Psychopharmacology/Advanced Practice Psychology

[RGMSU]

So why are you so interested in medical psychologist prescription rights if you believe in CBT over antidepressants? As per your article, you might be interested in the rebuttal "Do antidepressants work?" at http://ebmh.bmj.com/cgi/content/full/11/3/66.

I prefer a more subjective patient-by-patient examination over the use of arbitrary levels of change on a depression scale to determine effectiveness. This is the difference between research in the lab and seeing a patient in a clinic. Rebuttals would tend to indicate that there was a statistic significance to the change on drug versus placebo, but it did not meet arbitrarily set standards by the researchers. One example - a mean decrease in HDRS of 9.6 compared to 7.8 on placebo, but this difference is below the arbitrary 3 point difference mark. Variations also occurred depending on which antidepressant was used, which seems to belie the argument that they weren't working on the face of it. So, antidepressants are better than placebo (we can argue about how much), and effectiveness of antidepressants increases with severity of original presenting condition. Is that supposed to surprise anybody? Who cares about the placebo effect anyway? Half of modern medicine is still based on the placebo effect? Do you know how many people get an antibiotic from a doc for a URTI and then think it was the antibiotic when they start to get better in 5 days? Hell, they would have anyway by the natural course of the disease. I could probably make a pretty convincing argument that overuse of antibiotics is much more serious than "overuse" of antidepressants. It is interesting that the FDA defied this submitted data as well. The medical way of approaching this is entirely different from statistical analysis. Patient comes in with complaint, we ascertain whether the complaint is valid and its cause, then we develop a treatment to deal with the complaint. If the treatment works, we continue it. If it doesn't, we try something else. That's just the reality of medical care, and it is why I think people are somewhat naive when they tout "evidence-based medicine," as though everything we do in medicine can be quantified and graphed. If a study shows improvement over a placebo, then there is improvement, same as if a study shows a side effect (usually a small percentage change compared to placebo), it is still a side effect. And, personal experience trumps lab study for me anyway, but I don't think the lab evidence in this case proves one darn thing toward your argument. If medical psychologists start prescribing widely, you will discover that you and your colleagues move further and further toward the psychiatric treatment model. You will become what you despise in psychiatrists, the supposed "pill pushers," yet you want to have the script pad to "push the pulls" too. Psychiatrists used to spend thirty minutes with a patient on the big leather couch too you know? And it really wasn't that far back historically. And, if you think anybody can ever come up with a lobby powerful enough to counteract big pharm, you'd better think again. Last thing, if you expect to take Granny off of all her pulls and talk to her instead when you get prescription rights, don't expect to steal too much business from the psychiatrist. Trust me, people get really ticked off in medicine when you don't give them what they expect to receive.

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[cara susanna]

And, personal experience trumps lab study for me anyway

Then you're never going to agree with us on anything.

 

[doctorpsych]

(1) I would say severe OCD could likely be handled by a psychologist, shouldn't be handled by an FP unless it is until such time that the person may be referred. If anti-anxiety dosages become quite high, the case should probably go to a psychiatrist. Again, if I were an FP, I would still refer to a psychiatrist, but that is my personal privilege. Texas does not have medical psychologists anyway. (2) Debilitating panic disorder - maybe psychologist, again if highly severe with high anti-anxiety dosages, psychiatrist needed in my opinion. FP shouldn't treat it unless it is until such time that the referral can be made. (3) Li - psychiatrist only because of Li toxicity. (4) Clozaril - psychiatrist only because of box warnings concerning seizures, myocarditis, agranulocytosis. Would prefer an FP over a psychologist on this one because of the multiple internal medicine concerns. (5) Carbamazepine - concerns about aplastic anemia and agranulocytosis, so again - psychiatrist preferred, simple blood tests can reveal the aforementioned conditions so not a huge concern for either psychologist or FP, unless there is coexisting epilepsy that would be affected by dosage changes of carbamazepine or something along those lines, then you would really need a psychiatrist working with a neurologist. (6) Substance abuse titration - psychiatrist for the medical detox because of potential medical crises that could develop, psychologist after detox because much follow through would be needed. FP shouldn't be doing this. (7) Differentiation of childhood bipolar/ADHD - psychologist or pediatrician fine for this. Psychiatrist not explicitly necessary. (8) non-benzo for insomnia - Lunesta and such - might not have a problem with this, but it can be habit forming. I would say a family doc could definitely use this because sleeping difficulties are not inherently psychological nor psychiatric. I wasn't aware that medical psychologists could prescribe controlled substances? Probably disagree with that. (9) I don't have a problem with any of the non-physician prescribers you mentioned as long as they practice under physicians and seek guidance when necessary. My concern about the medical psychologists, at least on this forum, is that they seem quite hostile toward physicians (hah, and medical students), which makes me inclined to think they might not want to work very closely with a psychiatrist. I think a medical psychologist should practice with a psychiatrist on their license, which is the case for NPs and PAs in Texas. I don't see what DOs or FMGs have to do with this at all. Some physicians are well-trained. Some aren't. I suspect the same is true among psychologists. (10) I don't agree with GPs practicing without residency. They should do a residency, and I'm here to tell you that 99.999999% of them do. The trend you're talking about was literally decades ago dude. (11) My objections are obviously clinically based, as I mentioned specific internal medicine examples of thorny issues that could arise and go undiagnosed or improperly dealt with. (12) I haven't heard much mention of psychologists in proposed health reform - I suspect the proposed health reform will hurt all specialists to some extent and favor generalists. The intention will be to save money by reducing referrals, and the insurance companies/government won't care about whether the referral is to a psychologist or a psychiatrist. They will try to get the FP to do EVERYTHING, just like the HMOs did. (13) Don't play like St. Sebastian. You're posts before the "Hey Punk" thing were plenty nasty, and at least two of your comments (1 on a post and 1 on a PM) were rather bizarre sexually charged sorts of statements. I apologize to the other members of the forum as well, though. My behavior was unprofessional, reflected poorly on me and my school, and was driven by a quick temper and lack of patience.

