Barriers to practice?

[juddson]

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Maybe has been covered before . . .

I'm starting to get to that point in med school when its time to think seriously about what I'm going to do. Psych is high on the list, but one issue (you know the issue) is giving me pause - psychologists.

My question is this one: What sorts of non-artificial barriers exist preventing a PhD or Psy-D, educated under today's standards, from subsuming the entire modern practice currently occupied by board certified psychiatrists? I am hoping VERY MUCH that the answer is not simply that they are untrained to prescribe. Is this the only barrier to the practice of psychiatry by non-MD's?

Judd

 

[billydoc]

Maybe has been covered before . . .

I'm starting to get to that point in med school when its time to think seriously about what I'm going to do. Psych is high on the list, but one issue (you know the issue) is giving me pause - psychologists.

My question is this one: What sorts of non-artificial barriers exist preventing a PhD or Psy-D, educated under today's standards, from subsuming the entire modern practice currently occupied by board certified psychiatrists? I am hoping VERY MUCH that the answer is not simply that they are untrained to prescribe. Is this the only barrier to the practice of psychiatry by non-MD's?

Judd

Hey juddson, I'm pretty sure that you also know about mid-level providers, i.e psych NPs and FNPs with psych cert who are prescribing left and right, and do billing on their own. And these are niether physicians, nor doctors in a more broader context of Ph.D or Psy.D. But I really doubted that the physicians (MD/DO) role could even remotely be threatened. All those professions are important, and some do a wonderful job, but general public will never stand for a substitute of wanting to a see a doctor (in general, clinical understanding i.e a physician). Also, nobody except physician can direct the medical profession of psychiatry, and it's subspecialties. I think it'll a bit of a stretch to see Jane Doe, Psych NP, medical director. None of the above, non-physician professions are allowed to practice medicine without a license. Of course, many things that they do overlap with what physicians do, but it's not the same, never had been, never will be, IMHO.

So go for it, and become active in your professional organizations to protect your turf.

Best of Luck

 

[50960]

I must chime in here. I think it is really sad that some in psychiatry/med school are worried that psychology expanding its role will ever usurp psychiatry. It is not going to happen. At the end of the day psychiatrists are better trained, and always will be to treat serious psychiatric illness. Psychologists are better trained to treat most garden variety psych problems, to do research, and to do objective testing and assessment. I am a psychologist trained to prescribe, and do alot of medication work in primary care, but I do not touch serious mental illness, with multiple medical comorbidities etc..., and neither should a psych NP.

 

[Anasazi23]

I think Psisci is right in some ways. Psychiatrist are better trained to do what they do (medical model evaluation and treatment), and psychologists are better for what they do (assessment and research).

The more I exist in the medical world, the more disparity I see between the "physician life and lifestyle" and that of other providers. They're just completely different ballgames.

 

[PsychMD2100]

Turf wars are nothing new. See anesthesiologists and CRNAs, ophthalmologists and optometrists, etc. There's no end to it. If anything, the allied health professionals have brought about a growth in all of the fields. Rather than threatening our position as physicians, they elevate it since only we can handle the truly challenging cases.

 

[whopper]

Psychologists will not be paid to do some of the things psychiatrists do by insurance companies.

In most states, only practicing physicians can commit patients, not psychologists, and usually its only a psychiatrist that can commit a patient.

In almost every state, psychologists cannot prescribe medications, and in the cases where they can, its only because of a severe shortage of psychiatrists available. Even when a psycologist can prescribe a med, its still preferable for a psychiatrist to do so.

IMHO, there is more to fear from TMS taking away business from psychiatrists than there is from psychologists. I got a feeling that if TMS is as good as people claim, hardly anyone will want a psychiatrist--except for the psychiatrist that flips that switch to turn on the TMS machine.

 

[juddson]

but I do not touch serious mental illness, with multiple medical comorbidities etc..., and neither should a psych NP.

I don't see why not. You are, after all, a "psychologist, trained to prescribe". They don't teach you about schizophrenia in graduate school? And if not, surely they could. No?

