yet the person have a thyroid condition.

I?m glad to see that you recognized how disturbing this case is. I was also very disturbed by the case as was the patient?s PCP when we discussed my findings. It?s turned out to be a very valuable teaching case for my medical students and my doctoral students.

JRB

 

[JRB]

I have a patient now that I'm keeping on Synthroid despite normal thyroid studies. I do not anticipate a psychologist calling me to tell me that the labs are normal.

Anasazi, I would be remiss by not calling to discuss concerns if my clinical observations of your patient suggested medication mismanagement; and you would be remiss by not having such a discussion with me. Either one of these would be tantamount to a substandard of care.

JRB

 

[JRB]

Other examples such as the ER missing CO poisoning also makes me skeptical. It's easy to diagnose something in hindsight or when pathology has "settled in" and is presenting clasically. ER docs will be the first to tell you that most patients don't read textbooks. In order to have CO dementia acutely, you'd need low O2 sats, which are routine even in the triage. For this to be ignored is almost unbelievable to me.

It was almost unbelievable to me as well as to my physician colleagues, but as we all know, there are good physicians and not-so-good physicians. And sometimes, cases are not so simple and straightforward, and sometimes physicians just plain overlook stuff. This one did.

It?s exactly these types of cases that are referred to me. I am consulted because their physicians do not know, or are unsure, what is wrong with the patient. This is exactly what I was trained to do.

We all have our own expertise, experience, and perspective to bring to a case. When we function as colleagues and work in a collaborative way, the patient benefits. If we allow ourselves to become entrenched in bias and cannot place the patient above our own ego needs, we all suffer.


Regards,
JRB

 

[Anasazi23]

My fiancee continually asserts that I should "quit" this forum altogether, as people's opinions on these topics, not unlike religion or politics, will never change, and that it only seems to aggravate me. Perhaps she's right.

Despite what many would like, psychiatry as a profession is not going away, prescription privilages or not. Psychiatrists will not be relegated to dank hospital hallways seeing only the most insanely (pardon the pun) complex and comorbid cases, whilst psychologists make millions on 7th avenue prescribing Effexor to borderline housewives. Psychologists are not going to drive down the managed care market to the depths of hell so that psychiatrists are making $18.95 per hour while psychologists all triple their salaries. Psychologists are not going to force all psychiatrists to take extra years of psychotherapy so that they can survive, since they are so obviously *****ically deficient in this mode of treatment only to be understood by them. Psychiatrists will not not be forced to move to "rural" areas so that they can work in rainbow-traversing harmony in New Mexico mesas or Louisiana swamp-towns with psychologists and other health care providers in the utopia of self-actualization for our patients. Psychiatrists will not be made to ask permission of their supervising psychologists so that they can perform "evil, mind altering" ect. Psychiatry as a profession has survived much harder ill-minded reform than this, and by the nature of disease processes that are psychiatric illnesses, will continue to provide unique, needed, and comprehensive care for these patients.

It is one thing to be a passive learner and to apply skills and knowledge. It is quite another to go home every night wondering if the treatment regimin you have provided will kill your patient, considering their comorbid conditions. Or, if your physical exam was thorough enough, or if that chest pain should be treated to the hilt or dismissed as the 19th somatic complaint from that patient in the last 5 hours. Given the opinions on this forum, many psychologists seem to find no difference in the two professions. To them I say (hopefully for the last time) that the human physical condition and the brain are not separate from each other. While others will be very quick to point out erroneously that all psychiatrists have lost every glimmer of their physical medicine skills, I reiterate that psychiatrists have filled a need where it was needed. If you believe that there is a lack of psychiatrists in the U.S., then how can you hardly blame them for seeing patients more briefly than the more desired 50 minute hour? Are phone consultations with a PCP the answer to this dilemna? I hardly think so.

 

[Anasazi23]

...It?s exactly these types of cases that are referred to me. I am consulted because their physicians do not know, or are unsure, what is wrong with the patient. This is exactly what I was trained to do.

Another fine example of psychologists bailing out incompetent physicians?

We all have our own expertise, experience, and perspective to bring to a case. When we function as colleagues and work in a collaborative way, the patient benefits. If we allow ourselves to become entrenched in bias and cannot place the patient above our own ego needs, we all suffer.

Agreed. So then, I implore you to bring the message on high to your psychologist colleagues, so that they can remove their own biases toward psychiatry. I continually find it amazing that is only psychiatrists who are seen on this forum to harbor evil preconceptions and biases.

Ego needs? Let's be frank - this entire psychologist prescription privilage issue is one gigantic ego need.

 

[Anasazi23]

2. Contacted a PCP with concerns regarding a patient?s medication regimen? she was taking a non-therapeutic dosage of Wellbutrin, was on Synthroid as prescribed by another provider despite a history of normal thyroid studies, as well as an estrogen/progesterone compound? and Strattera. PCP did not know about any of this.......
I?m glad to see that you recognized how disturbing this case is. I was also very disturbed by the case as was the patient?s PCP when we discussed my findings. It?s turned out to be a very valuable teaching case for my medical students and my doctoral students.

