Carlat and Overzealous Psychiatrists

[Sneezing]

The Carlat Psychiatry Blog doc just sided with the over zealous psychologists...

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[OldPsychDoc]

I made a new thread, since the link is not, per se, related to the thread Sneezing unfortunately resurrected. Play nice, or it will be closed.

 

[billypilgrim37]

I think he was debating between this post and one that he had written that said that surgeons should just go back to barber school.

Daniel Carlat, like most thoughtful, valuable writers, spends much of his time sounding like a genius, but sometimes sounds like a complete and utter *****. I think he usually runs about a 15:1 ratio. Better than me, by far.

 

[Red Beard]

I don't think his point is to side with psychologists. I think it is to point out that psychiatry is losing its identity and meaningful role in the mental health world by focusing more and more on psychopharmacology and ignoring matters of the mind, which are inseparable from mental health and illness.

The other day, I went back and reread the CATIE paper, which revealed among other things that antipsychotic compliance was a fair bit worse than we had typically speculated. About a quarter of subjects in the trial withdrew due to side effects, but a greater proportion withdrew due to "patient choice," which is pretty ambiguous. I can't help wondering more about this group. Assuming they weren't experiencing significant side effects, what could have been done to keep them in the trial? I think the answer lies somewhere in psychotherapy and the therapeutic relationship. Unfortunately, this seems to be paid short shrift, lip service, by many (not all) in the profession.

However, this stuff is the bread and butter of psychology. Setting aside Carlat's assumption that psychologist prescribing will pose no safety threat, his assertion that psychiatry would do well to reemphasize the importance of the mind, psychotherapy, the doctor-patient relationship, etc. in practice seems reasonable to me.

We are already well placed to offer the 'full package' but many of us aren't dong it. What Carlat is saying (I think) is that prescriptive rights for PhDs may force us to compete, which ultimately will get us back on track.

 

[masterofmonkeys]

I'm on the record as being ok with psychologists prescribing so long as they know their limits (medically complicated patients who might require the finesse of an MD's more global knowledge of pharm/phys). I think it's preferable to midlevels and PCPs for many of the same reasons that Carlat pointed out.

And, while this gets dangerously close to another thread, I think he raises a very important point about the corner psych has been painted into, partly due to external forces, and partly due to our willingness to go along with it.

I have no idea why 3 med management visits should get billed at a higher rate than 45 min of psychotherapy. The latter requires quite a bit more effort and expertise, IMO. And med management without psychotherapy for a plurality of psychiatric conditions is just silly. You'd never think of trying to manage someone's diabetes without at least trying to help them lose weight...

Don't get me wrong, I really enjoy psychopharm quite a bit, but when you get down to it, it's really quite a small part of overall mental health. I'm hoping that my research career, focused on exercise, nutrition, mindfulness, and other important aspects of self-care will serve to highlight this. But first I have to get that grant

But, one point where I'll break from Dr. Carlat is that I do think that psychiatry and psychology are different, if significantly overlapping, fields. Granted my point of view is a bit iconoclastic, but I very much see myself as a physician first and a psychiatrist second. I think about n6/n3 EFA ratios, GH release during stage IV sleep, cardiovascular reactivity, HPA axis, musculoskeletal integrity, etc, all the time when dealing with my patients. Mens sana in corpore sano and all that.

I do believe there needs to be a change in medical education to reflect the importance of mental health. You have to be living under a rock not to recognize how intertwined somatic and mental health are. And its common knowledge how much of psychiatric illness is attempted to be treated by PCPs. I also feel IM, peds, and FM need to rotate through psych. If they are going to treat these illnesses they need to get some real honest to god training in it. Not whatever excuse for a 3rd year clerkship they had.

Mental health is intrinsically linked to physical health and all physicians need to be able to address this. Whether it's a psychiatrist poring over an EKG to try to see if it was a panic attack or some form of SVT, or a physiatrist recognizing pain catastrophizing and cognitive distortions in a rehab patient, every physician needs to be at least somewhat competent in all aspects of health.

I am sick and tired of dealing with the wreckage of the failure of other medical professionals to recognize, let alone manage, the psychiatric influence on patients' perceptions of somatic disease.

 

[nancysinatra]

I also feel IM, peds, and FM need to rotate through psych.

I guess they could do consult or emergency months. But otherwise I don't really see the utility. As psych residents we don't do outpatient until our third years usually, and then it's my understanding that we follow the same patients throughout the year. So they wouldn't be welcome in outpatient. Having IM, peds and FM rotate through inpatient psychiatry like a psych intern would expose them to very sick psychotic patients, borderlines, manic patients, people with delusional disorder, etc--but that's not what they're treating in the real world. That stuff they will always just refer to psych. If anything I think we need to rotate more in their programs to see the more high-functioning, mild illness end of the depression/anxiety bell curve that doesn't get represented so much in psych training but that outpatient medicine doctors treat with SSRIs, etc. (I haven't done outpatient yet but I'm speculating based on some stuff I saw in outpatient medicine clinic).

As far as the article if someone wants to reform psychiatry training altogether fine--but where will the psychiatrists come from if not med school? A lot of us had other interests when we started out.

 

[whopper]

I said this before. I don't mind the idea of psychologists prescribing so long as they have the proper training. (I've stated why I thought the Oregon bill did not mandate proper training).

Proper training being something that's clearly defined, with evidenced-based data to support it, and it being replicatable.

So if they do get the proper training, well that's independent of Carlat's opinion. Carlat is opining that psychologists prescribing could be a good thing. I actually dont' think it's a bad idea if there's proper training.

In terms of turf, I don't see it taking away any of our business in a significant manner any more than a NP. Like I said, no problem so long as there's proper training. Again, I didn't think the Oregon Bill mandated enough training.

The other thread need not be resurrected here since Carlat's opinion and the Oregon bill are separate questions.

But to counter Carlat, he argues that in his opinion, psychiatrists focus too much on the psychopharm aspects of treatment. I find it interesting that his solution to make the problem better is giving others more psychopharmacology prescription power. The article is also written as if psychiatrists don't do psychotherapy. Several do, and several prorams are strong in their psychotherapy training.

In fact, I sometimes wonder about people wanting psychotropic prescription power because I often times see too many people wanting to throw a pill at the problem without addressing the other issues.

 

[michaelrack]

You'd never think of trying to manage someone's diabetes without at least trying to help them lose weight...
.

it happens more than you would think

 

[Doc Samson]

The article is also written as if psychiatrists don't do psychotherapy. Several do

Perhaps more than that

 

[Therapist4Chnge]

The article is also written as if psychiatrists don't do psychotherapy. Several do, and several programs are strong in their psychotherapy training.

They are still in the vast minority.