You still didn't address my question. So in pretty much all of the situations noted, you would refer to a psychiatrist. My question was what would you do if a psychiatrist wasn't available? That's the real issue here. I wasn't asking how much you know or how well you can look up things, I wanted to know how you would justify not referring to a medical psychologist when a psychiatrist is not available. The unavailability of psychiatrists is a real thing and with the rxp movement going to full swing, with a third state coming on-line next year and with more psychologist receiving training every semester (and a large portion of these psychologist work and reside in locations where there are no psychiatrists), how can you justify not referring such cases to a medical psychologist who can, not only safely treat with psychotropics, but they can also provide effective psychological treatment. What would you propose that a pcp do with such patients? This is exactly what is occurring in areas where a psychiatrist is unreachable, which is anywhere far enough away from a large metro area. Btw, in regards to OCD, cbt+med show about 80-85% response rate so your best bet would be a medical psychologist who can do ERP/Flooding/med. Also, Barlow's Panic Control training has demonstrated better response than Alprazolam alone, and remission and recovery rates far exceeds med treatment upon discontinuation. So a psychologist or a medical psychologist would be your best bet here, not a psychiatrist as you correctly stated. Monitoring Li, tegretol, clozaril can all be safely done (and are currently being done) by medical psychologists. Medical psychologist are prescribing benzo when indicated and are titrating people off from them safely too. Childhood bipolar vs. adhd, better done by a medical psychologist who can do testing, behavioral management/parent training, and prescribe psychostim if ADHD and if deemed necessary. Research shows psychological treatment is more effective tx insomnia than meds, superior prolonged results, no habituation-- which is a problem with most if not all hypnotics. A medical psychologist would be able to do both modalities, using meds initially and titrating off meds once cbt effects kicks in. Again, medical psychs are all for collaborating with physicians... if you want to label it with a caste system, then you would call it supervision. The reason why I asked you about FMG's and DO's is that organized medicine also attempted to limit their practice of medicine with the same arguments and terror campaign... and it didn't work. Regarding the GP's, I guess you can practice medicine with only 4 years of medical school and 1 year of internship afterall. I don't disagree that they are the minority, but just a few months ago, I met 2 of them and I'm at a large metropolitant area with at least 3 medical schools in the top ten rankings. They seem to be doing just fine. The point is that legally they can. So what's the beef with medical psychologists who get 6 years of doctoral training and 2+ years of postdoc in psychopharm? Lastly, I already told you to be civil, but now you are just making things up. You started PMing me and I never replied to you with any bizarre responses. Stop playing the victim role here and stop insulting the intelligence of the members. I don't believe I'm the only psychologist here that finds your comments and tone offensive. I believe the comment that you are attempting to twist in one of my posts was a play on words regarding your ego and a tendency to put down med. psychology while agrandizing yourself for being a med student. I'm telling you again to be civil and the least that you can do is to be truthful.

 

[doctorpsych]

Then you're never going to agree with us on anything.

Yeah, I always thought that good medicine was evidence based.

 

[RGMSU]

So, is there ever an occasion where you believe a psychiatrist would be necessary? You don't think a psychiatrist would ever be preferred if one were available? The terms GP and family physician are two distinct situations, though they are thrown around loosely. A GP would fall under the category of internship only. A family physician completes a family med residency and is usually boarded by the American Board of Family Medicine, which is a specialty board just like the American Board of Psychiatry and Neurology. It's not really the length of education I was ever referring to. It was the content. Take the myocarditis side effect mentioned in one of my earlier posts. How exactly is a psychologist going to diagnose myocarditis without a background in general medicine? I wasn't aware that they taught auscultation in psychology class. I'm sure some psychiatrists and family physicians would find comments on here offensive too. Just dishing back a little of what has been dished out. You wrote something about giving me a popsicle I'd never had. Not really sure what you were referring to on that one. Sounds kinda strange to me. Let's both just drop it. I'm tired of writing that crap, and everybody was tired of reading it long ago.

