Psychopharmacology/Advanced Practice Psychology

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So...the movement is only about greed and the failures are about APA....what about the patients? You keep propping up your straw men (greedy psychologists, evil factions of the APA, conspiracy by training programs, etc) and ignore that RxP can help patients, and HAS helped patients. It really sounds like you have an axe to grind w the APA and the patients are...whatever/wherever/whoever. Maybe there is something lost in translation, but it really seems to be about the straw men and not actually the men and women the legislation can most impact. Just an observation...

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The Illinois law requires that the graduate program providing the RxP coursework be accredited by ARC-PA, the physician assistant accreditation organization. This is a major hurdle for the RxP advocates. The only feasible location of such a program is a university that already has an accredited PA program, and those universities apparently won't consider something this shaky.
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Can we get a link verifying this? I can't find it anywhere online.
 
As stated before, I support the underlying idea of of RxP. But, the implementation so far has been pretty botched, with unrealistic bills and guidelines. I'd actually be interested in a real debate of the benefits and downsides if done correctly. But, so far it's all just been hyperbole, strawmen, and vitriol. Light on data, heavy on rhetoric.
 
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Like clockwork.... Every time.

"It never passes, therefore it should not be tried."

We get it.

And many disagree.
 
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As stated before, I support the underlying idea of of RxP. But, the implementation so far has been pretty botched, with unrealistic bills and guidelines. I'd actually be interested in a real debate of the benefits and downsides if done correctly. But, so far it's all just been hyperbole, strawmen, and vitriol. Light on data, heavy on rhetoric.

If you mean by "underlying idea" that psychologists find some way, any way, to prescribe medications, then there would be little disagreement. That is, psychologists obtaining traditional training as an MD, PA or APN, would meet little to no controversy or opposition.

If you mean psychologists prescribing after having obtained training that is generally accepted by the health care system and all its professions as the minimum for safe and effective practicing but doing so as psychologists, you will find a good deal of discomfort with such an idea, since including the practice of medicine into our profession is controversial and brings with it a number of risks to the profession which are unnecessary when cross-training is available to all.

If you mean psychologists prescribing based on the extraordinarily low standards of training, low in both quantity and quality, that is proposed by the APA model which has been such a failure (for very good reasons) then you'll find a great deal of opposition.

You mentioned data ... a solid survey of licensed psychologists in Illinois found that a whopping 78.6 percent said any psychologists who prescribe should do so with the same training as other non-physician prescribers. I find that to be very convincing data, and you will not find any RxP advocate trying to explain that away. A very large national survey, 600+ respondents, of psychologists belonging to ABCT, a cognitive-behavioral therapy organization, found that the vast majority oppose the details of what is being sought by the APA model. For example, only 10 percent said they would refer a patient to someone whose training was that contained in the APA bill, and only 5.8 percent thought that learning how to practice medicine on the internet was appropriate.

The data opposing what we call "RxP" is there, actually. The arguments are quite clear. What you will find is a glaring vacuum of data from the two states experimenting with RxP where proponents produce no studies to show that RxP results in improved access in their communities, safe or effective prescribing. Ethical health care professionals base their practices on empirical science and not lobbyists.

I agree that a real debate available to all psychologists over these issues would be very helpful. Good luck with that.
 
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You can make a lot of interpretations of the ABCT data. For example I could say that in the low respondent rate, we had respondents who were overwhelmingly students and academics, people who do not work full-time in a clinical setting. We could say that about 40% of respondents were supportive of prescriptive authority. We all know the pitfalls of respondent data. And, majority support on an issue in the absence of data is not great data, these opinions constantly shift and flux through time. We can see the same regarding attitudes of certain treatments, pharmacalogic and psychotherapuetic alike.

I've still never gotten an answer to a question regarding a double standard for level of training. Is there data that says "X training" is efficacious/adequate/etc? I'm just curious as to where that same data was required from MD's, NP's, PA's? I'm not saying that we shouldn't be pursuing it, for every prescriber really, but why is this only applicable in this case? Heck, we actually have good data that MD's are not good at following best practices in psychopharm management. Look at data of current benzo prescription in elderly populations, specifically those with diagnosed or suspected dementia. Or patients who are prescribed zolpidem for years at a time. When do we apply that proof of evidence to everyone who prescribes, and not just one segment?

Now, I'm definitely opposed to online only training, pretty much in any context where clinical care is involved, but it seems that the opposition goes beyond that, to the mere idea itself, and would oppose anything short of essentially requiring the MD training equivalent, even though there is no data saying that is necessary to ensure an adequate training in psychopharm prescriptive authority.
 
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Survey data can be tricky, to be sure. RxP advocates typically ask people if they favor "properly trained" psychologists being able to prescribe. This opens up the interpretation so widely as to let almost anyone give an affirmative answer, including those who believe it means getting a full medical education and psychiatric fellowship. What makes such data interesting is that 40-60 percent of those asked are not supportive ... meaning that they would oppose it under any possible, imaginable circumstances? That would be very meaningful.

Such data is often misused by RxP advocates who clearly imply that this many psychologists support their proposals, rather than the specifics of what they lobby for. This is like saying most Americans favor lower taxes, and by implication support proposals to wipe out Social Security and the Department of Defense. Not so fast ...

The data I cite is more specific and I believe meaningful. It asks details of the proposals. Somewhere between a large majority and the vast majority of psychologists either do not support or are firmly opposed to RxP when the details are examined. The variance depends on which details are regarded. The data strongly suggests that if all psychologists had the opportunity to openly examine the issues involved, it would not be good for the RxP campaign, which may be one reason why APA has worked hard to not seek any consensus from the membership, or the community at large.