Not to nitpick, but just because someone is not on the "textbook" dose of a psychotropic, does not mean that it is ineffective or subtherapeutic. Perhaps the patient is a slow acetylator, or was having adverse reactions to the "non-therapeutic" dose of bupropion. In psychiatry, we use what appears to be sub-therapeutic dosages all the time, and there are reasons for this. The fact that the person was also on Synthroid suggests that a physician was using the wellbutrin and Synthroid in an adjunctive manner, which has anecdotal evidence, not unlike the acceptable lower therapeutic serum levels of lithium carbonate and valproic acid augmentation strategies.

 

[mdblue]

Not to nitpick, but just because someone is not on the "textbook" dose of a psychotropic, does not mean that it is ineffective or subtherapeutic. Perhaps the patient is a slow acetylator, or was having adverse reactions to the "non-therapeutic" dose of bupropion. In psychiatry, we use what appears to be sub-therapeutic dosages all the time, and there are reasons for this. The fact that the person was also on Synthroid suggests that a physician was using the wellbutrin and Synthroid in an adjunctive manner, which has anecdotal evidence, not unlike the acceptable lower therapeutic serum levels of lithium carbonate and valproic acid augmentation strategies.

You forgot Anasazi that thyroid gland is not a part of the brain, ergo, outside the realm of psychiatry.

 

[Svas]

It seems to me there is a simple solution to part of this. Have the RxPs take the board certification exams in general psychiatry. If they pass, they can then take the board exams in the specialty area (child/adolescent, or geriatric) that they want to enter.

I, for one, would wager BIG dollars on their being able to pass this exam. BIG dollars.

Of course, will they ever be allowed to take the exam. Purpledoc, would you be willing to lobby/advocate for their being able to take this exam? If they passed it, would you lobby/advocate for their ability to prescirbe?

Just my curiousity . . .

Svas

 

[PublicHealth]

I know a psychologist who is also a nurse practitioner. She chooses to do psychotherapy only, though she could prescribe. Any psychologist who wants to prescribe should simply follow that route.

Interestingly, purpledoc mentioned that he supports psychologists becoming nurse practitioners en route to prescribing psychotropic medications. I am willing to bet that his psychologist-nurse practitioner friend completed her nursing degrees prior to pursuing her psychology degree. Speaking of which, does anyone know of any programs that allow psychologists to complete an MSN/APRN without having to be a BSN/RN? Also, how would the MSN/APRN curriculum differ from the postdoctoral Master's curriculum in clinical psychopharmacology? I realize that I have asked these questions before, but purpledoc and others have failed to address it in any substantive manner, opting instead to provide recitations of their astute physical diagnosis skills.

I find it interesting that the physicians in this forum support training routes to prescribing such as MSN/APRN and PA but outright deny the appropriateness of existing MS in Clinical Psychopharmacology programs. What is it about these MS programs that makes them so inappropriate and deficient in preparing psychologists to prescribe compared to MSN/APRN and PA programs? Is it because they're "newer" than more traditional nonphysician prescriber programs such as MSN/APRN and PA? Maybe it's because these programs were designed by psychologists?

At this point, I'd like to recommend that our discussion shift to "What is/are the most appropriate psychopharmacology training program(s) for psychologists?" as opposed to "Clinical scenarios that psychologists are ill-equipped to handle." In anticipation of the inevitable, answering "medical school" to the former question would be inconsistent with the aforementioned quote from purpledoc.

We are making progress, people. I look forward to your replies.

 

[purpledoc]

Interestingly, purpledoc mentioned that he supports psychologists becoming nurse practitioners en route to prescribing psychotropic medications.

I did not say I supported it. I said the option was available. Speaking of assumptions, that should be, "she supports."

I am willing to bet that his psychologist-nurse practitioner friend completed her nursing degrees prior to pursuing her psychology degree.

Correct.

I find it interesting that the physicians in this forum support training routes to prescribing such as MSN/APRN and PA...

Again, "support" is not the correct word. I noted that psychologists already have other avenues to achieve the right to prescribe, as does any person with or without a psychology degree. My personal opinion of these training options is not the issue at hand.

...but outright deny the appropriateness of existing MS in Clinical Psychopharmacology programs. What is it about these MS programs that makes them so inappropriate and deficient in preparing psychologists to prescribe compared to MSN/APRN and PA programs? Is it because they're "newer" than more traditional nonphysician prescriber programs such as MSN/APRN and PA? Maybe it's because these programs were designed by psychologists?

...Or is it because they don't provide even a whiff of the general medical knowledge and physical diagnostic skills of an MSN/APRN/PA program?

At this point, I'd like to recommend that our discussion shift to "What is/are the most appropriate psychopharmacology training program(s) for psychologists?" as opposed to "Clinical scenarios that psychologists are ill-equipped to handle." In anticipation of the inevitable, answering "medical school" to the former question would be inconsistent with the aforementioned quote from purpledoc.

