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[deleted1016078]

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[deleted480308]

Video is about an hour, but essentially he is a doctorate level psychologist that did a masters program in biomedical pharmacology. I hope to be a psychiatrist one day, but I do feel he made some good points in his favor. Was just curious what those actually practicing might think about it...

If you want to be a doctor, go to medical school

 

[dl2dp2]

At this point I don't think it's going to go very far. They'll be competing with NPs.

It was kind of a hot thing a few years ago, but with NPs getting paid a higher salary and LCSWs doing therapy, PhDs are actually very squeezed.

There are several parts of all of this which are in MDs favor:
1) neither NPs/PhDs can/want to staff seriously sick patients: bipolar, psychotic, suicidal, inpatient, residential, polysubstance, borderline, etc.
2) neither NPs/PhDs can/want to staff medically complicated patients: dementia, children, chronic medical condition, inpatient medical, neurological, etc.
3) well-heeled professionals who want private MDs to sort through their complicated issues don't want an NP/PhD. Let's be honest, if your income is in the top 10% of the population and relies a lot on your optimized mental health, you are not gonna let a 2nd tier person take charge of managing these things that may seem routine but can be quite complicated: career issues, depression, alcoholism, marital conflict, ADHD, children's issues, etc.

PhDs in the community also developed this reputation of being "soft" (i.e. can't handle tough pathologies), which is true, because they really can't, even if the pathologies would rely mostly on therapy (i.e. BPD, etc). Very often these people need careful pharmacology. Patients know this and redirect their time.

 

[Tapepsi]

I hope to be a psychiatrist one day, but I do feel he made some good points in his favor.

I listened to it as well. Where are you at in your training? And what points did you think were good?

 

[Ironspy]

There’s no shortage of PCPs able to prescribe meds for uncomplicated depression and anxiety. Most NPs and psychologists want to see this population. There is a significant shortage of psychiatrists to see people with Severe mental illness, medically complex, Geri, prison psych and I don’t get the impression that most non psychiatrists are interested in seeing these individuals.

 

[lyla]

I listened to it as well. Where are you at in your training? And what points did you think were good?

Their tag says they're premed

 

[hebel]

Caveat: I did not listen to the podcast (I may give it a listen during my commute once I'm back from vacation).

The whole idea of lesser-trained PA's, NP's, psychologists, and whoever else wants to jump in on this sounds great when your view of psychiatry is similar to what medical student boards seem to want to dilute psychiatry down to: DSM categorized checklist diagnoses -> SRRI +/- CBT -> switch around the SSRI's until the side effects are tolerable -> DONE.

 

[calvnandhobbs68]

At this point I don't think it's going to go very far. They'll be competing with NPs.

It was kind of a hot thing a few years ago, but with NPs getting paid a higher salary and LCSWs doing therapy, PhDs are actually very squeezed.

There are several parts of all of this which are in MDs favor:
1) neither NPs/PhDs can/want to staff seriously sick patients: bipolar, psychotic, suicidal, inpatient, residential, polysubstance, borderline, etc.
2) neither NPs/PhDs can/want to staff medically complicated patients: dementia, children, chronic medical condition, inpatient medical, neurological, etc.
3) well-heeled professionals who want private MDs to sort through their complicated issues don't want an NP/PhD. Let's be honest, if your income is in the top 10% of the population and relies a lot on your optimized mental health, you are not gonna let a 2nd tier person take charge of managing these things that may seem routine but can be quite complicated: career issues, depression, alcoholism, marital conflict, ADHD, children's issues, etc.

PhDs in the community also developed this reputation of being "soft" (i.e. can't handle tough pathologies), which is true, because they really can't, even if the pathologies would rely mostly on therapy (i.e. BPD, etc). Very often these people need careful pharmacology. Patients know this and redirect their time.

Last point I’ve found to be true as well. I’ve gotten now several times from psychologists “patient says he’s hearing voices must be psychotic!!”. I was pretty confused by this until I realized that many psychologists, even those from good programs, just don’t get the exposure to actual hardcore psychosis or mania or self harm we get on months and months of inpatient units. Unless they’re specialized with working with this population specifically I’ve seen several get freaked out really easily. Not to say this is universal of course, but all psychiatry residents are required to do a substantial amount of inpatient time which just results in a different type of exposure.

Agree that they’re really looking to prescribe SSRIs to depressed/anxious people and be able to bill for it. Also agree that most PCPs are happy to do this as well with occasional psych input if needed every now and then.

I agree I think they’re finding there’s really no market for this. They’re trying to get into the psych NP market. Few people are gonna private pay hundreds of dollars an hour for a psychologist who took a “masters program in pharmacology” (but never actually took an anatomy or physiology class in his life) to manage their meds. They’ve also suffered from creep themselves as well, with all the various professions being allowed to do “therapy” now (which varies tremendously in its quality).