Judd

 

[50960]

Note the "with multiple medical comorbidities". Prescribing is not really the issue at all. Psychiatrists are not just trumped up psychologists who can prescribe meds; the training is completely different. Psychiatry had alot more to offer to severe mental illness than just knowing which AP to choose. My point for the OP is not to worry about psychologists like me or NP's etc... there will always be a need for psychiatry.

 

[whopper]

but I do not touch serious mental illness, with multiple medical comorbidities etc..., and neither should a psych NP.

I have a bachelors in psychology, and I'm a PGY-III psychiatry resident.

I have nothing against psychologists who prescribe meds, except that I do think they should only do so as psisci mentioned.

When you get your MD, and after you've done some work in internal medicine, you'll know what I'm talking about. Several psychaitric meds are harmful to the body. You need to have some medical knowledge. For example lithium can permanently ruin someone's kidneys, depakote can permanently ruin someone's liver, etc.

So let's pretend you got someone in the ICU, with multiple medical problems: congestive heart failure, mordibly obese, acute renal failure, hypertension just to name a few. Giving them an extra med can kill them. You need to know your internal medicine in these cases. While psychiatrists (in general) are not on the same par as internal medical doctors in this arena, they do have some training and do know how to interact with that IM doctor to see which meds can and can't be used if that patient has a psychiatric disorder.

Unfortunately, psychology and psychiatry have seem to have been pitted against each other, one of the reasons being psychologist being able to prescribe meds.

Psychologists know more in the areas they work in, psychiatrists know more in the areas we work in. If I were to ever have my own practice, I'd love to work with a psychologist, because I know there will be times where on a psychotherapeutic level, I won't know what to do, an the psychologist will be able to bail me out--and vice versa. These guys are our partners and we should be treating them that way.

As for the supposed war between us & them, if a state does try to give psychologists the ability to prescribe meds--a better question we psychaitrists should ask ourselves before we blow up in anger is---does that state have enough psychiatrists and is the anyone doing anything about it? Even in states where psychologists can prescribe meds, people still want the psychiatrist first and psychologists were given that power due to extreme need.

 

[juddson]

BTW, are their actual states where non-MD's/DO's can prescribe a full psychopharmacological formulary? Haloperidol is fine? Clozapine is fine? Medazolam is fine?

Judd

 

[TheWowEffect]

BTW, are their actual states where non-MD's/DO's can prescribe a full psychopharmacological formulary? Haloperidol is fine? Clozapine is fine? Medazolam is fine?

Judd

You are making it out to be too simplistic. Believe me, its not.

 

[billydoc]

BTW, are their actual states where non-MD's/DO's can prescribe a full psychopharmacological formulary? Haloperidol is fine? Clozapine is fine? Medazolam is fine?

Judd

The scope of practice and Rx privellege varies from State to State, but NPs are pretty much on their own with the above mentioned drugs. Sometimes there is chart review by physician involved, but it's usually "let's do lunch" kind of a thing from what I know.

 

[juddson]

You are making it out to be too simplistic. Believe me, its not.

In what sense am I making it out to be too simplistic? It seems to me that these drugs are serious meds, no? It seems to me that writing these drugs in a responsible manner would demand that one at least be able to bring to bear the whole of his medical education. Christ!! - we have boarded family practictioners and pediatricians scared to write SSRI's, but the psychologists and NP's have no qualms?!!?

I'm confused, no doubt. For what exactly am I going to medical school?

Judd

 

[Therapist4Chnge]

In what sense am I making it out to be too simplistic? It seems to me that these drugs are serious meds, no? It seems to me that writing these drugs in a responsible manner would demand that one at least be able to bring to bear the whole of his medical education. Christ!! - we have boarded family practictioners and pediatricians scared to write SSRI's, but the psychologists and NP's have no qualms?!!?

I'm confused, no doubt. For what exactly am I going to medical school?