As for downplaying the med side of things....the general medical training DOES make a difference. I did a residential RxP program, and I think it would have benefited with moving more classes to pre-reqs, and focusing more on various systems and general medical conditions during the beginning of training. It would still be no replacement of med school or even a PA program, but I think it would help. I also believe the collaboration model is far better than independant prescribing, as it would fit in well with some of Carlat's points.

 

[whopper]

I also believe the collaboration model is far better than independant prescribing, as it would fit in well with some of Carlat's points.

I think there is an argument to be made that with medical doctor supervision, even the final say, the debate against level of training for psychologist prescribers is weakened.

I see no problems with someone who is psychopharm trained making suggestions on medications, especially if that person is not the person giving the final say on medications, and a medical doctor is observing the patient for signs of medical problems.

A medical doctor looking for side-effects and other medical related issues, well that takes years of intense training. E.g. Monitoring for lithium levels, especially in one with diabetes, or having a patient going on dialysis while on a few psychotropic medications, and then seeing their levels get screwed up due to dialysis, that's something that requires very intense medical education.

Which is why I backed a collaboration model. The argument, however, that someone with a mere fraction of the training a psychiatrist, being able to give out something like Clozaril, without intense medical training-weaker than that of an NP, now that's just foolhardy IMHO.

And countering Carlat's argument, why not then encourage more and better psychotherapy among psychiatrists, and more collaboration with psychologists?

 

[Therapist4Chnge]

And countering Carlat's argument, why not then encourage more and better psychotherapy among psychiatrists, and more collaboration with psychologists?

Because the economics don't make sense, and psychiatrists are able to practice psychotherapy even if they have little to no training in it. Whether or not that is ethical.....that's not my call.

 

[whopper]

I think the economics do make sense for an M.D. or D.O. to provide medications while the person gets psychotherapy from someone else. Psychotherapy does not require as much costs and the need and benefits from it are not worthy of debate since we are all of a level of training to know that it does work.

(Though I do think you're intelligent enough and probably have enough examples that counter my above statement).

I think the issues are inconvience (for the therapist), and lack of relationships with those on the other end of the treatment. Several places where I've worked, they don't want the prescriber giving psychotherapy for cost reasons, though someone else was able to provide psychotherapy, under the same roof. Other places don't provide that.

psychiatrists are able to practice psychotherapy even if they have little to no training in it.

BTW: by ACGME training guidelines, psychiatrists are required to have training in psychotherapy, though with the current industry guidelines, several may be out of practice with it.

 

[Anasazi23]

It seems clear that Carlat's near obsession with the profession's ties to the pharmaceutical industry have come full circle to the point of, in a sort of sad and ironic twist, ceding psychiatry to "collaboration" and "getting everyone in the same room" to paraphrase. This, in my eyes, is code for de-medicalizing psychiatry - something to which I'm vehemently opposed.

I had read his material less and less as he appears to relentlessly claim that psychotropics basically don't work, and the cynicism toward new developments in the psychopharmacology field were too much to take and frankly, became a drag. Now, I have even less reason to read it. I'll likely stop altogether at this point, as I've been finding it less useful.

 

[whopper]

as he appears to relentlessly claim that psychotropics basically don't work,

Yet he wants more people to give them out? That's some strange logic on his part.

IMHO, I actually like people giving opinions, based on empirical evidence, and that's what he does. Reason why is this type of debate is going to lead us in a direction that the empirical evidence does not cover. Empirical evidence, we need to use it, but it only covers so much.

But since Carlat is one of the few people that debate in this area, it can be a bully pulpit with a strong emphasis on the word "bully."

To do something that may not be right-because it'll help our profession? Hmm, do the ends justify the means?

 

[notdeadyet]

Having IM, peds and FM rotate through inpatient psychiatry like a psych intern would expose them to very sick psychotic patients, borderlines, manic patients, people with delusional disorder, etc--but that's not what they're treating in the real world.

I agree with you here, nancysinatra, but I'm with masterofmonkeys that it's pretty criminal that you can become board certified in Family Practice without doing a single rotation in Psychiatry, given that FP probably ends up treating more depression and anxiety than Psychiatry does. I think an outpatient rotation in a clinic-type environment should be a must.

 

[notdeadyet]

BTW: by ACGME training guidelines, psychiatrists are required to have training in psychotherapy, though with the current industry guidelines, several may be out of practice with it.

I've heard this before. Out of curiosity, what exactly is the ACGME training guideline? Is there an hour requirement? Not disputing your point, I'm just not clear how much psychotherapy training is actually prescribed by the ACGME.

 

[whopper]

http://www.acgme.org/acwebsite/rrc_400/400_prindex.asp

Check them out for yourself.

I wanted to add then when I stated I like to hear opinions based on empirical evidence, I should clarify that I mean opinions on areas that are outside the realm of what we currently know based on the empirical evidence, and not in dispute of the empirical evidence.

 

[notdeadyet]

http://www.acgme.org/acwebsite/rrc_400/400_prindex.asp

Check them out for yourself.

Interesting stuff. According to the Psychiatry Program Requirements listed by the ACGME here, there are no specific psychotherapy requirements.

The reqs require that programs utilize psychotherapy, but not how much or for how long. Theoretically, a hard core pharm program could get by with very little instruction or encouragement in psychotherapy. Good thing for us looking at programs to specifically evaluate when choosing.

 

[nancysinatra]

I agree with you here, nancysinatra, but I'm with masterofmonkeys that it's pretty criminal that you can become board certified in Family Practice without doing a single rotation in Psychiatry, given that FP probably ends up treating more depression and anxiety than Psychiatry does. I think an outpatient rotation in a clinic-type environment should be a must.

Oh I agree as well--I just wonder if our programs provide the appropriate environment.

 

[whopper]

It might not be fair to say there are no specific requirements, when there are requirements that it needs to be included in the curriculm.

e.g.

IV.A.5.a).(5).(c).(i) evaluation and treatment of ongoing
individual psychotherapy patients, some of
whom should be seen weekly under
supervision;

However, if you meant there no good guidelines, or there should be a requirement that all programs provide very good psychotherapy training, that'd be more accurate. While programs are required to include psychotherapy, how much psychotherapy they choose to put into the program--well that's a grey area--probably intentionally done. Several will choose to put more than others.

If you review most laws and regs, they leave a lot of things up in the air because they don't want to micromanage every program. Occurs in almost every field of education.

Some programs have plenty of good training in psychotherapy. Others, well under the current ACGME guidelines, they can get away with not much at all. Just like several colleges are better than others, because the current federal guidelines don't require specific minimums that'd otherwise shut several of them down (e.g. students must have minimum SAT score of 1200).

Some programs are definitely better than others.....

