This is a point-counter point from Tonya Tompkins, PhD, an unlicensed psychologist who teaches at a small university in Oregon an board-certified neuropsychologist in Louisiana:
Dr Tompkins:
As a psychologist who strongly believes that we should ascribe to an evidence-based practice model of providing patient care I appreciate the editorial board’s stance which opposes allowing psychologists to prescribe. Despite what some proponents argue here and elsewhere, the data neither support claims of improved rural access nor improved outcomes for patients. In my own research and others’ study of the issue (e.g., Baird, 2007) the argument of reaching those without care is seriously called into question - almost no psychologists were practicing in true rural areas and non-metro psychologists were no more likely than their urban counterparts to pursue training to become a prescriber. Similarly, the claim has been made that 200,000 psychotropic medication orders had been safely and effectively written by Glen Ally’s Louisi...ana colleagues alone in the first four years of legislation (DeLeon, 2012, p.6).However, these claims appear to be divorced from reality and are not grounded in actual data. As of 2013, there were only 71 medical psychologists in Louisiana. In the four years between the passage of the bill and Ally’s estimation, there were substantially fewer prescribing psychologists. In fact, in the only published attempt to evaluate prescribers, Levine and colleagues (2011) identified only 25 (14 in Louisiana, 9 in NM) of the 59 psychologists with prescription privileges who were practicing part-time or full-time. Of the 17 interviewed, just over half reported that they saw 30 or more patients a week and approximately 70 to 80% of patients were prescribed medications by these prescribing psychologists. Thus, it appears as if this often quoted statistic is either a blatant overestimate or perhaps those who did not take part in the survey are overprescribing – a concern they often raise about Primary Care Physicians. Patients deserve better. If psychologists want to prescribe there are established routes available to them that build on a solid foundation and grounding in the physical sciences.
The medical neuropsychologist in LA:
I typically do not respond to folks such as this or those in the POPPP crowd, because they simply make assertions that have no basis in reality. For example, the assertion that psychologists will not be "safe" prescribers. After more than 20 years experience in the military and now 10 years experience in two states with not one malpractice complaint for prescribing, I think that, on its face, is evidence that psychologist ARE safe prescribers.
Despite the fact that, in my view, the evidence speaks for itself, it is someone like Dr. Tompkins, who purports to have a "minor in measurement and psychometrics" and who below stated that her "own research" and "others' study of the issue" make me call into question the quality of such "research." Dr. Tompkins evidently did not even bother to check public records to get accurate information. If her basic numbers are inaccurate what credence should I give her other information and, more importantly conclusions based upon such shoddy work.
Had Dr. Tompkins even bothered to verify her numbers with publicly available data on the Louisiana State Board of Medical Examiner's website, she would have discovered that in the year 2013, there were NOT 71 medical psychologists licensed in Louisiana, there were actually 82. Medical psychologists were licensed under the medical board since 2009 at which time there were 55. So, we have grown over the years. Of course, of the 82, a few indeed are nor prescribing. There are some who are administrators in various positions, etc. For example, one medical psychologist was the Chief Psychologist with the Louisiana Department of Health and Hospitals, until his retirement for State employment. He is now in private practice AND prescribing. But, Dr. Tompkins should have gathered accurate numbers for her "research."
Dr. Tompkins cites the numbers quoted by Dr. Levine and her colleagues and notes that there were only 25 medical psychologists in Louisiana and 9 in NM of the "59 psychologists with prescriptive authority..." Again, had Dr. Tompkins even bothered to do a simple check on the medical board website, she might have gotten this number a little more accurate as well. In 2011, there were 72 medical psychologists licensed in Louisiana. Medical psychologists in Louisiana, as you might imagine, have had requests from across the country on almost a daily basis for "data." There have been numerous requests to MPs to participate in numbers research studies, etc. Have you ever wondered why there is precious little research out there on the prescribing habits of say nurse practitioners, or physicians's assistants, or physicians themselves? What little research there is is done either on resident physicians or retrospectively by chart reviews. Problem is, no one keeps track of this info nor has time to keep track of such info. However, as psychologists we are always fascinated with "the data" perhaps this colleague should be more fascinated with ACCURATE data.
