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no, YOU keep redirecting all rxp discussions into a personal attack against YOU...and when you are called out, "you are evil, you are attacking me...snip, snip..." You react as if psychologist are gaining prescription rights and that's directed personally to you. Just go back to your posting for the past 2 years... it's obvious... The conversation here is not about rxp psychologist equating their training to psychiatry but you keep going back to that. You keep going back to training, come'on, training is not the real issue, it's your unwillingness to accept of an alternate solution. You are less resistant to NP's and PA's because they do not have the traditional rivalry with psychiatry. I bet you have problems with psychologist referring ourselves as doctors too don't you? this whole 'only medical doctors are real doctors' bs right? Put the nonsense aside bro, be real for a sec. here.
As posted numerous times, you have to take into account all the factors that play a role in our current fragmented and under supplied mental health care system. You are not, you keep going back to this 'I'm the goldstandard' bs and 'prove to me personally that you are of the same worth' bologna. Look, you have to take into account the decreasing supply of psychiatrists, the large portion of psychiatrists that use psych residencies as a means of least resistance to get into this country without real interest in mental health care (you wanna make fun of rxp psych here, I'm sure there are plenty of off the wall examples of psychiatrists that can barely speak English), the less than adequate training and by their own admission, that pcp's do not feel comfortable managing psychotropics (in most cases minus the ssri's). Good psychiatrists are in short supply and are very expensive, that's the problem... why do you think most hospitals (even ivy league connected ones) have a preference in hiring psych NP's and PA's over psychiatrists? that is a growing trend.
Do your own medical administration care about your "gold standard"? No! you have to work with the real world scenario. RxP psychologists fit into this ever increasing gap very well, IMO we fit especially well in primary care. With the medical home model gaining more and more acceptance, RxP can really shine here. RxP psychs are positioned to flow smoothly with pcp's, pharmacy and traditional bh, can interface with psychiatrists (that is if you are willing to accept our presence and work with us!). This is the setting that I'm in and I have to say that it's been working out wonderfully for the past 2+ years... and guess what, no pt's has died or placed in serious harm...and another surprise, there are plenty of level headed, academic grade psychiatrists that have offered to help us by providing consults (I have two lined up), they don't see this as a pissing contest but a solution to a problem. Admin loves it (bringing in more billable contacts), pcp's loves it (they feel someone can actually help them with bh pt's), pt's love it (they don't have the stigma of going to BH dept). BH dept. loves it because they don't have to get called out to the floor on crisis mode and feel that they can't fully help the pt.
You are a new attending and I get that, everyone has pride in what they do, but dude, you gotta stop this personal bs... this 'you have to go to med school to prescribe' is just nonsense given what's going on right now.
As posted numerous times, you have to take into account all the factors that play a role in our current fragmented and under supplied mental health care system. You are not, you keep going back to this 'I'm the goldstandard' bs and 'prove to me personally that you are of the same worth' bologna. Look, you have to take into account the decreasing supply of psychiatrists, the large portion of psychiatrists that use psych residencies as a means of least resistance to get into this country without real interest in mental health care (you wanna make fun of rxp psych here, I'm sure there are plenty of off the wall examples of psychiatrists that can barely speak English), the less than adequate training and by their own admission, that pcp's do not feel comfortable managing psychotropics (in most cases minus the ssri's). Good psychiatrists are in short supply and are very expensive, that's the problem... why do you think most hospitals (even ivy league connected ones) have a preference in hiring psych NP's and PA's over psychiatrists? that is a growing trend.
Do your own medical administration care about your "gold standard"? No! you have to work with the real world scenario. RxP psychologists fit into this ever increasing gap very well, IMO we fit especially well in primary care. With the medical home model gaining more and more acceptance, RxP can really shine here. RxP psychs are positioned to flow smoothly with pcp's, pharmacy and traditional bh, can interface with psychiatrists (that is if you are willing to accept our presence and work with us!). This is the setting that I'm in and I have to say that it's been working out wonderfully for the past 2+ years... and guess what, no pt's has died or placed in serious harm...and another surprise, there are plenty of level headed, academic grade psychiatrists that have offered to help us by providing consults (I have two lined up), they don't see this as a pissing contest but a solution to a problem. Admin loves it (bringing in more billable contacts), pcp's loves it (they feel someone can actually help them with bh pt's), pt's love it (they don't have the stigma of going to BH dept). BH dept. loves it because they don't have to get called out to the floor on crisis mode and feel that they can't fully help the pt.
You are a new attending and I get that, everyone has pride in what they do, but dude, you gotta stop this personal bs... this 'you have to go to med school to prescribe' is just nonsense given what's going on right now.
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I'd like you to cite the evidence for this. I have done no such thing, aside from pointing out that the typical response to my challenges for evidence or questioning the level of training and safety of RxP is to question my credentials, my motivations, or other such nonsense. To be clear, I have no issue with psychologists practicing what they're trained to do, what they have expertise to do. Pretending that the pitifully short amount of training in RxP programs (which doesn't even compare to the DoD program, which itself recognized that trainees at best had the medical expertise of a medical student at best), qualifies for safe practice of psychotropics and that questioning this must indicate a defect in the questioner is frankly insulting to the entire field of medicine.
And for the record, I take no issue with psychologists calling themselves "doctor" outside of the hospital setting. Within a hospital, though, this really obfuscates roles and titles, and is misleading to patients. My wife has a PhD in the arts, and I love that she calls herself a doctor.
Do you have actual evidence to show that this expensive training solution has increased access? This has been brought up multiple times in this thread and like any quality medical decision, the risks, benefits, and alternatives should be weighed.
Problem -- shortage of supply of psychiatrists in a rural area
Possible Solutions--
1) Expand the scope of practice of those with zero medical training to give them the rights to prescribe medication, despite insufficient didactices (400 hours?!), supervision (supervised by PCP's), simply because they have training in mental illness as a whole. As if understanding what schizophrenia looks like generalizes into understanding the conduction mechanisms in the heart and how to measure, diagnose, and manage QT prolongation in a patient with refractory psychosis. Presuming the training programs are state funded, this further requires a huge ongoing investment to maintain a training program that frankly isn't creating that many providers, but is creating tremendous risk with each undersupervised clinician.