 

[snarfer]

It seems clear that Carlat's near obsession with the profession's ties to the pharmaceutical industry have come full circle to the point of, in a sort of sad and ironic twist, ceding psychiatry to "collaboration" and "getting everyone in the same room" to paraphrase. This, in my eyes, is code for de-medicalizing psychiatry - something to which I'm vehemently opposed.

I had read his material less and less as he appears to relentlessly claim that psychotropics basically don't work, and the cynicism toward new developments in the psychopharmacology field were too much to take and frankly, became a drag. Now, I have even less reason to read it. I'll likely stop altogether at this point, as I've been finding it less useful.

Great post.

I hope Carlat is not modelling after the Peter Breggin and Thomas Sasz of the world. These two produced minimial scientific research papers but became famous and made a pile of money by writting books and speaking against psychiatry based on their 'personal experiences' and self serving agenda.

I do CBT in 20% of my patients. In real life, the majority of patients prefer medicine over listening and talking an hour every week. All my CBTs patients are mildly ill and can probably be seen by LICSWs or PHd/PsyD. The rest came to me so severely ill that only medicines could help. And yes, even ECT and/or TMS.

 

[BobA]

I don't think his point is to side with psychologists. I think it is to point out that psychiatry is losing its identity and meaningful role in the mental health world by focusing more and more on psychopharmacology and ignoring matters of the mind, which are inseparable from mental health and illness.

The other day, I went back and reread the CATIE paper, which revealed among other things that antipsychotic compliance was a fair bit worse than we had typically speculated. About a quarter of subjects in the trial withdrew due to side effects, but a greater proportion withdrew due to "patient choice," which is pretty ambiguous. I can't help wondering more about this group. Assuming they weren't experiencing significant side effects, what could have been done to keep them in the trial? I think the answer lies somewhere in psychotherapy and the therapeutic relationship. Unfortunately, this seems to be paid short shrift, lip service, by many (not all) in the profession.

However, this stuff is the bread and butter of psychology. Setting aside Carlat's assumption that psychologist prescribing will pose no safety threat, his assertion that psychiatry would do well to reemphasize the importance of the mind, psychotherapy, the doctor-patient relationship, etc. in practice seems reasonable to me.

We are already well placed to offer the 'full package' but many of us aren't dong it. What Carlat is saying (I think) is that prescriptive rights for PhDs may force us to compete, which ultimately will get us back on track.

Two responses to your post:
(1) I don't think psychotherapy would help much with compliance.

Have you ever undergone serious psychotherapy?

I'm actually doing twice weekly therapy as part of my residency training (therapist offers cut rate, insurance helps, I pay the rest), and it's TOUGH to keep looking at the truth about myself all the time!

Even as a relatively mentally healthy person, it's exhausting to keep lifting the layers of psychological defenses day after day, hour after hour. It's hard work, and I often think about giving up. It'd certainly be a lot easier than trying to see the truth and change, and be happy with that.

Then again, I'm undergoing psychotherapy more for "life enhancement" than for help with a diagnosed psych illness.

(2) I'm all for psychiatrists understanding the importance of psychotherapy, and especially recognizing it as standard-of-care for many mild psychiatric presentations. But if they're going to extend prescribing rights to PhD's, they better charge those PhD's huge licensing fees and use that money to pay off my med school debt. Many PhD's, remember actually get PAID to get their degrees!

 

[OldPsychDoc]

Two responses to your post:
(1) I don't think psychotherapy would help much with compliance.


......

From what you say in your post, you are undergoing some psychodynamically-based, insight-oriented therapy. This is one of many psychotherapies. No single type of therapy fits all situations. Therapies such as motivational interviewing and life skills training are useful in addressing issues such as med compliance.

 

[BobA]

From what you say in your post, you are undergoing some psychodynamically-based, insight-oriented therapy. This is one of many psychotherapies. No single type of therapy fits all situations. Therapies such as motivational interviewing and life skills training are useful in addressing issues such as med compliance.

Point well taken.

 

[Therapist4Chnge]

I do CBT in 20% of my patients. In real life, the majority of patients prefer medicine over listening and talking an hour every week. All my CBTs patients are mildly ill and can probably be seen by LICSWs or PHd/PsyD. The rest came to me so severely ill that only medicines could help. And yes, even ECT and/or TMS.

While I agree with you that if someone is floridly psychotic that medication is the only thing that will work until they are stabilized, but short of that there are definitely more options. OPD correctly differentiated on the type of talk therapy. In many cases your "severely ill" are in the most need of some type of talk therapy intervention. I've seen it often in the ED, though the agitated pts. just get shipped off/out, particularly when they start to add up.

My earlier comment about psychotherapy training during psychiatry residency ("..able to practice psychotherapy even if they have little to no training in it) was in reference to knowing more than the very basics of CBT or Psychodynamic Therapy, etc. Some residency programs are teaching things like motivational interviewing, but most don't.

*real MI, not a quick 1hr lecture on it. The majority of MI training I've seen has been pretty poorly implemented, and is no doubt less effective when the resident tries to use it.

 

[whopper]

I think it is to point out that psychiatry is losing its identity and meaningful role in the mental health world by focusing more and more on psychopharmacology and ignoring matters of the mind, which are inseparable from mental health and illness.

While I saw that point in his article, I doubt even Carlat, if he thoroughly examined the Oregon bill would've agreed there was enough training provided in it to the psychologist-prescribers.

Which is why I have a big problem with his op-ed. As I've said before, several time, I don't have problems with psychologists prescribing, so long as the training is adequate.

Opinions are like bung-holes. Everyone has one. People, especially one in Carlat's position, should thoroughly research the issue before they broadcast their opinion. Just like people in a newspaper will spout off how they hate the not guilty by reason of insanity plea is used by so many criminals, without actually knowing how the process works, well I suspect Carlat did the same thing in his opinion.

Its the same reason why mental health professionals aren't supposed to give their opinion on celebrity's mental health simply based on 10 second sound bytes. Having your M.D. stamped on your opinion misleads people to think that the opinion is well thought out and well researched.

As we've seen with the VT-Tech killer, so many professionals diagnosed him with schizophrenia, yet none of them actually examined him.

 

[Daniel Carlat]

While I saw that point in his article, I doubt even Carlat, if he thoroughly examined the Oregon bill would've agreed there was enough training provided in it to the psychologist-prescribers.

I'm glad my post helped get a good discussion going. My understanding is that the Oregon law requires psychologists to have completed a standard PhD or PsyD program (usually 5 to 7 years), then complete an APA accredited masters in psychopharmacology (two years) and then complete an 18 month residency, with a series of requiremens including inpatient work, outpatient work, work with specific diagnostic groups, etc....

