And we're at it again -- psychologist prescribing in Oregon

[Doctor Bagel]

I'm not ashamed of engaging in turf protection considering we have an 8 year investment (at least) in becoming psychiatrists. Not to mention the current costs of medical school and crappy interest rates on student loans. Couple that with living in a country with limited safety net. Yeah, I'm all over protecting my turf. Psychologists want to prescribe because their job market isn't so hot (from what I've heard), so it's not like they're on the side of virtue or anything in this fight. Hospitals and insurance companies want to pay less. None of this is really about access.

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[WisNeuro]

I suppose that would be one way of looking at it. It would also seem intuitive that if one were to advocate a legal change to the status quo that decreases the rigor with which something is obtained, that the burden of proof would be shouldered by the petitioner. Instead, we have an appeal to the expansion of access to care without any proof of how this would expand access or even proof that there's a shortage of psychotropics.

I believe that would be a valid argument, IF the same burden of proof had been given by the current practitioners. Instead, it's just an argument of "this is the way we do it, and it's the right way" without any real sort of evidence. You are expecting someone else to provide evidence of efficacy that the current practitioners have themselves never produced in the first place.

 

[WisNeuro]

None of this is really about access.

I'm in agreement with you about this. Turf management is real and we all do it. For people who are of above average intelligence, what we do is not hard. Trained monkeys with computer algorithms could replace 50%+ of healthcare services, with likely little degradation in outcomes. Hell, probably improve outcomes in some areas. I'm all about just dropping the pretenses and calling it what it is, for all involved.

 

[st2205]

I believe that would be a valid argument, IF the same burden of proof had been given by the current practitioners. Instead, it's just an argument of "this is the way we do it, and it's the right way" without any real sort of evidence. You are expecting someone else to provide evidence of efficacy that the current practitioners have themselves never produced in the first place.

You'd be correct. And we have countless examples of standards of care that have preceded the advent of evidence based medicine (as much as I cringe at that dogmatic term). I guess your argument would be that evidence must be produced to maintain the status quo rather than evidence produced to change the status quo (especially if you are lowering the standard).

There's no evidence that internists who did extra electives in interventional cardiology are any less safe at deploying stents than interventional cardiologists.

There's no evidence that social workers who take additional neurosciences courses are any less qualified to interpret neuropsychological testing than neuropsychologists.

There's no evidence that Mohs surgeons are any more effective than general dermatologists at Mohs surgery.

These standards of care, in conjunction with almost all training standards of healthcare, aren't really rooted in research but in tradition. If evidence is not available for a higher standard of care by tradition, does that make it a rational choice to lower it without evidence to support it (since you're invoking a double standard argument)?

 

[Armadillos]

I'm in agreement with you about this. Turf management is real and we all do it. For people who are of above average intelligence, what we do is not hard. Trained monkeys with computer algorithms could replace 50%+ of healthcare services, with likely little degradation in outcomes. Hell, probably improve outcomes in some areas. I'm all about just dropping the pretenses and calling it what it is, for all involved.

It's not just a medical issue, its more a societal one about licensing some indivuals to perform specific tasks.

Just because one "unqualified" person can do X better or as competently as someone legally qualified to do X, does that mean we need to change the requirements to do X? I'm not a lawyer, but I'm 100% sure I could find lawyers out there that I would outperform at practicing certain types of law. Does that mean MDs should be allowed to practice law? A libertarian position would be that anyone should be freely able to do anything, and it's up to the consumer to choose. I have sympathy for that argument, but it's not the society we live in.

 

[slappy]

Whoa people. Stop worrying so much.

Even if psychologists start prescribing, I doubt it's going to cause much damage to your income. NPs and PAs practice under the liability of the supervising physician. Can you imagine how much a psychologist's malpractice insurance would go up when they start prescribing, and people start suing when any number of things that can go wrong goes wrong? How many psychologists are going to want to take that on (and the headache of lawsuits) for a little added income?

At the same time, start differentiating yourself. Expand your turf, so to speak, instead of fighting over it. Do neurointerventions and intravenous interventions, even if they aren't yet proven to be effective. Invent new diagnoses in DSM, and add specialized indications and multiple blackbox warnings for age-old medications, making everything super complicated and confusing. It can't be that hard.

 

[splik]

At the same time, start differentiating yourself. Expand your turf, so to speak, instead of fighting over it. Do neurointerventions and intravenous interventions, even if they aren't yet proven to be effective. Invent new diagnoses in DSM, and add specialized indications and multiple blackbox warnings for age-old medications, making everything super complicated and confusing. It can't be that hard.

am assuming this is tongue in cheek? it's hard to tell in our universe of alternative facts when people are being serious or not...