2) Expand the number of PA's and NP's. These are defined paths, and psychiatrists supervise them in many health care systems across the country. They have baseline foundation in medical training, and have to rotate during that training throughout each major medical specialty in a clinical setting, with direct supervision. THEN they get more advanced specialty training.
3) Hire more psychiatrists. How much would that cost? I have no idea. But I'd look seriously at whether bumping the salary offered by 50k might bring in plenty more, and be cheaper than creating entire schools and regulatory programs to manage all of this.
Of course. How silly of me to emphasize medical training prior to prescribing medications. How ridiculous and short sighted I must be
The issue I take with the safety of RxP's, is that there seems little training into when you're out of your depths. You don't know what you don't know. And that's dangerous. Perhaps you could elaborate -- when do you actually call a consult? Polypharmacy issues? What co-morbid medical conditions might worry you that you can't handle? Are you trying to manage delirium on your own, and if so, how? When might an SSRI be contraindicated (in what medical conditions, other meds being taken)? The bravado here indicates that you feel you CAN do everything a psychiatrist does. But if that's not what you're saying then correct me. Where does RxP fall short? What CAN'T you do? If you're aware of your shortcomings, then you should be able to identify them. If you can't and you feel the training you have is sufficient to manage everything, then you're really flying blind.
And to add that even those in your own field question the utility and safety of RxP, I turn you (again) to http://psychologistsopposedtoprescribingbypsychologists.org/
Last edited:
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we are not pretending anything, we are doing it... and yep, was right, you do have qualms with psychologist using the term doctor. Whether you want to soften it or not, you have a prejudice against us, simply because you have an MD. BTW, I check EKG in rel to qtc issues all the time when I prescribe an SGA to a patient with cardiac problems/hx, Can you provide accurate and smooth testimony incorporating interpretation and psychometric properties of PSI, MCMI-III, WAIS-IV, CAP on the stand, while taking into account someone's psychiatric history, medications, and treatment history without sounding like a fool? I acknowledge that you are excellent in one thing (and you like to go narcissistic on that), but we are good in many things, that's why we are effective in many settings.
Do you have data that rxp psych are unsafe to the public? in light of lack of data on either side, you can only go with what's present, which is over YEARS of data supporting its effectiveness. Yeah, in theory NP's have more biomedical experience... I have full respect for my Psych NP colleagues, we have them as well and they do a great job working with the team without any egos getting in the way. But please provide a curriculum comparison OBJECTIVELY. btw, a few hours here and there doesn't translate in real world. I know plenty of MD's that just went by, went to overseas because they couldn't get into school in the States and are close to practicing medicine unethically. I rather have a team approach treating me than someone who likes to throw their MD every chance they get.
And your attempt to get off by demanding me to acknowledge shortcomings is simply too obvious. Keep up the good PD, you will be divorced and lonely soon... great job!
Do you have data that rxp psych are unsafe to the public? in light of lack of data on either side, you can only go with what's present, which is over YEARS of data supporting its effectiveness. Yeah, in theory NP's have more biomedical experience... I have full respect for my Psych NP colleagues, we have them as well and they do a great job working with the team without any egos getting in the way. But please provide a curriculum comparison OBJECTIVELY. btw, a few hours here and there doesn't translate in real world. I know plenty of MD's that just went by, went to overseas because they couldn't get into school in the States and are close to practicing medicine unethically. I rather have a team approach treating me than someone who likes to throw their MD every chance they get.
And your attempt to get off by demanding me to acknowledge shortcomings is simply too obvious. Keep up the good PD, you will be divorced and lonely soon... great job!
I'd like you to cite the evidence for this. I have done no such thing, aside from pointing out that the typical response to my challenges for evidence or questioning the level of training and safety of RxP is to question my credentials, my motivations, or other such nonsense. To be clear, I have no issue with psychologists practicing what they're trained to do, what they have expertise to do. Pretending that the pitifully short amount of training in RxP programs (which doesn't even compare to the DoD program, which itself recognized that trainees at best had the medical expertise of a medical student at best), qualifies for safe practice of psychotropics and that questioning this must indicate a defect in the questioner is frankly insulting to the entire field of medicine.
And for the record, I take no issue with psychologists calling themselves "doctor" outside of the hospital setting. Within a hospital, though, this really obfuscates roles and titles, and is misleading to patients. My wife has a PhD in the arts, and I love that she calls herself a doctor.
Do you have actual evidence to show that this expensive training solution has increased access? This has been brought up multiple times in this thread and like any quality medical decision, the risks, benefits, and alternatives should be weighed.
Problem -- shortage of supply of psychiatrists in a rural area
Possible Solutions--
1) Expand the scope of practice of those with zero medical training to give them the rights to prescribe medication, despite insufficient didactices (400 hours?!), supervision (supervised by PCP's), simply because they have training in mental illness as a whole. As if understanding what schizophrenia looks like generalizes into understanding the conduction mechanisms in the heart and how to measure, diagnose, and manage QT prolongation in a patient with refractory psychosis. Presuming the training programs are state funded, this further requires a huge ongoing investment to maintain a training program that frankly isn't creating that many providers, but is creating tremendous risk with each undersupervised clinician.
2) Expand the number of PA's and NP's. These are defined paths, and psychiatrists supervise them in many health care systems across the country. They have baseline foundation in medical training, and have to rotate during that training throughout each major medical specialty in a clinical setting, with direct supervision. THEN they get more advanced specialty training.
3) Hire more psychiatrists. How much would that cost? I have no idea. But I'd look seriously at whether bumping the salary offered by 50k might bring in plenty more, and be cheaper than creating entire schools and regulatory programs to manage all of this.