 

[RGMSU]

Yeah, I always thought that good medicine was evidence based.

If I see a patient in front of me whose depression seems to improve after they start Paxil for two-three weeks, I call that evidence.

 

[RGMSU]

Then you're never going to agree with us on anything.

I believe I've already noticed that.

 

[doctorpsych]

So, is there ever an occasion where you believe a psychiatrist would be necessary? You don't think a psychiatrist would ever be preferred if one were available? The terms GP and family physician are two distinct situations, though they are thrown around loosely. A GP would fall under the category of internship only. A family physician completes a family med residency and is usually boarded by the American Board of Family Medicine, which is a specialty board just like the American Board of Psychiatry and Neurology. It's not really the length of education I was ever referring to. It was the content. Take the myocarditis side effect mentioned in one of my earlier posts. How exactly is a psychologist going to diagnose myocarditis without a background in general medicine? I wasn't aware that they taught auscultation in psychology class. I'm sure some psychiatrists and family physicians would find comments on here offensive too. Just dishing back a little of what has been dished out. You wrote something about giving me a popsicle I'd never had. Not really sure what you were referring to on that one. Sounds kinda strange to me. Let's both just drop it. I'm tired of writing that crap, and everybody was tired of reading it long ago.

to clear things up for you, the popsicle comment was actually a quote from one of your sarcastic comments about the cause of depression. Yes, I've been proposing civility like 5 posts ago. And, yeah, they do teach us how to use a stethoscope, how to perform a physical, neuro exam, and how to read labs in psychopharm training. Why can't psychiatrists and medical psychologists work in the same market?

 

[doctorpsych]

If I see a patient in front of me whose depression seems to improve after they start Paxil for two-three weeks, I call that evidence.

in 2-3 week, the receptors may just start to down regulate so the therapeautic effect should kick in a bit later... however, the improvement may just be temporary in the case of a borderline patient, and how would you really know that their subjective report of the depression is indeed improving? Humans have very poor memory regarding feelings as feelings are easily influenced by small external and/or internal events. You would be better off using a BDI-II or even a PHQ-9 (prefer the first one) to at least keep the eval as objective as possible.

 

[Therapist4Chnge]

I prefer a more subjective patient-by-patient examination over the use of arbitrary levels of change on a depression scale to determine effectiveness. This is the difference between research in the lab and seeing a patient in a clinic.

Subjective v. Objective is an important point of differentiation. Self-reports are far from perfect, but it provides a more objective measure than a purely clinical judgment. A clinician's judgment of what "depression" is can vary greatly, while a score of 26 on the BDI is a 26. The ratings can be compared across multiple visits and provide more specific comparable data. In this example there is better consistency, as many times the initial provider will not be the same as the follow-up provider, yet they can still have objective and comparable data in their progress notes.

 

[RGMSU]

Why can't psychiatrists and medical psychologists work in the same market?

I believe it will ultimately glut the market and drive salaries down. Of course, for the time being there is great demand, but the baby boom generation won't last forever. Just ask some people who have received PhD's in English and History and been either unable to find a job or start off working for $40k annually what it's like. And they don't even usually have the loan indebtedness characteristic of professional programs. Of course, this is not unique to mental healthcare. You can see the same discussions with optometrists vs. ophthalmologists, NPs, PAs, and MDs, etc.

 

[RGMSU]

in 2-3 week, the receptors may just start to down regulate so the therapeautic effect should kick in a bit later... however, the improvement may just be temporary in the case of a borderline patient, and how would you really know that their subjective report of the depression is indeed improving? Humans have very poor memory regarding feelings as feelings are easily influenced by small external and/or internal events. You would be better off using a BDI-II or even a PHQ-9 (prefer the first one) to at least keep the eval as objective as possible.

I have heard subjective comments from patients expressing improvement in 2-3 weeks, but yes, I have seen estimates of 4-6 or even 6-8 weeks for effect. I guess I tend to trust the patient's own words. If they tell me they are better, I am inclined to think that's a positive result. We do the same thing in pain management for example. I can't REALLY know whether a patient is experiencing a pain level of 8 on a 10 scale. Sure there are some physiologic indicators of severe pain, but it is still subjective. I am not skeptical of a patient's assessment of themselves with an SSRI in most cases, though I can see where subjectivity would be reduced or even eliminated in cases of severe mental impairment. I'm not sure about the practice techniques of most psychiatrists, but I can tell you that a prescription of an SSRI by an FP or an OBGYN or somebody along those lines would be accompanied by a purely subjective assessment, in my experience.

 

[busi26]

If I see a patient in front of me whose depression seems to improve after they start Paxil for two-three weeks, I call that evidence.

You are using circular logic again. I think that most of us would agree that treatments should chosen based on science rather than gut, or intuition.