 

[slappy]

am assuming this is tongue in cheek? it's hard to tell in our universe of alternative facts when people are being serious or not...

Yeah...

 

[st2205]

I don't think prescribing psychologists would be a threat to psychiatrists in any real turf battle for at least a good 30+ years (if that). But I guess all the other arguments raised are just easy to not have to address by dismissing it all as turf protection.

I think, not infrequently, psychologists may feel slighted at the suggestion that a masters in psychopharmacology wouldn't really qualify them for being on a competent level with psychiatrists as far as medical management of patients. We certainly have a different experience in medicine with our colleagues. What I mean is that medicine is very broad. We get exposure across the board. We never become proficient in any other specialty and we see all our friends go off in to different fields. We all learn different things and have different experiences that differentiate a pediatrician from a psychiatrist from a surgeon. In my experience, most people in medicine generally recognize many fields of medicine that we're not qualified in because we don't have the requisite experience and we can respect that process, and we certainly don't feel slighted simply because we recognize that knowledge is gained through experience and not because we just lack the intelligence for it.

Psychology certainly has many different subspecialties and settings, but it's a significantly more narrow field as it's all encompassed by mental health (i.e. the difference between an ophthalmologist and a pathologist is significantly greater than the difference between subspecialties of clinical/counseling psychology). While clinical psychology training is deeper in a more narrow range of specialty, clinical medicine is all over the board -- so the exposure to many fields that you will never be competent is not viewed as threatening or a pissing match. So from my bias I can't help but wonder if being told a two year masters isn't sufficient is being interpreted as us saying they're not competent generally or if they feel their intellegence is insulted by not believing they would have that requisite knowledge and experience after two years.

I couldn't imagine that if I spent my PGY4 doing neuro electives and learning to read EEGs that any neurologist would take me seriously or think it wise for me to then set up a lab to take referrals -- or even lesser just send my own patients -- to offer official interpretation of that. This wouldn't offend, not because I wouldn't have the capacity to render such opinion given proper experience, but because I'm not a damn neurologist and it'd be kind of hard to separate out the other important components of neurology training that would inform those interpretations. But I'm sure the neurologists would just be engaged in hysterical turf-protecting.

 

[Doctor Bagel]

Whoa people. Stop worrying so much.

Even if psychologists start prescribing, I doubt it's going to cause much damage to your income. NPs and PAs practice under the liability of the supervising physician. Can you imagine how much a psychologist's malpractice insurance would go up when they start prescribing, and people start suing when any number of things that can go wrong goes wrong? How many psychologists are going to want to take that on (and the headache of lawsuits) for a little added income?

At the same time, start differentiating yourself. Expand your turf, so to speak, instead of fighting over it. Do neurointerventions and intravenous interventions, even if they aren't yet proven to be effective. Invent new diagnoses in DSM, and add specialized indications and multiple blackbox warnings for age-old medications, making everything super complicated and confusing. It can't be that hard.

NPs practice with no supervision in more than 20 states. I've had 2 jobs so far where my work responsibilities were identical to NPs. So yes that's probably the real threat. I'm just endlessly amazed by you sheltered folks living in states without independent NP practice. It's coming for you too. When I quit my last job, I was replaced by an NP. And no this is not because I'm a subpar psychiatrist. This is just how it's going where I am. Your hospital would love to replace you too.

 

[FlowRate]

NPs practice with no supervision in more than 20 states. I've had 2 jobs so far where my work responsibilities were identical to NPs. So yes that's probably the real threat. I'm just endlessly amazed by you sheltered folks living in states without independent NP practice. It's coming for you too. When I quit my last job, I was replaced by an NP. And no this is not because I'm a subpar psychiatrist. This is just how it's going where I am. Your hospital would love to replace you too.

And, as I like to mention when these threads come up, some of those NP's are 23 years old, straight out of a 5 year BS/FNP program with an additional 24 credit hours of PMHNP training. Very little of which is actually clinical.

I continue to find it baffling that NP's often have more independence than PA's, who have more actual medical training.

 

[WisNeuro]

These standards of care, in conjunction with almost all training standards of healthcare, aren't really rooted in research but in tradition. If evidence is not available for a higher standard of care by tradition, does that make it a rational choice to lower it without evidence to support it (since you're invoking a double standard argument)?