Of course. How silly of me to emphasize medical training prior to prescribing medications. How ridiculous and short sighted I must be
The issue I take with the safety of RxP's, is that there seems little training into when you're out of your depths. You don't know what you don't know. And that's dangerous. Perhaps you could elaborate -- when do you actually call a consult? Polypharmacy issues? What co-morbid medical conditions might worry you that you can't handle? Are you trying to manage delirium on your own, and if so, how? When might an SSRI be contraindicated (in what medical conditions, other meds being taken)? The bravado here indicates that you feel you CAN do everything a psychiatrist does. But if that's not what you're saying then correct me. Where does RxP fall short? What CAN'T you do? If you're aware of your shortcomings, then you should be able to identify them. If you can't and you feel the training you have is sufficient to manage everything, then you're really flying blind.
And to add that even those in your own field question the utility and safety of RxP, I turn you (again) to http://psychologistsopposedtoprescribingbypsychologists.org/
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Sheesh. And you say I'm the angry one.
You do not have data supporting its effectiveness. You have an absence of data of malpractice claims. Which is not the same thing.
Your listing of psychological testing is completely irrelevant. No standardized testing replaces a skilled clinical exam. Nor do I have need or desire to do testing to diagnose a patient.
I do not have biases against psychologists per se. I have biases against anyone using the term "doctor" in a hospital setting, where it implies expertise not present. Same issue I would have with a DNP or Doctoral physical therapists. Patients don't know the difference.
You may have had some lecture once on ordering an EKG, but RxP doesn't give you enough training to understand the underlying anatomy and physiology of how the heart functions, and thus no real foundation to understand the EKG. You may be able to look at some numbers and say "that's not normal," but that's not sufficient. And prescribing medications that change heart conduction properties (from antidepressants to antipsychotics) without understanding that is asking for trouble. Now you may never get sued, because as I've pointed out before the main factor that has been proven time and again to moderate malpractice is a good treatment relationship. And people tend to like their therapist. So they'll overlook errors. And you may skate by thinking you're doing a bang up job. That isn't the same as giving quality or safe care. Because you're completely unaware of every close call you cause.
You again conflate the issues as if I have a bias against psychologists. I do not. I have issue with psychologists practicing medicine without the proper training. As skilled as a psychologist may be in understanding mental illness, there is nothing about that that generalizes to medical expertise or understanding anatomy, physiology, psychopharmacology, pathology, or any number of other areas. It just isn't there.
You want some evidence against RxP?
How about the DoD program costing 6.1 Million Dollars to produce 10 psychologists, and no improvement in access. Even the GAO showed it was not cost effective.
http://onlinelibrary.wiley.com/doi/10.1002/jclp.10052/abstract
The DoD program went on for 7 years, with each trainee being directly supervised by a Psychiatrist, which current training programs cannot claim. Even WITH that level of supervision for that many years, the final report noted "While their medical knowledge was variously judged as on a level between 3rd or 4th year medical students, their psychiatric knowledge was variously judged as, perhaps, on a level between 2nd or 3rd year psychiatry residents."
https://www.acnp.org/Docs/BulletinPdfFiles/vol6no3.pdf
Now who would like their medications and problems being handled by someone with the knowledge of a medical student even after 6-7 years of additional post-graduate training? Doesn't sound safe to me. In fact there is SUBSTANTIAL evidence from the Institute of Medicine that level of training is associated with more medical errors (less training-->more errors). It's quite ridiculous that the training of psychologists somehow shields them from medical errors, considering they know even less about all of medicine and even of citing emergencies in general.
You really believe psychologists inherently can handle such medical treatment. The evidence speaks against that. In fact it tends to show that psychologists OVERESTIMATE their own competence and knowledge of medications, and their ability to handle them.
http://www.med.umn.edu/gim/prod/groups/med/@pub/@med/documents/asset/med_87453.pdf
Certainly nurses must think it's a good idea that psychologists get prescription rights. No? Wonder why? Allow them to elaborate and you can see that it isn't just physicians that think this is a safety risk.
http://www.ispn-psych.org/docs/11-01prescriptive-authority.pdf
How about some other scholarly critiques?
http://www.ncbi.nlm.nih.gov/pubmed/16396524
Which mentions the geographic location of psychologists doesn't lead to improved need. Nor is there ANY evidence aside from 1 study supplied by the APA, to show that there is such an undersupply that requires adding a scope of practice to those that don't have it, NOR is there any evidence to show that such a need could not be met otherwise.
All of this further bypasses what many identify as the real reason for RxP -- pursuit of expanded practice to maintain the viability of a profession (psychology) being oversupplied by too many schools, and with reduced need with the increase of masters level therapists.
If you really think I have something against YOU, then you really think too much about yourself. I could care less. And your pointing at me and calling Me narcissistic I only find humorous. Being able to practice medicine is a privilege. One I take up with humility, recognizing that I am not perfect, people are complex, and that I must struggle to continuously improve my knowledge base. I don't think skating by with 400 hours or didactics takes seriously enough the complexity of human physiology and pathophysiology, and moreso just demonstrates hubris.
And even amongst all of this, you still can't admit there are deficits in your knowledge or training. You have to be someone "good in many things." Arrogance.
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Guys, everyone, please try to keep it civil and refrain from personal attacks.
Thanks.
Thanks.
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I like your use of smilies... you wanna trade stories? how about two separate boarded ER docs giving haloperidol IM without anticholinergic/antihistamine and without keeping them in the ER for observation and later, on both occasions, the pts developed severe dystonia, one acute laryngeal dystonia and ended up in the ICU. BTW, I got a call from the psychiatrist from the second pt going off on the ER doc. The psychiatrist knows me as an rxp psychologist said that I should ask to get privileges at that hospital to help out at the ER.