Opposition to the RxP proposals varies as well. Some are rather satisfied with the IL law which requires PA-level training in PA-accredited programs with an extensive practicum since it does meet the standard that other non-physician prescribers mustt meet, others still oppose it because it incorporates the practice of medicine into our profession, which I've already mentioned. So I think characterizing opponents requires a little more complex thinking than some would suppose.

Some on this list have questioned whether APN's and PA themselves have sufficient medical training. Nursing organizations are actually upgrading their training/practice standards to require a clinical doctoral degree. Meanwhle, the RxP model is a kind of dumbing-down medical training and practice standards.

As for your double-standard argument, it is an interesting question and I hope you research all the training standards and measures of competence required of MD's, APN's and PA's and report back. However, expecting our colleagues to simply observe the most basic rules of empirically supporting what appears to be a very risky and substandard, experimental set of standards is not unreasonable regardless of what other professions have done. I have no doubt that other medical professions do indeed have data to support their training and practice standards, just as psychology has. I don't think it is incumbent upon me or anyone else to prove that others must meet reasonable standards in order to expect it of those making this proposal before challenging what seems to be grossly insufficient training.
 
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You can make a lot of interpretations of the ABCT data. For example I could say that in the low respondent rate, we had respondents who were overwhelmingly students and academics, people who do not work full-time in a clinical setting. We could say that about 40% of respondents were supportive of prescriptive authority. We all know the pitfalls of respondent data. And, majority support on an issue in the absence of data is not great data, these opinions constantly shift and flux through time. We can see the same regarding attitudes of certain treatments, pharmacalogic and psychotherapuetic alike.

The ABCT data was of psychologists only. It's possible that it included "academics." I'm a little surprised people think that the only psychologists whose opinions matter are those who stand to profit the most from RxP, and that persons who train psychologists, licensed or otherwise, should not be heard.

Aside from that, the data is very consistent with the survey in Illinois, which questioned only licensed Illinois psychologists. Again, a very large 78.6 percent said that psychologists who prescribe should have the same training as other non-physician prescribers. It was the most lopsided response given to questions about RxP, so it seems clear that they feel strongly about training standards, ones that the APA model of RxP does not come anywhere close to meeting.
 
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I have no doubt that other medical professions do indeed have data to support their training and practice standards, just as psychology has.

This may be where we disagree, I actually doubt that this exists for psychopharm specifically.

As for the ABCT data, it's clearly stated what occupational category people are from, we don't need to surmise, the data is there. It's not that their opinions "don't matter" but that they are more susceptible to being biased. If we did a poll on clinical supervision priveleges for academics, or a question about grant funding at academic institutions, and most of the respondents were private practice individuals, how much can we generalize that data? And, should we base policy on it?
 
Some on this list have questioned whether APN's and PA themselves have sufficient medical training. Nursing organizations are actually upgrading their training/practice standards to require a clinical doctoral degree. Meanwhle, the RxP model is a kind of dumbing-down medical training and practice standards.

And exactly how many of those "doctoral" classes directly relate to pharmacology, prescribing, etc? It's superfluous degree inflation and everyone knows it. It has ZERO to do with this conversation and zero to do with "advanced clinical training" based on the classes they typically offer.
 
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ome on this list have questioned whether APN's and PA themselves have sufficient medical training. Nursing organizations are actually upgrading their training/practice standards to require a clinical doctoral degree. Meanwhle, the RxP model is a kind of dumbing-down medical training and practice standards.

I can't remember if I've asked you to clarify this before, but exactly what do you mean when you say APN? In my locale, NPs can prescribe. An NP is only a 60 hour master's program. Not all of this 60 hours is in instruction. They have 36 hours of instruction, the rest is in practicums (pratica?). You made the argument before that many have more experience than that, but I don't see how that makes any difference to educational requirements. Could you, from your standpoint please explain why a BSN + NP masters is sufficient to prescribe many different categories of meds, as a minimum, but a Psych PhD + master's (45-60 hours? depending on state?) is not okay to prescribe only psychotropic meds? This makes no logical sense to me.
 
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And exactly how many of those "doctoral" classes directly relate to pharmacology, prescribing, etc? It's superfluous degree inflation and everyone knows it. It has ZERO to do with this conversation and zero to do with "advanced clinical training" based on the classes they typically offer.

And as far as I know CGOPsych's statement is not true. The DSN or DPN is a very controversial degree and there is no major push to have all NP's converted to doctorate degrees.
 
There is a *long* thread about the DNP degree in the NP/PA forum here, in case others are curious. It isn't about RxP, but it is worth a read if you are curious about how nursing is trying to side-step medicine.
 
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You keep propping up your straw men
The post below is not directed at T4C but a general statement about the critique of CGO's arguments.

I would like to draw a parallel from this topic to another often contested debate on this forum: for-profit, large-cohort, low accredited internship match rates, low EPPP pass rates training programs. We have ZERO data saying that those programs produce incompetent clinicians or scientists. Similarly, we have no data showing that RxP harms patients. The reasons for this are numerous but mostly b/c the research is difficult to execute and no one cares to fund it. Thus, we are left with creating inferences from the available data. I would not call this a straw man argument but the closest approximation of the accessible data. So, here we go:

I believe for-profit, large-cohort programs produces (in aggregate) poor professionals. Why? Well, the 2 closest measures of clinician competence we have are accredited match rates and EPPP pass rates (these are obviously not direct measures). We have empirical data showing a strong association between variables. We all definitely understand the limitation of these conclusions but these limitation do not invalidate the conclusions.