Totally agree, healthcare does a lot by tradition, rather than due to empiricism. Although, I would argue that there is some data, albeit sparse, that those with a shorter, arguably less rigorous course of training, are actually achieving similar outcomes. This applies to us all. In psychology we have mid-levels doing therapy, and we really don't have much data either way to say they are doing an inferior job. All I can bring out is anecdotes about mid-levels being more likely to offer junk therapies like EMDR and not really have a grasp on the theoretical underpinnings of anxiety treatments at different levels of analysis. Does the fact that I can expound on those different levels (e.g., neurobiological, personality, behavioral, cognitive) make my treatments more effective? Not sure. I'd like to say yes, but I really can't support that assertion empirically with a great level of confidence. I'm all about the call for data, and proving competence, but I think we should be producing it for both sides, the established and the new. IF we can deliver healthcare at a lower cost and achieve the same outcomes, we should. Everywhere in healthcare.

 

[jadedphysiotherapist]

I am not sure what you're trying to argue or from what vantage point (I think you're saying you're an NP, but I'm otherwise lost.)

And, as I like to mention when these threads come up, some of those NP's are 23 years old, straight out of a 5 year BS/FNP program with an additional 24 credit hours of PMHNP training. Very little of which is actually clinical.

I continue to find it baffling that NP's often have more independence than PA's, who have more actual medical training.

Not an NP. Physical therapist. Mental health is important to me so I like looking at other forums.

My point was that NP training doesn't have the countless hours of supervision you have in med residency. I was attempting to show differences in education training pathways as you had originally said NPs weren't that bad at Rx for mental health and could probably do it decently.

I was arguing that I think it's absurd they can do it and tried to argue about the difficulty of getting a dx correct if you haven't had med residency to get good subjectives and hx. I've known psychiatrists that say "I think this patient still has this dx" and the reason they used that terminology is because the dx could still be presenting as something else or could transition to something else.

Look at GAD. Absurd amounts of external stressors on an individual with that can lead to depletion of norepinephrine in the locus ceruleus in the brainstem. Over time that leads to depressive states and episodes with suicidal ideation since that neurotransmitter is invlolved in mood just like serotonin.

That may lead to the need for different medication management and monitoring of the patient as their body adjusts. You're a medical resident so correct me if I'm incorrect on the mechanism there, but that's my understanding. Continuity and watching patients closely is essential when having psychotropic Rx privileges.

Your second comment here shows that you seem to feel the same way tho.

Sorry for poor phrasing, argument, and going off topic with my point

 

[hamstergang]

Look at GAD. Absurd amounts of external stressors on an individual with that can lead to depletion of norepinephrine in the locus ceruleus in the brainstem. Over time that leads to depressive states and episodes with suicidal ideation since that neurotransmitter is invlolved in mood just like serotonin.

That may lead to the need for different medication management and monitoring of the patient as their body adjusts.

All good in theory, but there's no evidence I know of that picking a medication based on neurotransmitters like this leads to better outcomes.

 

[barzan]

A lot of bad things have happened with good intentions in mind. If you don't attend medical school and become a Physician, then you should not have any independence seeing patients/prescribing meds. Everything should run through the Psychiatrist. Period. This method of using a crisis to further one's agenda is a familiar one from the past. Here is a solution....create incentives for more Psychiatrists to be trained and increase reimbursements for Psych. End of story. If you want to pass the Steps and accept TOTAL responsibility without any consultation from those with more education, then you have massive cajones. See you in court, eventually.

I dont think your statement is realistic, NP's, PA's, prescribe all the time without direct supervision, I personally witnessed it at multilevel from ICU NP's to ED PA's. without being said I dont know why your objecting against clinical psychologist to see and prescribe meds.

 

[slappy]

NPs practice with no supervision in more than 20 states. I've had 2 jobs so far where my work responsibilities were identical to NPs. So yes that's probably the real threat. I'm just endlessly amazed by you sheltered folks living in states without independent NP practice. It's coming for you too. When I quit my last job, I was replaced by an NP. And no this is not because I'm a subpar psychiatrist. This is just how it's going where I am. Your hospital would love to replace you too.

I doubt that. I have a few unique skillsets. And I love teaching and research. And if I ever tire of all that, I'm fairly certain I have enough street-cred, connections and skills to set up a successful cash practice. If someone with less training than you is able to successfully do your job, you need to find ways to distinguish yourself and demonstrate your value better.

 

[jadedphysiotherapist]

All good in theory, but there's no evidence I know of that picking a medication based on neurotransmitters like this leads to better outcomes.

Interesting. Not my field again just interested and have benefited immensely as a youth. I would've thought that an SNRI would've been a better choice in that circumstance over SSRI and potential external stressors and circumstances would've led to Rx of one over another.

Chief resident knows best though.

 

[Doctor Bagel]

I doubt that. I have a few unique skillsets. And I love teaching and research. And if I ever tire of all that, I'm fairly certain I have enough street-cred, connections and skills to set up a successful cash practice. If someone with less training than you is able to successfully do your job, you need to find ways to distinguish yourself and demonstrate your value better.