You're telling me that ALL MD know how to treat psych pts safer than rxp psychologists? How about a boarded internist prescribing venlafaxine XR "to help him sleep?" or another pcp raising the dosage of mirtazapine thinking that it will make a depressed patient less insomnic? How about a pediatric pcp who keeps raising the dosage on Concerta without taking into consideration that the kid was raised in a completely disorganized environment? how about a family doc starting a patient with recent suicidal attempt with bupropion? See, you are not going to consider any of these REAL examples that I see regularly... and I'm sure many of my colleagues see too... simply because I didn't go to med school right? And you haven't even gone near my comment about the abundance of MD's that are not interested in psychiatry but only complete residency for secondary motives... you know that's a fact that you cannot ignore...
You just posted a bunch of old opinions, most over 10 years old, not scholarly objective analyses, not surprisingly since you follow the same discourse. so btw, are there any studies that shows better response to tx between psychiatrists vs. psych NP's? you keep referring to psych NP's being supervised by psychiatrists and that's just simply not the case... in MANY states they practice independently and the ones that do have to be supervised, in most cases they are a quick 'hello good bye' deal... and I think in many cases the psychiatrist gets paid...humm.
it's pretty silly that you think I'm arrogant while you are the one who refers yourself as "the gold standard"... here's an emoticon for you
btw: http://www.amazon.com/Handbook-Clin...76/ref=sr_1_11?ie=UTF8&qid=1329715612&sr=8-11
I guess you would say that one of your most influential figure in psychiatry sold out, huh? even when the ones that teaches you think that it's a good thing for the field that psychologist gain rxp, and you still think it's a personal attack onto you... man just give up...
You're telling me that ALL MD know how to treat psych pts safer than rxp psychologists? How about a boarded internist prescribing venlafaxine XR "to help him sleep?" or another pcp raising the dosage of mirtazapine thinking that it will make a depressed patient less insomnic? How about a pediatric pcp who keeps raising the dosage on Concerta without taking into consideration that the kid was raised in a completely disorganized environment? how about a family doc starting a patient with recent suicidal attempt with bupropion? See, you are not going to consider any of these REAL examples that I see regularly... and I'm sure many of my colleagues see too... simply because I didn't go to med school right? And you haven't even gone near my comment about the abundance of MD's that are not interested in psychiatry but only complete residency for secondary motives... you know that's a fact that you cannot ignore...
You just posted a bunch of old opinions, most over 10 years old, not scholarly objective analyses, not surprisingly since you follow the same discourse. so btw, are there any studies that shows better response to tx between psychiatrists vs. psych NP's? you keep referring to psych NP's being supervised by psychiatrists and that's just simply not the case... in MANY states they practice independently and the ones that do have to be supervised, in most cases they are a quick 'hello good bye' deal... and I think in many cases the psychiatrist gets paid...humm.
it's pretty silly that you think I'm arrogant while you are the one who refers yourself as "the gold standard"... here's an emoticon for you
btw: http://www.amazon.com/Handbook-Clin...76/ref=sr_1_11?ie=UTF8&qid=1329715612&sr=8-11
I guess you would say that one of your most influential figure in psychiatry sold out, huh? even when the ones that teaches you think that it's a good thing for the field that psychologist gain rxp, and you still think it's a personal attack onto you... man just give up...
Sheesh. And you say I'm the angry one.
You do not have data supporting its effectiveness. You have an absence of data of malpractice claims. Which is not the same thing.
Your listing of psychological testing is completely irrelevant. No standardized testing replaces a skilled clinical exam. Nor do I have need or desire to do testing to diagnose a patient.
I do not have biases against psychologists per se. I have biases against anyone using the term "doctor" in a hospital setting, where it implies expertise not present. Same issue I would have with a DNP or Doctoral physical therapists. Patients don't know the difference.
You may have had some lecture once on ordering an EKG, but RxP doesn't give you enough training to understand the underlying anatomy and physiology of how the heart functions, and thus no real foundation to understand the EKG. You may be able to look at some numbers and say "that's not normal," but that's not sufficient. And prescribing medications that change heart conduction properties (from antidepressants to antipsychotics) without understanding that is asking for trouble. Now you may never get sued, because as I've pointed out before the main factor that has been proven time and again to moderate malpractice is a good treatment relationship. And people tend to like their therapist. So they'll overlook errors. And you may skate by thinking you're doing a bang up job. That isn't the same as giving quality or safe care. Because you're completely unaware of every close call you cause.
You again conflate the issues as if I have a bias against psychologists. I do not. I have issue with psychologists practicing medicine without the proper training. As skilled as a psychologist may be in understanding mental illness, there is nothing about that that generalizes to medical expertise or understanding anatomy, physiology, psychopharmacology, pathology, or any number of other areas. It just isn't there.
You want some evidence against RxP?
How about the DoD program costing 6.1 Million Dollars to produce 10 psychologists, and no improvement in access. Even the GAO showed it was not cost effective.
http://onlinelibrary.wiley.com/doi/10.1002/jclp.10052/abstract
The DoD program went on for 7 years, with each trainee being directly supervised by a Psychiatrist, which current training programs cannot claim. Even WITH that level of supervision for that many years, the final report noted "While their medical knowledge was variously judged as on a level between 3rd or 4th year medical students, their psychiatric knowledge was variously judged as, perhaps, on a level between 2nd or 3rd year psychiatry residents."
https://www.acnp.org/Docs/BulletinPdfFiles/vol6no3.pdf
Now who would like their medications and problems being handled by someone with the knowledge of a medical student even after 6-7 years of additional post-graduate training? Doesn't sound safe to me. In fact there is SUBSTANTIAL evidence from the Institute of Medicine that level of training is associated with more medical errors (less training-->more errors). It's quite ridiculous that the training of psychologists somehow shields them from medical errors, considering they know even less about all of medicine and even of citing emergencies in general.