Is this enough to become a safe prescriber of a limited formulary of psychiatric meds? Probably so. We have a fairly impressive record of psychologists prescribing safely, through the DoD program, the New Mexico program and the Louisiana program. Obviously safety surveillance systems are suboptimal in all of medicine, and reports of adverse events are entirely voluntary. But there have been about 200,000 prescriptions written by psychologists thus far. If a psychologist made a stupid error causing a patient's death, it seems highly unlikely that such an event would not have been reported, given the politicized nature of the issue. When a patient dies or becomes extremely ill, many people other than the psychologist and the patient find out--including many doctors, both outpatient and inpatient, hospital administrators, often the malpractice insurance company. Each of these entities would likely report the event to the medical board, and you can bet that such an event would receive exhuberant coverage in all the psychiatric newspapers.

Thus, the scare tactics employed by my well-intentioned psychiatric colleagues have always been unconvincing. They typically involve a hypothetical patient who gets Stevens Johson Syndrome and an equally hypothetical bumbling medical psychologists who fails to recognize it. One can spin all kinds of other similar nightmare scenarios, but they are fictional.

At any rate, my main interest is not in winning prescription privileges for psychologists, but rather in reforming psychiatric training. What has become painfully obvious to me over my years of practicing and writing is that most of the medical school curriculum is not relevant to what I do on a day to day basis. Screening for medical conditions, recognizing potential drug drug interactions, knowing when to order Li levels and thyroid levels, etc..., do not require 4 years of medical school. They require focused course work in disease recognition and triage, pharmacology, neuroscience, biochemistry, and physiology. We can learn these things much more efficiently in a program dedicated to teaching mental health practitioners how to treat patients. And we can learn a lot about psychotherapy to boot.

 

[whopper]

My understanding is that the Oregon law requires psychologists to have completed a standard PhD or PsyD program (usually 5 to 7 years), then complete an APA accredited masters in psychopharmacology (two years) and then complete an 18 month residency, with a series of requiremens including inpatient work, outpatient work, work with specific diagnostic groups, etc....

This issue was argued in another thread, but since you brought in better data for the bill, I will respond.

Doctor, what empirical data do you have that this will be safe?

You cited the DOD bill, as I've written before, that bill is often used to back the safety of psychologist prescribers, but the specifics are not the same as the Oregon bill. In fact, the DOD study, while showing some positive aspects to psychologist presribers, was not the proof-positive those that support the practice often claim it to be. There were some negative issues with psychologist prescribers from that study.

Psychologists first obtained prescriptive privileges in the military through the Department of Defense demonstration project, and since then have been awarded privileges in both New Mexico (2002) and Louisiana (2004). The lengths of the training programs vary, though they are typically two year programs incorporating both didactics and a clinical practicum. Many have charged that these two year mini-programs cannot possible produce safe prescribers. But the evidence contradicts this position. There have been no adverse events reported in any of the programs operating thus far.

The above paragraph is from your blog.

There have been no adverse events from the statement above. Where is the evidence so we can examine this for ourselves? Several times in our debates over this issue, no one was able to provide any data to support this other than the claim, and even if this is true, how large is the pool of data? 10 prescribers? 100? 1000?

Would you be willing to say that psychologist prescribers under the Oregon guidelines will be trained to appropriately prescribe clozapine, lithium, depakote, propranolol?

And, how much of this in essence, experimental? E.g. the only study I've seen cited is the DOD study, which is different in several ways to the Oregon bill. Wouldn't it be safer to do a trial run over this under more similar guidelines?

As for several of the psychotropics such as antipsychotics, these require the use of labs to monitor a patient's metabolic status. Do you believe the Oregon bill provides enough training to interpret lab results? I'm not just talking lithium level. I'm talking reading a CBC, BMP, and then looking at the creatinine and BUN levels.

Do you believe the clinical curriculum is appropriate? Some have described the clinical training in psychologist prescriber programs as on the order simply shadowing a medical doctor.

Is this enough to become a safe prescriber of a limited formulary of psychiatric meds? Probably so.

Are you willing to put your name to support a bill on the grounds of "probably so"? What empirical data is this based on?

As you've probably read, I do not have a problem with psychologists prescribing if properly trained, but I do have a problem with people citing safety, but giving me no data to support that safety. In the thread that was previously closed, this was not provided, and most times I asked for it, I was given a response to the effect of "how sad, all you want to do is protect your turf."

Thus, the scare tactics employed by my well-intentioned psychiatric colleagues have always been unconvincing. They typically involve a hypothetical patient who gets Stevens Johson Syndrome and an equally hypothetical bumbling medical psychologists who fails to recognize it. One can spin all kinds of other similar nightmare scenarios, but they are fictional.

I'd hardly call Stevens Johnson Syndrome (SJS) a scare tactic when in fact I've seen several patients get a rash on Lamictal, indicating there was a risk for SJS. Or the several patients I've seen get hyperammonemia on Depakote, thyroid problems on lithium, etc. There are warnings on FDA labels for these problems for a reason.

Yes--the risks of these occurring are rare, when viewed in the spectrum of 1 person. When you treat over 100 people, as will be the case in a real life practice, the risks of at least a handful of your patients getting the rare medical side-effects that can lead to a potentially dangerous problem shift from the unlikely to the very likely.


No, I cannot support a practice unless I see some data showing it can be done safely. If someone were to present data, good data, then my mind may be changed.

(Assuming you are truly Carlat) I've read your opinions for some time and I respect the work you do, and I'm expecting better than personal attacks which I've received from the previous defenders of psychologist prescribers.

 

[loveoforganic]

What's the experimental set up for determining something like this, other than unleashing them and looking at outcomes? That seems to be pretty much what they're doing with CRNA's as well.

 

[whopper]

What's the experimental set up for determining something like this, other than unleashing them and looking at outcomes?

That's the problem I'm having.

There's several things that would assuage my fears.

M.D. or D.O. oversight. I have no problems with a psychologist recommending medications to a medical doctor, even if it's not a psychiatrist, so long as an M.D. is overlooking the process. It also creates a clear line of responsibility over who is medically responsible.

But that's not what's going on in the Oregon bill.

IMHO, to support something like this requires some actual data for us to examine under similar situations. No data? Then I'm going to ask for it. If I'm not provided it, then I'm going to ask--why is it not being provided over something that is a very important issue? Why not then obtain some data before one pushes for something where lives can be at stake?

That's where I'm at now.

One issue I didn't address:

At any rate, my main interest is not in winning prescription privileges for psychologists, but rather in reforming psychiatric training.

Very much agree there, but I don't think psychologists prescribing is going to lead to that reformation.

What has become painfully obvious to me over my years of practicing and writing is that most of the medical school curriculum is not relevant to what I do on a day to day basis. Screening for medical conditions, recognizing potential drug drug interactions, knowing when to order Li levels and thyroid levels, etc..., do not require 4 years of medical school

I disagree there. In my one year as an attending, I've had several medical issues occur in my patients where I had to detect the problem first. E.g. in one case an Ob-Gyn doctor was telling me the patient was not pregnant, when in fact the patient was pregnant, and I was able to prove it by ordering seriail serum quantitative B-hcg tests. I had another patient with normal pressure hydrocephalus, but everyone was labelling her as psychotic. As I've mentioned, these things are rare if you look at just 1 patient, but in the context of real-life practice, where you have several patients, the odds of this occurring shift to likely occurring in at least some of your patients. Some contexts much more than others.