For RxP, we have ZERO data on the safety and efficacy. CGO has presented (throughout his posts) the data we have available. We understand the limitations of that data and it does not invalidate his argument.

A lot of us here are basically set in our beliefs already. We have all presented our views, our data, and our critique of the data. I think it would be best to work together to fill in the gaps rather than keep the cycle going.

Just as we would post on here if a new state passes RxP, it seems equally important to provide updates when states reject bills. I do not see more data as a negative but only as more informative. For RxP supporters, these failed attempts can be an example of what needs to change in legislation. For those that oppose RxP, this provides continued vigilance. For the undecided, this provides information.
 
And as far as I know CGOPsych's statement is not true. The DSN or DPN is a very controversial degree and there is no major push to have all NP's converted to doctorate degrees.

Pardon my grumpiness, but I get tired of having to dig up support for statements to counter those of persons who don't do their homework but wish to accuse me of not knowing what I'm talking about. I'd appreciate it if you could get just a little bit of evidence before saying such things, it might make this process a little easier.

If you will look up the final report of the American Association of Colleges of Nursing, DNP Roadmap Task Force Report of 2006, it says that (bold font mine):

The task force made 13 recommendations, 4 of the most critical being:
1. The Doctor of Nursing Practice (DNP) is the degree associated with practicefocused
doctoral education.
2. The practice doctorate be the graduate degree for advanced nursing practice
preparation, including but not limited to the four current advanced practice
nursing (APN) roles: clinical nurse specialist, nurse anesthetist, nurse
midwife, and nurse practitioner.

3. A transition period should be planned to provide nurses with master’s degrees,
who wish to obtain the practice doctoral degree, an efficient mechanism to
earn a practice doctorate.
4. Practice-focused doctoral programs will be accredited by a nursing accrediting
agency recognized by the U.S. Secretary of Education (i.e., the Commission
on Collegiate Nursing Education (CCNE) or the National League for Nursing
Accrediting Commission).
 
2. The practice doctorate be the graduate degree for advanced nursing practice
preparation, including but not limited to the four current advanced practice
nursing (APN) roles: clinical nurse specialist, nurse anesthetist, nurse
midwife, and nurse practitioner.

I don't see you as grumpy ;) I said as far as I know your statement isn't true. Maybe I should have said, "not completely true" or "not currently true?" You do not seem to be aware of how controversial the DPN degree has become, and that because of that controversy, the bolded part of the task force suggestion may never be implemented. I suggest reading the thread that T4C recommended. It explains this topic in more detail and explains why the whole topic of DPN is controversial amongst nursing professionals and nursing schools. Many in the nursing profession believe, like T4C described, that the DPN is degree inflation.

The point I would like to see you address, is that nurses are currently prescribing with less education than you are alluding to, and that they would have less education than the IL bill you discussed previously -- I believe the PhD +PA education? I don't have a problem with suggesting that RxP should have a robust set of minimal standards. I just think it should be made clear that NPs currently prescribe with a bachelors + a masters. Even if they have 2 years of practice between bachelor's and the NP degree, that is not the minimum requirement. There are direct entry NP programs that exist. There are direct entry ONLINE NP programs that exist. I just don't think its fair to hold them up as this golden standard of prescriber education, when they have problematic programs of their own. How is an online RxP degree for psychologists different than an online direct entry NP program? I think they are both problematic and I would like to see you address that as a prescriber issue as well. You've made some good points, I'd just like to see you address that one.

I personally don't have a problem with NPs and PAs prescribing in their current capacity. Just to make that clear.
 
Comparing the RxP training models to that of APN's is more difficult than with PA's, for sure. You can look up a PA school's pre-reqs and curriculum in many places, and any person can take that training. By the way, the IL RxP model is NOT an APA RxP training program, It is nothing more than an analog of a PA program and not by accident. When the RxP advocates in IL were being beaten for the 15th year and looked at nothing but more failure for the future, one of them acting completely on her own opted to take the psychiatry people up on the idea of PA-level training. The psychiatry people lifted the entire PA training program from a state university's catalog and insisted on that, which was accepted by one RxP leader so she could score a "win" even though the resulting law probably ensures that no psychologist in Illinois will ever prescribe as a psychologist. She got an APA presidential citation and lots of glory, but only if no one revealed the details of what she agreed to. Her state association and APA made an effort to not reveal that information.

I don't know many details, but the nurse-practitioner model has been in evolution for some time. There are a number of them who were grandfathered in and the model has been changing. The DPN is the latest step. In that evolution it was assumed that nurses would have taken a lot of previous course work for their RN, BSN, MSN, etc. and they would have had extensive professional experience in medical settings. However, there are direct-entry programs that don't expect you to have any nursing background. Rush Medical Center is one example I've heard of. I haven't seen the pre-requisites and curriculum for those APN or DPN programs, so I can't comment on their academic stringency compared to the APA RxP model. I am fully confident that the APA RxP model is grossly inferior to anything required of APN's, and it is obvious that this is the case compared to PA programs.

There are other considerations. Even if you are comparing psychologist-prescribers with the few people who have no medical background whatsoever and obtain APN status through a direct-entry program (and I'm not sure if that's even allowed), you'll still be comparing persons who will almost certainly be practicing medicine full-time in a medical context such as hospitals among medical colleagues, with someone who by definition will only be practicing a slice of medicine part-time in a setting that is not medical, such as a private psychology office. As you can imagine, people get better when they do what they do a lot, and have a lot of intellectual support around them. RxP would create the country's first part-time medical practitioners working in non-medical settings. That, too, creates greater risk of incompetence in the long run.