 

[RGMSU]

You are using circular logic again. I think that most of us would agree that treatments should chosen based on science rather than gut, or intuition.

I noticed you didn't respond to my critique of your article. That wasn't exactly circular logic or gut feeling. Your proposal is great in principle but hard to implement. Again, when Suzy Q comes into her OBGYN's office speaking of depression after she just had a baby, and she heard her friend Jane Doe had the same problem and went on Prozac and got all better, it's hard to tell her she wouldn't benefit from it. Frankly, your patient won't believe you and probably will choose another provider, especially since she's seen all the nifty little commercials about antidepressants on TV. It's also hard for the OBGYN to refuse the antidepressant since he/she might be concerned about the patient's mental status worsening without some type of early intervention. Further, it is hard for the OBGYN to deny the antidepressant since he's the one who also treated Jane Doe and saw her improvement as well. You may call it circular, but it's the way things work in a real medical office every day all across America. Face it, spending 30 minutes with a therapist is not as desirable to most people as popping a pill in a fast-food society. Right or wrong - that's just public perception. Do many people need therapy instead of a pill? Yes. Do many people need a pill instead of therapy or in addition to it? Yes. Is depression underdiagnosed or overdiagnosed? Not sure. Probably under. Are antidepressants overused or underused? Not sure. In my experience, probably under. Is therapy underused? DEFINITELY YES. There is great resistance to the use of antidepressants by many people, even when they are not exactly a high-risk medicine in terms of side effects USUALLY. I believe a prevailing physician perspective is that you would rather be safe than sorry, so go ahead and give it if it seems appropriate, because the benefits will probably outweigh the risk. NOT SAYING I NECESSARILY AGREE WITH THAT, but I'm presenting it as a reality. Practicing purely evidence based medicine would require putting someone other than the patient in the driver's seat, and I don't see that happening anytime soon, excluding the times insurance/government says no. In case you haven't noticed, physicians/providers were ejected from the driver's seat long ago. I assume we can all argue, regardless of the letters behind our names, that physicians/providers should be the primary influence on decisions. Sometimes this is the case now, sometimes not. And, honestly, I found the article rebutting your article pretty convincing. In my book, improvement is improvement, as long as it is statistically significant, whether it meets an arbitrary cutoff or not.

 

[RGMSU]

And, yeah, they do teach us how to use a stethoscope, how to perform a physical, neuro exam, and how to read labs in psychopharm training. Why can't psychiatrists and medical psychologists work in the same market?

I'm glad to hear this content in the educational programs. Honestly, though, I doubt either a psychiatrist or a psychologist is going to be as proficient at auscultation or somatic diagnosis as someone who listens to 30 valve sounds a day (family physician, internist, pediatrician, etc), which is where a close working relationship with the primary care physician is in order. If myocarditis is even suspected, or any other somatic situation such as this, it should result in immediate contact of the primary care physician or immediate referral to ER/urgent care services, for the patient's sake as well as for the sake of the liability of the physician/provider.

 

[doctorpsych]

I'm glad to hear this content in the educational programs. Honestly, though, I doubt either a psychiatrist or a psychologist is going to be as proficient at auscultation or somatic diagnosis as someone who listens to 30 valve sounds a day (family physician, internist, pediatrician, etc), which is where a close working relationship with the primary care physician is in order. If myocarditis is even suspected, or any other somatic situation such as this, it should result in immediate contact of the primary care physician or immediate referral to ER/urgent care services, for the patient's sake as well as for the sake of the liability of the physician/provider.

don't disagree with you on that one. All the psychiatrists that I know almost never perform any physical and neuro exams. They refer medical issues to pcp or directly to ER.

 

[busi26]

Again, when Suzy Q comes into her OBGYN's office speaking of depression after she just had a baby, and she heard her friend Jane Doe had the same problem and went on Prozac and got all better, it's hard to tell her she wouldn't benefit from it. ... It's also hard for the OBGYN to refuse the antidepressant since he/she might be concerned about the patient's mental status worsening without some type of early intervention.

I hope you change your mind about this once you start to practice medicine. You can choose to prescribe meds that your patients want even though you (as a physican) know that the med is unnecessary or you can do the right thing. You have a choice! You talk a lot about how physicans have to go to school for a long time and get a lot of experience in order to know how to properly treat their patients (Of course I agree with you on this fact). However, your post suggests that a patient (e.g. Suzy Q), who has a very limited understanding of medicine, can diagnose and prescribe meds for herself and you have to do what she wants. You are not helpless as a physician, you don't have to give in to your patients if you disagree with them. Giving in can get you into a lot of trouble, that is why I hope you change your tune before it is too late for you.

By the way, it is sometimes going to be "hard" to tell patients (and family members) things they don't want to hear. It is part of the job!

