Oregon House Bill 2702 coming out of State Senate Committee for a full vote

[erg923]

I am an intern at a med school and have a higher show rate that any psychiatrist. This is because I work at MI in order to build motivation for them to change

I do not see a "may" clause here. I see a "may" clause above refering to your inference for a high no show rate of ronin's patients. However, I see a "this is because" satatement here, which to most reasonable people means you are making a causal assumption, no? So, Ill ask again, How have you causally linked your high show rate to your utilization of MI? And what was your methodology for this study?

However, I do know I am a better therapist than most of them.

How? How do you KNOW this? For someone with a Ph.D., you seem to throw around alot of absolutes ("no doubt", the best trained", etc.) without backing evidence. Im sure you can see the slippery slope you are engaging in here.

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[silas2642]

Wait, you're telling me to base my posts on facts and then you tell me that my curriculum had courses like sensation and perception, evolutionary psychology and industrial/organizational psych, but my school didn't. Maybe this is why you're against psychologist prescribing. We do take courses in social and cognitive bases of behavior, but the way these were taught at my school made them very germane to the assessment and treatment of psych disorders. Is your mind changed yet?


Clinical psychologists do have more training in mental illness than any other profession. While MDs are learning about the whole body, we are devoting most of our time to psychopathology. At my school, which is a extremely slanted towards research as opposed to straight clinical work, the research training we received enabled me to both better understand the fine details of assessment and treatment of the mentally ill .


Yes, you're probably right about the mediocrity of the school I am interning at: All of the psychiatry residents are FMGs, there is little research activity, and didactics are sparse. However, you get what you want out of your training, so I always read and seek extra training outside the internship. Otherwise, I would basically be wasting this year.

I wouldn't tell anybody that my show rates are higher because I don't know exactly why their patients aren't showing. It could be secondary to things like transportation issues or it could be due to therapist variables. Who knows? All I am saying is that we need to stop unilaterally blaming patients for treatment failure and look at what we contribute to the process. Mental health is the only field where we can blame treatment failure on the patient and completely absolve ourselves from responsibility.

Finally, I have never claimed I am "superior" to the psychiatrists with whom I work. However, I do know I am a better therapist than most of them. There is no doubt they can manage meds better than I can, but this does not make them superior to me, either...

I think it kind of helps to know about the entire human body instead of just studying psychopathology as you folks do in grad school, particularly since the mind and brain do not exist in a vacuum. There are just too many diseases that can present as or with psychiatric symptoms and you have to be able to rule them out first.

And don't diss FMG's either. I've met some really great docs who were foreign grads. I'm sure there are some FMG's there who could take you to school, so try to maintain some humility.

 

[silas2642]

I do not see a "may" clause here. I see a "may" clause above refering to your inference for a high no show rate of ronin's patients. However, I see a "this is because" satatement here, which to most reasonable people means you are making a causal assumption, no? So, Ill ask again, How have you causally linked your high show rate to your utilization of MI? And what was your methodology for this study?



How? How do you KNOW this? For someone with a Ph.D., you seem to throw around alot of absolutes ("no doubt", the best trained", etc.) without backing evidence

He doesn't have a Ph.D. Didn't you read the prior post? He's still a student, but he's a superior therapist. He's making you guys look bad, frankly.

 

[erg923]

Well, hes on the predoc internship year, which means he'll have it at the end of the year. Yes, kinda scary! Absolute statements like these shoot these people (and their argument) in the foot.

 

[scottresident]

and the legislators going to let this person prescribe medication that can be dangerous to other organs.

 

[Therapist4Chnge]

Well....this thread has run horrendously off course.

Can we get it back on topic please?

 

[scottresident]

edieb
I have great respect for many fmgs. many of them practice medicine, know more about medicine mental health than pre-doctoral student. you should of know by now that prescribing medications require extensive biochemical, physiological, and whole body knowledge.

 

[billypilgrim37]

Can we get it back on topic please?

I've got a better idea. Just make a sticky thread for "mental health workers bitching about other mental health workers with different degrees than you." Although it might crash SDN...

 

[OldPsychDoc]

I've got a better idea. Just make a sticky thread for "mental health workers bitching about other mental health workers with different degrees than you." Although it might crash SDN...

Could just extend it to all disciplines and make it a new subforum in the Lounge...

 

[edieb]

I am not going to keep fighting with psychiatry folks on here. Parsing apart each other's statements is getting nowhere. We all use absolutes: For example, when we distill anti-RxP arguments, they amount to the idea that psychologists must absolutely not prescribe medications even though the evidence shows they can do so safely.

Luckily, legislators are not as myopic as some on this board. I did not even post on the psychiatry board that Oregon passed an RxP law because I didn't want to hear people saying the sky is falling. Another SDNer did so. I know the best strategy is to keep my mouth shut and not give away details that could derail the movement.

In that spirit, it is important to note that I got word that another RxP bill, in a very populous state (I am not saying which because I want to avoid all of you telling legislators there that you're not going to move there if this bill passes, etc.), is making fast progress through the Senate and will also likely pass this year, too. It gives independent RxP to psychologists. So you can keep on saying psychologists should not prescribe, but the movement is gaining momentum and the outcome is inexorable at this point. You just keep parsing apart people's sentences and see how far that gets you

Outrageous!

 

[ronin12]

He doesn't have a Ph.D. Didn't you read the prior post? He's still a student, but he's a superior therapist. He's making you guys look bad, frankly.

May be she ??