I don't know the conditions of the online classes for NPs. The APA model for RxP calls for 100 percent online education from the basics of biology to the most complex prescribing for problematic populations, education to be taken by people who have never stepped foot in a hospital, or even a classroom. Online education is much more acceptable when you're learning things in addition to what you already know and have practiced. Thus CE for psychologists is fine online, but even APA does not accredit schools whose entire graduate education offering is online.
 
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Absence of safety data is not proof of danger. Absence of harm data is not proof of safety.

Failure of legislature is not evidence of something being a bad idea.
 
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Absence of safety data is not proof of danger. Absence of harm data is not proof of safety.

Failure of legislature is not evidence of something being a bad idea. Success of legislature is not evidence of something being a good idea.
FIFY
 
Absence of safety data is not proof of danger. Absence of harm data is not proof of safety.

Failure of legislature is not evidence of something being a bad idea.
I actually disagree with this. Good and bad is a value judgement so opinion of legislators is evidence on whether or not people (legislators are people too) think that it is a good idea. Now how much weight to give that evidence is another thing altogether.
 
I actually disagree with this. Good and bad is a value judgement so opinion of legislators is evidence on whether or not people (legislators are people too) think that it is a good idea. Now how much weight to give that evidence is another thing altogether.

That disregards the role played by money & lobbying.
 
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That disregards the role played by money & lobbying.
I was just pointing out the logical flaw inherent in the thinking that a value judgement could be empirically tested and money and lobbying would also be evidence about how people view the issue. That's why they are putting their money and effort into it. The pro people think it is a good idea and the anti think it is a bad idea and both sides will put money and effort into promoting their values.
 
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I was just pointing out the logical flaw inherent in the thinking that a value judgement could be empirically tested and money and lobbying would also be evidence about how people view the issue. That's why they are putting their money and effort into it. The pro people think it is a good idea and the anti think it is a bad idea and both sides will put money and effort into promoting their values.

I think you add good points. I do think it leaves out the idea that one side of the argument may have more money and power than another. So it's not evenly weighted. Yes, both sides will contribute money to the issue, but not at the same rate. Unfortunately sometimes the side with more money (therefore exposure) wins, despite the quality of outcome.

^^wow, that sounds like super anti-capitalist statement, but it's not meant to be that way. It was just meant to highlight that sometimes lobbies unduly influence outcome. There are examples of this on both sides of the fence.

I really enjoy reading the discussion of this topic, but have been personally frustrated with the "if the bill didn't pass = it must be bad for patients" argument. I realize that is probably reductionist, and there is some small discussion in those posts about why the bills are bad, but it's mostly touchy-feely (IMO) stuff. I'd personally like to see the discussion turn back to evaluating data or the issues of lack of data. Or even why there is or is not a shortage of prescribers.

But really, I probably just described the problem with every Internet discussion or debate ever, so...
 
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A record of 183 failures of the same proposal across 29 states over 20 years is meaningful. Interpretations may vary, and those of us who have followed the politics of legislation have learned how many factors enter into a bill's success or failure. Great ideas can fail and bad ones can prevail. But 183 failures in 29 states over 20 years is a little like batting .010 in baseball. You didn't just get a bad call from an ump or the shortstop didn't just make a lucky catch. This record over the long run does say something about the acceptability of the proposal.

One meaning is that APA is wasting the money of those who pay the practice assessment by pouring it down the RxP black hole. I mean millions of dollars.

Another is that APA doesn't seem to be able to adjust its proposals to make them more acceptable. There is a political reason for that: RxP is heavily influenced by the schools that sell the online classes, and if the proposals are modified to make them more acceptable, all those certifications are out of date.

Further, APA has a problem that if the training standards approach what the rest of society (legislators, medical experts and yes, psychologists) believe is ethically appropriate, it will be too hard and they won't attract candidates. The Illinois law, which is essential physician-assistant level training, is considered to be a tight barrier against psychologist prescribing. How many people have the time and interest to go through 6 years of full-time training so they can write prescriptions?

So one bill failure, or 10 or 20 certainly suggests it's not a popular idea, but it may have a future. But this record is up there. It is not trivial.
 
I think you'll need to spend a little more time asking a question and explain its relevance.
 
Absence of safety data is not proof of danger. Absence of harm data is not proof of safety.

Failure of legislature is not evidence of something being a bad idea.

Absence of evidence is strong evidence that evidence is absent. If evidence is required to be present for the ethical practice of risky procedures, then the absence of evidence is evidence that insufficient evidence is not evident.

Legislatures and individuals make many mistakes. When 183 bills fail in 29 states over the course of 20 years, that is a very hefty opinion by large numbers of people across a long time span in independent judgments that what is being proposed is not appropriate.
 
Absence of evidence is strong evidence that evidence is absent. If evidence is required to be present for the ethical practice of risky procedures, then the absence of evidence is evidence that insufficient evidence is not evident.

Legislatures and individuals make many mistakes. When 183 bills fail in 29 states over the course of 20 years, that is a very hefty opinion by large numbers of people across a long time span in independent judgments that what is being proposed is not appropriate.
It is some very solid evidence that the strategies of the RxP proponents has not been very effective. It may be that the evidence for effective prescribing is weak or it may be that they are not very politically savvy. My experience with psychologists tells me that the latter is probably more the case.
:p
In other words, we get so caught up in empiricism we forget that the rest of the world doesn't operate that way.
 
Absence of evidence is strong evidence that evidence is absent. If evidence is required to be present for the ethical practice of risky procedures, then the absence of evidence is evidence that insufficient evidence is not evident.

Once again, I'm very curious as to where the evidence is for other prescribing professions.
 