You really believe psychologists inherently can handle such medical treatment. The evidence speaks against that. In fact it tends to show that psychologists OVERESTIMATE their own competence and knowledge of medications, and their ability to handle them.
http://www.med.umn.edu/gim/prod/groups/med/@pub/@med/documents/asset/med_87453.pdf
Certainly nurses must think it's a good idea that psychologists get prescription rights. No? Wonder why? Allow them to elaborate and you can see that it isn't just physicians that think this is a safety risk.
http://www.ispn-psych.org/docs/11-01prescriptive-authority.pdf
How about some other scholarly critiques?
http://www.ncbi.nlm.nih.gov/pubmed/16396524
Which mentions the geographic location of psychologists doesn't lead to improved need. Nor is there ANY evidence aside from 1 study supplied by the APA, to show that there is such an undersupply that requires adding a scope of practice to those that don't have it, NOR is there any evidence to show that such a need could not be met otherwise.
All of this further bypasses what many identify as the real reason for RxP -- pursuit of expanded practice to maintain the viability of a profession (psychology) being oversupplied by too many schools, and with reduced need with the increase of masters level therapists.
If you really think I have something against YOU, then you really think too much about yourself. I could care less. And your pointing at me and calling Me narcissistic I only find humorous. Being able to practice medicine is a privilege. One I take up with humility, recognizing that I am not perfect, people are complex, and that I must struggle to continuously improve my knowledge base. I don't think skating by with 400 hours or didactics takes seriously enough the complexity of human physiology and pathophysiology, and moreso just demonstrates hubris.
And even amongst all of this, you still can't admit there are deficits in your knowledge or training. You have to be someone "good in many things." Arrogance.
Last edited:
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I like your use of smilies... you wanna trade stories? how about two separate boarded ER docs giving haloperidol IM without anticholinergic/antihistamine and without keeping them in the ER for observation and later, on both occasions, the pts developed severe dystonia, one acute laryngeal dystonia and ended up in the ICU. BTW, I got a call from the psychiatrist from the second pt going off on the ER doc. The psychiatrist knows me as an rxp psychologist said that I should ask to get privileges at that hospital to help out at the ER.
Your telling me that ALL MD know how to treat psych pts safer than rxp psychologists? How about a boarded internist prescribing venlafaxine XR "to help him sleep?" or another pcp raising the dosage of mirtazapine thinking that it will make a depressed patient less insomnic? How about a pediatric pcp who keeps raising the dosage on Concerta without taking into consideration that the kid was raised in a completely disorganized environment? how about a family doc starting a patient with recent suicidal attempt with bupropion? See, you are not going to consider any of these REAL examples that I see regularly... and I'm sure many of my colleagues see too... simply because I didn't go to med school right?
it's pretty silly that you think I'm arrogant while you are the one who refers yourself as "the gold standard"... here's an emoticon for you
IM anticholinergics is not indicated in single dosing of haldol unless someone has a history of dystonia or other EPS responses. That's a great anecdote, and show an ADR but nothing about the expertise of an RxP. Hindsight is 20/20. You could line up X number of psychiatrists to testify on your behalf, and I could line up Y number to tell you stories about other incompetent RxP's that I've dealt with. They're just that. Anecdotes.
How about the RxP's who give antipsychotics as first line agents for anxiety? Or those that forget to check blood levels and baseline renal panels on those on mood stabalizers?
And what does a suicide attempt have to do with bupropion? There's not contraindications, and you've been reading a few too many FDA warnings without reading the actual data behind them. Just like the QTc issue with ziprasidone you've mentioned before as a brilliant tidbit has actually been shown to be an overblown overestimated risk and not any worse than any other antipsychotic -- You don't know what you don't know. You challenge the credentials of others, touting yourself as an example of the best way to do things, of the expertise of psychology now carried over into another domain. I use the term "gold standard" to point out there is a higher standard than RxP for psychotropic understanding and for that of medical and psychiatric interactions. Something you can't seem to admit. My only conclusion, and it may be inaccurate, is that you identify so strongly with your role as RxP that my questioning the safety and wisdom of putting the undertrained into the medical field as a direct attack on you. I don't know YOU. I know that the practice is inherently unsafe. There's plenty of bad physicians out there, but on AVERAGE they will still be able to prescribe more safely than an RxP.
Fascinating that you can't have a discussion about the weaknesses of the whole RxP system without taking it so personally. I could care less about you because I don't know you. I DO care about improving the mental health system, and there is no convincing evidence that the financial costs and substantial RISKS that patients are being put in are worth the minimal benefits (none of which have been substantiated).
Shall we have a list of 20 questions that you have to answer without looking them up?
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Fair point that everyone can cite an anecdote and it doesn't advance the discussion.
So you respond with....a vague accusation that has even less merit than an anecdote? Your response is akin to me saying, "How about that psychiatrist who practices polypharmacy and prescribes 2 antipsychotics, a benzo for anxiety, and a non-benzo hypnotic for sleep? Or those psychiatrists that forget to schedule regular blood draws for patients on Clozeril?"
Last edited:
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So you respond with....a vague accusation that has even less merit than an anecdote? Your response is akin to me saying, "How about that psychiatrist who practices polypharmacy and prescribes 2 antipsychotics, a benzo for anxiety, and a non-benzo hypnotic for sleep? Or those psychiatrists that forget to schedule regular blood draws for patients on Clozeril?"
Those ARE anecdotes from RxP's I've seen in person.
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As were mine....which I posted for irony.
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actually not looking anything up... but wondering if you are... anticholinergics are not standard but it would behoove anybody who is administering haloperidol IM to keep a pt for observation.. the point is that and MD didn't even think about that... tapping into my point here of lack of knowledge...you are not recalling clearly (I thought you are supposed to be smarter than me because you went to med school)... in rel to the qtc issue, I said I check ekg if I use an sga with a pt with a hx of cv problems.. not all pts... I do blood work on all my pt's that I prescribe meds to... I hardly use abilify in monotherapy, more augmentation, never targeting anxiety...long half life which could be good or bad... suicide attempt and bupropion? not referring to FDA bro, I'm surprised at you man... cheeze and all that med school... you are totally responding with very limited knowledge of what we know... you are reacting with prejudicial impulses... it's pretty clear that we know more than you think we know...
btw... when I see that a pcp lacks a specific knowledge, unlike you, I don't laugh at them... and your clinical interview is worth close to nothing in court if you put it up against a psychologist that does an equally good clinical interview plus testing. Interesting here, another prejudice... your answer suggest that psychiatrist are better at conducting clinical interviews than psychologists... your ignorance is greater than your arrogance.