Psych NPs are much more of a problem. Take all comer programs who basically accept anyone with a pulse and a BSN are pumping them out by the thousands every year.

 

[cara susanna]

Personally speaking as a psychologist, I don't want to be a prescriber. I'd rather we work on protecting our own scope than honing in on someone else's. I don't want to be relegated to a mid-level provider. And, finally, I just don't want to deal with medication. That's why I opted against psychiatry in the first place.

 

[hebel]

Personally speaking as a psychologist, I don't want to be a prescriber. I'd rather we work on protecting our own scope than honing in on someone else's. I don't want to be relegated to a mid-level provider. And, finally, I just don't want to deal with medication. That's why I opted against psychiatry in the first place.

I completely agree with you, and as a psychiatrist view quality therapy as invaluable to helping people get sustainably better. I actually wish psychologists came together under the demand that what's considered "therapy" be clarified and held to a higher standard (maybe you guys already are trying). I get sick of recommending "therapy" to patients, who often end up with a non-PhD doing never-ending supportive therapy...I'm appalled at how often this results in a "therapist" who simply acts like the patient's "friend" or parent.

 

[Madden007]

Most educated consumers would not go or take their children to a non MD for a comprehensive assessment. Treating MDD and anxiety spectrum disorders are often straight forward., that is once correctly dignosed. Now, do you trust a non-MD to differentiate catatonia from negative symptoms? Herpes complex on the temperal lobe from psychotic spectrum disorder? Lupus induced mania versus bipolar? Non-MDs may not even know their blindspots.. I would take my child to an NP for a well child visit but if there's something funky going on, I am asking for the MD.

 

[Jules A]

Most educated consumers would not go or take their children to a non MD for a comprehensive assessment. Treating MDD and anxiety spectrum disorders are often straight forward., that is once correctly dignosed. Now, do you trust a non-MD to differentiate catatonia from negative symptoms? Herpes complex on the temperal lobe from psychotic spectrum disorder? Lupus induced mania versus bipolar? Non-MDs may not even know their blindspots.. I would take my child to an NP for a well child visit but if there's something funky going on, I am asking for the MD.

I agree but would add most people, regardless of their education if non-healthcare, know very little about these nuances.

I get sick of recommending "therapy" to patients, who often end up with a non-PhD doing never-ending supportive therapy...I'm appalled at how often this results in a "therapist" who simply acts like the patient's "friend" or parent.

Perhaps this is based on the motivation and skill of the actual clinician more so than their education? I've seen masters level therapists who are quite skilled, encourage patients to do the work and elicit growth and a few PhDs where therapy amounts to years of basically sitting around having tea and a chat. Although many of the PsyDs I know focus on testing for which there is a huge need in my area.

 

[hebel]

I agree but would add most people, regardless of their education if non-healthcare, know very little about these nuances.



Perhaps this is based on the motivation and skill of the actual clinician more so than their education? I've seen masters level therapists who are quite skilled, encourage patients to do the work and elicit growth and a few PhDs where therapy amounts to years of basically sitting around having tea and a chat. Although many of the PsyDs I know focus on testing for which there is a huge need in my area.

I agree, it's not all about the degree. One of my biggest sources for learning a particular form of therapy was an LCSW. I believe masters and doctorate level therapists have bell curves of effectiveness (with higher levels of training shifting the curve farther to the right as a field). There's definitely plenty of examples of bad PhDs and amazing masters level therapists.

 

[deleted480308]

I recently interviewed at a DO school and am waiting to hear back. I thought he made some good points about the economy of a physicians time, and how a psychologist is able to spend a lot more time talking to the patients and this may prevent over prescribing drugs. In particular, he mentioned that this is a big problem with primary care physicians that see patients often very briefly and who prescribe a large majority of our nation's mental health drugs. It seems to me (from my limited perspective on what I have read) that with many of these mental health conditions drugs are not always necessary or the best case for treatment and this approach at focusing talk before prescribing, that he claims is more prevalent in the psychologist world, is appealing to me. Also, his point of how prescribing psychologists have already been a thing in the military for some 20 years without issue I think is pretty good for his case. With that being said, this is all my humble opinion based off no experience in the field, and I posted here to see from experienced clinicians the other side and why I might be wrong in my assumptions.

The military is too cheap to buy enough psychiatrists, that’s not an endorsement for psychologists prescribing

 

[Tapepsi]

It seems to me that with many of these mental health conditions, drugs are not always necessary or the best case for treatment and this approach at focusing talk before prescribing, that he claims is more prevalent in the psychologist world, is appealing to me

I see. Have you considered going the psychologist route?