 

[ronin12]

I am not going to keep fighting with psychiatry folks on here. Parsing apart each other's statements is getting nowhere. We all use absolutes: For example, when we distill anti-RxP arguments, they amount to the idea that psychologists must absolutely not prescribe medications even though the evidence shows they can do so safely.

Luckily, legislators are not as myopic as some on this board. I did not even post on the psychiatry board that Oregon passed an RxP law because I didn't want to hear people saying the sky is falling. Another SDNer did so. I know the best strategy is to keep my mouth shut and not give away details that could derail the movement.

In that spirit, it is important to note that I got word that another RxP bill, in a very populous state (I am not saying which because I want to avoid all of you telling legislators there that you're not going to move there if this bill passes, etc.), is making fast progress through the Senate and will also likely pass this year, too. It gives independent RxP to psychologists. So you can keep on saying psychologists should not prescribe, but the movement is gaining momentum and the outcome is inexorable at this point. You just keep parsing apart people's sentences and see how far that gets you

Outrageous!

Hmm!! you sound upset, tell me more about your feelings

 

[erg923]

I feel embarrassed......

 

[whopper]

Erg, don't feel embarrassed. Every field has their fair share of good & bad. I've seen too many good psychologists to know that this person isn't indicative of others in the field.

Actually I'm not even sure if this person was a psychologist. He/she mentioned he/she wasn't a psychologist.

Oh well.

 

[appelsoranjes]

I find it humorous that one would claim to be a "better therapist" when we as a field aren't able to precisely quantify meaningful units of therapeutic ability. Psychologists (and psychiatrists) are just as susceptible as "normal folk" to leaps in logic (confirmation bias, illusory correlations etc.) - so to grant yourself the title of a superior therapist outside of a well-controlled study is going against your training young skywalker.

As far as prescription privlidges go, this is where the field is moving - like it or not. Eventually psychiatrists will be responsible only for the most complex cases. Psychologists, with the proper training (which, admittedly should be more significant than the current requirements) - can and will manage medications as well as psychiatrists do. All the training in medical school is superfluous to the day-to-day work of most psychiatrists in private practice - and the distrubution of crappy PhD prescribers will likely be similar to MD samples.

Mind you, professional school aside, it is more difficult to get into a fully-funded PhD program in clinical psychology than to medical school (typically 300+ applicants for 6 open spots). Good psychologists, like good physicians, should know the limits of their knowledge and act accordingly.

 

[ronin12]

I find it humorous that one would claim to be a "better therapist" when we as a field aren't able to precisely quantify meaningful units of therapeutic ability. Psychologists (and psychiatrists) are just as susceptible as "normal folk" to leaps in logic (confirmation bias, illusory correlations etc.) - so to grant yourself the title of a superior therapist outside of a well-controlled study is going against your training young skywalker.

As far as prescription privlidges go, this is where the field is moving - like it or not. Eventually psychiatrists will be responsible only for the most complex cases. Psychologists, with the proper training (which, admittedly should be more significant than the current requirements) - can and will manage medications as well as psychiatrists do. All the training in medical school is superfluous to the day-to-day work of most psychiatrists in private practice - and the distrubution of crappy PhD prescribers will likely be similar to MD samples.

Mind you, professional school aside, it is more difficult to get into a fully-funded PhD program in clinical psychology than to medical school (typically 300+ applicants for 6 open spots). Good psychologists, like good physicians, should know the limits of their knowledge and act accordingly.

you repeated same unscientific assumptions about quality/quantity of medical education required for psychiatrist,and predicted crappiness of psychologist just like psychiatrists.
regarding difficulty entering psychology school, I can only say good for you and good luck.
"the more we learn,the more we know how little we know"

 

[Doctor J 216]

Edieb, I feel sad for you. The chip you carry on your shoulder must be overwhelming. And your career has barely started. Your arrogance is astounding for someone still in training. I think many on this board would think of the diathesis stress model you mentioned when thinking of you specifically.

I personally don't mind psychologist prescribing, it's the training and other political maneuvering that infuriate MDs.

1. safe prescribing does not equal effective prescribing

Where I work, we already get a large number of referrals from psychologists who think they know what they are doing until they clearly don't.

Here is just one recent case. Addicted person treated by primary care physician, psychologist giving "recommendations" (absolute malpractice) to PCP for meds. Gives alcoholic lorazepam for anxiety, leads to overdose. No major injuries though so I guess that's safe. What a ringing endorsement for RxP.

Another psychologist had the audacity to question the prescription of prozac for anxiety in a teen, suggesting that they would have chosen lexapro. I asked what the rationale or evidenced based literature was, and they mumbled some "I had one patient who once, a friend of mine..." and was clearly embarrassed. Again, not dangerous but not good either. I could go on forever.

2. where is the clause that ensures rural access to mental health care as a result of this bill? Is it "trickle down" psychiatry? All medical disciplines are lacking in rural areas, not just psych. I wish RxP proponents would stop promoting patient need as an thinly veiled disguise for guild and financial motives. Be honest about what you want, both sides know these arguments are deceitful. Psychologists will continue to congregate in high population areas. Also, where is the data that says there LA and NM now have no problems with mental health care shortage? Are they now the models of care for public mental health care delivery? Last time I checked, psychiatrists were leaving both states in droves. Way to dry up any talent left in your state Oregon.