In C&L psychiatry, your medical knowledge will come into play, in inpatient or ER psychiatry, you will often catch medical problems the ER doctor missed, sometimes to the point where the patient should've been put on a medical floor instead of a psychiatric unit. In residency, while I did my ER rotations, this was on the order of occurring about once a week.

The only field of medicine where I felt was very overkill for psychiatry was surgery which is still needed for proper medical training. IM, pediatrics, ob-gyn, primary care, I've had several cases where having knowledge in these fields saved the day in my psychiatric practice.

 

[nancysinatra]

I had another patient with normal pressure hydrocephalus, but everyone was labelling her as psychotic.

The NPH case is a good example. The way I learned NPH in medical school was that you expected the triad of gait changes, dementia and urinary incontinence. However if I'm not mistaken you can actually see NPH without actual incontinence, and just with urgency. So some NPH patients are going to be mistriaged to psych, it would seem like. I honestly don't think I would consider NPH routinely if I hadn't rotated through neuro in med school. If you're going to take medical training out of psychiatry, you better perfect the triaging system then. That applies to all causes of dementia or psychosis, not to mention depression and mania--there better not be a single mistriaged case again in America because without psychiatrists who know enough medicine to know when to be suspicious, we sure won't recognize those cases. Perhaps no more delirium consults in the ER either, and no more detox admissions. Those cases are medically at least somewhat sophisticated. (I.e. those are cases where I've had to debate at times with other services over where the admission goes, or where I've needed input from them.)

Also--wow--if we didn't do med school we then couldn't do any intern year medicine, neuro or peds. We psych interns would be even less able to handle medical emergencies that arise on the floors or during call. Wow. Believe me, when chest pain or acute one sided weakness occurs on the psych floor, I'm always glad for what little medical knowledge I have! I guess attendings farther out in practice forget that psych patients have medical problems, and that interns and residents are often faced with them when they're on the inpatient unit. And often alone. Just this year I've had rapid GI bleeding, a stroke, and transfers to everywhere from ENT to the MICU. Sometimes without my personal advocacy for these transfers (which were urgent)--they wouldn't have happened.

Also, we call a lot of consults. Being able to talk to other services is important.

 

[Daniel Carlat]

The NPH case is a good example. The way I learned NPH in medical school was that you expected the triad of gait changes, dementia and urinary incontinence. However if I'm not mistaken you can actually see NPH without actual incontinence, and just with urgency. So some NPH patients are going to be mistriaged to psych, it would seem like.

I've worked in many different inpatient units, and I well remember that during residency there is a culture of the resident wanting to keep up his or her medical skills and aggressively pursue diagnosis and treatment of neurological and medical diseases. After residency, most inpatient units function very differently. Admission physical exams are often done by internal medicine as a consult. If there is a hint of medical problem, the attending requests a consult to properly diagnose the condition and start treatment.

Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.

Nonetheless, I see a continued role for medical school for an increasingly narrowly defined role, that might be termed a Neuropsychiatrist. In the current issue of Psychiatric Times, Ron Pies in fact argues that psychiatry and neurology should be merged. That would be fine with me, but it will then absolutely require us to create another profession. I don't even know what you'd call it. Maybe doctors of mental health, or medical psychologists, or pharmacopsychotherapists--the point is that these are people who are experts at understanding psychological symptoms, and treating these symptoms with all the tools available--medication and therapy.

 

[whopper]

After residency, most inpatient units function very differently. Admission physical exams are often done by internal medicine as a consult. If there is a hint of medical problem, the attending requests a consult to properly diagnose the condition and start treatment.

Some places also require the psychiatrist to also do a physical examination, which IMHO is not a bad idea, even if one is of the opinion that the IM or ER doctor should do it.

1) Psychiatrists, from a mental health perspective can look for different physical signs from patients.

E.g. scars on the wrist, cigarette burn marks, poor dentition, hepatomegaly, mees lines, hand shaking (sometimes seen in ADHD), Kayser-Fleischer rings....

2) From my own experience, ER doctors had to "medically clear" the patient, yet despite this, I often times found something very worrisome. The reality of the situation is ER doctors by training are looking for somewhere to put the patient. If they see a psychiatric issue, they often direct their further investigations to push that patient into psychiatry.

As much as I can complain about turfing, after talking to several ER doctors, I'm more understanding of their position. They have to evaluate a patient, and have limited time to make a decision, where the psychiatrist has much more time to evaluate the situation and find problems that may have been missed.

But, whether you want to blame ER doctors or not, the bottom line is several get turfed to psychiatry that still have very troublesome medical problems. As I mentioned before, on the order of once a week, I'd have to go to the ER doctor and tell them a problem they missed that was to the degree where it warranted the patient go to the medical floor. E.g. patient who attempted suicide by jumping off the 4th floor of a building with 2 broken legs, a punctured lung, BP of 230/130 mixed with a headache, delirium due to hyperammonemia (dx'd as psychosis), etc.

3) At least where I did training, as well as in several hospitals, IM doctors don't want to be consulted simply for a physical exam, or a minor issue that they feel is a waste of their time. As one IM doctor told me, to do a consult, when the only thing wrong with the patient was a slightly high blood pressure, he felt that should've been in handled by the psychiatrist. In my opinion he's right. Psychiatric patients are at much higher risk for a medical disorder than the general public.

Dr. Carlat, I understand you may want to reform psychiatry, and I agree with that stance. I agree that psychotherapy is a valuable tool in treating patients. I also believe that with proper training, psychologists should be able to prescribe. The Oregon Bill IMHO is not proper training, nor would allowing psychologists to prescribe, in my opinion would help reform psychiatry.

In my opinion, more psychotherapy requirements in the ACGME guidelines, more psychotherapy-based questions on the board exam, and encouraged collaboration between psychotherapists and medical doctors is a better approach. Managed care and both APAs should also encourage a collaboration model.

As for psychotherapy, I encourage it whenever I can, but I completely admit, I leave it to others on occasion. Why? Market forces--but market forces that are reducing the bottom line, which in effect makes health care more affordable for everyone. I, for example, had several borderline personality disorder patients, where I referred them for DBT. Knowledge of that disorder of course is helpful because it allows me to communicate with the psychotherapist, and I know what's going and the progress. In terms of cost-effectiveness, it does end up costing the system less. It's a personal pet-peeve of mine to see several psychiatrists misdiagnose people because they cannot pharmacologically treat it. Borderline personality disorder and dissociative disorders, for example, I often see misdiagnosed for bipolar or psychosis, then improperly treated by a psychiatrist that refuses to see otherwise because they don't know how to psychotherapeutically treat borderline or dissociation.