Says the resident who again probably has no knowledge of what's happening in states with NP independent practice. I always love too how these comments from posters here try to shame those of us who are out there seeing the negative effects on our profession from NPs. There's a poster on another psychiatry group who is being replaced by an NP purely for cost related issues. All the community MH jobs in my community hire NPs to do the same work as physicians. My last inpatient job went from being one NP and 4 physicians to being 2 physicians and 3 NPs by the time I left (after I was replaced by the third NP). All the CL jobs at my hospital are held by NPs. The new free standing inpatient hospital in my city that merged multiple inpatient units is maybe half physician/half MD even though 2 of the 3 hospitals that merged into it were physician only.

 

[slappy]

Says the resident who again probably has no knowledge of what's happening in states with NP independent practice. I always love too how these comments from posters here try to shame those of us who are out there seeing the negative effects on our profession from NPs.

Not meant to be shaming. Just common sense!

 

[deleted736562]

I'm in agreement with you about this. Turf management is real and we all do it. For people who are of above average intelligence, what we do is not hard. Trained monkeys with computer algorithms could replace 50%+ of healthcare services, with likely little degradation in outcomes. Hell, probably improve outcomes in some areas. I'm all about just dropping the pretenses and calling it what it is, for all involved.

I really disagree with this. I'm assuming by "healthcare services" you mean the job MDs do. There's a very good reason why we need to go through 4 years of college, followed by 4 years of medical school and 3+ years of residency and 7+ hours board exams. We're dealing with an incredibly complex system and it requires this level of integration of knowledge, skills, intelligence and judgement to make the sort of life-altering clinical decisions that need to be done. If you are under the impression that it's this easy algorithm, it's not... Having said that, psychiatry is the sort of oddball out there and it does not require the same level of medical knowledge as other fields. Still though, psychopharmacology is complex enough to warrant training in medicine, nevermind the significant overlap between psychiatric symptoms and a myriad of medical conditions. Yeah, we don't have data yet on outcomes, but studies are also not perfect and we can't wait for the perfect study to start acting either. We deal with what we have.

 

[F0nzie]

Oregon is a great state to analyze because their NP situation gives us a glimpse into the future. If psychologists gain prescribing rights in Oregon, it will be the perfect state for market observation. The additional marginal costs of finding a good employed position or distinguishing oneself in a stifling environment may not be worth it.

 

[deleted343839]

Psychology certainly has many different subspecialties and settings, but it's a significantly more narrow field as it's all encompassed by mental health (i.e. the difference between an ophthalmologist and a pathologist is significantly greater than the difference between subspecialties of clinical/counseling psychology).

I don't know. There is some epistemological variety in psychology that doesn't seem so prominent in medicine. BUT to your point, in terms of content, yes, physicians' common frame of reference means that they can at least superficially connect the dots across areas of medical knowledge and therefore aren't out of their depth when dealing with medically complex patients, adverse effects, etc. The RxP laws in New Mexico and Louisiana sort of reflect that by requiring physician oversight... but IMO if you're going to introduce more fragmentation of care there should be a positive trade-off, and I'm not seeing it with RxP.

If psychologists gain prescribing rights in Oregon, it will be the perfect state for market observation.

Would you expect a different trend than from the states where RxP legislation has already been enacted? Who's observing the market in those states, anyway? It's difficult for me to even find the number of psychologists with active prescribing rights. Despite my opposition to RxP, I haven't learned of anything to suggest that the sky is falling in the market. For that matter, I doubt that access to psychiatric care has changed much in RxP states, despite claims from supporters. I am more and more inclined to just shrug at the whole thing.

 

[splik]

All the CL jobs at my hospital are held by NPs. The new free standing inpatient hospital in my city that merged multiple inpatient units is maybe half physician/half MD even though 2 of the 3 hospitals that merged into it were physician only.

Though apparently they are looking for CL psychiatrists - I got a flyer about it in the mail!

 

[Doctor Bagel]

Though apparently they are looking for CL psychiatrists - I got a flyer about it in the mail!

And not to say there aren't still lots of jobs for psychiatrists in Oregon right now. I'm would just be surprised if we don't see a decrease in the future especially as the number of NPs grow (they're churning them out like crazy with all those online schools and whatnot).

It's also narcissistically injuring for me (and I suspect most doctors) to be confused with NPs all the freaking time which happens when you wind up in identical jobs. My current job does not have NPs in an identical role which is a plus.