3. Big business owns you. Physicians know well the double edged sword of dealing with insurance companies and big pharma. We've been burned before. Pharma wants you to prescribe because you are more easily influenced, insurance companies to save cost. You think psychiatrists do 15 min med checks out of choice? Welcome to the world of mid level practitioners. Call yourself doctor all you want, the businesses that control you won't think of you that way.

4. This goes further to show the public that mental illness is a second degree illness and somehow requires less training to treat than other medical illnesses. Great job RxP. Now states will have more reason to cut mental health funding (cheaper right?). I can't believe someone who gets their degree long distance or online can prescribe. Whack. Wouldn't fly for physicians.

On a purely academic level, doesn't anyone lament the loss of psychology's roots? I think we will all one day (including psychologists) regret the recent series of events and its impact on mental health.

 

[Therapist4Chnge]

How is any of the above anything but useless anecdotal "examples"?

N=1 means.....what?

You basically reduced the discussion down to Story Time.

Fiction?

 

[appelsoranjes]

you repeated same unscientific assumptions about quality/quantity of medical education required for psychiatrist,and predicted crappiness of psychologist just like psychiatrists.
regarding difficulty entering psychology school, I can only say good for you and good luck.
"the more we learn,the more we know how little we know"

Yes, the crappyness statement was an assumption. Obviously there is no data available to support either position - which is why I said "likely"... if such data were available, I'd bet that the distribution of poor prescribers would be similar. We hear anecdotes about horrible phd prescribers (and I'm sure there are plenty) - but there are similar stories of MD prescribers.

As far as medical training being superflous for the day-to-day activities of a private practice psychiatrist - the only way to test this would be to alter the training requirements to see if they have any meaningful effect on treatment outcomes. Neither of us can argue our points without this data, but it is my opinion - and perhaps an underlying reason why psychiatrists get less "respect' than their MD brethen - that private practice psychiatrists use significantly less of their basic medical training than other MD specialists.

Let's be real - behavior is always selfishly motivated, and helping rural patients (or protecting them from undue harm) isn't the ultimate goal of either camp. Instead of fighting off RxP, psychiatrists should be helping to devise a more rigorous and efficient postdoctoral training program that would allow only the most capable psychologits from gaining RxP privlidges. In this sense, I think Oregon made the right step in creating that multidisciplinary board. Hopefully they get along better than the folks here

 

[Doctor J 216]

How is any of the above anything but useless anecdotal "examples"?

N=1 means.....what?

You basically reduced the discussion down to Story Time.

Fiction?

What is this the New England Journal of Medicine? Seems this is a common "devastating" comeback from you student therapist. You offer opinions whenever you want, everyone else must give a citation. Right.

If you are getting a PsyD (vs PhD), do you even know what N=1 is? I'm kidding (sadly many psychologists will get the joke), but I forgot to mention the lack of standardization between PhDs and PsyDs. That's what my "stuck up" PhD friends say anyway.

 

[appelsoranjes]

3. Big business owns you. Physicians know well the double edged sword of dealing with insurance companies and big pharma. We've been burned before. Pharma wants you to prescribe because you are more easily influenced, insurance companies to save cost. You think psychiatrists do 15 min med checks out of choice? Welcome to the world of mid level practitioners. Call yourself doctor all you want, the businesses that control you won't think of you that way.

Are you saying there is no choice? There is a choice, but it is influenced by financial incentives. Psychiatrists could do combined therapy+meds, they could extend patient care and spend an hour with each patient instead of 15 minutes. It is mainly an economic choice to do short med checks. One could argue it also extends care to more people; but I'm sure if we designed a study controlling for reimbursement.......

Of course, this only applies to PP...those grinding it out working "for the man" don't have a choice.

 

[appelsoranjes]

4. This goes further to show the public that mental illness is a second degree illness and somehow requires less training to treat than other medical illnesses. Great job RxP. Now states will have more reason to cut mental health funding (cheaper right?). I can't believe someone who gets their degree long distance or online can prescribe. Whack. Wouldn't fly for physicians.

On a purely academic level, doesn't anyone lament the loss of psychology's roots? I think we will all one day (including psychologists) regret the recent series of events and its impact on mental health.

Not less training. different training. After four years of undergrad (at UC San Diego, where everybody takes the pre-med courses regardless)- it will have taken me 4 years of graduate classes, 1 year of a predoctoral internship (which only 75% of students able to match nationwide), 1 year teaching as a university professor (optional), and 2 years doing post-doctoral clinical work (and research) to become a licensed clinical psychologist - so 8 years after college. Add 2 years for the RxP training, and it comes to 10 years. Nurse practioners, who can prescribe in 12 states can do their training in 2 years after undergrad. Have they sullied the reputation of mental illness in their 10 years in this role?

 

[Doctor J 216]

Are you saying there is no choice? There is a choice, but it is influenced by financial incentives. Psychiatrists could do combined therapy+meds, they could extend patient care and spend an hour with each patient instead of 15 minutes. It is mainly an economic choice to do short med checks. One could argue it also extends care to more people; but I'm sure if we designed a study controlling for reimbursement.......

Of course, this only applies to PP...those grinding it out working "for the man" don't have a choice.

You make a good point Appels. But the choices are harder to make when one starts their career in their early 30s and has 120k + in debt. I was just trying to forewarn about the dangers of partnering with big business. Fortunately, my situation is blessed, but I did have to make some difficult choices due to finances (if I were paid all the same, I would stay and work in the inner cities where I trained).

Thank you also for keeping things civil. I too think psychologists and psychiatrists could work together. I would embrace a model similar to CRNAs and anesthesiologists but I fear the political hurdles for that are too great at this point.