 

[doctorpsych]

I believe it will ultimately glut the market and drive salaries down. Of course, for the time being there is great demand, but the baby boom generation won't last forever. Just ask some people who have received PhD's in English and History and been either unable to find a job or start off working for $40k annually what it's like. And they don't even usually have the loan indebtedness characteristic of professional programs. Of course, this is not unique to mental healthcare. You can see the same discussions with optometrists vs. ophthalmologists, NPs, PAs, and MDs, etc.

well, that's the rule that we live by, in our capitalistic sociocultural environment. Competition will drive down prices but also quality increases, ultimately the consumers win out. Getting a doctorate and then get additional 2+ years of training is alot of work, not every psychologist is going to do that and many are perfectly happy specializing in psychotherapy, neuropsych, forensics, etc.

do you know how much some psychiatrist make? I've seen ranges as high as $300-$400 k. I understand psychiatrist in the prison system in Cali gets rediculous amounts... Salaries may go down but, don't think it would be as low as 40k...

 

[busi26]

I noticed you didn't respond to my critique of your article.

You wanted a reference so I sent you a metaanalysis that included tons of references. Look up the specific papers if you want.

 

[doctorpsych]

So, is there ever an occasion where you believe a psychiatrist would be necessary? You don't think a psychiatrist would ever be preferred if one were available? The terms GP and family physician are two distinct situations, though they are thrown around loosely. A GP would fall under the category of internship only. A family physician completes a family med residency and is usually boarded by the American Board of Family Medicine, which is a specialty board just like the American Board of Psychiatry and Neurology. It's not really the length of education I was ever referring to. It was the content. Take the myocarditis side effect mentioned in one of my earlier posts. How exactly is a psychologist going to diagnose myocarditis without a background in general medicine? I wasn't aware that they taught auscultation in psychology class. I'm sure some psychiatrists and family physicians would find comments on here offensive too. Just dishing back a little of what has been dished out. You wrote something about giving me a popsicle I'd never had. Not really sure what you were referring to on that one. Sounds kinda strange to me. Let's both just drop it. I'm tired of writing that crap, and everybody was tired of reading it long ago.

I was aware of the difference btw GP and Fam. But my point was that legally, you can practice medicine in the U.S. with 4 years of med school and 1 year of residency...no restriction on formulary.

Now, 2+ years of narrowly focused training in psychopharm and 1 year of internship doesn't sound so unreasonable (not to include 6+ years of previous psychological training)...with restricted formulary on psychotropics.

 

[cara susanna]

If I see a patient in front of me whose depression seems to improve after they start Paxil for two-three weeks, I call that evidence.

And I would ask the following:
- Is it possible the patient merely experienced the placebo effect?
- Is it possible that this change was due more to situational factors rather than chemical ones?
- Was this change real?
- Was this change clinically significant?

It's great if a patient seems to improve on meds, but using that as evidence that an intervention is effective is pretty flawed in my book.

 

[Ollie123]

pretty flawed in my book.

You are far more generous than I. Given everything we know about psychology at this point in time, I would say it is much much worse than "pretty flawed".

 

[Therapist4Chnge]

You are far more generous than I. Given everything we know about psychology at this point in time, I would say it is much much worse than "pretty flawed".

It reminds me of a quote about assumption....no, not from Benny Hill, but from another scientist.

"The invalid assumption that correlation implies cause is probably among the two or three most serious and common errors of human reasoning" -S.J. Gould

 

[cara susanna]

True, it is far worse than that. I tend to be equivocal in my posts, heh.

 

[busi26]

I think we convinced RGMSU that medical psycholgists who receive the proper training (see previous posts) can safely prescribe meds! Good job all of you who posted cogent, persuasive arguments.

 

[RGMSU]

I hope you change your mind about this once you start to practice medicine. You can choose to prescribe meds that your patients want even though you (as a physican) know that the med is unnecessary or you can do the right thing. You have a choice! You talk a lot about how physicans have to go to school for a long time and get a lot of experience in order to know how to properly treat their patients (Of course I agree with you on this fact). However, your post suggests that a patient (e.g. Suzy Q), who has a very limited understanding of medicine, can diagnose and prescribe meds for herself and you have to do what she wants. You are not helpless as a physician, you don't have to give in to your patients if you disagree with them. Giving in can get you into a lot of trouble, that is why I hope you change your tune before it is too late for you.

By the way, it is sometimes going to be "hard" to tell patients (and family members) things they don't want to hear. It is part of the job!

I'M BACK! I wouldn't just be conceding. I haven't seen anything yet that convinces me it wouldn't be useful. Oh, and when it's a perfect world, let me know I would think a bunch of psychologists would respect gray more than just black and white.

 

[RGMSU]

I think we convinced RGMSU that medical psycholgists who receive the proper training (see previous posts) can safely prescribe meds! Good job all of you who posted cogent, persuasive arguments.

