Opinion On Illinois Becoming 3rd State

[greenlion]

I just received an email saying that our tele-psychiatrists for children 12 and under is going to be up and running and to start referring kids there. Right now we have an PMHNP for 13 and up and soon to be tele-doc for the kids. This is the solution for the community. The medical doctors would rather have me do the job than the mid-levels because they recognize my expertise in diagnosing and treating mental illness. The primary care docs don't want to deal with psychiatric care. If we had enough psychiatrists, it wouldn't be a problem. From what I hear, the shortage is not just in rural areas like my own, so what is the solution, if not psychologists?

***edit*** FYI just wanted to add that I used to be more anti-RxP, but the needs of my patients and the community are pushing me in the other direction.

Honestly, doctors liking you isn't a credential to practice medicine. It's a recommendation letter in a medical school application.

And this part is controversial among psychiatrists: but... it's my opinion that the increased psychotropic medication demand is artificial and not based in proper diagnosis. For example the annual rate of psychotropic medication use by children/adolescents was 1.4 per 100 in 1987, 3.9 per 100 in 1996 and 8.3 percent in 2000-2001. (-Adams, WICHE 2009) Recent data isn't published but it is likely over 10% if the trend continued. Likewise SSRI use in the USA from ages 18-44 increased nearly 400% from 1988-1994 to 2005-2008. (-Pratt, NCHS Data Brief 2011) Further OECD figures show USA leads other countries in antidepressant prescriptions. The OECD (these are developed countries btw in case you aren't familiar with economics) average antidepressant daily dose per 1,000 population? 52.5. USA average? well over 100.

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[PikminOC]

If true, no field is safe but maybe surgery. Parity would make them family docs, ob/gyns, IM, derm, etc. No way would psychologists stick with psych when they could make derm money.

It's coming to sugery, gi, etc.

 

[AcronymAllergy]

Honestly, doctors who like you isn't a credential to practice medicine. It's a recommendation letter in a medical school application.

And this part is controversial among psychiatrists: but... it's my opinion that the increased psychotropic medication demand is artificial and not based in proper diagnosis. For example the annual rate of psychotropic medication use by children/adolescents was 1.4 per 100 in 1987, 3.9 per 100 in 1996 and 8.3 percent in 2000-2001. (-Adams, WICHE 2009) Recent data isn't published but it is likely over 10% if the trend continued. Likewise SSRI use in the USA from ages 18-44 increased nearly 400% from 1988-1994 to 2005-2008. (-Pratt, NCHS Data Brief 2011) Further OECD figures show USA leads other countries in antidepressant prescriptions. The OECD (these are developed countries btw in case you aren't familiar with economics) average antidepressant daily dose per 1,000 population? 52.5. USA average? well over 100.

I certainly wouldn't argue that it's possible the American public, by and large, is over-medicated. I could see there being push from multiple directions to have this be the case--possibly-flawed (and/or overstated) psychopharm research regarding efficacy of various drugs in various populations for various conditions; hospital/clinic admins pushing providers to maximize profit and minimize costs, which I'd imagine generally leads to pressure for the 15-minute rather than 45-minute appointment...and since no one's going to be doing evidence-based therapy in 15 minutes, you're essentially left with one option; and patients who, for various reasons (no doubt including the rather massive marketing campaign of big pharma), are essentially demanding meds while perhaps not even knowing about other treatment options.

How do we fix all that? Eh, no clue, at least not off the top of my head. Who knows, maybe at some point things will reach a critical mass and folks will begin demanding that they not be put on meds, or that adjunctive therapy be utilized.

As for the bill itself, there are parts that I like and parts that I don't like. As I mentioned in the psychology forum, I can appreciate having the coursework added in at the grad school level, as this provides a greater opportunity for the courses to be taken in a more traditional environment and for more collaborative and structured supervision to occur. And I do feel that well-trained psychologists have the potential to be effective prescribers, especially in that sort of setting. Conversely, particularly if some of the...less-than-stellar schools in the Illinois area really latch on to that training model (and let's be honest, the for-profit schools are going to be MUCH more interested and move MUCH more quickly on this than will traditional universities), I could see the psychology side of things getting short shrift. Then, they're essentially churning out not folks with expertise in mental health/psychology who have additional psychopharm training, but some bastardized, mid-level hybrid with PA-equivalent psychopharm and a paltry psychological foundation on which to base it and practice from. If psychology as a field had greater parity of training, I'd be much less worried about this happening.