 

[Therapist4Chnge]

What is this the New England Journal of Medicine? Seems this is a common "devastating" comeback from you student therapist. You offer opinions whenever you want, everyone else must give a citation. Right.

If you are getting a PsyD (vs PhD), do you even know what N=1 is? I'm kidding, but I forgot to mention the lack of standardization between PhDs and PsyDs. That's what my "stuck up" PhD friends say anyway.

You make a good point Appels. But the choices are harder to make when one starts their career in their early 30s and has 120k + in debt. I was just trying to forewarn about the dangers of partnering with big business.

Thank you also for keeping things civil. I too think psychologists and psychiatrists could work together. I would embrace a model similar to CRNAs and anesthesiologists but I fear the political hurdles for that are too great at this point.

I'd suggest doing the same, as the above is not civil nor professional.

 

[Doctor J 216]

Not less training. different training. After four years of undergrad (at UC San Diego, where everybody takes the pre-med courses regardless)- it will have taken me 4 years of graduate classes, 1 year of a predoctoral internship (which only 75% of students able to match nationwide), 1 year teaching as a university professor (optional), and 2 years doing post-doctoral clinical work (and research) to become a licensed clinical psychologist - so 8 years after college. Add 2 years for the RxP training, and it comes to 10 years. Nurse practioners, who can prescribe in 12 states can do their training in 2 years after undergrad. Have they sullied the reputation of mental illness in their 10 years in this role?

I have to disagree on this one. I don't want to digress about how hard it is to get into school etc but years in training does not equal years in training. Residents and med students work far more hours than grad students (trust me, I had therapy supervision for years alongside psychology peers, they had weekends off, I slept in the ER). So the 10 years for me post college (4 med school, 4 residency, 2 fellowship) is a bit different. And my first year in residency was before the 80 hour work week (I logged 90+ per week 3 or 4 times at least, three 36 hour shifts seeing psychotic veterans will do that). You should break it down by hours, breadth of training, acuity (complicated patients) etc.

It's like we both spent the same amount of time at a restaurant, but you had a decent sized sandwich and a coke, and I had a buffet and drank out of a fire hydrant. It's just like your moniker appels.

The thing with NPs is that they are under the fold of the medical model (not saying that is the best or only model) and that does help with alignment and teamwork. I don't know if psychologists would be comfortable being included in a medical model.

 

[appelsoranjes]

I have to disagree on this one. I don't want to digress about how hard it is to get into school etc but years in training does not equal years in training. Residents and med students work far more hours than grad students (trust me, I had therapy supervision for years alongside psychology peers, they had weekends off, I slept in the ER). So the 10 years for me post college (4 med school, 4 residency, 2 fellowship) is a bit different. And my first year in residency was before the 80 hour work week (I logged 90+ per week 3 or 4 times at least, three 36 hour shifts seeing psychotic veterans will do that). You should break it down by hours, breadth of training, acuity (complicated patients) etc.

I agree that medical school is more intense & demanding than graduate school - however, the question was whether the training requirements would influence the reputation of mental illness as as second-class illness. In the mind of the lay person (many of whom couldn't tell you the difference between a psychiatrist or psychologist in the first place), I'm not sure it would.

As far as difficulty getting into medical school, I would argue that it is as difficult to get into a funded phd program in psychology. Granted the minimum prerequisites aren't as rigorous to complete, but the competition-to-slots ratio means acceptance rates in the 1-5% range. PsyDs are a different story, of course.

 

[whopper]

In the mind of the lay person (many of whom couldn't tell you the difference between a psychiatrist or psychologist in the first place), I'm not sure it would.

Agree, though I still think the original point is valid. Whether or not it is interpreted as such as such by the layperson, the precedent it creates can still be interpreted by the "experts" for what it is.

In fact, given the Oregon law, it creates a standard that allows one to prescribe with very few requirements vs medical school, and several of those requirements are not tested on a standard with tons of data such as the USMLE, or the teaching standards approved by a higher body such as the ACGME. As I mentioned before--one could simply go to a doctor's office & watch TV all day long given the requirements, and if the supervising doctor was was not on top of the teaching situation.

One could for example argue that Ph.D. level excercise science majors, physical therapists, social workers, counselors, etc should now be able to prescribe with the similar 2 year curriculum. Heck in fact physical therapists get more medical training than psycholoigsts in a standard curriculum for that profession.

As for medical school or graduate school being more difficult, the argument is moot IMHO. IMHO medical school in general is more difficult. I've had semesters where I've had 25 or more credits. The requirements are difficult (in general). I have friends who current are working on a psychology Ph.D. and these people actually have lives--I did not in medical school. That being said, there's plenty of very difficult Ph.D. psychology programs that are much more difficult than the lesser competitive programs. The variability between Ph.D. programs is much more than medical school.

All that really is moot. One could brag that theirs was more difficult. The bottom line is if the profession has enough qualifications to prescribe medications, several of which can be fatal, several of which require an understanding of things such as metabolic disorder. IMHO, the Oregon law does not require enough.

 

[sunlioness]

I really don't understand why how hard it is to get into a certain field or how many years you spend training for it is even relevant.

It's really hard to get into Harvard Business School. Probably harder than it is to get into med school or grad school for psychology. That doesn't mean graduates of Harvard Business School should be able to prescribe medications.