You thought you'd gotten rid of me huh? I will say my views have been altered, yes. I still think you guys are a bit hostile toward primary care physicians and psychiatrists, but it's a two way street. It would be best if we could all cooperate on a healthcare team and bring each of our strengths to the table. Nobody can know everything. I'm still trying to figure out why some of you even want prescription rights. With your attitudes toward antidepressants, you want the right to prescribe so you can refuse to prescribe I suppose?

 

[RGMSU]

It reminds me of a quote about assumption....no, not from Benny Hill, but from another scientist.

“The invalid assumption that correlation implies cause is probably among the two or three most serious and common errors of human reasoning” -S.J. Gould

I would say there is more than just assumed correlation. There is the biochemical evidence of an SSRI effect on serotonin - the whole point of the drug's design. It would be more difficult to prove how increased serotonin levels would not be beneficial frankly, unless you're completely discounting that neurochemical levels are playing a role here. Again, kind of a strange argument to make.

 

[RGMSU]

well, that's the rule that we live by, in our capitalistic sociocultural environment. Competition will drive down prices but also quality increases, ultimately the consumers win out. Getting a doctorate and then get additional 2+ years of training is alot of work, not every psychologist is going to do that and many are perfectly happy specializing in psychotherapy, neuropsych, forensics, etc.

do you know how much some psychiatrist make? I've seen ranges as high as $300-$400 k. I understand psychiatrist in the prison system in Cali gets rediculous amounts... Salaries may go down but, don't think it would be as low as 40k...

If they go much lower, there will be nobody interested in psychiatry in medical school. There is already not much interest at all. When you have to pay back $150,000 in loans over the course of ten years to the tune of $1,700 a month, these are things that must be considered. This is why most medical students lean toward higher risk specialties that offer better remuneration and are more difficult to be replaced by non-physicians in. It's not because we're all greedy.

 

[RGMSU]

And I would ask the following:
- Is it possible the patient merely experienced the placebo effect?
- Is it possible that this change was due more to situational factors rather than chemical ones?
- Was this change real?
- Was this change clinically significant?

It's great if a patient seems to improve on meds, but using that as evidence that an intervention is effective is pretty flawed in my book.

I just do what works. That's good enough for me most of the time. If I saw evidence that suggested blatantly it didn't work, I wouldn't do it. If there's a chance it might help, don't mind trying it. There is plenty of evidence that SSRIs produce an effect beyond placebo effect. One of your own colleagues here posted such a reference that I responded to.

 

[cara susanna]

A lot of people want Rx privilege even though they wouldn't use it themselves simply because they feel it's the best next step. Like I've said numerous times, however, I am against it and you will find others on this board who are as well.

Yes, there is a general effect with anti-depressants, but you can't know for sure that they are what caused the improvement in your patient. I'm not saying take anyone off of the meds, I am saying you don't have enough evidence to say that the anti-depressants necessarily are what lowered her depression. I am also suggesting that, though her depression may seem lower, it may not be significant in terms of how much it decreased. So, though it's great that this hypothetical patient improved and I'm not saying take her off of the meds, I simply think you cannot point to it as evidence of the efficacy of SSRIs. If you want to point to controlled medical studies as support, sure, but earlier you were saying that if a patient seemed to improve after a few weeks of being on an SSRI, that was enough for you, and that is with which I disagree.

 

[RGMSU]

Next logical step toward what? Looks like to me the medical psychologist will wind up being similar to the optometrist - limited overall medical exposure, but sufficient for a certain area of practice. I was actually referring to the evidence of a patient improving being validation of those studies that suggest SSRI effectiveness, not merely the anecdotal effectiveness in isolation. As per the OBGYN example, I think most of them are afraid of being on TV with the next mother who drowned her new baby, etc. One facet of medical education is that it is very negative in orientation. We are constantly presented with the negative. We're regularly told we're not good enough to be doing this. We're encouraged to look for what's wrong instead of what's right. In the differential diagnosis process, the emphasis is on considering worst case scenario and eliminating that as a possibility, even though the most likely diagnosis usually isn't that. I think this leads to a mindset that overtreating may be preferable to under-treating among most physicians. Whether this is right or wrong, it leads to a lot of the problems in American medicine being discussed right now, including cost control. When you constantly have lawyers lurking over your shoulders, you really don't have a choice. If you guys and gals don't have lawyers lurking over your shoulders yet, you will with prescription responsibilities I would imagine.

 

[cara susanna]

Every healthcare provider has lawyers lurking over their shoulders. Psychologists regularly see patients who are suicidal, homicidal, etc., so it's not like they have no idea what the threat of malpractice lawsuits is like.

 

[RGMSU]

Every healthcare provider has lawyers lurking over their shoulders. Psychologists regularly see patients who are suicidal, homicidal, etc., so it's not like they have no idea what the threat of malpractice lawsuits is like.

Good - welcome to the club

 

[doctorpsych]

If they go much lower, there will be nobody interested in psychiatry in medical school. There is already not much interest at all. When you have to pay back $150,000 in loans over the course of ten years to the tune of $1,700 a month, these are things that must be considered.

but at what expense? keep the supply low so psychiatrists can command higher salaries?