 

[birchswing]

Now, do you trust a non-MD to differentiate catatonia from negative symptoms? Herpes complex on the temperal lobe from psychotic spectrum disorder? Lupus induced mania versus bipolar? Non-MDs may not even know their blindspots.. I would take my child to an NP for a well child visit but if there's something funky going on, I am asking for the MD.

MDs seem to use more latitude to do funky things. Like get speaking gigs for a drug and then try to use it on a huge portion of their panel. NPs might be more limited, but they also seem more NHS-like in that they seem more obligated to follow consensus-based medicine. They might miss the zebras more often perhaps? Not sure. I've seen good and bad providers of all degrees.

 

[PikminOC]

A little, but I feel like not having the option to prescribe if I knew it would be helpful would bother me once I got out in the field. If I get into this DO school I will almost certainly go aiming towards psychiatry.

Have you looked at the states where psychologists prescribe and what ends up happening?
Hint: the psychologists don't spend time with patients and just become med Management..

 

[dl2dp2]

MDs seem to use more latitude to do funky things. Like get speaking gigs for a drug and then try to use it on a huge portion of their panel. NPs might be more limited, but they also seem more NHS-like in that they seem more obligated to follow consensus-based medicine. They might miss the zebras more often perhaps? Not sure. I've seen good and bad providers of all degrees.

My experience actually is NP is more prone to overmedicate and they don't know how to deal with controlled substances. Lots of inappropriate upper/downer combinations. I *wish* NPs would actually follow guidelines, but it seems that they are incapable of that as such.

 

[Tapepsi]

A little, but I feel like not having the option to prescribe if I knew it would be helpful would bother me once I got out in the field. If I get into this DO school I will almost certainly go aiming towards psychiatry.

Well I wish you all the best with this interview season! It’s such a nerve wrecking time for applicants.
My best advice to you is to focus on getting through medical school. Before you can even get to the point of deciding how you want to practice as a provider, many hours of studying, patient interactions, provider shadowing, and examinations lie before you. You’ll be doing countless hours of non-psych work for the next four years. Even once you get to residency you’ll still be expected to do medicine for a good portion of your first year. And in my program we really didnt get into psychotherapy until PGY3.

 

[SourceOfDenial]

It’s a bit narcissistic to think that 4 years of med school and 4 of residency is the only possible path to learn how to prescribe medications. Clinical pharmacists often do an incredible job in this space reducing polypharmacy, changing medications and maximizing an individuals regimen.

We would do a whole lot better as a field if instead of battling over the same stupid part of the pie the emphasis was on how can we lobby for greater integration across professions. I’d pick adding a pharmacist and a psychologist to my team versus adding another two psychiatrists or prescribers doing essentially the same. At this rate it’s a race to the bottom.

 

[pediatric_psydoc]

It’s a bit narcissistic to think that 4 years of med school and 4 of residency is the only possible path to learn how to prescribe medications. Clinical pharmacists often do an incredible job in this space reducing polypharmacy, changing medications and maximizing an individuals regimen.

We would do a whole lot better as a field if instead of battling over the same stupid part of the pie the emphasis was on how can we lobby for greater integration across professions. I’d pick adding a pharmacist and a psychologist to my team versus adding another two psychiatrists or prescribers doing essentially the same. At this rate it’s a race to the bottom.

I think you make excellent points and it’s refreshing to see these points made by an attending physician.

I think other considerations are rural and underserved areas. I am in a city with 150,000 people and there are only three psychiatrists in town. In addition, the next city with over 20,000 people is over three hours away, so these 3 psychiatrists are also serving the surrounding areas, often times through telehealth.

A counterpoint may be the PCPs could manage the psychiatric medications. However, I know that in my office (I’m the only psychologist and I am with 7 pediatricians) all but one of the pediatricians get uncomfortable and refer to psychiatry once antidepressants or mood stabilizers may be needed; they are usually only comfortable prescribing ADHD meds. Once there is an inpatient hospitalization or DMDD diagnosis, among others, a referral to psychiatry is placed. Then you have a very, very long waitlist for said 3 psychiatrists. I do not believe this experience is uncommon in these rural communities.

I think the question of the quality of the medication management can be made among any prescribers, not just the NPs or RxPs, due to differences in the quality of training received as well as other factors.

 

[cara susanna]

I agree that psychologists are able to spend more time with patients, and that also would end if we were put into a prescribing role. Also, you can still push therapy as an intervention even in the psychiatrist role. Most of our therapy referrals in our clinic come from psychiatry.