It is some very solid evidence that the strategies of the RxP proponents has not been very effective. It may be that the evidence for effective prescribing is weak or it may be that they are not very politically savvy. My experience with psychologists tells me that the latter is probably more the case.
:p
In other words, we get so caught up in empiricism we forget that the rest of the world doesn't operate that way.

To attribute the massive failure of the APA model for RxP to a lack of political expertise by persons who are too focused on science may be an attractive stereotype, but in reality exactly the opposite is true. It is a fact that no empirical evidence has ever been developed to show that the persons prescribing under this model do so safely or effectively. I would invite you to pause and ponder how very important such evidence would be in reversing the tidal wave of legislative failure, and that proponents certainly have the money to conduct such research.

As for the naivete of RxP advocates, nothing could be further from the truth, although it is understandable that you and many others may believe the stereotype of a few psychologists innocently trying to sway the legislatures.

In Illinois, they collected $640,000 just for the most recent effort. $120,000 of that came from practice assessment funds. More was spent in earlier years. RxP proponents hired an astounding eight lobbyists, sometimes a ninth to influence a single member of the House. They had a sophisticated communications outfit spewing information. Nevertheless, their RxP bill failed hands-down. The leader of the RxP campaign apparently knew that after 15 years of failure, they were looking at nothing better in the future, so she agreed to a bill that rejects everything about the RxP campaign and agreed to one with far higher standards in quantity and quality, based on PA training, and one that very likely will not see one psychologist prescribing.

In Louisiana, RxP activists spent $1 million in a state that is relatively small and with a political system that is rather famous for its moral flexibility in the face of rewards. Half that money was in PAC funds that could be and was delivered in direct donations to legislators.

So I understand the image of the naive and underpowered scientist-psychologist simply unable to get traction in the political system, but I assure you that is incorrect.
 
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Once again, I'm very curious as to where the evidence is for other prescribing professions.

Interesting question. So why aren't you answering it? If you're not willing or able to answer it yourself, why expect other people to do your work for you?
 
Interesting question. So why aren't you answering it? If you're not willing or able to answer it yourself, why expect other people to do your work for you?

If the opponents of RxP are demanding this data, and claiming that it is necessary for adoption, they must first prove that the data is available for other methods currently in use. If you are claiming that a certain training model has been shown to be safe and effective you need to have the data supporting that before you can denigrate another model for not having that data.
 
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To attribute the massive failure of the APA model for RxP to a lack of political expertise by persons who are too focused on science may be an attractive stereotype, but in reality exactly the opposite is true. It is a fact that no empirical evidence has ever been developed to show that the persons prescribing under this model do so safely or effectively. I would invite you to pause and ponder how very important such evidence would be in reversing the tidal wave of legislative failure, and that proponents certainly have the money to conduct such research.

As for the naivete of RxP advocates, nothing could be further from the truth, although it is understandable that you and many others may believe the stereotype of a few psychologists innocently trying to sway the legislatures.

In Illinois, they collected $640,000 just for the most recent effort. $120,000 of that came from practice assessment funds. More was spent in earlier years. RxP proponents hired an astounding eight lobbyists, sometimes a ninth to influence a single member of the House. They had a sophisticated communications outfit spewing information. Nevertheless, their RxP bill failed hands-down. The leader of the RxP campaign apparently knew that after 15 years of failure, they were looking at nothing better in the future, so she agreed to a bill that rejects everything about the RxP campaign and agreed to one with far higher standards in quantity and quality, based on PA training, and one that very likely will not see one psychologist prescribing.

In Louisiana, RxP activists spent $1 million in a state that is relatively small and with a political system that is rather famous for its moral flexibility in the face of rewards. Half that money was in PAC funds that could be and was delivered in direct donations to legislators.

So I understand the image of the naive and underpowered scientist-psychologist simply unable to get traction in the political system, but I assure you that is incorrect.
So your contention is that the sole reason it is not passing is because it is such a bad idea that most legislators can see that it would be riskier to have us prescribe for psychiatric disorders than any other practitioners?
 
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If the opponents of RxP are demanding this data, and claiming that it is necessary for adoption, they must first prove that the data is available for other methods currently in use. If you are claiming that a certain training model has been shown to be safe and effective you need to have the data supporting that before you can denigrate another model for not having that data.

You seem to think that your contribution to the debate is to ask questions of fact and expect other people to do your homework. Good luck doing the work and please get back to us as to what you've found.
 
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So your contention is that the sole reason it is not passing is because it is such a bad idea that most legislators can see that it would be riskier to have us prescribe for psychiatric disorders than any other practitioners?

I didn't say that. Bills fail for many reasons, but this sort of massive failure is meaningful. The opinion of so many legislators for so long clearly suggests that they find these proposals to be very lacking.

I mean really, Smalltown, do you think that many people find it credible that persons with no history of any biomedical education or practice experience can learn enough in 8.8 or 10 semester courses, taken on the internet, to prescribe powerful medications that have lots of side effects, for children, elderly, people with major medical conditions, etc.? Frankly, I think the failure of 183 bills in 29 states over 20 years shows a lot of common sense.
 
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You seem to think that your contribution to the debate is to ask questions of fact and expect other people to do your homework. Good luck doing the work and please get back to us as to what you've found.

To be honest, I have looked for this data, and I have found none. And now, I am asking for those who are demanding this data to provide it, since it does not seem to be readily available. If you want to keep pushing the double standard with no evidence, I guess that is your right.
 
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I didn't say that. Bills fail for many reasons, but this sort of massive failure is meaningful. The opinion of so many legislators for so long clearly suggests that they find these proposals to be very lacking.