 

[OldPsychDoc]

....Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.
....

Delighted to have you contributing, Dr. Carlat--I've been an admirer for some time--which makes it all the more surprising to read the apparent inconsistency in the paragraph above--am I to understand that although you see a psychologist as fully qualifiable to prescribe psychotropics such as valproate, lithium, and clozapine, you would not trust a physician-psychiatrist to manage a statin or hypertension meds?

 

[nancysinatra]

I've worked in many different inpatient units, and I well remember that during residency there is a culture of the resident wanting to keep up his or her medical skills and aggressively pursue diagnosis and treatment of neurological and medical diseases. After residency, most inpatient units function very differently. Admission physical exams are often done by internal medicine as a consult. If there is a hint of medical problem, the attending requests a consult to properly diagnose the condition and start treatment.

Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.

Nonetheless, I see a continued role for medical school for an increasingly narrowly defined role, that might be termed a Neuropsychiatrist. In the current issue of Psychiatric Times, Ron Pies in fact argues that psychiatry and neurology should be merged. That would be fine with me, but it will then absolutely require us to create another profession. I don't even know what you'd call it. Maybe doctors of mental health, or medical psychologists, or pharmacopsychotherapists--the point is that these are people who are experts at understanding psychological symptoms, and treating these symptoms with all the tools available--medication and therapy.

If a major change occurred such as what you are mentioning, what would then replace the residency portion of training? Also who would take care of those inpatients who are now being taken care of by psych residents? Those medical problems will still arise. It seems to me that either you need someone one the floor who knows both enough psychiatry and medicine to help out with both problems, or you need two people. At least I can't see how you could leave the inpatients without medical coverage of some sort.

I think the idea of neurology and psychiatry merging is very interesting--but how could neurology get by without medicine training? They treat acute stroke patients, as well as neuro ICU patients. They also overlap with neurosurgery. Plus they do LPs every day, and treat infectious illnesses such as meningitis... You'd have to cut out most of neurology to make the argument that you can merge these fields and then separate us all from the rest of medicine and surgery. Even just to understand neurology it seems to me essential to do all of anatomy (to understand the peripheral nervous system) plus histology, pathology, microbiology, and radiology. That's most of the first 2 years of med school right there. In the 2nd two years they are learning the things needed to treat stroke patients, etc. Regardless of the needs of psychiatry, neurology definitely requires antihypertensive and other knowledge! I didn't see the article in the Psychiatric Times but I don't see how you could cut away neurology from the rest of medicine without being extremely creative.

 

[Daniel Carlat]

I think the idea of neurology and psychiatry merging is very interesting--but how could neurology get by without medicine training?

The proposal is not to take neurologists out of medical school, but to have neurology and psychiatry merge. A Neuropsychiatrist would indeed go through the standard medical training--the 2 years of didactics, all the clinical rotations--and then do a 3 or 4 year neuropsychiatry residency. Neuropsychiatrists would be experts at a variety of neuropsychiatric diagnostic procedures and would presumably know how to treat the full range of neurological and psychiatric diseases, primarily through biological modalities.

The inpatient units might be staffed by neuropsychiatrists. The Doctors of Mental Health would not go to medical school, but would receive plenty of training in psychiatric diagnosis and psychopharmacology and therapy treatment.

 

[Daniel Carlat]

am I to understand that although you see a psychologist as fully qualifiable to prescribe psychotropics such as valproate, lithium, and clozapine, you would not trust a physician-psychiatrist to manage a statin or hypertension meds?

Well, let's not mix up terms here. I don't believe a psychologist should prescribe anything without proper psychopharm training. So, no, I do not consider a psychologist fully qualified to prescribe anything. However, after a two year masters in psychopharm and a year or two of residency, I would consider a medical psychologist qualified to prescribe from a formulary of psychotropics. Whether that formulary includes depakote and clozapine depends on how good I believe the training is.

But let's not confuse prescribing skills with the practice of medicine. I prescribe lots of clozapine in my practice. Here's how. I order a baseline CBC, then prescribe clozapine, beginning at 25 mg BID and ramping up gradually from there. I make sure the patient is enrolled in the monitoring program and follow the WBC. I compare the weekly WBC to the baseline and to the printed guidelines. As long as the WBC does not plummet, I continue clozapine. I also monitor the patients lipids periodically. If the lipids rise, I might switch meds, or if clozapine is working spectacularly, I would call the PCP and ask him or her to decide if the patient can go on a lipid lowering agent so that we can continue the clozapine.

I know many would look at this scenario and say, "hey, how can you possibly do all this medical work without going to med school?" Sorry, but I disagree. Ordering labs and following them, and calling a PCP for treatment of a medical illness, does not require 4 years of medical school. What it does require is excellent coursework in how to prescribe antipsychotics, how to keep track of lab data, and how to interpret labs when they are off. And, of course, what to do when the labs go awry. To those who say that this is equivalent to the practice of medicine, I disagree. The practice of medicine involves being in charge of the treatment of diseases for which we understand the underlying pathophysiology. Thus, a cardiologist understands the pathophysiology of heart disease, and based on that understanding, deploys a range of treatments to target the known defects.

We do not do this in psychiatry, because we do not yet understand the underlying pathophysiology of the diseases we treat. We diagnose based on symptoms clusters and we choose medications and therapy via a matching process.

Some will look at this description and accuse me of being "anti-psychiatry" or of demeaning my profession. Absolutely wrong. We are doing the best we can given the complexity of the human brain. And by using DSM symptom clusters and matching treatments to such clusters, we are extremely helpful to many patients. But in my view, the essential task of psychiatry is fundamentally different from the rest of medicine.

When we dabble in medicine--that is, when we order the standard lab screen and neuroimaging studies--we do so (with a few exceptions) in order to rule out a medical illness which we will not be treating when we discover it.

Again, I am describing the way that, IMHO, the vast majority of psychiatrists actually work in their practices. In these discussions, I hear from psychiatrists who maintain that they use all their medical knowledge for all their patients, everytime they prescribe everything, etc.... All the power to them. These would be the doctors who would end up going into neuropsychiatry, and there will certainly always be a place for them. But for vast majority of patients who seek psychiatric help, the key skills that we offer are psychological and psychopharmacological, and not medical.

 

[billypilgrim37]

Hi Dr Carlat,

1) It seems I could replace "psychiatry" with "orthopedic surgery," "physiatry," "ophthalmology," "radiology," etc, change a few other words, and make the same arguments with ease: That a good portion of the work done in many (if not most) non-IM subspecialties has nothing to do with large chunks of what we endure in medical school.