Also there are many other fields that require a lengthy education and training process and a lot of hard, grueling work within them. But if you're not gaining the experience necessary to be able to safely prescribe, so what? If you're a PhD archaeologist and Egyptologist, the top of your field, and published, I am going to admire you and the dedication you put into getting where you are. But that doesn't mean you should be allowed to prescribe medications.

All this argument about how hard school is to get into either way and how long it takes either way and how hard one works while one is there just seems a distraction to me. Whether used for pro or used for con, it's still irrelevant.

 

[appelsoranjes]

I really don't understand why how hard it is to get into a certain field or how many years you spend training for it is even relevant.

It's really hard to get into Harvard Business School. Probably harder than it is to get into med school or grad school for psychology. That doesn't mean graduates of Harvard Business School should be able to prescribe medications.

Also there are many other fields that require a lengthy education and training process and a lot of hard, grueling work within them. But if you're not gaining the experience necessary to be able to safely prescribe, so what? If you're a PhD archaeologist and Egyptologist, the top of your field, and published, I am going to admire you and the dedication you put into getting where you are. But that doesn't mean you should be allowed to prescribe medications.

All this argument about how hard school is to get into either way and how long it takes either way and how hard one works while one is there just seems a distraction to me. Whether used for pro or used for con, it's still irrelevant.

Agreed; the difficulty of entrance should have no bearing on the logic of a RxP argument. For the record, a harvard MBA isn't as difficult as it may sound... they accept 15-20% of applicants in a pool of 6,700. Granted, I don't know the features of the applicant pool...but IMHO an MBA is more about networking and opening doors than about learning anyways.

If PhD archaeologists had significant training in the etiology, diagnosis, and treatment of mental illness - then I'd be supportive of them gaining RxP rights with suitable medical training (perhaps the equivalent of a NP). As it stands right now, I think the additional training requirements for RxP psychologists lack in depth and rigor. As someone who has taken a year of physics, biology, chemistry, and calculus at the undergraduate level - I don't see the value of such courses in functioning as a psychiatrist. I'd dare venture, in order of importance, the skills to be: critical thinking, ability to diagnose correctly, psychopharmacology, and medical training (enough to be able to rule out that the symptoms are originating from an undiagnosed medical condition and to order/interpret labs) - of course, this is for RxP. ECT and DBS are another story.

 

[ronin12]

I guess this discussion is not going anywhere so to end this, let me state to console infinitely fragile ego of my psychology colleagues." You are educated people psych D or PHD both. getting phd is not child's play ,you are undoubtedly among the most educated people of our society. all my respects to your contribution to the field of mental health.Frankly it is psychotherapy part of psychiatry which really makes it so cool and distinctive among other medical specialities.
"BUT"
"You are not qualified to prescribe medications,or nor will be without going through med school.Law might allow you to do so, but unfortunately it will be mumbo, jumbo medicine and patient will suffer. Unfortunately this is my observation with NP's PA's, which probably have far more exposure to medicine then psychologists"
signing off.

 

[appelsoranjes]

I guess this discussion is not going anywhere so to end this, let me state to console infinitely fragile ego of my psychology colleagues." You are educated people psych D or PHD both. getting phd is not child's play ,you are undoubtedly among the most educated people of our society. all my respects to your contribution to the field of mental health.Frankly it is psychotherapy part of psychiatry which really makes it so cool and distinctive among other medical specialities.
"BUT"
"You are not qualified to prescribe medications,or nor will be without going through med school.Law might allow you to do so, but unfortunately it will be mumbo, jumbo medicine and patient will suffer. Unfortunately this is my observation with NP's PA's, which probably have far more exposure to medicine then psychologists"
signing off.

Classy. I love the passive-aggressiveness. As a psychiatrist I would expect you to be a bit more introspective in how your own ego is involved as well. I sincerely hope you don't bring that attitude in the room with you during your work with patients. Even the best of drugs wouldn't counteract such bedside manner. If, as a result of scope-increase, psychologists become as ignorant in the importance of introspection, empathy, and an alliance - then I do pray that RxP doesn't progress.

 

[E Dubble]

I guess this discussion is not going anywhere so to end this, let me state to console infinitely fragile ego of my psychology colleagues." You are educated people psych D or PHD both. getting phd is not child's play ,you are undoubtedly among the most educated people of our society. all my respects to your contribution to the field of mental health.Frankly it is psychotherapy part of psychiatry which really makes it so cool and distinctive among other medical specialities.
"BUT"
"You are not qualified to prescribe medications,or nor will be without going through med school.Law might allow you to do so, but unfortunately it will be mumbo, jumbo medicine and patient will suffer. Unfortunately this is my observation with NP's PA's, which probably have far more exposure to medicine then psychologists"
signing off.

Even after medical school we aren't qualified to prescribe meds. Medical school is just the beginning. Residency is where the real training occurs. I'm a physician but I'm not a psychiatrist. Being a physician, I know enough to know what I don't know. And how do I know this? Because I have actually taken care of people. Sick people. In real life. Beyond a starting dose, MOST physicians whom I have worked with (that are not psychiatrists) don't wanna touch psychotropic meds. These drugs are dangerous. If most internists aren't comfortable managing these meds how in the heck can a psychologist. Its really sad. They really don't know what they don't know. And who cares which school is harder to get into? What does that have to do with anything?