 

[vistaril]

It's coming to sugery, gi, etc.

nonsense....ask most people how they would feel about a PA/NP performing unsupervised invasive surgery(say a partial bowel resection) on them. Now ask them how they feel about an NP/PA writing them a prescription for Cymbalta or augmentin(primary care).

Only a true moran would believe they are comparable.

 

[TexasPhysician]

nonsense....ask most people how they would feel about a PA/NP performing unsupervised invasive surgery(say a partial bowel resection) on them. Now ask them how they feel about an NP/PA writing them a prescription for Cymbalta or augmentin(primary care).

Only a true moran would believe they are comparable.

What's a moran and why can't PA's operate a scope? A teenager with gaming skills could be taught in a couple hours.

 

[MacDonaldTriad]

Where are all of those psychiatrists with the strong need to believe that this is the end of the world as we know it? If we let this happen, the next thing you know, Rush Limbaugh will lobby for Illegal alien amnesty and Al Gore will renounce global warming. Sometimes I think $599.00 of my $600.00 APA dues go to this issue.

Look at this, I forgot I asked for it. It is like pin head and saying his name three times.

 

[PikminOC]

With all due respect...Didnt they? The therapy market is completely saturated... I have not had a single patient that wanted to come in strictly for therapy because they felt they needed an expert with an MD trained in Psychiatry.

I am all for greater access to care. However, in my opinion, this will just further erode Psychiatry's financial competitiveness as a medical specialty. We are already hanging out at the bottom justifying our lower incomes by tweaking numbers and talking about our sweet lifestyles. Don't get me wrong Psychiatry is a great specialty and we are currently in a sweet spot.

But as this movement of double encroachment continues to expand, I do not think we will necessarily be regarded as the experts in pharmacologic management as we currently see ourselves. In the same way a patient would not consider a psychiatrist for better therapy despite the fact we dominated psychotherapy prior to the 1970s and we continue to receive the training.

Regarding who gets the best training: Psychiatrists vs. Psychologists. I did not go to an Ivy league residency but we received top notch training from attending who graduated from Yale who's father was also a psychoanalyst. The psychologists at my program didn't get nearly the amount of therapy training that we did. The only difference I see is that these psychologists go out and do therapy and we don't so they are "better".

There are so many pop up psyd schools and training is not well standardized.

We have very regulated and standardized training with therapy. I do see patients just for therapy.

 

[PikminOC]

My opinion is if a NP can prescribe without a doctor hovering around then a psychologist who has done 4 years of undergrad , 5 years to get there PHD and then continue on to do a course in pharmacology is more than ready to prescribe. I don't think it's a very good idea for NP's or psychologists to prescribe but times are changing. I would see a regular doctor anyday over a NP sorry I just don't trust someone with that little experience . I live in Illinois btw.

What do you do? What exactly is your job title? I know people with other kinds of long educations like phds etc. What does that education have anything to do with medical education?

 

[PikminOC]

I’m not so sure psychiatrists were pushed out of doing therapy or if we walked out. There are still MD’s with PhDs in psychoanalysis doing full time therapy for cash on the barrelhead. There are also psychologists doing this. The rest of the “therapists” are collecting pay rates from insurance that psychiatrists are not interested in. You might argue that if the other therapists didn’t exist, then insurance would have to pay more, but I doubt they would.
As far as quality of therapy training MD vs PhD, for psychiatrists, the minimum is a little better than a beefed up introduction. We can go on and further specialize in a particular brand, but trying to teach half a dozen approached in two maybe three years of part time effort just can’t be the same as PhD’s training in this. I’m not saying there aren’t any fine MD therapists, I’m just saying there are a lot of MDs who don’t do therapy and they aren’t good at it because they don’t do it.

We aren't talking just about phd. Psyd is a different animal.

 

[PikminOC]

Here's a recent excerpt of what I though about it in the "competitiveness" thread... figure it is relevant here to:

In regards to this recent Illinois bill, it looks like there are pretty tight reins on patient population (no one aged under 18, no one aged 65+, no one with a "serious mental condition") and also constraints on the meds which can be utilitzed. As always, things can quickly change from this point.

Encroachment is starting to take place at the specialty-level for many different areas of medicine (Psych, Gas, FM, Ophtho, EM, IM, Derm). Other specialties are more insulated against encroachment from midlevels (surgical specialties, RadOnc, Rads, Neuro, Path) -- but have their own problems ranging from hellish lifestyle, to poor job market, to high risk of low satisfaction.