2) If we assume (and I believe this is a relatively fair assumption) that the reason psychiatrists don't do therapy is a) because reimbursement favors pharmacotherapy, and b) outside of major metropolitan areas, the demand for med management is so high that a psychiatrist doing therapy means that pts who need med management have less access, and c) residencies have responded by emphasizing biology according to the incentives in a) and b), then what does your proposed solution offer over the current model? It seems your solution addresses the wrong problem.

Thanks!

 

[Daniel Carlat]

Hi Dr Carlat,

1) It seems I could replace "psychiatry" with "orthopedic surgery," "physiatry," "ophthalmology," "radiology," etc, change a few other words, and make the same arguments with ease: That a good portion of the work done in many (if not most) non-IM subspecialties has nothing to do with large chunks of what we endure in medical school.

I see your point--but I disagree, because in each of the specialties you mention, the core function entails an understanding of pathophysiology of a biological disease entity. Orthopedic surgeons must learn pathophysiology of bones and joints in order to treat patients. Physiatrists, the physiology of muscles. Ophthomologists, the physiology of the eye and brain. Radiology, the pathophysiology of just about every disease. Psychiatry is the only medical specialty lacking an understanding of the pathophysiology of the diseases it treats, and therefore the only specialty for whom medical school is inappropriate.

 

[whopper]

All the power to them. These would be the doctors who would end up going into neuropsychiatry, and there will certainly always be a place for them.

What about those that intend to keep using their medical knowledge and knowledge of psychotherapy?

There is almost always a place for psychotherapy, even in non-psychiatric medical fields. Creating a new field with the goal of steering a physician away from the psychotherapeutic, and more to the physiological could encourage even less emphasis on psychotherapy.

As for my previous posts, I don't feel you addressed some of the issues. I understand that you don't have a problem with psychologists prescribing, and I don't either under the right conditions. A specific issue, however, is the Oregon bill...

Do you support that bill? Your op-ed didn't specifically say you supported it, though within the context of the entire article, it seems you do.

 

[Daniel Carlat]

What about those that intend to keep using their medical knowledge and knowledge of psychotherapy?

There is almost always a place for psychotherapy, even in non-psychiatric medical fields. Creating a new field with the goal of steering a physician away from the psychotherapeutic, and more to the physiological could encourage even less emphasis on psychotherapy.

You're right that all specialties use psychotherapy though they may not label it such. "Neuropsychiatrists" would use plenty, and might call it alliance building, or advice giving, or supportive therapy, etc.... These are also the techniques typically used by those psychiatrists who consider themselves to be primarily psychopharmacologists.

 

[Daniel Carlat]

As for my previous posts, I don't feel you addressed some of the issues. I understand that you don't have a problem with psychologists prescribing, and I don't either under the right conditions. A specific issue, however, is the Oregon bill...

Do you support that bill? Your op-ed didn't specifically say you supported it, though within the context of the entire article, it seems you do.

Yes, I support the bill. I believe that the training required is sufficient, especially with the 18 month residency and the requirement of ongoing collaboration with physicians.

I sympathize with your concern about wanting to ensure safety. Some have likened allowing psychologists to prescribe to introducing a new drug without adequate safety testing. I don't agree with the analogy. We're not talking about a new medication, but rather about well trained professionals using a limited formulary of well established medications after 31/2 years of psychopharm training on top of 5 to 7 years of training in diagnosis of psychiatric disorders. In addition, they are required to collaborate with a physician for their entire career.

Can I be absolutely certain that no psychologists will make mistakes? Of course not, just as I can't be sure that psychiatrists won't make mistakes. But as long as there is a medical board providing oversight, I feel comfortable with the system.

 

[Faebinder]

I think the true influence behind these bills that give psychologists prescription rights are the pharm companies who want more sales (even though people claim no influence on the Oregan bill). I think they are foolish and beating a dead horse as many of the psych drug seekers are ready to sue when experiencing side effects they didnt expect from meds they didnt need to begin with.

Will it improve psychiatry overall? Maybe. Maybe we'll see more TMS/ECT and psychosurgeries.. more clozaril. More therapy. Who knows what modalities will be forced to evolve.

 

[worriedwell]

I'm excited about this thread, as it has some legitimate discourse rather than defensiveness and I'm pleased that Dr. Carlat is actually willing, as a psychiatrist, to take a stand on the issue for other practicioners prescribing.

I actually think the safety argument lacks strength, and one in which NPs and PAs successfully deal with all the time and I don't think (although it is true I don't have the data specifically) that will ever be the problem with the proper training.

I do have concerns about further marginalization of mental health, and lack of "power" to do research on actually learning about and understanding the underlying pathophysiology without the institution of medicine involved. There is also something about the ethic of being a medical doctor that I find important and reassuring when it comes to those in charge of working with mental illness (but I'm biased as an M.D). I think medicalization has had major downsides for progress in many instances in mental health care, but I'm not sure the solution then is just to abandon the medical model for mental illness for the majority of the profession. Not to mention the great upside it has had as well.

To say that psychiatry should be separate from other fields simply because we don't understand why our medicine works, but only that it works in many cases, is in my opinion (and with all due respect) a silly argument.

There are hundreds of examples of medical doctors doing things that either a) in hindsight was stupid (like bloodletting), or b) in hindsight we now know why they work and have refined the techniques further.

The discussion within psychiatry, in my opinion, should focus on why we have driven it so far into the biological model of causality without sufficient evidence, rather than how we can remove medical doctors from helping people with mental problems.

Also, there is a whole pool of bright and talented people who go into medicine to be a "doctor" and be all that this title means to them. Many of the best and brightest psychiatrists don't choose psychiatry prior to medical school, but rather find a great mentor or a very rewarding experience and see the merits of psychotherapy, and then decide on psychiatry. Many of those same people would rather be shot than be an inpatient psychiatrist for various reasons that I'd be happy to elaborate on. So with your neuropsychiatrist model, those people would essentially only have that option after medical training, and this would be unfortunate. There is a long history of "career changers" in medicine from other fields (even surgical ones) to psychiatry who are really some of the absolute best.

But then again, I don't know that any of the arguments can trump strong economic and access pressures, so I think psychologist prescribing is an inevitability. In fact, I think it can only help me as an MD who has a fee for service practice of 45 minute sessions where I do combined treatment. Many people will view my training as higher level than others just based on my type of degree and will preferentially go to me. So I'm not going to lose sleep over it personally.

 

[whopper]

Dr. thank you for the reply, and your responses have been much better than the others on this forum who defended the practice of psychologists prescribing.