 

[appelsoranjes]

Even after medical school we aren't qualified to prescribe meds. Medical school is just the beginning. Residency is where the real training occurs. I'm a physician but I'm not a psychiatrist. Being a physician, I know enough to know what I don't know. And how do I know this? Because I have actually taken care of people. Sick people. In real life. Beyond a starting dose, MOST physicians whom I have worked with (that are not psychiatrists) don't wanna touch psychotropic meds. These drugs are dangerous. If most internists aren't comfortable managing these meds how in the heck can a psychologist. Its really sad. They really don't know what they don't know. And who cares which school is harder to get into? What does that have to do with anything?

So if your extensive medical school training prevents you from presrcibing these meds effectively, what do would feel would eventually help you do so (aside from doing a psych residency)?

 

[ronin12]

Classy. I love the passive-aggressiveness. As a psychiatrist I would expect you to be a bit more introspective in how your own ego is involved as well. I sincerely hope you don't bring that attitude in the room with you during your work with patients. Even the best of drugs wouldn't counteract such bedside manner. If, as a result of scope-increase, psychologists become as ignorant in the importance of introspection, empathy, and an alliance - then I do pray that RxP doesn't progress.

oops!! I was expressing my honest opinion, rather providing online therapy session to "psychology prescriber wanna bees".
I guess rather consoling I hurt this infinitely fragile ego.
good luck .I hope one day you will find peace and inspiration with in.

 

[whopper]

So if your extensive medical school training prevents you from presrcibing these meds effectively, what do would feel would eventually help you do so (aside from doing a psych residency)?

2 years of residency IMHO--& that is a minimum, leaving the resident with only a beginning understanding.

I mentioned this in a previous thread, but IMHO you really only truly understand prescribing in medical treatment after at least 1 year of residency. I know of several good residents who after 6 months of reading labs will only get an inkling of understanding, where a resident who's done 2 years gets an acceptable level.

And that's under the guidelines of an ACGME program that has a structured setting far above the Oregon requirements with senior residents & attendings supervising, morning reports, calls, about 80 hrs a week of work etc.

As I mentioned in the previous thread concerning this issue, the Oregon law really is only about 2.5 (or was it 3.5? I forgot) equivalent months in terms of hours, with the possibilty that the attending supervisor might not give adequate supervision since the supervision guidelines mentioned are few.

Add to that--M.D.s have 2 years of clinical experience in addition to residency where medical students are attempting to interpet labs & such.

There's a reason why for example I had to take Ob-Gyn. I've had several patients in the past year where their pregnancy status was in question. The pregnancy test was positive--but the patient had several clues to make me think the test was a false positive. Turned out one of them had retained placental products. I had a pregnant patient where the Ob-Gyn doctor covering the same patient argued she wasn't pregnant--even wrote that in her notes. He was not doing enough work, and didn't order 2 consecutive B-HCG tests, nor did an ultrasound. It turned out she was pregnant. Both patients required medications which could have lead to a birth defect.

How could one know that without medical training in Ob-Gyn? How would have a psychologist prescriber handled such a situation other than flee to a psychiatrist or other M.D. for help? Interpret labs? There's no Ob-Gyn training in the Oregon law. There are several psychiatric meds that can cause birth defects & cause other problems with children (be passed into the mother's milk etc).

So IMHO--a better way to make psychologists acceptable would be for them to have at least 2 years of clinical experience (arguably more) that are of ACGME residency quality, and they'd have to pass an exam on the order of the USMLE 1, 2 & 3. Not just some exam that covers the same material--but have a pass rate on the same order with the psychologist prescribers being able to numbers on the order of their psychiatric colleagues, or to pass an exam that is on the same order as taken by nurse practitioners or PAs--with the same pass rate.

 

[Therapist4Chnge]

So IMHO--a better way to make psychologists acceptable would be for them to have at least 2 years of clinical experience (arguably more) that are of ACGME residency quality....

I still believe there should be req. collaboration based on the current requirements, and I am supportive of this level of clinical experience, though I'm curious how it compares to NP requirements?

 

[appelsoranjes]

oops!! I was expressing my honest opinion, rather providing online therapy session to "psychology prescriber wanna bees".
I guess rather consoling I hurt this infinitely fragile ego.
good luck .I hope one day you will find peace and inspiration with in.

You are familiar with the word projection, no? With all this repeated talk about fragile egos, it has got me wondering about you ronin - I do know that psychiatry gets the short-end of the stick in the "MD-respect" world (talk about high school), and you have my empathy for that... but alas, I don't do online therapy as well (and, I tend to avoid unfalsifiable interventions anyways).

 

[appelsoranjes]

So IMHO--a better way to make psychologists acceptable would be for them to have at least 2 years of clinical experience (arguably more) that are of ACGME residency quality, and they'd have to pass an exam on the order of the USMLE 1, 2 & 3. Not just some exam that covers the same material--but have a pass rate on the same order with the psychologist prescribers being able to numbers on the order of their psychiatric colleagues, or to pass an exam that is on the same order as taken by nurse practitioners or PAs--with the same pass rate.

I think your requirements are sound; hopefully the Oregon task-team (which contains a prominent OHSU psychiatrist) will come up with similarly rigorous requirements.

 

[hereandnow]

_Proposed Double-Blind Experiment Using Standardized Patients_

First, thank you to everyone who has endeavored to maintain civil discourse in what is clearly a deeply impassioned dialogue. I thought it might be a good idea to attempt to construct a model experiment which might determine adequacy or inadequacy of psychotropic prescriptive training for aspiring RxP psychologists. These are my thoughts on how we might scientifically (rather than anecdotally) make a determination on this very important issue.