The current solution for many of the specialties in the earlier group would be to pick a subspecialty and further differentiate yourself from the midlevels trying to claim equal SOP. For example, Ophtho can do VR surgery, IM can do Heme/Onc, Psych can do CA, etc. The solution for the specialties in the latter grouping is less clear cut.



In regards to your questions:

On whether it is a "good" or "bad" thing, it all depends on from whose perspective we are looking:

For psychologists = it is great to have an increase in SOP at their disposal if they choose to pursue it.

For patients = it will be a mixed bag. Some might indeed benefit from new accessibility to providers that can provide them with treatment that wasn't available in their community before. However there will also be some prescribing problems -- over prescribing, under prescribing, odd polypharm, or just wrong med choice.

How do I know? Because there are plenty of psychiatrists that make those same errors...and their physicians. In other words, pharm has been one of their main tools for a long time now and plenty of psychiatrists don't bat .1000 when it comes to making the correct choice.

I think it is very naive to think that psychologists will suddenly come out of this new training experiment magically more effective than those that went through 4+ years of residency training with prescribing and years under their belt with prescribing out in the real world.

For psychiatrists = it will be a mixed bag. Some docs might lose business if they were once considered the only option in town and now suddenly the more well-liked, popular psychologist becomes an option to get the meds filled. Other docs will benefit by employing a prescribing psychologist in their practice. As an employer, you have someone that is presumably well-versed in therapy and can also do basic meds...at a greatly discounted price...sounds like a good deal for the employing psychiatric practice. If you are a psychiatrist looking for an employed position youself, it might be a neutral development at best -- this will not help your cause.

Psych can do ca? Unlike every other nonmedical field there are requirements and standards. We cant all do the residency or make up things. And good luck in a courtroom if you don't have the training or board certs in a hearing.

 

[PikminOC]

I just received an email saying that our tele-psychiatrists for children 12 and under is going to be up and running and to start referring kids there. Right now we have an PMHNP for 13 and up and soon to be tele-doc for the kids. This is the solution for the community. The medical doctors would rather have me do the job than the mid-levels because they recognize my expertise in diagnosing and treating mental illness. The primary care docs don't want to deal with psychiatric care. If we had enough psychiatrists, it wouldn't be a problem. From what I hear, the shortage is not just in rural areas like my own, so what is the solution, if not psychologists?

***edit*** FYI just wanted to add that I used to be more anti-RxP, but the needs of my patients and the community are pushing me in the other direction.

Alot of training goes into becoming a bc child psychiatrist. It doesn't come with shortcuts. I can take on new patients within a week. My schedule is not full.

Let's see how many of the RXPers help in your community.

There are no pop up medical schools. Illinois is churning out the Psyd's.

 

[Frazier]

Psych can do ca? Unlike every other nonmedical field there are requirements and standards. We cant all do the residency or make up things. And good luck in a courtroom if you don't have the training or board certs in a hearing.

I dont know if we are saying the same thing...

The backdrop for the scene was 'example options on how to further insulate oneself from encroachment'.

"Psych can do CA" ... as in "psychiatrists can do a fellowship in children+adolescents".

This is touching upon the fact that the illinois bill does not permit RxP scope of practice to include those under 17 in age...therein lies the "insulation".

I'm not sure what your post is saying.


..If you are saying "not all psychiatrists can do CA fellowships". Well, of course. Just as all IM folks can't do heme/onc.

 

[bearpsychmd]

clearly efforts to divide the labor force by the real decision makers goes unnoticed by you guys

Its about being able to charge $200 and pay your labor $50, instead of $100. Thats why psych NPs are becoming the preferred labor. They bill the same rate to medicare and insurance, get paid less, and follow corporate policy better.

its beyond salary because physicians allow themselves to be qualified as exempt (even as employees) for holiday pay, OT, schedule differentials and labor rights the rest of the workforce enjoys and that reduces your actual salary signficantly

Here is microcosm of the preferred set up
http://www.valuesbasedpsychiatry.com/meet-the-team/

At least these are actual people and not a huge health system with more socially irresponsible finances

Its a fixed and monopolized system that you have zero control over as physician so why are you even complaining

 

[PikminOC]

I dont know if we are saying the same thing...

The backdrop for the scene was 'example options on how to further insulate oneself from encroachment'.