 

[adaptation1]

I can only speak from experience. I was never against psychologists prescribing. I recognize the demand that isn't being filled in certain locations. Then I began seeing, over and over again, regimens I couldn't even make up: 2-3 antipsychotics for depression; frequent inadequate medication trials due to dosage and short lengths of trial; indiscriminate usage of benzodiazepines (Restoril + Valium) for mood disorders. The list goes on. I recognize that what we routinely do as psychiatrists is not rocket science nor mysterious. But a gap in training must be recognized.

 

[cara susanna]

I can only speak from experience. I was never against psychologists prescribing. I recognize the demand that isn't being filled in certain locations. Then I began seeing, over and over again, regimens I couldn't even make up: 2-3 antipsychotics for depression; frequent inadequate medication trials due to dosage and short lengths of trial; indiscriminate usage of benzodiazepines (Restoril + Valium) for mood disorders. The list goes on. I recognize that what we routinely do as psychiatrists is not rocket science nor mysterious. But a gap in training must be recognized.

Ugh. It surprises and saddens me that my discipline would be over-prescribing benzos. I feel like we're better equipped than some to understand why it's a bad idea (I mean in terms of behaviorism, not medicine).

 

[clausewitz2]

It’s a bit narcissistic to think that 4 years of med school and 4 of residency is the only possible path to learn how to prescribe medications. Clinical pharmacists often do an incredible job in this space reducing polypharmacy, changing medications and maximizing an individuals regimen.

We would do a whole lot better as a field if instead of battling over the same stupid part of the pie the emphasis was on how can we lobby for greater integration across professions. I’d pick adding a pharmacist and a psychologist to my team versus adding another two psychiatrists or prescribers doing essentially the same. At this rate it’s a race to the bottom.

My fantasy office has a door that leads to a large-ish closet where a psychologist and pharmacist are just hanging out all day so I can ask them any question whenever I think it would be useful.

 

[erg923]

My fantasy office has a door that leads to a large-ish closet where a psychologist and pharmacist are just hanging out all day so I can ask them any question whenever I think it would be useful.

So, a VA primary care clinic with an embedded PCMHI psychologist and a pharm?

We were literally all next-door to each other in a row of offices. One of the few great things about this set-up, if you ask me?

 

[SourceOfDenial]

So, a VA primary care clinic with an embedded PCMHI psychologist and a pharm?

We were literally all next-door to each other in a row of offices. One of the few great things about this set-up, if you ask me?

Ha, I was thinking the same thing. VA, palliative care, or hospice team(swap SW for psychologist). Pretty standard.

 

[Liquid8]

Listened to the podcast yesterday but spent more time than I planned for being caught in the pre-Christmas shopping crowds.

While the speaker made some points that might be informative to a lay population, it didn’t really tell me anything I don’t already know. Eg. There was a comment about Rexulti being similar to Abilify and acting like this was some kind of revelation not widely known by psychiatrists.

It seemed to promote psychology prescribing as some kind of wider ranging approach to practice that supposedly doesn’t exist, whilst at the same time denigrating both primary care providers and specialist psychiatrists. I know that the vast majority of our Australian psychiatrists utilise medication and therapy approaches and would see consults for a minimum half hour, and from what I’ve read here and discussed with other US psychiatrists similar styles exists in private practices.

For instance made some spurious arguments about how people were being prescribed drugs after a 10 minute consult, and while that isn’t advisable it also ignores the concept of making a spot diagnosis when a condition is very obvious.

The training seems light-on, and he also skirted around questions about the training by basically stating that it wouldn’t have been approved if it wasn’t good. Our doctors can start prescribing after 4-6 years of medical school, but until training is completed (6+ years) it’s going to be supervised with consultant oversight. There was a comparison with NPs which seem a bit off to me, but I get that US NPs have pretty low entry requirements. Our NPs also have to have 3-years’ experience at the top of the specialist area before the Masters, and it typically takes many more years to get there.

Comments here about psychologists not being able or willing to address the more difficult psychiatric cases resonate too. Can remember some years ago one of our Child Psychologists was hyping up psychology prescribing as something that would definitely come to our shores. But they would only deal with depression, not the “hard stuff” like bipolar or schizophrenia. Another psychologist I worked with in the public service was specialised in therapies for psychosis, and I can remember her telling me that she’d been involved in the low prevalence conditions for so long that she didn’t feel confident going out and doing standard depression/anxiety psychology.

 

[clausewitz2]

So, a VA primary care clinic with an embedded PCMHI psychologist and a pharm?

We were literally all next-door to each other in a row of offices. One of the few great things about this set-up, if you ask me?

The VA might object to the other elements of my fantasy office, such as the ornate writing desk upon which I shall use a fountain pen to inscribe only trenchant observations about my most interesting cases on the highest quality vellum.


...aaaaaalmost enough to make me want to work for the feds again, though.