I mean really, Smalltown, do you think that many people find it credible that persons with no history of any biomedical education or practice experience can learn enough in 8.8 or 10 semester courses, taken on the internet, to prescribe powerful medications that have lots of side effects, for children, elderly, people with major medical conditions, etc.? Frankly, I think the failure of 183 bills in 29 states over 20 years shows a lot of common sense.
Isn't that quite a bit less than what the states who have passed this require? I would also be against any bill that allowed online education for this so if that is what they are introducing then they are really wasting a lot of time and money. My understanding is also that practicing under a physician for a year or two is part of the requirements. So if a psychologist takes about two years worth of real coursework and works under a physician for a couple of years, that doesn't sound woefully inadequate to me.
 
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CGOPsych...Again….you are not being forthright with the actual training standards. Below I addressed each piece of misinformation you provided.

Here are the training standards as stated in the law for Louisiana (highlighted in blue). Prior requirements from the APA-acred. standards for counseling/clinical psychology training are quoted in orange. My comments are normal black text.

...that persons with no history of any biomedical education

Has successfully graduated with a post-doctoral master's degree in clinical psychopharmacology from a regionally accredited institution or has completed equivalent training to the post-doctoral master's degree approved by the board. The curriculum shall include instruction in anatomy and physiology, biochemistry, neurosciences, pharmacology, psychopharmacology, clinical medicine/pathophysiology, and health assessment, including relevant physical and laboratory assessment.

B3. Program implements a coherent curriculum that enables students to demonstrate substantial understanding of and competence in the following areas (see Implementing Regulation C-16, Broad & General Preparation for Doctoral Programs):
  • The breadth of scientific psychology including:
    • Biological aspects
    • Cognitive and affective aspects
    • etc.
The practical outcome of this requirement includes: Biological Basis of Behavior, Psychopharmacology, and similar classes. There are also electives that some students take. There are even some psychologists that teach neuroanatomy, neurophysiology, and similar in med school, nursing school, etc. I regularly lecture on these and related topics as part of my duties in the residency and fellowship programs at my AMC.

can learn enough in 8.8 or 10 semester courses, taken on the internet…

While I agree that the training should be residentially-based, every prescribing psychologist (or medical psychologist in this case) must pass a national exam.

(3) Has passed a national exam in psychopharmacology approved by the board.

...or practice experience….

...to prescribe powerful medications that have lots of side effects, for children, elderly, people with major medical conditions, etc.?

A. Medical psychologists shall prescribe only in consultation and collaboration with the patient's primary or attending physician, and with the concurrence of that physician.

B. The medical psychologist shall also re-consult with the patient's physician prior to making changes in the patient's medication treatment protocol, as established with the physician, or as otherwise directed by the physician. The medical psychologist and the physician shall document the consultation in the patient's medical record.

C. In the event a patient does not have a primary or attending physician, the medical psychologist shall not prescribe for that patient.


If this is done for a minimum of 3 years….

Medical psychologists who satisfy the requirements specified by R.S. 37:1360.55(A) of this Part and who possess all of the following additional qualifications to the satisfaction of the board shall be issued a certificate of advanced practice:

(1) Three years of experience practicing as a medical psychologist. For those individuals licensed under R.S. 37:1360.55(A), such experience shall be deemed to have commenced with the issuance of the original certificate of prescriptive authority issued by the Louisiana State Board of Examiners of Psychologists.

(2) Treatment of a minimum of one hundred patients including twenty-five or more involving the use of major psychotropics and twenty-five or more involving the use of major antidepressants which demonstrate the competence of the medical psychologist.

(3) The recommendation of two collaborating physicians, each of whom holds an unconditional license to practice medicine in Louisiana, and who are each familiar with the applicant's competence to practice medical psychology.

(4) The recommendation of the Medical Psychology Advisory Committee.

(5) The completion of a minimum of one hundred hours of continuing medical education relating to the use of medications in the management of patients with psychiatric illness commencing with the issuance of a certificate of prescriptive authority by the Louisiana State Board of Examiners of Psychologists prior to January 1, 2010, or by the board after this date.


I personally don't like that the ascribed numbers to specific types of meds, but that's how they chose to do this.

So…that is a lot more training and supervision than you included in your statement.
 
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CGOPsych...Again….you are not being forthright with the actual training standards. Below I addressed each piece of misinformation you provided.

Here are the training standards as stated in the law for Louisiana (highlighted in blue). Prior requirements from the APA-acred. standards for counseling/clinical psychology training are quoted in orange. My comments are normal black text.



Has successfully graduated with a post-doctoral master's degree in clinical psychopharmacology from a regionally accredited institution or has completed equivalent training to the post-doctoral master's degree approved by the board. The curriculum shall include instruction in anatomy and physiology, biochemistry, neurosciences, pharmacology, psychopharmacology, clinical medicine/pathophysiology, and health assessment, including relevant physical and laboratory assessment.

B3. Program implements a coherent curriculum that enables students to demonstrate substantial understanding of and competence in the following areas (see Implementing Regulation C-16, Broad & General Preparation for Doctoral Programs):
  • The breadth of scientific psychology including:
    • Biological aspects
    • Cognitive and affective aspects
    • etc.
The practical outcome of this requirement includes: Biological Basis of Behavior, Psychopharmacology, and similar classes. There are also electives that some students take. There are even some psychologists that teach neuroanatomy, neurophysiology, and similar in med school, nursing school, etc. I regularly lecture on these and related topics as part of my duties in the residency and fellowship programs at my AMC.



While I agree that the training should be residentially-based, every prescribing psychologist (or medical psychologist in this case) must pass a national exam.

(3) Has passed a national exam in psychopharmacology approved by the board.