"Psych can do CA" ... as in "psychiatrists can do a fellowship in children+adolescents".

This is touching upon the fact that the illinois bill does not permit RxP scope of practice to include those under 17 in age...therein lies the "insulation".

I'm not sure what your post is saying.


..If you are saying "not all psychiatrists can do CA fellowships". Well, of course. Just as all IM folks can't do heme/onc.

I understand what you are saying about encroachment. But there are only so many spots for CA. The APNP's are allowed to prescribe to 13 year old and above in Wisconsin so this further specialization for us doesn't make the difference.


I'm not a fan of working with or collaborating with any of these midlevels. I don't want to contribute to their further encroachment and eventual independent practice. But that is just me.

 

[Frazier]

I understand what you are saying about encroachment. But there are only so many spots for CA. The APNP's are allowed to prescribe to 13 year old and above in Wisconsin so this further specialization for us doesn't make the difference.

I'm not a fan of working with or collaborating with any of these midlevels. I don't want to contribute to their further encroachment and eventual independent practice. But that is just me.

Gotcha

 

[PikminOC]

A lot of psychologists may not want to do this RxP as this legislation is very different from NM and LA, as it requires much more education. There are other educational pathways that would result in less restrictions. But who knows.
10 years ago when the other states came out with this NM and LA, it was thought then that we were in for numerous other states following
So no one can predict this.

 

[erg923]

I think that's been covered well enough. I would of course recommend reading my posts on the topic.

http://forums.studentdoctor.net/threads/psychiatry-and-psychological-tests.1019863/

 

[smalltownpsych]

Alot of training goes into becoming a bc child psychiatrist. It doesn't come with shortcuts. I can take on new patients within a week. My schedule is not full.

Let's see how many of the RXPers help in your community.

There are no pop up medical schools. Illinois is churning out the Psyd's.

If my state allowed it, then I would probably pursue this and the docs I work with would be glad to provide the supervision. You are correct that the Illinois bill doesn't allow for pediatrics. I will ask the question again, how is psychiatry going to help the people who are being under-served? I guess in your community it is not an issue, but it has been in every place that I have worked, three different states and it has been the worst with kids. In the meantime, the PCPs keep prescribing Concerta for everything whether it is behavioral, depression, Bipolar, Autism Spectrum, PTSD, GAD - you name it. As someone who has been working with these kids for years with little to no help from psychiatrists, I get a bit frustrated at times. Ethically, I am on thin ice if I even tell the parents that a stimulant might not be a good idea for their anxious kid because I don't want to be making medical recommendations.

 

[erg923]

There are no pop up medical schools. Illinois is churning out the Psyd's.

I think that's a fair point that should be discussed. Graduates from professional schools, which many psychologists feel have subpar scientific training in psychology/clinical psychology will be jumping on this bandwagon. If we believe these people are getting subpar doctoral education, then we obviously would have to be worried about them practicing psychiatric medicine as well, I would think.

 

[TexasPhysician]

I will ask the question again, how is psychiatry going to help the people who are being under-served?

How will psychology? In my region, decent psychologists are hard to find. Go a little more rural and I can't get children needed therapy at all. School counselors are the best option, and they are weak at best.

Psychologists don't want prescribing rights in only rural areas. They want it everywhere. Urban areas will become more saturated, and rural areas will continue to suffer.

 

[TexasPhysician]

The best fix is loosing federal/state regulations on telepsychiatry.

 

[vistaril]

What's a moran and why can't PA's operate a scope? A teenager with gaming skills could be taught in a couple hours.

partial bowel resections are done with scopes?? Note that I responded to one part of his two part example, and you chose to make an issue of the other part. That's what a moran does btw to answer your other question.

And yeah, I don't see pa/np's making great ground on procedure based medicine subspecialties.....there is too much training there required to be autonomous.

 

[vistaril]

Alot of training goes into becoming a bc child psychiatrist. It doesn't come with shortcuts. I can take on new patients within a week. My schedule is not full.
.

yes but do you take insurance? You can't claim there aren't access problems just because you have open slots of you don't take insuance

 

[PikminOC]

yes but do you take insurance? You can't claim there aren't access problems just because you have open slots of you don't take insuance

So all patients should have insurance? The midlevels will accept all insurances?