 

[TexasPhysician]

I recently interviewed at a DO school and am waiting to hear back. I thought he made some good points about the economy of a physicians time, and how a psychologist is able to spend a lot more time talking to the patients and this may prevent over prescribing drugs. In particular, he mentioned that this is a big problem with primary care physicians that see patients often very briefly and who prescribe a large majority of our nation's mental health drugs. It seems to me (from my limited perspective on what I have read) that with many of these mental health conditions drugs are not always necessary or the best case for treatment and this approach at focusing talk before prescribing, that he claims is more prevalent in the psychologist world, is appealing to me. Also, his point of how prescribing psychologists have already been a thing in the military for some 20 years without issue I think is pretty good for his case. With that being said, this is all my humble opinion based off no experience in the field, and I posted here to see from experienced clinicians the other side and why I might be wrong in my assumptions.

Except his thoughts are all wrong. Midlevels providers that don’t understand meds tend to over-prescribe. That’s what they would become. They have no idea what they are doing with meds. Most PCP’s are not creating poly-pharmacy with psych meds. They try 1-2 meds and then punt to psych. There have been issues with psychologists prescribing in the military world, but lawsuits in the military are almost non-existent due to federal laws. They literally have no idea what is going on with meds. It’s the Wild West. The military also uses GMO’s to handle everything. Would you accept that for your family? A MS2 with a psych rotation is better prepared than psychologists to prescribe. I routinely have psychologists market themselves to me by “we do ADHD testing for you to quickly prescribe”. Hard pass. That’s a good way to get off my referral list. I’m in desperate need of psychologists that do quality testing and counseling.

 

[dl2dp2]

I think you make excellent points and it’s refreshing to see these points made by an attending physician.

I think other considerations are rural and underserved areas. I am in a city with 150,000 people and there are only three psychiatrists in town. In addition, the next city with over 20,000 people is over three hours away, so these 3 psychiatrists are also serving the surrounding areas, often times through telehealth.

A counterpoint may be the PCPs could manage the psychiatric medications. However, I know that in my office (I’m the only psychologist and I am with 7 pediatricians) all but one of the pediatricians get uncomfortable and refer to psychiatry once antidepressants or mood stabilizers may be needed; they are usually only comfortable prescribing ADHD meds. Once there is an inpatient hospitalization or DMDD diagnosis, among others, a referral to psychiatry is placed. Then you have a very, very long waitlist for said 3 psychiatrists. I do not believe this experience is uncommon in these rural communities.

I think the question of the quality of the medication management can be made among any prescribers, not just the NPs or RxPs, due to differences in the quality of training received as well as other factors.

The answer to such shortages IMO is NOT to pay underqualified providers but to pay a higher/market salary, especially given telepsych is feasible, why can't facilities build an infrastructure contracting remote psychiatrists to see more patients? Why are the stakeholders not interested in paying a fair salary for someone who actually knows what they are doing? Why is it that we think it's acceptable that places with no money deserve no psychiatrist, whereas if they have a hernia they'd still get a surgeon? Why not just train a PA to operate on people and have nurse anesthetists do their anesthesia?

These phenomena exist because there is no real mental health parity.

Is it really a wonder that there's a rural overdose and suicide crisis? People are dying daily because of mental health diagnoses and nobody cares. That's the real issue.

Except his thoughts are all wrong. Midlevels providers that don’t understand meds tend to over-prescribe. That’s what they would become. They have no idea what they are doing with meds. Most PCP’s are not creating poly-pharmacy with psych meds. They try 1-2 meds and then punt to psych. There have been issues with psychologists prescribing in the military world, but lawsuits in the military are almost non-existent due to federal laws. They literally have no idea what is going on with meds. It’s the Wild West. The military also uses GMO’s to handle everything. Would you accept that for your family? A MS2 with a psych rotation is better prepared than psychologists to prescribe. I routinely have psychologists market themselves to me by “we do ADHD testing for you to quickly prescribe”. Hard pass. That’s a good way to get off my referral list. I’m in desperate need of psychologists that do quality testing and counseling.

This is EXACTLY what I see as well and I think is a fairly universal phenomenon. PCPs underdose and perhaps have too short of a trial, but at least they are very careful. NPs overmedicate with meds they don't understand (notably benzo, antipsychotics, and off label meds such as lamictal), and rarely take into consideration more complex phenomenology (personality disorders, malingering, neurological/medical confounding, etc).

 

[erg923]

Except his thoughts are all wrong. Midlevels providers that don’t understand meds tend to over-prescribe. That’s what they would become. They have no idea what they are doing with meds. Most PCP’s are not creating poly-pharmacy with psych meds. They try 1-2 meds and then punt to psych. There have been issues with psychologists prescribing in the military world, but lawsuits in the military are almost non-existent due to federal laws. They literally have no idea what is going on with meds. It’s the Wild West. The military also uses GMO’s to handle everything. Would you accept that for your family? A MS2 with a psych rotation is better prepared than psychologists to prescribe. I routinely have psychologists market themselves to me by “we do ADHD testing for you to quickly prescribe”. Hard pass. That’s a good way to get off my referral list. I’m in desperate need of psychologists that do quality testing and counseling.