A. Medical psychologists shall prescribe only in consultation and collaboration with the patient's primary or attending physician, and with the concurrence of that physician.

B. The medical psychologist shall also re-consult with the patient's physician prior to making changes in the patient's medication treatment protocol, as established with the physician, or as otherwise directed by the physician. The medical psychologist and the physician shall document the consultation in the patient's medical record.

C. In the event a patient does not have a primary or attending physician, the medical psychologist shall not prescribe for that patient.


If this is done for a minimum of 3 years….

Medical psychologists who satisfy the requirements specified by R.S. 37:1360.55(A) of this Part and who possess all of the following additional qualifications to the satisfaction of the board shall be issued a certificate of advanced practice:

(1) Three years of experience practicing as a medical psychologist. For those individuals licensed under R.S. 37:1360.55(A), such experience shall be deemed to have commenced with the issuance of the original certificate of prescriptive authority issued by the Louisiana State Board of Examiners of Psychologists.

(2) Treatment of a minimum of one hundred patients including twenty-five or more involving the use of major psychotropics and twenty-five or more involving the use of major antidepressants which demonstrate the competence of the medical psychologist.

(3) The recommendation of two collaborating physicians, each of whom holds an unconditional license to practice medicine in Louisiana, and who are each familiar with the applicant's competence to practice medical psychology.

(4) The recommendation of the Medical Psychology Advisory Committee.

(5) The completion of a minimum of one hundred hours of continuing medical education relating to the use of medications in the management of patients with psychiatric illness commencing with the issuance of a certificate of prescriptive authority by the Louisiana State Board of Examiners of Psychologists prior to January 1, 2010, or by the board after this date.


I personally don't like that the ascribed numbers to specific types of meds, but that's how they chose to do this.

So…that is a lot more training and supervision than you included in your statement.
This is pretty concrete evidence that CGO seems to be knocking down a straw man!
 
Isn't that quite a bit less than what the states who have passed this require? I would also be against any bill that allowed online education for this so if that is what they are introducing then they are really wasting a lot of time and money. My understanding is also that practicing under a physician for a year or two is part of the requirements. So if a psychologist takes about two years worth of real coursework and works under a physician for a couple of years, that doesn't sound woefully inadequate to me.

Online training is allowed under the LA and NM bills and in every bill offered under the APA RxP model.
As is often the case, the devil is in the details. What do you mean by "under" a physician? The LA and NM laws do require consultation - with NM be much more stringent than LA. Bill proposals I've seen have offered that the psychologist inform a physician treating the patient, but are not required to consult with the physician. That's not the same thing as working under the supervision of a physician.

Physician collaboration has been a medical safety backup in LA and NM, which is one reason why claims that they are prescribing safely are not entirely accurate - they do so because someone with many times the training and experience is backing them up. I think it would be required for anyone who has so little education to be allowed to prescribe. However, the LA law, Act 251, changes that.
 
This is pretty concrete evidence that CGO seems to be knocking down a straw man!

That's a little rude, but nonetheless ....
The law seems impressive, but the details show this to be less stringent. This law was written by RxPers. It is filled with impressive language that has a somewhat different reality behind it.

As has already been detailed, the education is online and it consists of a minimum of 400 clock hours - the equivalent of 8.8 semester courses - taken online. This would cover everything from the basics of biology, chemistry, physiology, to the prescription of meds for children with serious medical conditions. There is no provision for special populations, such as the elderly, children, persons with multiple medical problems, etc. In this online education, the tests can be easily passed because students can look up the answers online. Therefore, it would be hard to fail any of these courses. The only "accreditation" of this education is a sort of general approval by APA without any actual examination of the content or method of instruction.

Of course, the bill and the RxPers make the education sound very impressive, and those eager to believe will be impressed. I notice that RxP advocates are always talking about all the marvelous things this education covers, but one has to consider that this massive breadth is covered in the equivalent of 8.8-10 courses of three semester hours each. I think we call that a short-cut overview, not an education with depth.

For example, the "National Examination" sounds very impressive. It is actually one written by APA and whose passing score was set by APA, the organization that has spent millions lobbying to get more psychologists prescribing. It is not appropriate for a qualification exam to be written and supervised by a political organization that is biased towards passage.

The "continuing medical education" is a doozy: Act 251 requires that the prescribers purchase at lest 25 percent of their CE from LAMP, the political action committee (not a professional organization) run by RxP activists. As payment for that CE the psychologists have to make a $2,500 donation to LAMP's PAC. The CE are earned in the annual conference for LAMP and the contents of the CE are secret.

Approval by the Medical Psychology Advisory Committee sounds very impressive. The committee consists of LAMP members who are, obviously, highly biased towards allowing psychologists to prescribe. Their proceedings are secret so that we don't know how they actually approve people for prescribing. Some information that has leaked out says that physicians who collaborate with the psychologist-prescriber- candidates have performed so badly that physicians refused to sign off on them. However, that information is kept secret. That's another example of how the surface looks very impressive but the underlying reality is less so. It does, however, impress those who are eager to be impressed.

I don't mean to sound like I grow fatigued pointing out the reality behind the claims, but this could go on forever. Those who want to believe will do so and any information otherwise just won't matter. I write for those who are genuinely interested in learning other aspects of this campaign's proposals.

If you look at the Illinois law it tells a different story, which includes training criteria that are the current minimum - except for the dumbed-down APA model in LA and NM. Seven undergraduat courses in biology, physiology, etc. and with labs. This is almost as much as the entire APA RxP mode. Maybe some of these courses can be taken online by an accredited college or university, but certainly not the labs.