You are still not commenting on the massive supply of practicing psychiatrists that completed residency only as a means of least resistance to the US. This is not just a few, but a great percentage. You are telling me that they don't impact pt care? you can have your opinion and I'm more than entitled to mine but you take it to a whole different level when you just want to compare size little man
btw... when I see that a pcp lacks a specific knowledge, unlike you, I don't laugh at them... and your clinical interview is worth close to nothing in court if you put it up against a psychologist that does an equally good clinical interview plus testing. Interesting here, another prejudice... your answer suggest that psychiatrist are better at conducting clinical interviews than psychologists... your ignorance is greater than your arrogance.
You are still not commenting on the massive supply of practicing psychiatrists that completed residency only as a means of least resistance to the US. This is not just a few, but a great percentage. You are telling me that they don't impact pt care? you can have your opinion and I'm more than entitled to mine but you take it to a whole different level when you just want to compare size little man
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So psychiatrists differ from clinical psychologists because they spend their first four years studying what is required by the prerequisites of a medical school. A psychiatrist then attends medical school and finally finished their qualifications with a few years becoming familiar with psychological and social sciences. There are individuals who take premed course work to complete a degree in neuroscience and psychology. They then continues on in a clinical psychology program focused on the diagnosis and treatment of psychiatric/psychological disorder. The person then continues on to take specialize course work expected of a medical student (with some variance in specificity of the course work). The materials being covered by such an individual is the same and the person, due to both their premedical focus and graduate course work/fellowship in a psychiatric/neuropsychological/hospital setting. How would this lead to decreased care of patients and what would the person be missing if they met the qualifications you had to meet aside from the M.D.?
I guess im confused as to whether its the omission of a formal M.D. that bothers you? If a person is an expert in psychopharmacology, gained more experience in the social sciences than a psychiatrist, and take the necessary course work that would allow the person to meet all criteria (except for a formal M.D.) to prescribe safely while conducting psychotherapy, how would this be harmful?
Prescribing psychologists and patients' medical needs: Lessons from clinical psychiatry. Klusman, Lawrence E.
I really did not read through this thread as much as I should have. I would like your take on this article. My opinion is this. If I took the same course work, continued taking one additional graduate course to better my knowledge of anatomy, physiology, infectious disease, genetics, and possess an expertise in neuroscience, pharmacology, neuropsychopharmacology, and knowledge of the current literature pertaining to pharmacotherapeutics for a variety of illnesses, psychiatric conditions, and comorbid conditions, why should I be deprived of the opportunity to help out my clients in any way I can whether its reducing costs for them, helping them deal with the acute effects of medications that may reduce compliance, and helping them not only take their medication but utilizing my knowledge of psychotherapeutics to help promote lasting changes in a client that could lead to a decreased risk of relapse/decreased time for remission of an illness. Those are my opinions and I would like your take on the article mentioned above.
I had to write this out pretty quickly. Only had a few minutes but I really wanted to get some of my opinions/ideas out to continue the debate. I am just curious as to other people's perspectives as to why a perfectly qualified individual who has the academic course work, practicum experience, internship experiences, and research experiences, could not have the opportunity to help out to the best of their abilities.
PS. This article as well articulating some of the ideas I did not have a chance to type out.
http://ap.psychiatryonline.org/article.aspx?articleID=48094
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The coursework is not the same, and substantially less than even a PA or NP for RxP's. So they are not "experts" in psychopharm. Psychiatrists do 4 years (not "a few years") of intensive training in mental health care, with substantially more hours of patient exposure seeing substantially sicker patients than psychologists do, on average. The exposure and training is also in a more diverse range of training environments. Even aside from the coursework (which again is a pittance in RxP), a large part of medical training process is rotation and practice in a variety of medical specialties in the clinical environment, as well as direct supervision. RxP's like to critique that PCP's don't have the expertise they do, yet they set up those same PCP's as their supervisors to legitimize having some level of supervision. Hypocritical and dangerous.
Errr... well this is a bit off of the current discussion but I just thought I'd ask a quick question, as I'm fairly ignorant in the area of psychopharm, etc.
My question is would a graduate and fully licensed Counseling Psychologist be able to receive psychopharm training to receive perscriptive abilities? I know Counseling and Clinical doctoral programs have quite a bit of overlap and are probably more similar than different, but I was just curious. Sorry if this was addressed previously in the thread.
My question is would a graduate and fully licensed Counseling Psychologist be able to receive psychopharm training to receive perscriptive abilities? I know Counseling and Clinical doctoral programs have quite a bit of overlap and are probably more similar than different, but I was just curious. Sorry if this was addressed previously in the thread.
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Yes in the States of Louisiana and New Mexico. Also in the DOD, IHS, and Territory of Guam. Possibly by the time you graduate and become licensed that a number of other States will have prescription privileges. Some psychologist have completed Advanced Nurse Practitioner training and they are prescribing under the supervision of a MD/DO.
Since you are relatively young, my guess is that in your life time that most or all States will adopt legislation for psychologist with postdoctoral training to engage in limited prescription privileges of pharmacological medications. I am moving to Louisiana for internship and plan on gaining licensure in Louisiana as a medical psychologist with prescription privileges.
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I'm pretty much 50/50 with whether or not I see it gaining traction anywhere else. I know it's come up for vote in a few other states and has thus far been shot down. I'd imagine that if it's going to gain widespread appeal, as you've mentioned, they're going to have to up the reqs to bring them more in line with what most physicians would feel to be adequate. Then again, I honestly don't know what the current opinion of "most physicians" is regarding RxP, so I don't know how much of a change needs to be made in that respect.