Judd

*I don't want to side track this into an RxP privledges 'discussion', so I kept my comments as much away from that as possible*

I've talked to some rural FPs that run into this problem. Their referrals are 50-100 miles away, and it puts their pts in a bind to have to travel, see another provider, etc. I don't think prescribing psychs or NP's take their job any less seriously than the FP, and I think there is a middle ground for everyone involved.

I am in support of having a consulting relationship between MD/DO's, NPs, and prescribing psychs.....so a provider isn't left on an island. I think most people can run into problems if they don't have others to consult with. I think consultation shares information, keeps each other up to date with research/products, brings in another set of eyes to look at a case, etc.

Maybe with this setup, it would make the process more beneficial for all pts and providers involved.

-t

 

[juddson]

*I don't want to side track this into an RxP privledges 'discussion', so I kept my comments as much away from that as possible*

I've talked to some rural FPs that run into this problem. Their referrals are 50-100 miles away, and it puts their pts in a bind to have to travel, see another provider, etc. I don't think prescribing psychs or NP's take their job any less seriously than the FP, and I think there is a middle ground for everyone involved.

I am in support of having a consulting relationship between MD/DO's, NPs, and prescribing psychs.....so a provider isn't left on an island. I think most people can run into problems if they don't have others to consult with. I think consultation shares information, keeps each other up to date with research/products, brings in another set of eyes to look at a case, etc.

Maybe with this setup, it would make the process more beneficial for all pts and providers involved.

-t

I'm afraid I don't know what you are talking about. In what sense do you suppose that the average psychologists is more willing to set up a clinical practice in a rural area than a psychiatrist is?

Also, I'm not sure whether you are a psychologist or a psychiatrist (or neither) but have you seen the psychopharmacology training programs available to psychologists to get scripting rights? They all consist of 450 hours of biomedical training (ie., "medical science" and pharmacology training combined), most of which may be taken by correspondance over the computer or closed line. Then they must get supervised training and treat 100 patients (or about 100 hours of clinical psychpharm work). WTF!!!???

A physcian gets 1440 hours of medical/science training a year for two years (total 2880 hours of medical science training) followed by roughly twice that amount of time of clinical training with patients all while still in med school. Then, if he should choose psychiatry, he gets another (roughly) 8000 hours of clinical training in psychiatry, very much of which involves the acute and managed application of psychopharmacology. That's freaking 16,000 hours of medical science and clinical training. In that time the psychiatrist will have taken at least 4 national medical board examinations. The medical profession has determined that this is what is needed to make a physician safe. But the psychologists think they can do it with 450 hours of correspondance work.

Judd

 

[Therapist4Chnge]

I'm afraid I don't know what you are talking about. In what sense do you suppose that the average psychologists is more willing to set up a clinical practice in a rural area than a psychiatrist is?

I think there would be more opportunities for psychologists to setup a clinical practice in a rural setting. Medical psychologists are a very small minority, and I don't think they'd ever be a large portion of prescribers (compared to psychiatry, GPs, FPs), but I think they would increase coverage and availability.

Also, I'm not sure whether you are a psychologist or a psychiatrist (or neither) but have you seen the psychopharmacology training programs available to psychologists to get scripting rights? They all consist of 450 hours of biomedical training (ie., "medical science" and pharmacology training combined), most of which may be taken by correspondance over the computer or closed line. Then they must get supervised training and treat 100 patients (or about 100 hours of clinical psychpharm work). WTF!!!???

Clinical psych, though not licensed yet. As for the psychopharm stuff.....I am a supporter of the training (in general), but I share some of the same concerns you have. I feel much better about programs that are classroom based (this may be my own bias of learning better in a classroom setting. I haven't taken any classes online before, so that isn't something I can speak to)

As for the practicum experiences (you mentioned above)....I think there should be a higher requirement. I'm always in favor of more training hours, but I'm not sure what that # should be. There is also a 2 year (forget the hr req, varies by state) residency, working under the supervision of an MD/DO/prescribing psych. Once the classwork and residency hours are completed, the person needs to pass the national exam. In one of the states even after licensure, a certain % of cases (20?) still need to be shared, on a consulting basis with an MD/DO. I happen to like the consulting aspect (I mentioned this above), and though autonomy might be preferred by most, I think it is good to have that contact. I think this is a way to ensure that there can be consulting/collaboration as needed.