After that one takes 60 semester hours - 20 courses - of graduate study in a program accredited by a non-APA group, the independent organization that accredits PA programs. You'll notice that this is not just an in-house job run by psychologists. After that they are required to take a 14-month full-time practicum in a variety of medical settings. The NM and LA laws, and other proposals, allow psychologists to do their practicum in their own offices, treating a certain number of patients - one prescription for one patient would count.

When the IL law was passed, RxPers were very upset because in this state they would have to actually get the training that has long been considered appropriate, rather than training that is grossly inferior in quality and quantity. True, for appropriate training it would take about 6 years of full-time application, but I submit to my colleagues who can consider this objectively, maybe that's what it takes to prescribe such medications to all persons of all ages, all medical conditions and taking all types of other medications safely and effectively.

Also, I have to once again point out that there is not a scrap of empirical evidence that the NM or LA prescribers practice safely or effectively. Even though RxP seems very lucrative and can make one feel very powerful, health care is an applied science and our ethics require us to practice based on science. Lobbying does not ethically substitute for science.
 
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I'm still waiting on an answer to my query. Also, in case you don't believe that I have looked for the evidence myself, feel free to come check my google scholar and pubmed search histories. Just wondering if a bar has been set for RxP which has not yet been passed by other prescribers.
 
I'm still waiting on an answer to my query. Also, in case you don't believe that I have looked for the evidence myself, feel free to come check my google scholar and pubmed search histories. Just wondering if a bar has been set for RxP which has not yet been passed by other prescribers.

I think you're going to be waiting a long time for me to do your research for you. And no, I don't wish to see your search results. If you believe that there is no such research, then I'd advise you to say so. But I would suggest that you be careful what you are actually saying, and to do so with clarity. Proving the negative can be tricky. You may wish to contact the persons who would actually know about this to find out, and have your question formulated precisely. I would recommend contacting someone at the psychiatric APN society first, but my job is not to be your research mentor, either. Your allegations in the past have not been very clear, although I'm sure the eager-to-be-impressed would find them helpful. What you are claiming is actually the case may be different than how you characterize it. I'll look forward to seeing your progress on this.

BTW, I am going away on vacation, and I'll probably take a vacation from RxP. Despite what we say, RxP is a massive failure and the campaign is unlikely to change its tune, so that it appears to continue this string of failure until psychologists decide that it's not a good idea, for one reason or another.
 
Ok, here goes. In terms of the research claiming safety and efficacy that the opponents of RxP are demanding, I would like to evidence that this has already been established for pre-existing prescribers. Without it, there is an anomalous benchmark that is arbitrarily set and not defensible. If you are going to use this as a plank for your platform, you should be able to defend it with something. Argue it away with semantics all you want, but it has been a major part of your argument against, and you have done so without any evidence. For someone with such a vested interest in this issue, I would assume that if such evidence existed, you would at least know something about it.
 
That's a little rude, but nonetheless ....
I didn't think it was that rude. I don't know where we draw the line for what would be effective training and on the surface the law sounds like it calls for that. I am not sure if psychologists should prescribe or not. I go back and forth on it, but it seems that is a separate issue from level of training required.
 
As I see it, here are Cogpsych's arguments:

1) RxP bills are a bad idea because of how many times they have failed.

My response: This is a flawed logic. For example: Several civil rights movements lasted much longer and ended up being a pretty damn great idea.

2) RxP is dangerous.

My response: There is no evidence of this.

3) RxP is going to change how psychology is practiced.

My response: Psychology is always changing. First we were just researchers. Then clinicians. Then healthcare workers, then not healthcare, then healthcare again. There are many different sub-specialties in psychology that have their own ways of practicing and special laws regarding these specialties. Neuropsychology and forensic psychology are practiced in a manner that is substantially different than general clinical psychology.

4) RxP training is inadequate

My response: There is no evidence of this.

5) The APA was deceptive in obtaining funds.

My response: I would think that someone who is possibly associated with a group that may have signed people's names to protests without getting the consent of all the names on the list would be a bit more forgiving about such things. APA made a mistake, admitted to it, and paid everyone back. Get over it.

6) RxP is expensive

My response: If the spending money is an issue, then Cogpsych should be opposed to groups like POPP and the state medical boards spending money on their own campaigns.


*these are just my opinions and are accurate to the best of my knowledge.
 
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As I see it, here are Cogpsych's arguments:

1) RxP bills are a bad idea because of how many times they have failed.

My response: This is a flawed logic. For example: Several civil rights movements lasted much longer and ended up being a pretty damn great idea.

2) RxP is dangerous.

My response: There is no evidence of this.

3) RxP is going to change how psychology is practiced.

My response: Psychology is always changing. First we were just researchers. Then clinicians. Then healthcare workers, then not healthcare, then healthcare again. There are many different sub-specialties in psychology that have their own ways of practicing and special laws regarding these specialties. Neuropsychology and forensic psychology are practiced in a manner that is substantially different than general clinical psychology.

4) RxP training is inadequate

My response: There is no evidence of this.

5) The APA was deceptive in obtaining funds.

My response: I would think that someone who is possibly associated with a group that may have signed people's names to protests without getting the consent of all the names on the list would be a bit more forgiving about such things. APA made a mistake, admitted to it, and paid everyone back. Get over it.

6) RxP is expensive

My response: If the spending money is an issue, then Cogpsych should be opposed to groups like POPP and the state medical boards spending money on their own campaigns.


*these are just my opinions and are accurate to the best of my knowledge.
I actually think that reason number 3 is the one that we should be discussing more. Basically, my point would be that we need to decide if we see that the profession should move in this direction. The other issues are more along the lines of how to implement it.
 
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