I've toyed with the idea of taking the course post-grad for no other reason than self-edification/increased knowledge, and would definitively commit if it weren't so cost-prohibitive. I've also toyed with ending up back in LA at some point, but that's still up in the air, as is whether I'd actually ever realistically consider RxP should that be the case.
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what fantasy world are you living in?
Its been over 25 years since RxP have been pushed and over a decade since Guam approved it. it. At that rate we can expect all 50 states to adopt RxP in 240 years.
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yes.
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This is why I did it, and the training has definitely informed my day to day clinical practice. I'll probably sit for the PEP this summer, just to get it out of the way. I still don't plan on prescribing as part of my practice (as I hold little interest in the day to day work), but it is nice to have as an option. If there is a decent chance that you will end up back in LA...you should strongly consider doing it and getting licensed to prescribe.
As for the training requirements, I'm in agreement with most; they leave a lot to be desired. I did mine at the only fully-residential post-doc MS program....but that is now defunct, so people are left with online training programs.
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If you don't mind my asking (feel free to PM), what did it end up costing? And did your employer reimburse anything?
Most of the faculty I know who've sat for the class and licensure had both paid for by their organizations. The individuals in private practice of course didn't, but they came from highly-successful clinics to begin with, so that was likely of reduced concern to them.
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There was a white paper/document floating around a number of years ago that compared training costs amongst the various programs, though I'm not sure how accurate those $'s are now. My pharma cohort was small (N=8), and I believe it was evenly split between advanced standing students/recently graduated and much more established professionals. The students paid out of pocket, though I'm not sure what the other people did. I did the training over 4+ years, so the credit costs were managable ($15k).
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I completed the two-year training as well in 2007 and the knowledge and training is very helpful in my current job as a therapist as well as in my doctoral level clinical psychology training. I have not taken the PEP or done the preceptorship yet. I too attended a cohort that met once a month on weekends over two years, but now it does seem that many have gone to online programs. Fortunately I landed a internship near Louisiana and I plan on living in Louisiana and would like to eventually be licensed in Louisiana.
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Anecdotes may be worthless but terrible providers are EVERYWHERE. It can be a psychiatrist, a PA, an NP, an RxP, a PCP, a neurologist, a nonRxP. I have no interest in prescribing, but I really hope that our words can carry some weight when it comes to potentially adverse effects of polypharmacy or the use of certain drugs. I may not have the proper medical and/or pharmacological training like the above professionals do, but I know how altered mental status, delirium look like. I know how dystonia, akathisia, tardive dyskinesia, and Parkinsonism look like. I know that certain heavy duty drugs are tough on individuals who already have serious cardiac, pulmonary, renal, and liver problems. I may not know WHY something strange is happening, which is why I like to refer out, and/or encourage patients and family to go speak with their medical providers. I resent it when other providers minimize certain symptoms and/or tell my patients "it's all in your head."As were mine....which I posted for irony.
Well, I suppose your brain is in your head and it's an essential part of the central nervous system and the human body. So, yes, it may mostly be "in your head." Just because you can't figure out what is "wrong" doesn't mean that the person is "faking."
If there is ONE reason for me to go to medical school, it is to see if other medical providers may actually begin to listen. According to my psychiatrist friends, unfortunately, they often don't get much respect from other specialists either. Every field has its own hierarchy. Our responsibility and duty are to our patient but somehow this is often forgotten in the midst of inadequate training, poor communication, and easily bruised egos.
I'd like to see a healthcare system in which we have mostly good psychiatrists, who are willing to listen, and have the same kind of respect as other specialists. That should be Step 1. I am not only talking about the mental health system but healthcare overall. PCP's that hand out sleeping pills, pain pills, benzos, and antidepressants like candies terrify me sometimes.
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IL RxP bill out of committee. Goes today to the Senate.
Here is the contact info for your state senator, if you are in IL.
http://www.ilga.gov/senate/
Here is the contact info for your state senator, if you are in IL.
http://www.ilga.gov/senate/
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It only came out of subcommittee because the bill was presented by State Senator Harmon-D who is President Pro Tempore. The vote was along party lines with 6 dems and 4 repubs. Actually 2 dems did not vote a straight "yes" as they needed "more time to think about it". The dems did not want to vote against Harmon. When the Illinois Psychiatric Society spoke with Senator Harmon he was quite surprised about the facts. Two other republican state senators who did not serve on the committee thought the idea was "ridiculous" since they have family members who are being treated by Psychiatrists. The bill may not even go to the senate floor if Harmon believes that the bill will be killed on the floor according to his straw polls. Already 24 republicans will vote no and just need 6 democrats.
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During the committee meeting the psychologists were claiming they would have enough training to prescribe to children. I still don't feel comfortable prescribing to kids after 4 years of residency. They also claim to be working in rural areas where there is a shortage of psychiatrists. When you look at the location of medical psychologists in New Mexico and Louisiana they are located in the same areas as Psychiatrists. The Illinois bill only requires 450 "contact hours" but does not define this phrase. This certainly does not compare to the over 10,000 hours of training that occurs in residency.
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I don't agree with the low # of contact hours (however they are defined), though the Apples to Apples comparison should be to NPs & PAs. I also question the "10,000hr" number that gets thrown around because I believe it includes call as well as a ton of other hours that are peripherally related. If you want to count those hours, then the training hours for psychologists should be included because they are also in peripherally related areas.
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When you are on call you are sometimes learning more because decisions have to be made sometimes without the guidance of an attending. The 10,000 hrs is derived from a 50-55 hr work week for 48 weeks a year for 4 years. Effective use of medications requires a thorough understanding of physiology, chemistry, drug-drug interactions, and medical diseases that can masquerade as mental illness. This training does not occur while a psychologist is in grad school. There is no basic science background in the training of a psychologist. They are not required to take pre-med courses before being accepted into grad school.