Here is a copy of one of the Oregon bills, not the specific one that passed.

http://www.leg.state.or.us/09reg/measures/hb2700.dir/hb2702.intro.html

(c) Has completed, in no less than 12 months and no more than
24 months, an integrated, supervised clinical experience of at
least 250 hours, including differential diagnosis and applied
pharmacological management of patients congruent with the
specialty role sought;

At least 250 hours. I found that very irresponsible. 250 hrs as you know is about 3-5 weeks of residency training. I think we'd all agree that 250 hours is not enough, even if it's spread over a year. Worse, the guidelines for training are very vague, much more than ACGME requirements.

Now in fairness, the above bill is not the one that actually passed, this is the one....
http://www.leg.state.or.us/bills_laws/concepts/sen/SB1046.pdf

Nowhere in that bill do I see a minimum on the amount of hours for clinical training.

As you are well aware, if psychologist prescribers are not given a specific curriculum in a clinical setting, it could very well be education on the order of an elective, where the person simply shadows a doctor, while in a daydream, and does not do much. (You know what I'm talking about!) Compare that to an ACGME residency where residents are required to carry patients and treat them under supervision.

And this section concerning collaboration between a psychologist and a "health care professional."

SECTION 7. (1) The Oregon Medical Board, with the concurrence of the State Board of
Psychologist Examiners, shall adopt rules requiring a prescribing psychologist to maintain
an ongoing collaboration with the health care professional who oversees a patient's medical
care to ensure that:
(a) Necessary medical examinations are conducted;
(b) The prescribed drug is appropriate for the patient's medical condition; and
(c) The prescribing psychologist and the health care professional discuss, in a timely
manner, any significant changes in the patient's medical or psychological condition.
(2) The prescribing psychologist and the health care professional shall each document the
collaboration under subsection (1) of this section in the clinical records of the patient.

The "health care professional" does not have the final say. Psychologist prescribers can still give out medications, even against the advise of the "health care professional."

Why not simply have the "health care professional" be the one that gives out the prescription, while the psychologist can give recommendations concerning psychotropic medications?

As for the "limited formulary", as far as I know this formulary hasn't been specified yet. Correct me if I'm wrong.

I'm excited about this thread, as it has some legitimate discourse rather than defensiveness and I'm pleased that Dr. Carlat is actually willing, as a psychiatrist, to take a stand on the issue for other practicioners prescribing.

As am I. Dr. Carlat's responses have been far more informed, respectable, and worthy of consideration vs. the other psychologist prescriber defenders who, well, just gave out personal attacks.


My recommendations....
1) A medical professional should have the final say on prescriptions, not psychologists under the current training guidelines I've seen in the Oregon bill.
2) Psychologist prescribers should be given a curriculum on the order of an ACGME approved residency if they are going to prescribe. I don't think it may be fair to consider their training on the order of a "residency" given what I've read (250 hours? No way.)
3) The formulary should be spelled out.

 

[whopper]

So I'm not going to lose sleep over it personally.

I don't see the psychologists prescribers as hurting my ability to make money, or take away my patients, at least while I intend to practice. Maybe decades down the road....but by then I'll be out of practice.

In fact, this was the only point brought up by the previous defenders of psychologist prescribers that I felt had some merit. There will be several psychiatrists who will fight this as a turf-war, though I'm not in that crowd, and everytime I asked for some data, I was not provided with any, and only accused of fighting a turf war.

In the few areas where it was approved, the numbers of psychologist prescribers have been small (which actually just points out that if there truly weren't any adverse outcomes, a small sample size is not much data to back it's safety), and I suspect those prescribers wouldn't even give out some of the hard-core meds I'd be worried about such as Depakote or Clozaril.

The reason why I chose to debate this issue is because from a legal perspective, I see several issues with the Oregon law, and these are issues that can lead to medical problems for patients. Does it directly affect me? No, but on an educational level, with medstudents and residents on this board, much of the data being given out was misleading. I felt I had to retort.

I figure that Dr. Carlat and I actually agree on more than we disagree, and in my own opinion, psychiatric training in general does not teach several things that are important in mental health treatment. I know this because I do have a degree in psychology. However, likewise, all my reviews on the issue of psychologist prescriber show to me that at least in the Oregon bill, they may lack training over medical knowledge needed to prescribe.

(edit--repeated a paragraph above).

I haven't read the specific bills in Louisiana or New Mexico, but I have heard in those states, the medical doctor has the final say. I'm much more comfortable in that type of situation, then one where a psychologist prescriber must collaborate with a health care professional, but can still prescribe if in disagreement.

 

[Daniel Carlat]

To say that psychiatry should be separate from other fields simply because we don't understand why our medicine works, but only that it works in many cases, is in my opinion (and with all due respect) a silly argument.

There are hundreds of examples of medical doctors doing things that either a) in hindsight was stupid (like bloodletting), or b) in hindsight we now know why they work and have refined the techniques further.

I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."

I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.

I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.

If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.

 

[Daniel Carlat]

In fact, this was the only point brought up by the previous defenders of psychologist prescribers that I felt had some merit. There will be several psychiatrists who will fight this as a turf-war, though I'm not in that crowd, and everytime I asked for some data, I was not provided with any, and only accused of fighting a turf war.

In the few areas where it was approved, the numbers of psychologist prescribers have been small (which actually just points out that if there truly weren't any adverse outcomes, a small sample size is not much data to back it's safety), and I suspect those prescribers wouldn't even give out some of the hard-core meds I'd be worried about such as Depakote or Clozaril.

Whopper--I think you're right about medical psychologists actually not representing a huge turf threat. I've heard through the grapevine that in Louisiana, it is a non-issue because there is so much business to go around.

But there are a number of safety issues outstanding that haven't been answered entirely to my satisfaction. Like where did the figure "200,000" subscriptions come from. How many subscriptions and patient visits have there actually been? What exactly is the supervisory system in Louisiana and NM? What kind of surveillance system is set up in those states, and does it differ from the surveillance of psychiatrists' practices? How is the medical board involved in those states? Which drugs are on the psychologists formulary and how is that decided?

If anyone out there knows the answers please enlighten us!

 

[whopper]

Dr. Carlat,

Based on your posts, especially your last one, I feel you have represented yourself very well.

I still believe that the Oregon bill does not provide enough specifics, but you intelligently brought forth your argument, and did not resort to personal attacks. You weren't involved in the thread where the debate occurred, but I felt it devolved to the point where the thread should've been shut down.

I also highly respect that you are asking for more data. That's something that I think anyone, no matter what side you are on, should ask for in this issue.

I think if I continue, I will just be repeating myself.

A personal story, a psychologist I came to know in N.J. was working on his nurse practitioner's degree so he could prescribe psychotropic medication. He wanted to work with a psychiatrist in private practice who could double check his cases. He asked me to fulfill that role. I would've been more than happy to do so (unfortunately I moved, and I have no plans to move back to N.J. at this time). He was a good clinician, and I would've been proud to work with him.