This reminds me of the old, sexist joke in which a man asks a woman sitting next to him at the bar to go home with him. She laughs and says, "Only for a million dollars." He then offers her $20 to go to a hotel with him. When she gets angry and says, "What do you think I am?" he says, "We've already established that, madam, we're only negotiating about the price." It is absurd to propose that simply because I mentioned the existing pathways that allow non-MDs to prescribe, it means I must support some form of a "psychopharmacology training program."

The appropriate question should be, "What should be the minimum requirements of a training program to allow any person to medically treat illnesses with psychiatric symptoms?" The simple answer is that it must be a training program that is sufficient to teach someone how to medically treat illnesses, period. "Psychopharmacology training" makes no more sense than "cardiopharmacology training" to allow people to prescribe cardiac medications. Psychologists cannot "jump the line" in terms of medical training because they have been trained in graduate school in psychotherapy and work with mentally ill people any more than biochemists can "jump the line" in medical training.

Sorry, Public, I know you thought you'd won this point, but you haven't. The debate can continue.

Peace,
Purpledoc

 

[purpledoc]

I, for one, would wager BIG dollars on their being able to pass this exam. BIG dollars.

Of course, will they ever be allowed to take the exam. Purpledoc, would you be willing to lobby/advocate for their being able to take this exam? If they passed it, would you lobby/advocate for their ability to prescirbe?

Just my curiousity . . .

Svas

I do not believe it would be so simple for the vast majority of them (psychologists with a masters in psychopharm) to pass the exam, since the general psychiatry board exam contains 33% neurology board questions, just as the neurology board contains 33% psychiatry board questions. Furthermore, I'd like to see most of them without many additional years of clinical experience under their belts pass the oral boards: Interview a patient in just 30 minutes and immediately present the patient, give a complete differential diagnosis -- which is a skill that we begin learning how to do in medical school and takes years to truly master -- and outline a medical treatment plan. The board exams in geriatric or child psychiatry cannot even be taken until one has passed the general psychiatry boards.

As for advocating, I am proposing this merely as an additional qualification for those who wish to experiment on children and the elderly. The exams themselves, however, are not so sufficient in and of themselves that I would say that passing them is enough to allow them to prescribe safely, anymore than someone who passes a psychology exam is then able to do psychotherapy.

So, I guess the short answer to both questions is, "No."

 

[Svas]

Just my 2 cents: I think you are vastly underrating the skills of these folks. It is for this reason that I have encouraged people to spend some time with those psychologists who have done the additional 2 years of training. As I've already stated, I think that they would easily pass for psychiatrists.

Before you and I debate this (and I don't know what value that would have in this forum), can I simply suggest that you see what you can do to get together with someone with this training (NOT the distance learning programs, but the university based training) and see what your thoughts are?

BTW, are you suggesting that our boards lack ecological validity?

Very respectfully,

S

I do not believe it would be so simple for the vast majority of them (psychologists with a masters in psychopharm) to pass the exam, since the general psychiatry board exam contains 33% neurology board questions, just as the neurology board contains 33% psychiatry board questions. Furthermore, I'd like to see most of them without many additional years of clinical experience under their belts pass the oral boards: Interview a patient in just 30 minutes and immediately present the patient, give a complete differential diagnosis -- which is a skill that we begin learning how to do in medical school and takes years to truly master -- and outline a medical treatment plan. The board exams in geriatric or child psychiatry cannot even be taken until one has passed the general psychiatry boards.

As for advocating, I am proposing this merely as an additional qualification for those who wish to experiment on children and the elderly. The exams themselves, however, are not so sufficient in and of themselves that I would say that passing them is enough to allow them to prescribe safely, anymore than someone who passes a psychology exam is then able to do psychotherapy.

So, I guess the short answer to both questions is, "No."

 

[JRB]

Not to nitpick, but just because someone is not on the "textbook" dose of a psychotropic, does not mean that it is ineffective or subtherapeutic. Perhaps the patient is a slow acetylator, or was having adverse reactions to the "non-therapeutic" dose of bupropion. In psychiatry, we use what appears to be sub-therapeutic dosages all the time, and there are reasons for this. The fact that the person was also on Synthroid suggests that a physician was using the wellbutrin and Synthroid in an adjunctive manner, which has anecdotal evidence, not unlike the acceptable lower therapeutic serum levels of lithium carbonate and valproic acid augmentation strategies.

This is an excellent point, Anasazi, and one that demonstrates the complexity of psychophysiological processes that must taken into consideration when developing diagnostic hypotheses for an individual case.

For the sake of brevity, I didn't give details regarding the cases that I listed earlier. In this case, the PCP had Rx'd the Wellbutrin but was simply unaware that the patient had reduced the dose on her own accord or that she had gone elsewhere and gotten the Synthroid and hormone compound. Then she came back to his PA and told him that she thought she had ADHD and the PA Rx'd Strattera. The PA did not know she reduced the Wellbutrin, and did not know about the other meds. She was referred her to me for diagnostic differentiation of mental status change.

This case, as I said, is an excellent teaching case for many reasons.

Peace,
JRB

 

[JRB]

As for advocating, I am proposing this merely as an additional qualification for those who wish to experiment on children and the elderly.

Purpledoc,

You may have missed my post earlier. I'm interested in your thoughts on the practice of empirical medicine.

JRB