 

[greenlion]

This talk about who can help rural areas is missing an important fact: rural areas offer less service in pretty much every field by definition. From late night pizza delivery to someone to come fix your furnace. It's the inescapable cost of rural living. Hence the invaluable PCP and invaluable general surgeon. Bastardizing medical education/training isn't a solution to this. Anyway it would take a colossal effort of flooding the market with lesser-trained providers until enough are forced to go rural in order to find a job. (and the problem being: you'd have to make your standards pretty darn low to make enough of these providers). After all it's not like psychologists prefer rural areas more than others. Telepsychiatry is perhaps the best compromising solution.

 

[smalltownpsych]

How will psychology? In my region, decent psychologists are hard to find. Go a little more rural and I can't get children needed therapy at all. School counselors are the best option, and they are weak at best.

Psychologists don't want prescribing rights in only rural areas. They want it everywhere. Urban areas will become more saturated, and rural areas will continue to suffer.

Again, not pointing toward a solution, although I don't disagree with what you are saying. In our rural area, we do have psychologists, although other areas in the state do have a shortage, we have no psychiatrists, so prescriptions for mental health issues are primarily from a couple of PMHNPs. I work with one and she appears to know the meds pretty well, I really don't feel comfortable with her ability to diagnose and think critically about cases as I hear a few too many loose labels thrown about. I also am concerned about the ability to interact in a therapeutic manner with the patients, gives a lot of advice. Not sure if this is representative of level of training overall, but I guess the solution some are proposing by default is to just let them do it.

 

[smalltownpsych]

The best fix is loosing federal/state regulations on telepsychiatry.

I see that you did post a solution after all. That could help and that is what we will be doing shortly at our company. My experience has been that this leads to less collaboration than if we were working at same company or office, but that could be the same even with psychiatrist in same town. This will be my first experience with tele-med for children so it will be interesting to see how that goes.

 

[F0nzie]

Inadequate training leads to:

Poor diagnostic skills
Poor medical knowledge
Poor pharmacology
Poor therapeutic skills

All are critical in the practice of Psychiatry. That's why you need to go to medical school and residency.

Practicing in a State that is over-run by independent NPs here is what I observe on a daily basis. As an outpatient psychiatrist I do doc-to-docs when my patients are hospitalized. 80% of the time the inpatient psychiatrist is an NP( no wonder I couldn't find an inpatient job). I also get a lot of transfers from NPs in the community and in private practice. Anyways, NPs using antipsychotics strictly for sleep (ie. patient with an adjustment disorder), not recognizing tardive dyskinesia, combining TCAs and SSRI's way too often, using way too much Xanax, giving way too many benzos to alcoholics and opiate addicts, giving Depakote as a first line to a hep C patient with elevated liver enzymes, offering a check box/ typing interview style, not asking pertinent questions, not reading the patient, and using an authorative style of interaction and aggravating patients. I also believe substance abusers and med seekers see nurses as easy targets and get their way more often due to their limited psychopharm knowledge and poor understanding of psychopathology. There are some naturally talented NPs but as a group I do not feel they meet the minimum competency requirements to practice our specialty. Nurses trained by nurses to practice Psychiatry.

And no they are not going to rural areas because there are so many NPs in practice it should have fixed Arizona's rural shortage by now. Just go on Psychology Today and search Psychiatrists in Portland Oregon and take a look at all the out of network NPs charging $200-$300 an hour. Wake up everybody!!!

 

[vistaril]

So all patients should have insurance? The midlevels will accept all insurances?

(sigh)

most midlevels are going to take the more popular/common insurances, yes. You saying "you aren't full" isn't proof that there isn't an unmet need. When people talk about an unmet need, they obviously aren't referring to cash only appts. Of course if someone is willing to pay a lot out of pocket there
is going to be a way to get in. With you and a heck of a lot of other different psychiatrists.

 

[vistaril]

So all patients should have insurance? The midlevels will accept all insurances?

(sigh)

most midlevels are going to take the more popular/common insurances, yes. You saying "you aren't full" isn't proof that there isn't an unmet need. When people talk about an unmet need, they obviously aren't referring to cash only appts. Of course if someone is willing to pay a lot out of pocket there
is going to be a way to get in. With you and a heck of a lot of other different psychiatrists.

 

[PikminOC]

(sigh)

most midlevels are going to take the more popular/common insurances, yes. You saying "you aren't full" isn't proof that there isn't an unmet need. When people talk about an unmet need, they obviously aren't referring to cash only appts. Of course if someone is willing to pay a lot out of pocket there
is going to be a way to get in. With you and a heck of a lot of other different psychiatrists.