 

[splik]

And not to say there aren't still lots of jobs for psychiatrists in Oregon right now. I'm would just be surprised if we don't see a decrease in the future especially as the number of NPs grow (they're churning them out like crazy with all those online schools and whatnot).

It's also narcissistically injuring for me (and I suspect most doctors) to be confused with NPs all the freaking time which happens when you wind up in identical jobs. My current job does not have NPs in an identical role which is a plus.

While I think these turf wars are unproductive, I have a lot of sympathy for this. Let's face it, it's a slap in the face when you've worked this hard for many years, likely racking up steep depths, gaining mastery of your field to find that you are basically interchangeable with some wet behind the ears NP who insists on being called "dr." and can command the same reimbursement from insurance companies as you, while your patients don't even know that you're a doctor...

 

[F0nzie]

Oregon is unique to independent practice states because NPs receive equal pay to physicians. Because of this, Oregon will likely continue to receive a natural flow of NPs despite the excessive rain. This process should continue until the market saturates or salaries fall to the point that it is no longer worth putting up with the excessive rain. The cumulative effect of NP and Rxp in Oregon may be an interesting observation if anybody even cares. I am thinking probably not. Psychologists may a bit late in the Oregon game though and should try California or Texas instead-- although it may be a better strategy to go unnoticed through the smaller states first.




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[splik]

Oregon is unique to independent practice states because NPs receive equal pay to physicians. Because of this, Oregon will likely continue to receive a natural flow of NPs despite the excessive rain.

This is not quite correct. NPs can bill the same as psychiatrists from insurance companies, but to my knowledge, do not usually make the same as psychiatrists in salaried positions. Also there is a sunset clause in the law so it can potentially be reversed when time comes for review. the main problem with NPs being able to claim the same as MDs from insurance companies is that what is to stop them reducing the reimbursements by 15%?

 

[hamstergang]

the main problem with NPs being able to claim the same as MDs from insurance companies is that what is to stop them reducing the reimbursements by 15%?

"An insurer may not reduce the reimbursement paid to a licensed physician in order to comply with this section."

https://olis.leg.state.or.us/liz/2013R1/Downloads/MeasureDocument/HB2902

 

[splik]

since when have insurance companies ever took heed of the law?

 

[deleted343839]

Psychologists may a bit late in the Oregon game though and should try California or Texas instead-- although it may be a better strategy to go unnoticed through the smaller states first.

They're trying in Texas. HB 593 for those interested: http://www.capitol.state.tx.us/tlodocs/85R/billtext/pdf/HB00593I.pdf

 

[Merovinge]

Way too many people have such an inflated idea about how hard their job really is, on both sides of this particular aisle.

Maybe doing a passable job that meets standard of care and can be billed is "easy", but certainly providing optimal psychiatry or psychologic care is not. You don't know what you don't know, particularly in a field like medicine with rare diseases/presentations being a common occurrence if one sees a high enough clinical volume. You can also generate lots of needless side effects from poor choice of medications; there is absolutely no way to quantify this so the practice can just continue. Who's to say the young person on Paxil or Remeron would not have gained weight anyway even had you chosen Prozac instead. Sure you are clearly elevating the rate of SI with Paxil if they are under 25 but the absolutely incidence of actual suicide success is low enough that any individual provider is likely to sneak past, and hey, depressed people commit suicide, it's easy to not blame the sub-optimal provider.

 

[Jules A]

And not to say there aren't still lots of jobs for psychiatrists in Oregon right now. I'm would just be surprised if we don't see a decrease in the future especially as the number of NPs grow (they're churning them out like crazy with all those online schools and whatnot).

It's also narcissistically injuring for me (and I suspect most doctors) to be confused with NPs all the freaking time which happens when you wind up in identical jobs. My current job does not have NPs in an identical role which is a plus.

Sadly you are 100% correct and I do foresee a glut of NPs, most with zero nursing experience let alone psych experience, in the near future. In fact it is apparent in my area already. The quality of their diagnosing and prescribing is anecdotally lousy and as concerning to me is they also have no business savvy and will accept whatever crap wage and duties an employer offers. Unfortunately part of the problem is that its fairly easy to suck at diagnosing and prescribing in our specialty without killing anyone so I don't think the outcomes will support the assertion that NP schools which have historically been light on medicine are now light on everything are going to have significantly worse outcomes. The other point is despite being 100% aligned with psychiatrists and their superior education the truth is I have seen as many horrible Psychiatrists as NPs. In fact after legit LOL-ing at Seroquelled's post that none of the docs they know prescribe benzos or anticholinergics to geri patients or give an erroneous BiPad dx to BPD patients I am planning to message and ask where this most delightful environment exists because I'd like to move there.