There is no "ADHD testing." You are referring for a second (diagnostic) opinion. There are no "test results" that should override (or "confirm") your clinical impression based on thorough history, interview, and other diagnostic rule-outs. "Co-morbid" is the most parsimonious conclusion in most cases....

This whole "ADHD testing issue" is especially weird to me because psychologists don't do depression "testing." We don't do schizophrenia "testing." Well, sometimes we are called upon for the more latent stuff, but I'm not really sure who benefits from this most times? I mean, psychiatrists are oddly confident there... but not with ADHD??? Its not like the DSM criteria state "show deficits on test of attention." And its not as if this would be diagnostically sensitive or discriminatory of the disorder if they did, right? Its weird. I mean, even Alzheimer's disease can be pretty reliably diagnosed based on the clinical picture and history unless there are other potential medical and neurological events (ask any memory disorder specialist). I wish everyone would catch up with the literature and realize that "ADHD testing" is a wishful fantasy. It doesn't cover anyone's A.

 

[clausewitz2]

There is no "ADHD testing." You are referring for a second (diagnostic) opinion. There are no "test results" that should override (or "confirm") your clinical impression based on thorough history, interview, and other diagnostic rule-outs. "Co-morbid" is the most parsimonious conclusion in most cases....

This whole "ADHD testing issue" is especially weird to me because psychologists don't do depression "testing." We don't do schizophrenia "testing." Well, sometimes we are called upon for the more latent stuff, but I'm not really sure who benefits from this most times? I mean, psychiatrists are oddly confident there... but not with ADHD??? Its not like the DSM criteria state "show deficits on test of attention." And its not as if this would be diagnostically sensitive or discriminatory of the disorder if they did, right? Its weird. I mean, even Alzheimer's disease can be pretty reliably diagnosed based on the clinical picture and history unless there are other potential medical and neurological events (ask any memory disorder specialist). I wish everyone would catch up with the literature and realize that "ADHD testing" is a wishful fantasy. It doesn't cover anyone's A.

You misunderstand. The testing is so you can put a hurdle up to reduce the number of people asking for a controlled substance. Being medical folks many psychiatrists are weirdly uncomfortable saying no to people who are articulate and sympathetic. The contrast of this with the high degree of comfort they have with temporarily imprisoning people with decompensated SMI and what that might say about the ethos of the profession is worth reflection.

 

[erg923]

You misunderstand. The testing is so you can put a hurdle up to reduce the number of people asking for a controlled substance. Being medical folks many psychiatrists are weirdly uncomfortable saying no to people who are articulate and sympathetic. The contrast of this with the high degree of comfort they have with temporarily imprisoning people with decompensated SMI is and what that might say about the ethos of the profession is worth reflection.

Who do you think should pay for this, uh, "service?"

 

[TexasPhysician]

You misunderstand. The testing is so you can put a hurdle up to reduce the number of people asking for a controlled substance. Being medical folks many psychiatrists are weirdly uncomfortable saying no to people who are articulate and sympathetic.

Won’t work with my population. They’ll show up to the psychologist and get something that says they have ADHD. Then they come back and want meds. It’s best to be honest and just say they don’t meet criteria for ADHD.

 

[clausewitz2]

Won’t work with my population. They’ll show up to the psychologist and get something that says they have ADHD. Then they come back and want meds. It’s best to be honest and just say they don’t meet criteria for ADHD.

.

Who do you think should pay for this, uh, "service?"

...yeees, that was sarcasm. ADHD testing is not a real thing, don't do it.

 

[FlowRate]

Won’t work with my population. They’ll show up to the psychologist and get something that says they have ADHD. Then they come back and want meds. It’s best to be honest and just say they don’t meet criteria for ADHD.

If a learning disorder or other condition worth testing is on the differential, I still order testing. Otherwise, it's never changed my opinion about whether or not I think a patient "really" has ADHD. Nor has a wender-utah or any other self-report measure.

The discomfort with adult ADHD is that you rarely have strong third-party collateral the way you do with children.

 

[Mass Effect]

You misunderstand. The testing is so you can put a hurdle up to reduce the number of people asking for a controlled substance. Being medical folks many psychiatrists are weirdly uncomfortable saying no to people who are articulate and sympathetic. The contrast of this with the high degree of comfort they have with temporarily imprisoning people with decompensated SMI and what that might say about the ethos of the profession is worth reflection.