Let R1% be the percentage rate at which individuals who undergo psychiatric training nevertheless remain incompetent as prescribers.
Let R2% be the percentage rate at which individuals who undergo psychopharmacological training/internship post-clinical psychology Ph.D. nevertheless remain incompetent as prescribers.

Let incompetence be defined so as to also include the inability to appropriately refer cases beyond the scope of one's competence.

Based on the testimony of individuals on this board, there appears to be anecdotal evidence that both R1 and R2 are not zero. However, because there have not (to my knowledge) been any direct scientific studies on this, it is difficult to know a priori which percentage value, R1 or R2, is in fact greater.

Certainly, if R2 is significantly greater than R1, then there is a problem with the psychopharmacological training/internship that aspiring prescribing psychologists undergo.
Conversely, if R1 is significantly greater than R2, then there would appear to be a problem with the psychiatric training/residency that aspiring psychiatrists undergo.

There is anecdotal evidence that prescription trained psychologists may in some instances correct or improve upon pre-existing psychiatric prescriptions. There is also anecdotal evidence that psychiatrists may in some instances correct or improve upon the prescriptions of RxP-trained psychologists.

I would think that there should be some way of constructing a double-blind experiment -- perhaps through using a large number of standardized patients -- so that accurate determinations of R1 and R2 may be made. This would seem to be a way of scientifically (rather than anecdotally) determining an aspiring prescriber's fitness to prescribe. Hopefully this kind of scientific experiment can be constructed and carried out.

Although the scientific study cited by edieb which purportedly demonstrates the capacity of RxP psychologists to prescribe safely appears to be valid, I would think that a double-blind experiment would be a more rigorous study.

A study of this kind may in fact demonstrate that R2 is unacceptably higher than R1 -- in which case the training criteria for RxP should be significantly revised. Or, it may demonstrate that there is more parity of competence than one might initially think. And if by some chance R1 was higher than R2, it would be interesting to attempt to determine why this might in fact be the case.

 

[scottresident]

If my recollection serves me correctly, the defense department study terminated early because it shows the prescribing psychologists have medical knowledge equivalent to 4th year medical students, and no additional benefits for the patients while cost more to train. I think psychologists were under psychiatrists' supervision in that study, not independent.

 

[scottresident]

the American public also need to be informed of the difference between psychiatrists and psychologists. not all "doctors" are train the same. I've seem it all the time on TV. they have PhD diagnose and tx patients.

 

[Therapist4Chnge]

The information below was pulled directly from the GAO report (in blue).

If my recollection serves me correctly, the defense department study terminated early because it shows the prescribing psychologists have medical knowledge equivalent to 4th year medical students, and no additional benefits for the patients while cost more to train.

Granting these graduates full or partial independent status indicates hospital officials' belief that the graduates need no more supervision than do other prescribing providers.

The overall training cost was more, which was the reason for discontinuing the training, not because they were equivalent to 4th year medical students.

I think psychologists were under psychiatrists' supervision in that study, not independent.

Initially, all graduates received close supervision by psychiatrists, in accordance with guidance issued as part of PDP. For example, each graduate's supervisor reviewed the graduate's charts for patients receiving medication. Other elements of supervision varied but included observing patient sessions or meeting separately with patients; holding formal weekly meetings to discuss cases; and requiring written approval for either starting, stopping, or changing the dosage of medications. The level of supervision was subsequently reduced for all graduates, seven of whom were granted independent status—meaning that they are subject only to the same level of chart review as other providers at their location. Another graduate has been granted independent status for treating outpatients—the bulk of the graduate's caseload—but is supervised when treating inpatients.

The remaining two graduates have not been granted independent status. Officials stationed at one graduate's location told us that they had anticipated granting him independent status; however, before officials reevaluated his status, the graduate was transferred to a new location. The second graduate serves at a facility that has a policy requiring continued supervision of all physician extenders (such as prescribing psychologists, physician assistants, and nurse practitioners) who prescribe medication, regardless of length of service or level of performance. According to the graduate, hospital officials at the graduate's new location have not yet determined whether he will be granted independent status.

 

[appelsoranjes]

the American public also need to be informed of the difference between psychiatrists and psychologists. not all "doctors" are train the same. I've seem it all the time on TV. they have PhD diagnose and tx patients.

Yes, let's undertake a huge national public awareness campaign. Ronin's ego may finally feel at peace

 

[ronin12]

]You are familiar with the word projection, no? With all this repeated talk about fragile egos, [/B]it has got me wondering about you ronin - I do know that psychiatry gets the short-end of the stick in the "MD-respect" world (talk about high school), and you have my empathy for that... but alas, I don't do online therapy as well (and, I tend to avoid unfalsifiable interventions anyways).

wow! not only fragile but unstable ego, regresses so quickly.
till this date I have no plan of pursuing twisted legislative backdoor or through internet advocacy attain something for which either I am not qualified or could not achieve on the basis of talent or merit.
I could not stress more, you should look inside for inspiration,other wise you will keep on projecting feelings of inadequacy about your processional accomplishments by repeating how hard it is to get into grad school and by so called increasing the scope of psychology by getting prescription privileges.To the best of my knowledge no psychiatric organization,person or department is pursuing any legislation to increase the scope of psychiatry.

peace.

 

[appelsoranjes]

wow! not only fragile but unstable ego, regresses so quickly.
till this date I have no plan of pursuing twisted legislative backdoor or through internet advocacy attain something for which either I am not qualified or could not achieve on the basis of talent or merit.
I could not stress more, you should look inside for inspiration,other wise you will keep on projecting feelings of inadequacy about your processional accomplishments by repeating how hard it is to get into grad school and by so called increasing the scope of psychology by getting prescription privileges.To the best of my knowledge no psychiatric organization,person or department is pursuing any legislation to increase the scope of psychiatry.

peace.