As physicians I believe you are likely the only group, until the public becomes aware of the flimsy NP education and admission requirements, with the ability to address and change this trend. Nurses gain power with numbers and universities have found a gravy train by insisting it is best to remain in school, paying tuition, without working as a RN through grad school. Get your lobbyists to fight this on a legislative level, bring the doctor title issue up at your facilities and insist on a policy of who can call themselves "Dr". I have attempted to discuss this with nurses organizations, nursing accrediting bodies and universities all with a vested interest in keeping this sham going and was driven from town by an angry mob with pitchforks despite this being a major concern of quality NP providers also. The quality of care will suffer as will wages across the board and I find neither of those options acceptable.

This is not quite correct. NPs can bill the same as psychiatrists from insurance companies, but to my knowledge, do not usually make the same as psychiatrists in salaried positions.

Correct and this is a driving force for employers who could give a rip about quality. The inexperienced 23yo's with no RN experience and no business savvy mentioned earlier are driving wages into the ground. This is not good and unfortunately I don't see the trend reversing unless physicians bring it to the public light. The lack of providers, if this is even as prevalent as we have been led to believe, doesn't negate the need for quality care for this vulnerable population. Although it would take a little longer to beef up the NP admission requirements and quality of education at the very least it would reduce the tripe we are seeing and will continue to see with the plethora of Online Us granting a degree to anyone who can fog up a mirror held below their nose and pay the tuition.

Bottom line is NPs aren't going away but there are areas that physicians who are forward thinking can attempt to shape into a more positive situation. Instead of looking at all NPs as adversaries consider working with the ones who have some potential. Shaping their knowledge and practice to model your philosophy is a decent strategy which benefits everyone especially patients. Discuss acceptable wages. The physicians I work with don't want NPs undercutting their wages too drastically or doing stupid secretarial crap that the admin needs to handle and have assisted NPs in wage, duties and contract negotiation. Groom them like you have PAs and although there is a small faction of NP twits who think they are freaking Drs the majority in my experience are cognizant of your superior education and will defer to your insight hopefully making the best of what could be a bad situation.

 

[Crayola227]

In some sense I think we are lucky that the extreme skepticism that all of medicine is now under from patients, that of all the providers they distrust, they trust the MD most.

though I can't say for sure if it's based on reality, I hear many talking of "fake doctors" and "nurse practitioners" as "doctors of death," and people wanting a "real doctor."

I can't say I do much to divest people of this notion that if given the choice, the MD is best. That I would only see an NP I was sent to one by an MD, and even then.

 

[singasongofjoy]

I think a better solution to a lot of the problems being described on this thread are more integrative medicine clinics rather than RxP. Stick some seasoned psychologists in family medicine clinics. That would probably go a long way towards overall decreasing the amount of meds that people are on. The people who are willing to take SSRIs indefinitely but resistant to therapy are a lot more likely to see a psychologist if it's seen as just part 2 of going to see their PCP. Especially in the small towns I've lived in, where access to both psychology and psychiatry are extremely limited, and family med doctors or NPs are doing all the prescribing and management. I've been lucky to work in a few places - including inpatient and residential - where the psychologists and psychiatrists had a strong alliance and the psychology team spent a lot of time targeting how to decrease people's meds. Especially when they'd come in from the prison system and be on a crazy cocktail of 5 psychotropics. I'd love to see more of that type of collaboration in the general medical clinic setting with family doctors and etc. I've no interest in prescribing, but I am interested in additional psychopharm training because it's always relevant and makes it easier to have efficient and effective conversations with other providers about a patient when you've got a kid who is so sedated that they can't learn the new behavioral skills to effectively treat whatever challenging behaviors got them on so many meds in the first place. I can't tell you how often I see this in my kids with ASD and I wish it were easier to collaborate with prescribing providers. Hence need for more integrated clinics.

 

[Jules A]

In some sense I think we are lucky that the extreme skepticism that all of medicine is now under from patients, that of all the providers they distrust, they trust the MD most.

though I can't say for sure if it's based on reality, I hear many talking of "fake doctors" and "nurse practitioners" as "doctors of death," and people wanting a "real doctor."

I can't say I do much to divest people of this notion that if given the choice, the MD is best. That I would only see an NP I was sent to one by an MD, and even then.

I truly hope the public doesn't distrust MDs the most but unfortunately due to what I believe can be best described as excessive handholding the public's love for NPs often far exceeds their actual abilities. I also wouldn't go to a NP or PA unless they were referred by a MD who examined myself or family member first. With a MD at the very least their education is adequate and they have usually come by high recommendation from a colleague.