I agree that psychiatrists just need to be up-front. If they don't feel comfortable prescribing stimulants, just say so. No use putting them through unnecessary testing and costs when you just don't want to prescribe. That said, I have to say that there are patients out there who genuinely struggle with ADHD and aren't being treated because some of us refuse to prescribe unless we have records from 4th grade.

 

[Jules A]

Working an acute unit allows one to see the skill set and patterns of a large number of prescribers. It is odd that so many here are equating NPs with high doses of multiple medications because in my experience while I think many NPs suck at diagnosing and prescribing what I tend to see is a large number of medications but generally nothing at therapeutic doses. So my take is while it is incompetent and not efficacious there isn't the danger factor I see with some. The high dose polypharmacy I encounter in my area is largely psychiatrists, the old docs who really need to retire...anecdotal and my opinion only.

As for the shortage that is a physician issue because the rural areas around here are willing to pay $300,000-$350,000 for a psychiatrist and the supply isn't there. Something to consider, universities must increase psychiatry programs or midlevels will in fact take over market share.

 

[TexasPhysician]

Working an acute unit allows one to see the skill set and patterns of a large number of prescribers. It is odd that so many here are equating NPs with high doses of multiple medications because in my experience while I think many NPs suck at diagnosing and prescribing what I tend to see is a large number of medications but generally nothing at therapeutic doses. So my take is while it is incompetent and not efficacious there isn't the danger factor I see with some. The high dose polypharmacy I encounter in my area is largely psychiatrists, the old docs who really need to retire...anecdotal and my opinion only.

As for the shortage that is a physician issue because the rural areas around here are willing to pay $300,000-$350,000 for a psychiatrist and the supply isn't there. Something to consider, universities must increase psychiatry programs or midlevels will in fact take over market share.

No disagreement with older docs in general, but NP’s create insane regimens in my area. Starting Lamictal at high doses, extreme weight gain using Depakote and Seroquel to treat depression, and diagnosing everyone with bipolar. 5 year olds with Zyprexa for their bipolar (adhd). I could go on forever. One of my “referral” sources is failures with a NP.

Telepsychiatry has made rural areas a problem of the past in many states. $300k is not a pay differential worth moving. In my graduating residency class, 66% earn over $350k. The 1/3rd that doesn’t either works in academia ($250k) or county health system in large urban areas ($250k). The 66% aren’t moving rural for a pay cut. Those that choose $250k to be in a cushy academia gig aren’t going rural for $50k extra. Those that choose a county population to live/navigate an urban area aren’t going rural for $50k. Rural jobs are also typically more demanding and have limited or no coverage when needed. If the government really cared about rural areas, they wouldn’t pump out NP’s which predominantly work in urban areas. They would create grants or bonus pay structures for rural areas to make it worth it.

 

[PikminOC]

The mid-levels are not necessarily filling up rural areas. They congregate in the bigger cities too.

Call me a dinosaur, but I think it's important to take into consideration organic causes as well.

People do not get cornered into prescribing. It's the way to make more re money, but the liability increases exponentially.

 

[dl2dp2]

As for the shortage that is a physician issue because the rural areas around here are willing to pay $300,000-$350,000 for a psychiatrist and the supply isn't there. Something to consider, universities must increase psychiatry programs or midlevels will in fact take over market share.

Well, maybe if you can't get a psychiatrist for 350k you should consider paying 500k. Someone will show up. Or maybe you should ship your patients to somewhere where there are psychiatrists. Traveling out of state once a month is really not that hard. If it's bone marrow transplant people would travel. If it's refractory epilepsy people would travel. If it's a schizophrenia patient on Clozaril you get an NP? WTF?

 

[pediatric_psydoc]

Well, maybe if you can't get a psychiatrist for 350k you should consider paying 500k. Someone will show up. Or maybe you should ship your patients to somewhere where there are psychiatrists. Traveling out of state once a month is really not that hard. If it's bone marrow transplant people would travel. If it's refractory epilepsy people would travel. If it's a schizophrenia patient on Clozaril you get an NP? WTF?

Traveling out of the state? Take off work for the entire day and, if the patient is a child, take the child out of school for an entire day to travel out of the state to see the psychiatrist. And hope that their BCBS of their home state covers the visit from the out of state provider, and if the patient has Medicaid or managed Medicaid then you have more issues. But I suppose for the copious amounts of people with money here in the rural area who can afford to pay out of pocket, your solution makes perfect sense.

 

[dl2dp2]

Traveling out of the state? Take off work for the entire day and, if the patient is a child, take the child out of school for an entire day to travel out of the state to see the psychiatrist. And hope that their BCBS of their home state covers the visit from the out of state provider, and if the patient has Medicaid or managed Medicaid then you have more issues. But I suppose for the copious amounts of people with money here in the rural area who can afford to pay out of pocket, your solution makes perfect sense.