I don't think anybody here has a negative view of ALL psychiatrists. I can only speak for myself...I have a great deal of respect for psychiatrists that are professional and competent. In fact, some of your fellow MD psychiatrists that regularly posts on the psychiatry forum seemed to be very competent, professional, objective, follow an evidence based approach, respectful of psychologists, and appear to 'know what they are doing' from his/her posts (e.g. whopper). I wouldn't mind collaborating with someone of that caliber. I do have issues with psychiatrist who don't give a crap about their pts. and see 25-30 pts. a day, for 5-10min sessions, and who clearly used the psychiatry residency as a way to the US (off course, not all psychiatry FMG's are like this, but you can tell pretty much off the bat who they are by the way they talk about their pts, by the way they can barely communicate in English and their poor practice, money oriented behaviors). Just like I'm sure others would have negative views of some of psychologists out there. And, I have no beef with pcp's at all. They are prescribing most of the psychotropics in this country is not because they are choosing to do so, but because of the high demand and very limited supply of psychiatrists. Something has to be done, don't you agree? Don't you think the state of our mental healthcare simply sucks? What do you propose?

 

[RGMSU]

I'm just saying that psychologists should, as a guild, make sure that they don't accept too many people into medical psychology programs and that they don't allow a proliferation of junky programs lacking in reputation. The medical community has recognized for decades that supply and demand need to equal out, and they have adjusted their residency programs and medical school enrollment accordingly. You won't attract good talent if potential students believe there is a chance all their preparation might be for nought. Nobody benefits from a glutted market. It doesn't look good for the profession to have psychology PhDs or psychiatry MDs driving taxis for extra money. So, psychologists should just be careful that they keep their own field under control and don't turn a shortage into a surplus, thereby shooting themselves in the foot. With high admissions standards, strong quality programs affiliated with top universities, and realistic caps on enrollment, this shouldn't be a problem.

 

[Ollie123]

With high admissions standards, strong quality programs affiliated with top universities, and realistic caps on enrollment, this shouldn't be a problem.

I agree, albeit for somewhat different reasons (I agree finances has an impact, but think there is far more to it than that). Unfortunately, the RxP movement has generally not been coming from that direction - a great deal of its support is coming from the bottom barrel, "we accept anyone" instititutions. That's one of the main reasons I'm against it, I feel like there is near-zero chance of quality control - at least until APA or someone else takes a more active role in "fixing" a number of the programs out there. I could probably come up with a pretty decent list of the places that are likely to offer this training in the near future if overnight all states allowed RxP and they saw a market for it (that should tell you which ones right there). A majority of them I don't trust to train regular psychologists, I surely don't trust them to train prescribing psychologists.

 

[cara susanna]

Good point, Ollie. I hadn't even considered that.

 

[RGMSU]

I agree, albeit for somewhat different reasons (I agree finances has an impact, but think there is far more to it than that). Unfortunately, the RxP movement has generally not been coming from that direction - a great deal of its support is coming from the bottom barrel, "we accept anyone" instititutions. That's one of the main reasons I'm against it, I feel like there is near-zero chance of quality control - at least until APA or someone else takes a more active role in "fixing" a number of the programs out there. I could probably come up with a pretty decent list of the places that are likely to offer this training in the near future if overnight all states allowed RxP and they saw a market for it (that should tell you which ones right there). A majority of them I don't trust to train regular psychologists, I surely don't trust them to train prescribing psychologists.

How many times have I said something about "fly-by-night" programs on here? Why is it magically different if somebody else says it?

 

[doctorpsych]

RGMSU, there's an interesting debate going on in the psychiatry forum about 10 min. med checks, sorta touching on the same issues alluded in one of our own debates here.

http://forums.studentdoctor.net/showthread.php?t=671429

 

[RGMSU]

RGMSU, there's an interesting debate going on in the psychiatry forum about 10 min. med checks, sorta touching on the same issues alluded in one of our own debates here.

http://forums.studentdoctor.net/showthread.php?t=671429

Thanks for pointing that out. I posted on that and a couple other psychiatry forums. I think a 10 min med check is unrealistic. I posted my belief that the absolute max patients you can see in an hour is 4. And about 25 per day, which is a lot. This, of course, would require a close relationship with other therapists. I would prefer a close relationship with a PhD psychologist who offered 30 minute counseling sessions as needed. Someone said they did 1 minute worth of dictation for documentation, and I thought that was unrealistic as well. I wouldn't feel comfortable with the lack of thoroughness of a 10 min med check and 1 min documentation. Scheduling four patients an hour provides the flexibility for some patients that take a little longer and some a little shorter amount of time, rounding out to a 15 minute visit including documentation time. Running 5 minutes early or 5 minutes late here and there isn't going to make anybody too angry. I would prefer to document during a visit, probably by tablet PC, but it would take some skill to do that and not appear disinterested. I'm just too forgetful not to document while I'm talking.