 

[Crayola227]

I truly hope the public doesn't distrust MDs the most but unfortunately due to what I believe can be best described as excessive handholding the public's love for NPs often far exceeds their actual abilities. I also wouldn't go to a NP or PA unless they were referred by a MD who examined myself or family member first. With a MD at the very least their education is adequate and they have usually come by high recommendation from a colleague.

lol, maybe misread

they distrust the whole establishment
yet somehow MDs are still the gold standard for most people

 

[Crayola227]

I think a better solution to a lot of the problems being described on this thread are more integrative medicine clinics rather than RxP. Stick some seasoned psychologists in family medicine clinics. That would probably go a long way towards overall decreasing the amount of meds that people are on. The people who are willing to take SSRIs indefinitely but resistant to therapy are a lot more likely to see a psychologist if it's seen as just part 2 of going to see their PCP. Especially in the small towns I've lived in, where access to both psychology and psychiatry are extremely limited, and family med doctors or NPs are doing all the prescribing and management. I've been lucky to work in a few places - including inpatient and residential - where the psychologists and psychiatrists had a strong alliance and the psychology team spent a lot of time targeting how to decrease people's meds. Especially when they'd come in from the prison system and be on a crazy cocktail of 5 psychotropics. I'd love to see more of that type of collaboration in the general medical clinic setting with family doctors and etc. I've no interest in prescribing, but I am interested in additional psychopharm training because it's always relevant and makes it easier to have efficient and effective conversations with other providers about a patient when you've got a kid who is so sedated that they can't learn the new behavioral skills to effectively treat whatever challenging behaviors got them on so many meds in the first place. I can't tell you how often I see this in my kids with ASD and I wish it were easier to collaborate with prescribing providers. Hence need for more integrated clinics.

Yes, integrated clinics are the answer.

I'm not sure the data was as amazing as people hoped, but I think there have been typical issues with implementation: money and providers. (not providers of Rx's, providers of the appropriate types for such a clinic)

 

[FlowRate]

As for states where NP's can practice MEDICINE independently, it's a real shame those states' Boards of Medicine allowed the Boards of Nursing to give themselves unlimited scope.

The thing I like about PA's (and specifically PA training programs) is that they go into it with the intention and understanding that they will learn to do the 80% of our jobs (by patient volume, not scope) under the supervision of an MD. They embrace the midlevel role.

 

[deleted343839]

Hence need for more integrated clinics.

I agree. This article summarizes the issue nicely: http://onlinelibrary.wiley.com/doi/10.1111/cpsp.12054/full

However, it's sobering to look at the job market for behavioral health consultants in primary care. Most position listings treat master's level clinicians and psychologists as interchangeable, and the salary reflects it. That puts us (psychologists) in a similar position, needing to advocate for the value of our higher level of training. RxP is sometimes framed as a "solution" to that problem and I'm troubled by the sheer number of people who fail to appreciate the irony there.

 

[Doctor Bagel]

While I think these turf wars are unproductive, I have a lot of sympathy for this. Let's face it, it's a slap in the face when you've worked this hard for many years, likely racking up steep depths, gaining mastery of your field to find that you are basically interchangeable with some wet behind the ears NP who insists on being called "dr." and can command the same reimbursement from insurance companies as you, while your patients don't even know that you're a doctor...

It's also this feeling that I just finally got to the table after being a resident with essentially no say in my life or control over my work and then I find out that I could have just gone to school for a few years with no call and get paid say 80% of what I make now and do the same work (although not as well, but people don't seem to know that).

 

[Crayola227]

If we believe in Medicine as a Profession, with Capital Letters for Ideals, as what it is best for patients - then we fight to our dying breath and make no apologies for doing so to anyone.

Great, do some EBM. There will never be EBM double blinded placebo controlled trial of the outcome of jumping out of an airplane with and without a parachute. Some answers will never come from EBM and we must use common sense still.

 

[erg923]

If we believe in Medicine as a Profession, with Capital Letters for Ideals, as what it is best for patients - then we fight to our dying breath .

Save yo Drama for yo Moma!

 

[MLT2MT2DO]

Interestingly enough this is also something currently trying to be pushed through by the state Psychological association in Nebraska.

So much for "it's the lawmakers trying to mandate this, us psychologists have no interest in pursuing this"

Sent from my SM-G900V using SDN mobile

 

[PistolPete]

It's also this feeling that I just finally got to the table after being a resident with essentially no say in my life or control over my work and then I find out that I could have just gone to school for a few years with no call and get paid say 80% of what I make now and do the same work (although not as well, but people don't seem to know that).

My feeling as well.

 

[Crayola227]

lol like any of our associations represent us anymore

we've all be sold out

"Yes sir, she can do that, she can do that and tie cherry stems into knots with her tongue!"