I'm confused. What is really the difference between someone with refractory inflammatory bowel disease who needs to see a GI doctor out of state for injectable and someone with refractory opioid use disorder who needs to see an addiction psychiatrist out of state for injectables? What about someone with refractory schizophrenia who needs an injectable?

Why is it that everyone involved thinks that it's acceptable that we'll go out of our way to get this person out of state to get the treatment, or pay lots of money to get the GI doctor in state, but in the latter, we hire an NP instead who doesn't even know how to properly evaluate whether someone like this would NEED the specialized treatment?

By the way, this is not just a rural problem. Why is it that all the CMHCs are now only staffing homeless schizophrenics with NPs who put them on multiple antipsychotics? Why are children on Medicaid only staffed by NPs? IMO regulations should be introduced that the most severe and vulnerable patients should not be ALLOWED to be staffed by midlevels. When I see patients somewhere else where I see NPs are doing bad stuff, I call the director of the clinic and report them. There is a limit to what I can do personally, but I am not going to apologize for advocating for people who are harmed by the system.

 

[TexasPhysician]

Traveling out of the state? Take off work for the entire day and, if the patient is a child, take the child out of school for an entire day to travel out of the state to see the psychiatrist. And hope that their BCBS of their home state covers the visit from the out of state provider, and if the patient has Medicaid or managed Medicaid then you have more issues. But I suppose for the copious amounts of people with money here in the rural area who can afford to pay out of pocket, your solution makes perfect sense.

I think y’all are arguing different points. Of course, the goal is everyone to access any specialty within a reasonable distance. This isn’t always possible though. When it isn’t, would you use a vacation day to drive out of state or see the local NP? I’d make the drive for my family. It’s a silly argument though as NP’s aren’t going rural, so that isn’t really an option either.

 

[Mass Effect]

Traveling out of the state? Take off work for the entire day and, if the patient is a child, take the child out of school for an entire day to travel out of the state to see the psychiatrist. And hope that their BCBS of their home state covers the visit from the out of state provider, and if the patient has Medicaid or managed Medicaid then you have more issues. But I suppose for the copious amounts of people with money here in the rural area who can afford to pay out of pocket, your solution makes perfect sense.

Depending on the area, you may not have to leave the state. But that's not the point. I would rather leave my state for a day than be treated by an NP who may or may not know what he/she is doing. Leaving rural areas and driving to another state for specialized treatment isn't something strange or rare. At some major academic centers, people come from all over the U.S. and even travel from other countries to be seen.

 

[PikminOC]

It doesn't matter what we think. Patients want it their way and it's much easier to score feel good drugs from mid-levels.

 

[finalpsychyear]

Seems like everyone has a case for prescribing meds these days. First Nurses, Pa's, pharmacists, psychologists pretty soon you;ll see social workers get in on the action... utter travesty what has happened and i dread what is coming down the pipe

I would NEVER go to a non MD/DO for my medical care

 

[downwithDTB]

If you're prescribing medications or acting as a primary specialty physician would (i.e. accepting primary responsibility for diagnosis, treatment recommendation and referrals) you should feel comfortable and have experience managing the patient up to the need for an available higher level of care (i.e. PHP or inpatient). That means managing and interpreting labs, EKGs, commorbidities like ESRD, hepatitis, ect that develop. That means having had a lot of experience with SI dispo and treatment at all levels of care. You have to be willing and able to start lithium and antipsychotics when your patient on an SSRI becomes psychotic or manic and you need to be able to manage more complex meds when your frontline stops working. You can't just hope that someone else will fix your mess when the patient changes or expect that a psychiatist will be around if you're solving the rural access problem.

The problem with expanding prescribing to solve the rural mental health crisis is that even if you accept that np and PhD will move to rural place, which doesn't happen enough, you end up decreasing demand for MDs such that there is definitely no psychiatist with adequate training to manage anyone with a commorbidity or SMI.

The reciprocal problem in saturated areas is that all the NPs/PhDs need to fill their practice, so you end up either with them seeing the poor and complicated that they definitely aren't trained to see OR needing to fill a practice giving meds to everyone with mild MDD or worse adjustment disorder. MDs do not need to fill practices by prescribing unnecessarily (doesn't mean that none do). Further, by keeping psychologists doings therapy, you keep more of a supply of a very important service that is desperately needed.

 

[Merovinge]

Just got to 17:35 and witness our race to the bottom. "As you know, sometimes Beta Blockers, clonidine or propranolol...". This is the "expert" at the "forefront" of RxP. I can't remember the last MS3 on their first psych rotation say something like that.

Edit: He actually calls "them" beta blockers on two occasions...