With respect to the work of Dr. Levine and colleagues, Dr. Levine actually had to struggle to get the 14 respondents from Louisiana that she did get. There are several reasons for this. But primarily, does one actually think that after the first month or so that anyone with prescriptive authority actually keeps track of the number of prescriptions written? I guess one could do that a little more easily by simple counting the number of prescriptions in a prescription pad and the number of pads ordered and then count how many are left...easy, right? But for many of us, we are simply not exclusively in private practice. I will use myself as example...I have a private office where I see patients two days a week. I provide contract services at the Community Mental Health Center two days a week, and I provide contract services to a large Cancer Center one day a week. In addition to that, I see consults hospital-wide for a 340 bed general hospital. These consults I see generally after normal business hours. In each of those four settings, prescription pads are provided by the facilities. So, I can't just count prescriptions. Several of my colleagues do similar kinds of things. That is, several colleagues work more than one location. MPs are actually quite a bit in demand. I've said before, MPs may not get a great deal more reimbursement that licensed psychologists, but they have greater opportunities then licensed psychologists. There is great demand for MPs to do a variety of contract type work.
Parenthetically, Dr. Tompkins seems to have made another erroneous assumption. That is, just because medical psychologists may not have offices in all rural areas, her assumption seems to be that we have not increased access or provided services to rural areas. Dr. Tompkins' lack of knowledge of the mental health system seems to rival her lack of thorough research skills. As noted above, I provide contract services at a REGIONAL Community Mental Health Center. That CMHC serves a seven parish (county) area that includes all rural communities in those seven parishes. Before another MP and myself contract with the CMHC, there were several vacancies for psychiatrists that had remained vacant for 10 or more years. Two of us took contracts there so that essentially increased their providers and prescribers by two and thereby increased access for more of the folks in those parishes. Since we took those contracts some 6 years ago, three more MPs have taken positions at other CMHCs. In the CMHC, I see patients every half hour, 16 patients a day. My colleagues do the same, but they actually provide services 5 days a week.
Finally, let's look at the ESTIMATE I provided of more that 200,000 medication orders by medical psychologists and how once again, Dr. Tompkins just doesn't get it. I say and have said that the number was an estimate and that is what it is...an ESTIMATE. That estimate is a fairly educated estimate, but an estimate, nonetheless. I will speak to only Louisiana as I am not sure how many are currently prescribing in NM. As noted above, as of 2013 there are 82 MPs in LA. There are a few who do not prescribe, but the vast majority do. Approximately half of the MPs (about 40) are Advanced Practice MPs. That means that they had to have prescribed for at least 100 patients (according to the statute that I am sure Dr. Tompkins didn't read) as one criteria to become "advanced practice." That's 100 patients, that means AT LEAST 100 psychotropic medications, but for many patients, there may have been more. For example, some patients may have gotten antidepressant medication and a sleep medication. That would be two medication orders. On many occasions, MPs have provided refills for patients who may have been on three or four psychotropic medications. So basic fact...number of prescriptions does NOT equal the number of medications ordered. So, if we take the number of Advanced Practice MPs and multiply by 100, we know there were at least 4000 prescriptions written just to qualify 40 Advanced Practice MPs. We must also keep in mind, that MPs in Louisiana were prescribing since 2005 and "Advanced Practice MPs" did not come into existence until we moved to the medical board in 2009. Those 4000 prescriptions were in addition to all that was written prior to 2009. So there were four years of prescribing before that move to the medical board and Advanced Practice. MPs who were not and are not "Advanced Practice" were and are still prescribing, they simply must have "concurrence" by a physician for the prescriptions they write, but they still prescribe. As noted above, there were 55 MPs beginning in 2009, so most of those 55 were writing scripts before the switch to the medical board. But, back to the estimate.