PsyD will meet this "unmet" need? Tell me how.

 

[vistaril]

PsyD will meet this "unmet" need? Tell me how.

the same way that more psychiatrists or psychiatric nps would- simply by increasing the volume or prescribers. Duh.

Note that I don't neccessarily think there is an 'unmet need' as I agree with another poster who said it's mainly artificial and driven by misdiagnosis and an overprescribing mentality in general. But that's a separate argument. My only interest in contributing here was pointing out that just because cash pay psychiatrists have openings doesn't meet there isn't an unmet need. In much the same way that Ruth's chris having reservations available tnite doesn't mean that hunger isn't a problem.

 

[vistaril]

combining TCAs and SSRI's way too oftenQUOTE]

there are plenty of thought leaders who do this too though.

 

[PikminOC]

the same way that more psychiatrists or psychiatric nps would- simply by increasing the volume or prescribers. Duh.

Note that I don't neccessarily think there is an 'unmet need' as I agree with another poster who said it's mainly artificial and driven by misdiagnosis and an overprescribing mentality in general. But that's a separate argument. My only interest in contributing here was pointing out that just because cash pay psychiatrists have openings doesn't meet there isn't an unmet need. In much the same way that Ruth's chris having reservations available tnite doesn't mean that hunger isn't a problem.

You are adorable.
So what we need are more prescribers? PCP's don't prescribe?

 

[vistaril]

You are adorable.
So what we need are more prescribers? PCP's don't prescribe?

I certainly wouldn't say I'm adorable, but thanks. I do know I'm not illiterate, which you seem to be on the verge of based on this thread. As has been pointed out already regarding this issue(and numerous times in threads you've been involved in), most pcps don't want to deal with managing patients whose primary reason for presentation is related to mental illness/psych issues. So they are looking to send(or dump if you want to look at it that way) these pts to mh providers who are going to prescribe psychotropics.

 

[PikminOC]

I certainly wouldn't say I'm adorable, but thanks. I do know I'm not illiterate, which you seem to be on the verge of based on this thread. As has been pointed out already regarding this issue(and numerous times in threads you've been involved in), most pcps don't want to deal with managing patients whose primary reason for presentation is related to mental illness/psych issues. So they are looking to send(or dump if you want to look at it that way) these pts to mh providers who are going to prescribe psychotropics.

Ad hominem attack.
Nice. Now I remember why I don't post on here.
Thanks vistaril.
I see you haven't changed a bit.

 

[vistaril]

Ad hominem attack.
Nice. Now I remember why I don't post on here.
Thanks vistaril.
I see you haven't changed a bit.

Ad hominem attacks are poor form when there is disagreement on a clear subject where the argument is well understood. Which is not the case here because it's irrelevant what I believe about psychologist or np prescribing rights. I was simply calling out a ridiculous inference on your part(that because a cash pay psychiatrist has openings that says something about unmet needs), and then from there you ask another illogical and unrelated question.....

 

[whopper]

A thing I don't understand is PCPs are the largest prescribers of psychotropics. If one wanted psychologists opening some doors, why not have some PCPs team up with psychologists? The psychologist, if they have some psychotropic training, could tell the PCP, and make some recommendations with the PCP having the final say.

Why not encourage that model instead of making new laws? Seems like the latter to me is like trying to mash a fist though a straw.

 

[birchswing]

From my perspective as a patient, the issue is not who prescribes medications but whether people who prescribe medications are qualified to do so and know what they are doing. There are many psychiatrists I've seen who ruin lives (I count the long-term prescription of high-dose benzodiazepines without informed consent as at the least causing temporary life-ruing effects) and aren't qualified for their jobs. But I've also been in an ER with an emergency medicine doctor who wasn't qualified to prescribe psychiatric medication and tried to anyway. Are psychologists qualified to prescribe psychiatric medicines? I would say most probably aren't, unless they receive good training and there are standards. But are there standards now?

Is there any US equivalent to the British National Formulary? The way I've seen psychiatric medicines prescribed is the way I see misinformation spread between gossips. Everyone is certain, and most are wrong.