 

[erg923]

I think that "10 minute med check" thread is a perfect example of what underlies the tension between the 2 professions at times. Maybe a 10 minute med check is adaquate, phamacologically speaking, I dont know, i dont really care, cause that not the issue that popped out at me. The issue was that its comments like that that reinforce the steroptypic mindset that people view many modern day psychiatrists as having. That is, how much interaction do I have to have with these patients in order to make money? This steroptype is of course not true for most psychiatrists, but its questions like that that breed and reinforce the strereotype.

The fact that the poster of that thread commented that he was a "straight to the point kinda a guy" and thus would prefer to practice in that manner shows blinding ignorance of the population he would be working with.

 

[RGMSU]

I thought the same thing reading his "straight to the point" comment. Hah, I don't think psychiatry is the right field for somebody who doesn't want to talk to their patients. And, I disagreed with his attempt to cut patient contact times to a minimum. And, I said I wouldn't mind running several minutes late and making it up later in the day if a patient needed the extra time. And, I said that it would be important to me to have arrangements with therapists to provide additional care as needed. So, not every medical student/physician/psychiatrist has the same mindset.

 

[doctorpsych]

I thought the same thing reading his "straight to the point" comment. Hah, I don't think psychiatry is the right field for somebody who doesn't want to talk to their patients. And, I disagreed with his attempt to cut patient contact times to a minimum. And, I said I wouldn't mind running several minutes late and making it up later in the day if a patient needed the extra time. And, I said that it would be important to me to have arrangements with therapists to provide additional care as needed. So, not every medical student/physician/psychiatrist has the same mindset.

I'm glad you agree. It's not only unrealistic, but in most cases, I suspect that it's highly unethical. what are you going to do if in one of these med checks you get a pt that voices SI/HI? That would be an interesting situation... a natural assessment of the doctor's motivation.

 

[doctorpsych]

I agree, albeit for somewhat different reasons (I agree finances has an impact, but think there is far more to it than that). Unfortunately, the RxP movement has generally not been coming from that direction - a great deal of its support is coming from the bottom barrel, "we accept anyone" instititutions. That's one of the main reasons I'm against it, I feel like there is near-zero chance of quality control - at least until APA or someone else takes a more active role in "fixing" a number of the programs out there. I could probably come up with a pretty decent list of the places that are likely to offer this training in the near future if overnight all states allowed RxP and they saw a market for it (that should tell you which ones right there). A majority of them I don't trust to train regular psychologists, I surely don't trust them to train prescribing psychologists.

that's true, but like in every business (and higher ed is certainly a business too), this less stringent approach is frequently observed in the beginning of a start up. Not that I agree with it, but these programs needs customers. I hope that when the movement matures and becames solidly established, quality assurance will improve. It seems that its moving towards that direction with talks about accreditation of programs and most likely a boarding process too. IMO, it's early enough in the rxp movement right now that the natural selection process screens out most of the poor candidates. At this point, most of the students that I've encountered are pretty darn committed. They were mostly established and seasoned psychologists (a lot of them hold directorship positions). A lot of them are involved in the 'bill pushing' part and most of them would not reap the benefits of rxp themselves, given the timeframe and point in their career. Nonetheless, they are still receiving their training and using it in their practices (without getting paid more, and without formally prescribing). I think that says a lot. Off course, you'll get some weird ones here and there that you can tell immediately that they were not even properly trained in graduate school, but that's the minority, and you'll find those students in any field.

 

[RGMSU]

I'm glad you agree. It's not only unrealistic, but in most cases, I suspect that it's highly unethical. what are you going to do if in one of these med checks you get a pt that voices SI/HI? That would be an interesting situation... a natural assessment of the doctor's motivation.

In cases of SI/HI? Just reschedule for next week? Joke. Less than ten minutes may not even be enough time to get a patient to admit to something that personal, much less deal with it if they do. If they do, I think you would have to consider that an emergency like any other. Sometimes emergencies take more time and press a doctor's schedule back. Unavoidable. Depends on how serious the threat is judged to be, whether hospitalization is warranted, etc.

 

[cara susanna]

Yeah, I was taken aback by some of the comments in that thread as well.

 

[RGMSU]

Yeah, I was taken aback by some of the comments in that thread as well.

Not exactly a well-spring of compassion floating around in that thread.

 

[cara susanna]

No kidding. I also can't believe how one of the people acted towards erg because erg's title didn't say Med Student or Doctor.

 

[erg923]

no no, its fine. Its just defensive responding. I asked the person in question to perform a task which he was obviously very unfamiliar with (self-reflection and exploration of multiple non-medical/biological issues). He either 1.) did not know how to do this, or 2.) was so unfamiliar the concept he couldnt even deduce what I was getting at. Im not sure which it is, but a knee jerk reaction accompanied by questioning of my "credentials" (ie., my right to make him think) was not at all surpriing to me....