Meanwhile, we're lucky if we can get a partially qualified PA or CNS (or prescribing psychologist, Sazi?) to see the really sick patients in ERs and community clinics.
It's already happening in LA.
From a prescribing psychologist in LA (copied from Div 55 listserv):
"My experiences are very similar to Jim Q's experiences. My patient mix has
actually shifted as well. I am on medical staff at one LTAC that has two
campuses and another LTAC. In addition, I am the only psychologist on medical
staff at a free standing Rehab Hospital (30 beds) and on medical staff at two
general hospitals...both one with rehab unit and the other with both rehab and
psych units. At each of the above, I am the only neuropsych.
My prior patient load tended to be chronic pain, TBI, spinal cord injury, and
geriatric stroke. In addition, I tended to see consults in the general
hospital for general psych issues. Because the wait time, even in the hospitals,
is rather long for a psychiatry consult (and psychiatrists are not on staff in
some of the LTACs and Rehab Hospital), I started getting more and more med
management for patients with psych issues and more serious psych issues. I, too,
started getting more SMI patients in the general hosp. on the med-surg
floors and in private practice as more and more primary care physicians seek to
have someone help with the care of these patients. At the present time, the
psychiatric unit still requires (per hospital policy) a psychiatrist to be the
attending. However, I am working slowly but surely to get that changed. With a
20 bed psych unit and three psychiatrists admitting, there has definitely been
no problem keeping the unit at capacity...especially since there are
virtually no services available in New Orleans. The problem has been finding and
keeping nursing staff. We are in a severe shortage. So, there is no incentive at
this time to have psychologists as attending...its not a matter of filling
beds. While the psychiatrists are busy taking care of the psych patients on our
20 bed unit, I have been taking care of the patients in the rest of the 320
beds of the hospital.
In my experience, since being able to write prescriptions (Feb '06), I have
written approximately 500 including refills. My experience is also similar to
John Bolter's. I would say I have discontinued, reduced (simplified), or
"corrected" about half that many as well. The most frequent medication I have
prescribed has been Lexapro (in the hospital setting). I have prescribed some
atypical antipsychotics, several antidepressants, several benzos, on a couple of
occasions...mood stabilizers, antihypertensives (akathisia), hypnotics
(sleepers), and others. I have ordered lab work...including CBC, electrolytes,
lipid profiles, LFTs, testosterone level (geriatric men), urine drug screen, and I
have ordered speech therapy, EEG, X-ray, CT, and very recently MRI and other
stuff I may be forgetting now.
Having said some of the above, there are some caveats here. As soon as
psychologists are eligible to become attendings that will in all probability mean
that we will have to take "call." Since there are no other medical
psychologists on staff at the hospitals where I work, that will mean I will have to be in
the call rotation with the psychiatrists and their nurse practitioners. That
sounds great and like a huge step forward for psychologists. HOWEVER, that
means that I will then have to take any patient that comes through our
emergency room and needs psych care...REGARDLESS of ability to pay. In Louisiana,
psychologists are not reimbursed by MEDICAID and, of course, collect nothing on
"self-pay" (interpret "no-pay") patients. This has been the cry of physicians
for a long time. The must take these patients with all of the liability and
no reimbursement. For psychologists that will be even worse.
So, while I can control the amount of "pro bono" I do now, as soon as I begin
taking emergency room call, that control will be out of my hands.
As is typically the case, nothing is ever as simple as it sounds."