 

[vistaril]

A thing I don't understand is PCPs are the largest prescribers of psychotropics. If one wanted psychologists opening some doors, why not have some PCPs team up with psychologists? The psychologist, if they have some psychotropic training, could tell the PCP, and make some recommendations with the PCP having the final say.
QUOTE]

how is that model going to be paid for though if there is no extra billing to the patient or third parties(which Im pretty sure nobody would pay for).....keep in mind that in the pcp/midlevel model for outpt primary care, the midlevel in that setting doesn't 'make some recommendations'......rather they see the patient completely solo and do everything in the vast majority of cases. That is why that model is so successful from a business perspective. If you applied that model to psychology/pcp teams, I'm not sure what the benefit to the patient would be. It's a different type of implied 'backup' than the midlevel/pcp role.

Instead, your model would seem to place the psychologist in more the role of unpaid consultant......and that's a role that nobody would have any interest in.

 

[smalltownpsych]

A thing I don't understand is PCPs are the largest prescribers of psychotropics. If one wanted psychologists opening some doors, why not have some PCPs team up with psychologists? The psychologist, if they have some psychotropic training, could tell the PCP, and make some recommendations with the PCP having the final say.

Why not encourage that model instead of making new laws? Seems like the latter to me is like trying to mash a fist though a straw.

We already do work with PCPs. Unfortunately, I can't and wouldn't want to make recommendations for medications because I don't have the appropriate training, education, and supervised experience to do so. I will tell the PCPs what the diagnosis is and then it is up to them to choose what to prescribe or not. I could seek out more education on medication but as I don't have prescriptive authority - a) as Vistaril pointed out, I wouldn't make money off consulting (except for referrrals which is how it works now) b) more importantly - without a legal authority to make recommendations on medications wouldn't I be practicing medicine without a license?

 

[TexasPhysician]

We already do work with PCPs. Unfortunately, I can't and wouldn't want to make recommendations for medications because I don't have the appropriate training, education, and supervised experience to do so. I will tell the PCPs what the diagnosis is and then it is up to them to choose what to prescribe or not. I could seek out more education on medication but as I don't have prescriptive authority - a) as Vistaril pointed out, I wouldn't make money off consulting (except for referrrals which is how it works now) b) more importantly - without a legal authority to make recommendations on medications wouldn't I be practicing medicine without a license?

I don't think that was the point. PCP's don't have the time to develop a thorough psych diagnosis with patients and safely monitor them. The PCP's I know are incredibly busy. If psychologists would really team up with PCP's by providing a thorough diagnosis and monitor all psych patients within the PCP clinic, PCP's would be more on board with prescribing meds. From a safety standpoint, this is much more ideal.

 

[erg923]

A thing I don't understand is PCPs are the largest prescribers of psychotropics. If one wanted psychologists opening some doors, why not have some PCPs team up with psychologists? The psychologist, if they have some psychotropic training, could tell the PCP, and make some recommendations with the PCP having the final say.

Why not encourage that model instead of making new laws? Seems like the latter to me is like trying to mash a fist though a straw.

This is generally what happens in VA primary care clinics. At least if the integrated care psychologist is doing his/her job right. I do not advise which meds, but I often do advise when or when I do not think anxiolytics or antideprssants could be clinically indicated or helpful.

 

[Therapist4Chnge]

Inadequate training leads to:

Poor diagnostic skills
Poor medical knowledge
Poor pharmacology
Poor therapeutic skills

In theory….yes, but there has yet to be any peer-reviewed research to show that PA, NP, or RxP Psych have inadequate training.

 

[smalltownpsych]

I don't think that was the point. PCP's don't have the time to develop a thorough psych diagnosis with patients and safely monitor them. The PCP's I know are incredibly busy. If psychologists would really team up with PCP's by providing a thorough diagnosis and monitor all psych patients within the PCP clinic, PCP's would be more on board with prescribing meds. From a safety standpoint, this is much more ideal.

I would love to work more closely with the PCPs but I don't get paid for that so that limits the amount of discussion that could be had. I have had conversations with the medical providers and they have no problem with relatively high-functioning individuals on a trial of an SSRI. What happens when I meet with the patient, evaluate and find that it is more complex than that? The PCP and I both want someone with more expertise with medications, we just don't have that option. I can't safely monitor the patients as I am not going to be spending much time in session on side effects and efficacy of medication. I have found that those discussions tend to be not very useful as I am not the one responsible for the medications.

 

[TexasPhysician]

In theory….yes, but there has yet to be any peer-reviewed research to show that PA, NP, or RxP Psych have inadequate training.

True, but it would be impossible to complete a good study on that. There are plenty of successful lawsuits stemming from "inappropriate monitoring of midlevels". Any time a midlevel messes up, who do you think takes blame? Inappropriate monitoring would not occur with competent care.