When this was explained to the senators they agreed that psychologists do not receive adequate training to safely prescribe. Many senators admitted that they did not know what is involved in the training of a physician and especially a Psychiatrist.
When this was explained to the senators they agreed that psychologists do not receive adequate training to safely prescribe. Many senators admitted that they did not know what is involved in the training of a physician and especially a Psychiatrist.
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Does anyone have any experiences with three generational family therapy? My son's (5 years old) doctor says this will cure him of the physiological issues he has. I'm having a hard time researching it...Thanks!
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trolololo
This is a bit of a tangent, but I think the clinicians in this thread might be well-suited to answer this question. Can anyone recommend a good psychopharmacology book for a social work student? In a couple of months, I'll start working with clients with severe and persistent mental illness, and I'd like to augment my knowledge of psychiatric medications before I start.
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Stahl's book on psychotropics is a quick & dirty run down of psych meds. It is more of a reference than a textbook, so it won't "teach" you the in's and out's of pharmacodynamics or pharmacokinetics, etc., but it isn't bad if you want to look ups med and see the common side effects or similar.
D
deleted106747
After working in the field, I am less likely now to go for script rights, and more likely to go for the 2 year program without the license, so I can work hand in hand with primary care physicians, who prescribe most of these medications, and offer them some expertise in a consultative role. I don't want to lose my identity and my role as a psychologist, and I don't want to end up with fifteen minute med check appointments for a career. However, I do feel that knowledge of these medications is extraordinarily helpful, and that a partnership between a pharmacologically educated psychologist and a medically educated primary care physician is an excellent model to address the shortage of psychiatrists and mental health providers. So that's where I'm going to go with it. No DNP, no NP, no med school for me, because I like what I do too much, and more importantly I value it.
That being said, I'll be damned before someone takes away my doctor title in my practice or in the hospital. It does NOT imply "expertise not present" because I HAVE invaluable, doctoral level expertise in assessment, diagnosis and treatment. I'm proud of what I've learned and worked for, and it is in no way lesser than what a physician brings to the table. Most physicians I have encountered appreciate this, and value it, and it has been a blessing to work with such providers jointly to bring comprehensive care to patients.
That being said, I'll be damned before someone takes away my doctor title in my practice or in the hospital. It does NOT imply "expertise not present" because I HAVE invaluable, doctoral level expertise in assessment, diagnosis and treatment. I'm proud of what I've learned and worked for, and it is in no way lesser than what a physician brings to the table. Most physicians I have encountered appreciate this, and value it, and it has been a blessing to work with such providers jointly to bring comprehensive care to patients.
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I wonder if a consultative arrangement like this can increase the income of the clinical psychologist in private practice. Other than an increased number of referrals, that is.
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Anyone have any insight on the change in CPT codes? I read on the psychiatry forum about these changes and it sounds like they will be very beneficial for psychiatrists (allowing them to use E&M codes), but potentially harmful for prescribing psychologists (forcing them to use a separate, non-E&M code). I was wondering if any prescribing psychologists are on this forum or know anything about this? I'm curious about how these changes work... do psychiatrists and prescribing psychologists currently use the same code?
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As you know, clinical psychologists (in the US) are already permitted to supervise the hospital care of their Medicare patients under current law. The new Medicare Mental Health Access Act (S. 483/HR 831) undermines necessary medical training and would allow clinical psychologists to supervise the overall care of patients in inpatient facilities that receive Medicare reimbursement. Furthermore, if this bill is passed, it could provide momentum for legislation in states to expand scope of practice and grant clinical psychologists the ability to prescribe potent psychiatric medications without a medical degree.
How do you guys feel about psychologists potentially having prescribing privileges in the future? Are you all for or against it?
How do you guys feel about psychologists potentially having prescribing privileges in the future? Are you all for or against it?
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It's already happening in two states. In those states, prescribing psychologists are commonplace in medical settings. The future is now.
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It'll happen nationally over time, state by state. There are too few psychiatrists to out there. With mid-level practitioners receiving prescriptive privileges, the push for psychology RxP will continue. If you're under 40 there's probably a good chance it'll be a part of your career at some point if you elect for the additional training.
I would personally PP to remove medications. I do think there will be some who will join the med-check train. This will definitely change our profession.
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I don't necessarily doubt that RxP could spread, but part of the reason it hasn't done so is because state psychological associations simply haven't put in the time, effort, and (perhaps most importantly) money necessary to successfully lobby their state legislatures. If RxP does indeed begin to pick up traction outside of NM and LA, the main thing I'd be happy about is that it would possibly mean the psychologists in those states have finally begun to seriously politically/publicly advocate for the profession.
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A big impediment is that psychologists are so divided on the issue. When our state psych association puts any money or effort into advocating for this there are several older, near retirement influential folks who raise hell and say that they don't want their money used to "ruin" the profession. I find this very disturbing because maybe these old timers don't need to worry about being able to afford college for their kids, but some of us still do. Also, one in particular is an academic and I suspect she is pretty out of touch with the reality of the patients in our state attempting to get psychiatric care.
Dr. E
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How long would the additional training be?
I know a clinical psychologist who went ahead and got certified as a nurse practitioner as well, so I guess psychologists could also go that route too if they want prescribing privileges.
Although, I am assuming this might take longer.
But, I think it would be great, considering the earnings potential would become a lot higher for psychologists if they can prescribe.
I would take a "pro choice" stance on this issue. Those psychologists who want Rx rights can go ahead and get them. Those that don't, don't have to get them. But, those who are against it shouldn't prevent others from doing so.
I know a clinical psychologist who went ahead and got certified as a nurse practitioner as well, so I guess psychologists could also go that route too if they want prescribing privileges.
Although, I am assuming this might take longer.
But, I think it would be great, considering the earnings potential would become a lot higher for psychologists if they can prescribe.
I would take a "pro choice" stance on this issue. Those psychologists who want Rx rights can go ahead and get them. Those that don't, don't have to get them. But, those who are against it shouldn't prevent others from doing so.