 

[Fan_of_Meehl]

I don't know. There is some epistemological variety in psychology that doesn't seem so prominent in medicine. BUT to your point, in terms of content, yes, physicians' common frame of reference means that they can at least superficially connect the dots across areas of medical knowledge and therefore aren't out of their depth when dealing with medically complex patients, adverse effects, etc. The RxP laws in New Mexico and Louisiana sort of reflect that by requiring physician oversight... but IMO if you're going to introduce more fragmentation of care there should be a positive trade-off, and I'm not seeing it with RxP.



Would you expect a different trend than from the states where RxP legislation has already been enacted? Who's observing the market in those states, anyway? It's difficult for me to even find the number of psychologists with active prescribing rights. Despite my opposition to RxP, I haven't learned of anything to suggest that the sky is falling in the market. For that matter, I doubt that access to psychiatric care has changed much in RxP states, despite claims from supporters. I am more and more inclined to just shrug at the whole thing.

Anecdotally--being from Louisiana--we still appear to have the same shortage of (and demand for) psychiatrists that other areas of the country continue to experience.

What strikes me the most about mental health care is just how so darn fragmented it all is...everyone from bachelors level (licensed practical counselors), primary care physicians, social workers, psychologists, psychiatrists, pastoral counselors, educational professionals, etc. ad nauseam.

I don't think that in Louisiana (or anywhere else) there is a real 'crisis' in terms of the mentally ill being able to get access to psychiatric medications...my experience is that the real crisis is a lack of access to mental health professionals/teams who know what they're doing (esp. as regards differential diagnosis, case formulation, application of evidence-based interventions, skills at developing appropriate professional relationships with patients (including boundaries), etc.) or who can devote the time necessary to really successfully apply the solid clinical science and methods that exist (so far) in mental health.

 

[FlowRate]

Anecdotally--being from Louisiana--we still appear to have the same shortage of (and demand for) psychiatrists that other areas of the country continue to experience.

What strikes me the most about mental health care is just how so darn fragmented it all is...everyone from bachelors level (licensed practical counselors), primary care physicians, social workers, psychologists, psychiatrists, pastoral counselors, educational professionals, etc. ad nauseam.

I don't think that in Louisiana (or anywhere else) there is a real 'crisis' in terms of the mentally ill being able to get access to psychiatric medications...my experience is that the real crisis is a lack of access to mental health professionals/teams who know what they're doing (esp. as regards differential diagnosis, case formulation, application of evidence-based interventions, skills at developing appropriate professional relationships with patients (including boundaries), etc.) or who can devote the time necessary to really successfully apply the solid clinical science and methods that exist (so far) in mental health.

At least in my local market, that reminds me of the ridiculousness of group homes around here. Someone gets in a yelling match at group home? Off to the ED for a "safety evaluation" (8 hours of babysitting) and a $1000 bill for the taxpayer. There's gotta be a point at which someone finally realizes that all the $$ we waste on popping these folks in- and out- of the ED (and occasionally psych inpatient) could be better spent hiring better/more people for these group homes. Methinks the incentive structure should be setup such that the group homes are fined for excessive inpt/emergency care of their folks (or rewarded for less care, either way.)

 

[PistolPete]

At least in my local market, that reminds me of the ridiculousness of group homes around here. Someone gets in a yelling match at group home? Off to the ED for a "safety evaluation" (8 hours of babysitting) and a $1000 bill for the taxpayer. There's gotta be a point at which someone finally realizes that all the $$ we waste on popping these folks in- and out- of the ED (and occasionally psych inpatient) could be better spent hiring better/more people for these group homes. Methinks the incentive structure should be setup such that the group homes are fined for excessive inpt/emergency care of their folks (or rewarded for less care, either way.)

Totally agree. But so much of mental healthcare is still so taboo and so politically incorrect to talk about that I don't think much will happen for another decade or two, probably more.

 

[WisNeuro]

In this example, I don't think this is as much about the "taboo" of mental health as much as it is CYA and liability in the case of a lawsuit.

 

[Candidate2017]

I doubt that. I have a few unique skillsets. And I love teaching and research. And if I ever tire of all that, I'm fairly certain I have enough street-cred, connections and skills to set up a successful cash practice. If someone with less training than you is able to successfully do your job, you need to find ways to distinguish yourself and demonstrate your value better.

You are not a special snowflake. You are just another physician who thinks they can be successful at an endeavor in which they have no experience. Dr. Phil with a prescribing license could set up a cash pay clinic, staffed entirely by NPs, next door to the world's best psychiatrists and run them out of business.