It is hard to do any good study on "adequate training" without putting all the blame on midlevels and having them be independent.

The better question should be about the number of residency years required. When a standard is set - that should be the minimum. Make RxP a 4 year full-time program. If it's not needed, the government should shorten residency length to meet demand.

Saying RxP is adequate with a few hundred hours is just inappropriate and absurd compared to all other training entities.

 

[TexasPhysician]

I would love to work more closely with the PCPs but I don't get paid for that so that limits the amount of discussion that could be had. I have had conversations with the medical providers and they have no problem with relatively high-functioning individuals on a trial of an SSRI. What happens when I meet with the patient, evaluate and find that it is more complex than that? The PCP and I both want someone with more expertise with medications, we just don't have that option. I can't safely monitor the patients as I am not going to be spending much time in session on side effects and efficacy of medication. I have found that those discussions tend to be not very useful as I am not the one responsible for the medications.

Right. I'm saying you should work in tandem with prescribers though for ideal care. The government doesn't seek intelligent solutions though.

 

[smalltownpsych]

Right. I'm saying you should work in tandem with prescribers though for ideal care. The government doesn't seek intelligent solutions though.

They don't want to pay for it. Not the government, rather the insurance companies who tell the government what to do.

 

[AcronymAllergy]

They don't want to pay for it. Not the government, rather the insurance companies who tell the government what to do.

Yep, that would be a major roadblock, although it's one reason why (as erg mentioned) it seems to happen more in the VA--providers typically have the time to consult like that, and don't subsequently have to worry about trying to bill insurance for it. If a similar CPT code were somehow magically available (e.g., something you could tack on to your diagnostic eval to bill for time spent consulting with a PCP), I'd imagine plenty of private practice and AMC-affiliated psychologists would be all for it.

 

[Therapist4Chnge]

Saying RxP is adequate with a few hundred hours is just inappropriate and absurd compared to all other training entities.

Posting this in a thread talking about the IL requirements is at best disingenuous and at worst purposefully misleading.

Here are the educational requirements. Additional requirements about ongoing collaboration, limited formulary etc. can be found farther along in the bill.

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(225 ILCS 15/4.2 new)
Sec. 4.2. Prescribing psychologist license.
(a) A psychologist may apply to the Department for a

prescribing psychologist license. The application shall be made on a form approved by the Department, include the payment of any required fees, and be accompanied by evidence satisfactory to the Department that the applicant:

(1) holds a current license to practice clinical psychology in Illinois;

(2) has successfully completed the following minimum educational and training requirements either during the doctoral program required for licensure under this Section or in an accredited undergraduate or master level program prior to or subsequent to the doctoral program required under this Section:

(A) specific minimum undergraduate biomedical prerequisite coursework, including, but not limited to: Medical Terminology (class or proficiency); Chemistry or Biochemistry with lab (2 semesters); Human Physiology (one semester); Human Anatomy (one semester); Anatomy and Physiology; Microbiology with lab (one semester); and General Biology for science majors or Cell and Molecular Biology (one semester);

(B) a minimum of 60 credit hours of didactic coursework, including, but not limited to:
1 Pharmacology; Clinical Psychopharmacology; Clinical
2 Anatomy and Integrated Science; Patient Evaluation;
3 Advanced Physical Assessment; Research Methods;
4 Advanced Pathophysiology; Diagnostic Methods; Problem
5 Based Learning; and Clinical and Procedural Skills;
6 and
7 (C) a full-time practicum of 14 months supervised
8 clinical training of at least 36 credit hours,
9 including a research project; during the clinical
10 rotation phase, students complete rotations in
11 Emergency Medicine, Family Medicine, Geriatrics,
12 Internal Medicine, Obstetrics and Gynecology,
13 Pediatrics, Psychiatrics, Surgery, and one elective of
14 the students' choice; program approval standards
15 addressing faculty qualifications, regular competency
16 evaluation and length of clinical rotations, and
17 instructional settings, including hospitals, hospital
18 outpatient clinics, community mental health clinics,
19 and correctional facilities, in accordance with those
20 of the Accreditation Review Commission on Education
21 for the Physician Assistant shall be set by Department
22 by rule;
23 (3) has completed a National Certifying Exam, as
24 determined by rule; and
25 (4) meets all other requirements for obtaining a
26 prescribing psychologist license, as determined by rule.
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