As you will recall, I mentioned I work at the CMHC and see 16 patients per day there (2 days a week). That's 32 patients a week with orders for say two medications times 52 weeks works out to be 3328 medicationn orders annually. While I do have some patients on just one medication, I also have many who have orders for four or more meds. But, let's crunch some numbers. I also mentioned that I have three other colleagues who work at CMHCs doing the same thing except FIVE days a week. So, 16 patients with two medication orders times 5 days weekly, times 52 weeks works out to 8320 medication orders, annually. 8320 time three colleagues = 24960 medication orders annually, plus my 3328 medication orders annually = 28,288 medication orders annually. Multiply that times the 5 years we have been at CMHCs = 141,440 medication orders.
That's 141,440 medication orders over the past 5 years for only FOUR MPs working at CMHCs. That is not counting the other 36 Advanced Practice MPs or the other 40 or so MPs. That's also only over the past 5 years. MPs in LA have been prescribing now for 10 years. That is also not counting some of the MPs licensed in LA who work outside of LA. For example, we have a couple of MPs who work in the US Public Health Service. We have at least one LA MP who is working in NM. We have at least one MP who has been in the military and prescribing for the past 10 years. I don't know their numbers. So, if you think that some 40 MPs in LA over the past 10 years have not written approximately 60,000 prescriptions, then indeed Dr Tompkins may be correct and my number of 200,000 could be wrong...its possible. But, if I am a betting man, I would put my money on my estimate...remember I said my Rxs were 2 days a week at the CMHC. I would be willing to bet that in the other three settings in which I work (general hospital averaging about 4-5 consults a week, Cancer Center seeing 10-12 patients daily, and private practice seeing 7-8 patients daily) over a 10 year period I have provided about a third of those 60,000 still to be accounted for. I also know from personal communications that MPs have far exceeded that 60,000. There are other MPs working in general hospitals, Children's Hospital in New Orleans, a large neuromedical center with more than 40 neurologists and neurosurgeons and three MPs, physical medicine and rehabilitation hospitals, and many in private practice who I believe easily make up that 60,000 medication orders over 10 years.
We also tend to think only in terms of putting patients on medications. We often do not think of discontinuing medication as a medication order, but indeed it is. What I have not included in this count however, are those orders to discontinue medications and all the orders for tests and labs by MPs. Most of us order preliminary lab work and periodic monitoring lab work. Once a patient is stable at the CMHC, we order lab work annually on patients. Those orders are not included in my estimate. Trained as a neuropsychologist, I have ordered (thought not very frequently) CT scans, MRIs, ECGs, and EEGs. I have ordered sleep studies. These orders are not included in my estimate either.
So, I am confident in my estimated number, in fact, I believe it to be low and that was done purposely because there will always be people like Dr. Tompkins who will spout off bogus numbers and then reach spurious conclusions using those bogus numbers to justify their inaccurate conclusions.
Now, how do I KNOW some of these numbers...not only are the numbers regarding MPs available on the website of the Louisiana State Board of Medical Examiners, I sit on the Medical Psychology Advisory Committee to the Lousiana State Board of Medical Examiners and have been sitting on this Committee since 2009. So I know the numbers regarding MPs. I also know my own numbers regarding he CMHC and in fact, when I did a workshop at APA in the past, on of the slides included a picture of the scripts I have written at the CMHC. At the CMHC, the scripts have duplicates...the original goes to the patient, a copy goes into the patient's chart (yes, there is still a paper chart), and I get to keep the other copy. I have as stack that is literally a 10 inches tall. I also included a photo of a prescription for a patient that included 5 psychotropic medications with the name redacted and noted that there were more in the stack with 4-5 meds than there were with only one med.
Again, I am confident in my numbers and mine are verifiable. But, keep in mind. This exercise is a waste of time if the objective is to attempt to convince people like Dr. Tompkins and some of the other more vocal opponents. They have never let facts get in the way of erroneous conclusions before and I doubt that pointing out real facts will convince any of them now or get them to cease making unsubstantiated claims.
I hope the above is clear. I apologize for the length.
I am not sure where Dr. Tompkins obtained her numbers, but the old saying "Garbage in, garbage out" comes to mind