I think as other states pass prescribing psych laws, they will get more consistant with the particulars in training, etc. I think the current states that have the laws have shown that they work. I think that there can be a middle ground where everyone can be happy with the outcome, it is just going to take some time.

-t

 

[whopper]

Juddson, I'm sorry I can't be of more help on the spectrum of meds that psycholgists with prescribing power can give out. They do not have this power in NJ and I do not know how they'll handle it.

Another thing is several psychiatric meds have non psychiatric benefit--e.g. Depakote treats seizures, Topamax, though not approved for bipolar does have mood stabilizer benefit and is a seizure med.

You brought up a good question. I don't think though that we're going to get some good answers here unless we get a psychologist with prescribing power to discuss this in detail on this forum.

I though would not worry that psychologists will somehow steal our profession away from us. There's too many areas that psychiatry covers that psychology does not. Also, psychology getting the power to prescribe will vary from state to state and there's a shortage of psychiatrists, which is one of the problems giving more psychologists the power to prescribe.

 

[50960]

I addressed Judd's issue early on in this thread. In NM there is a limited formulary, but totally independent Rx rights after a period of supervision. In LA there is no formulary limitation, but all Rx's are supervised by a physician. I am an RxP trained psych, and I favor the LA alot more, and think other laws coming this year will likely be similar.

I would like to request we get away from the psychology prescribing debate, and address to OP's questions. I only brought it up as I feel RxP will not effect psychiatry at all. Myself, Anasazi23, and most members have no desire to return to the RxP debate again, and I am sure any such threads will be closed by the MOD.


psisci, psychology MOD

 

[gardilimo]

just some things that i have found interesting on the interview trail...

in WA state, before a patient is committed there has to be a legal third party involved to make the final decision. hence the MD does not make the final decision...NP's also have a very large role in doing everything that we do.

in DC, social workers can and will do the whole H&P and make the diagnoses on intakes. all you have to do is write the orders. that confused me.

at Hopkins they told me that in CA, psychologists can prescribe meds. i dont think CA has any shortage of psychiatrists...

@ Hopkins they also said how they did away with NP's in their psych dept because the NP's did not want to answer to the docs so instead they hired all PA's because they were assistants to the physician and therefore did not challenge them as much...


any thoughts?

 

[juddson]

in DC, social workers can and will do the whole H&P and make the diagnoses on intakes. all you have to do is write the orders. that confused me.

I can't see how this would be even remotely possible.

Judd

 

[Therapist4Chnge]

I can't see how this would be even remotely possible.

Judd

I was wondering that also.

-t

 

[PsychMD2100]

There's nothing to fear for MDs. Health care remains one of the fastest expanding sectors of the US economy. In a lot of ways, these allied health professionals do a lot toward taking care of a lot of the rudimentary cases that we're probably not that interested in seeing.

At the end of the day, people will want to see a psychiatrist for complex mental health problems. Similarly, if one of our family members had to undergo surgery, we would probably insist on an anesthesiologist rather than a nurse anesthetist. Our place is safe. Don't worry, be happy! 🙂

 

[whopper]

in DC, social workers can and will do the whole H&P and make the diagnoses on intakes. all you have to do is write the orders. that confused me.

It may be allowable under their local regulations.

I don't know those local regulations so I can't say its right or wrong.

I can though say that several of the social workers I worked with, after being on the psyche ward for long enough do get enough knowledge to be able to do an H&P minus the physical exam and plan, but I don't think a social worker is the ideal person to do one.

However I can also say that several psychiatrists I've seen have chesed out of doing proper physical exams. Some get a lazy approach and just admit someone and say everything is normal when in fact it is not, and ER doctors dumping psyche patients to the crisis center & giving a medically clear stamp when the patient really isn't medically stable happens a lot.