Wait, I thought you didn't do therapy online? Since your Fruedian lingo is so conveniently unfalsifiable, I could spit back the same type of "analysis" about your own over-defensiveness and quick-to-belittle demeanor (they did teach you in your "superior" training model that the root of narcissistic behavior is critically low levels of self-worth, right?). I readily admit my ego is involved in this discussion- at least I have the self-awareness (and ego strength) to admit it.

 

[whopper]

The GAO mentioned several points, which some on this thread (though most of those people are now now longer posting) have manipulated.

It did mention that the psychologist prescribers did do a fairly good job, and that their psychiatric colleagues--although against the idea at first did open up to the psychologist prescribers.

However it also did mentiont the following...
-use of psychologist prescribers didn't really help with availability to those in need of psychotropics
-the use of psychologist prescribers in the military did not correlate well in real life practice, and therefore the study could not condone such
-use of psychologist prescribers actually costed the system more than just using pyschiatrists alone
-psychologist prescribers did acknowledge that they did not have as much medical knowledge as their psychiatrist colleagues, and did refer to them when needed.

Further, as Anasazi mentioned in another thread--psychologist prescribers in the GAO study only prescribed SSRIs, and were only working on non pediatric & nongeriatric patients who were found to have no nonpsychiatric medical disorders.

The Oregon law does not restrict psychologist prescribers to only SSRIs, to only non-peds/non geriatric patients, to those where a nonpsychiatric medical disorder has been ruled out. If it did, then the GAO study would actually have some merit to be used. This is clearly not the case.

 

[appelsoranjes]

The GAO mentioned several points, which some on this thread (though most of those people are now now longer posting) have manipulated.

It did mention that the psychologist prescribers did do a fairly good job, and that their psychiatric colleagues--although against the idea at first did open up to the psychologist prescribers.

However it also did mentiont the following...
-use of psychologist prescribers didn't really help with availability to those in need of psychotropics
-the use of psychologist prescribers in the military did not correlate well in real life practice, and therefore the study could not condone such
-use of psychologist prescribers actually costed the system more than just using pyschiatrists alone
-psychologist prescribers did acknowledge that they did not have as much medical knowledge as their psychiatrist colleagues, and did refer to them when needed.

Further, as Anasazi mentioned in another thread--psychologist prescribers in the GAO study only prescribed SSRIs, and were only working on non pediatric & nongeriatric patients who were found to have no nonpsychiatric medical disorders.

The Oregon law does not restrict psychologist prescribers to only SSRIs, to only non-peds/non geriatric patients, to those where a nonpsychiatric medical disorder has been ruled out. If it did, then the GAO study would actually have some merit to be used. This is clearly not the case.

Clearly the DOD study isn't generalizable, and clearly this discussion will not be resolved without solid data. I'm sure in 5-10 years time, such data will be available by way of LA/NM, whether it will be in the form of a well-designed methodology is another question (and, doubtful IMHO).

I'm an academic psychologist who does clinical work on the side; personally I wouldn't feel comfortable dealing with children/geriatrics or polypharmacy without med-school training, and even if I had RxP, I would be very conservative with it.

My father is an OB/GYN, so I have great respect for physicians and medical-training. However, I don't see it as the only path to understanding psychopharmacology and medicine. The problem is in the checks/balances and quality-control of non-Md paths to RxP. There needs to be more rigorous requirements and testing.

Complex cases will ultimately be referred to psychiatrists regardless of psych RxP, so I don't see the market for psychiatry being effected (with the exception of seeing less "easy" cases for PP psychiatrists).

Ironically, I just read that children's hospital in new orleans has hired their third medical psychologist (by way of APA newsletter)...

 

[scottresident]

one of the premises that medical psychologists claim was to increase access in the underserved area, but they tend to be in big cities. they now pushing for hospital admission right, and be on the same level as attending psychiatrists in LA.

 

[ronin12]

one of the premises that medical psychologists claim was to increase access in the underserved area, but they tend to be in big cities. they now pushing for hospital admission right, and be on the same level as attending psychiatrists in LA.

frankly we can not convince them, how misguided/ignorant they are by pursuing this legislation. they will never get it, first they lack what is takes to know how little they know. above all they are desperate for monitory gains/gaining relevancy to changing mental health arena(getting more biological). most repugnant aspect is their willingness to jeopardize patient safety by intentional overlooking their shortcomings. Most surprising aspect is their blind defense of their ignorance, to physicians it is so evident and they lack that insight to even know how ill prepared they are.It makes it more fun to read their arguments, as they sound so ridiculous.

 

[Faebinder]

frankly we can not convince them, how misguided/ignorant they are by pursuing this legislation. they will never get it, first they lack what is takes to know how little they know. above all they are desperate for monitory gains/gaining relevancy to changing mental health arena(getting more biological). most repugnant aspect is their willingness to jeopardize patient safety by intentional overlooking their shortcomings. Most surprising aspect is their blind defense of their ignorance, to physicians it is so evident and they lack that insight to even know how ill prepared they are.It makes it more fun to read their arguments, as they sound so ridiculous.

Just let it be, sooner or later someone will die and the state will come down on them. Someone will think someone is psychotic and keep increasing meds when the patient is actually impacted and decompensating.