 

[gardilimo]

It may be allowable under their local regulations.

I don't know those local regulations so I can't say its right or wrong.

I can though say that several of the social workers I worked with, after being on the psyche ward for long enough do get enough knowledge to be able to do an H&P minus the physical exam and plan, but I don't think a social worker is the ideal person to do one.

However I can also say that several psychiatrists I've seen have chesed out of doing proper physical exams. Some get a lazy approach and just admit someone and say everything is normal when in fact it is not, and ER doctors dumping psyche patients to the crisis center & giving a medically clear stamp when the patient really isn't medically stable happens a lot.

sorry! they can do the H of the H&P and also the diagnoses. all you do is write the orders and do a physical.
yeah, it seems different per state (or district) as far as what auxiliary members can do. altho im sure a lot of those social workers are much more fit to be making those decisions than i will as an intern 😉

 

[whopper]

I hate saying it but I'd rather have the social worker doing the H.

Most attendings I've seen write terrible H&Ps. Residents write better ones. Social workers write even better ones.

These of course are generalities, but I think most of you know what I'm talking about. We all have the occasional attending that writes lame H&Ps but expect better from the residents.

 

[drmistga]

just some things that i have found interesting on the interview trail...

in WA state, before a patient is committed there has to be a legal third party involved to make the final decision. hence the MD does not make the final decision...NP's also have a very large role in doing everything that we do.

in DC, social workers can and will do the whole H&P and make the diagnoses on intakes. all you have to do is write the orders. that confused me.

at Hopkins they told me that in CA, psychologists can prescribe meds. i dont think CA has any shortage of psychiatrists...

@ Hopkins they also said how they did away with NP's in their psych dept because the NP's did not want to answer to the docs so instead they hired all PA's because they were assistants to the physician and therefore did not challenge them as much...


any thoughts?

Actually half of your info is completely wrong-

1. I did med school in DC at GW and also interviewed at 2 other places that do this-OSU being one of them-basically a social worker is on with a resident and when things get crazy busy the social worker sees patients alone and gets the history and formulates an idea and then discusses it with the resident and an MD writes the orders. The patient is not being seen and not discussed-and usually this is in an ED situation which to be honest is not hard to make a decision to either admit or not to admit-only a few criteria-is he/she Suicidal, homocidal? And that is about it as far as emergently admitting someone-some have softer admits but still not much to thinking. It is not like they are formulating the treatment plan.

Second in more hospitals than not, who are not residency training programs or do not have psych in the facility-social workers do the same thing all over the country-get a history and diagnosis and then contact and consult an outside psychiatist to come in and evalaute-again they are seen by a doc.

This only helps out residents when busy-for example OSU has a social worker on call with you all night for the very reason to help all night with intakes-doing all the social work stuff if it is managable and if it gets crazy helping see patients and get whoever is admittable in or out. This occurs in many cities and that is how it worked in DC

Second-read some info but cali has one of the highest shortages of psychiatrists in the country.

And as far as this post goes-my .04 on the issue. Personally there is such a shortage of psychiatrists that I do not even think having a bunch of psychologists and NP's will make a dent in our work. There are just too many patients and too few psychiatrists at every psych facility in most cities that it is out of control and most psychiatrists I know welcome the help.

Also you have to keep in mind that many of the psychologists, or good ones that do therapy are cash pay businesses and for them to jump into prescribing meds and getting paid by insurance for doing so is a huge paycut and waste of their time since they likely have a good therapy practice running that they are cash paying it-not all of them but a good chunk. Very few psychologists want to prescribe meds to be honest and that is a large reason of why they chose the therapy/psychologist track. So between all those reasons, I think they can only help the field and will never threaten it.

 

[50960]

Very true, and Ca. does not have an RxP law. It may have a limited one this year based upon a lawsuit that will probably settle out...

 

[Therapist4Chnge]

I thought that was a very informative post.

psisci...do you have a link for an update about that court case? I heard about it awhile ago, but haven't had a chance to read up on it.

-t