Current status of turf war with psychologists?

[PublicHealth]

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I don't think that there will be much of a "turf war", because most patients would prefer a doctor's expertise.

...and chiropractors, podiatrists, psychologists, and naturopaths are all DOCTORS in their respective professions.

Please don't belittle healthcare professions as subordinate if you do not know what they're about.

 

[50960]

And publichealth is back!!! Good points! 😉

 

[PsychEval]

There will always be some misinformed people who will see chiropracters for back pain, podiatrists for a broken foot, nurse practitioners for gyn exams, psychologists for meds, naturopedists for cancer, etc. But the vast majority of patients know that medical doctors are the experts in their field. Medical doctors will continue to preferably refer to medical doctors. I don't think that there will be much of a "turf war", because most patients would prefer a doctor's expertise.

In my experience, to say medical doctors will continue to preferably refer to medical doctors is not accurate. The hospital where I work, psychiatrists are rarely consulted by other physicians because they are not perceived as a viable referral source. In my department, psychiatry is only consulted for folks with bi polar I or psychosis. The psychologists receive 98% of the referrals. In fact, I have observed on several occasions OB/GYN attendings who are furious at psychiatry for not admitting a psych patient because of a small open wound. Consequently, the psych patient takes up a surgical bed. Then the OB/GYN’s complain at staff meeting, “surely a psychiatrist can manage a band aid and neosporin, they did go to medical school didn’t they?” Everyone laughs. So I am amazed when I read all the drama from psych on this forum, “We are real Doctors, the Captain of the Ship, what’s next, flight attendants trying to fly the airplane?” I agree patients prefer a doctor’s expertise, that is why patients see me, a Psychologist. Like many of the psychiatrists who have helped to train me, I love what psychiatry could be, but I am very disappointed in what psychiatry has become.

 

[Solideliquid]

I am trying to understand your mentality, without success. What would you change about the way psychiatrists work/interact with patients and other health care professionals?

 

[mdblue]

[/B]

In my experience, to say medical doctors will continue to preferably refer to medical doctors is not accurate. The hospital where I work, psychiatrists are rarely consulted by other physicians because they are not perceived as a viable referral source. In my department, psychiatry is only consulted for folks with bi polar I or psychosis. The psychologists receive 98% of the referrals. In fact, I have observed on several occasions OB/GYN attendings who are furious at psychiatry for not admitting a psych patient because of a small open wound. Consequently, the psych patient takes up a surgical bed. Then the OB/GYN’s complain at staff meeting, “surely a psychiatrist can manage a band aid and neosporin, they did go to medical school didn’t they?” Everyone laughs. So I am amazed when I read all the drama from psych on this forum, “We are real Doctors, the Captain of the Ship, what’s next, flight attendants trying to fly the airplane?” I agree patients prefer a doctor’s expertise, that is why patients see me, a Psychologist. Like many of the psychiatrists who have helped to train me, I love what psychiatry could be, but I am very disappointed in what psychiatry has become.

Sorry to hear about your disappointment.
I am sure there is a lot of turfing/burfing issue behind the refusal. Once I rotated thru a med-psych unit where all the psych attdg and nursing were comfortable in tx of extremely medically complicated pts. And I can not generalize this experience-it's an personal anecdote-just like the above post.
As I've mentioned earlier there was a lot of demedicalization of psych in 60/70. At one point psych residency training even abolished the internship. We are still carrying the legacy of those times, but fortunately things are changing rapidly from the training perspective. 🙂

 

[Anasazi23]

[/B]

In my experience, to say medical doctors will continue to preferably refer to medical doctors is not accurate.

It is in every single NYC area hospital I've worked in.

The hospital where I work, psychiatrists are rarely consulted by other physicians because they are not perceived as a viable referral source. In my department, psychiatry is only consulted for folks with bi polar I or psychosis.

We transfer 1-4 patients from psychiatry to medicine per month, and call many times more medical and surgical consults when we need it. In fact, we are the number one in-hospital referral source for medicine, and routinely refer to outpatient medicine upon discharge. I'm not sure that what you say is true at all.

The psychologists receive 98% of the referrals. In fact, I have observed on several occasions OB/GYN attendings who are furious at psychiatry for not admitting a psych patient because of a small open wound. Consequently, the psych patient takes up a surgical bed. Then the OB/GYN’s complain at staff meeting, “surely a psychiatrist can manage a band aid and neosporin, they did go to medical school didn’t they?” Everyone laughs.

Psychologists do what with the referrals? They cannot manage agitation, psychosis, severe anxiety, panic attacks, delirium or many of the other common hospital referrals. They must be seen by a psychiatrist - most often for medication or alteration of medical management. You can't talk someone out of an agitated psychotic break or delirium. If you say you can, then you have a lot of reading to do.

As far as not admitting the patient with the wrist lac: Did you check to see if there were psychiatry beds available? Did you check to ensure that the stay would be paid for by insurance (many will pay for medical management, not inpatient psych service, where they can be followed by C/L). Did the patient have concomitant medical conditions that precluded them from being admitted to the psych floor? Did they have a white count with a shift? Were there psych boarders in the ER without anticipated discharges? It's probably more complex than you or the OB doctor think.

So I am amazed when I read all the drama from psych on this forum, “We are real Doctors, the Captain of the Ship, what’s next, flight attendants trying to fly the airplane?” I agree patients prefer a doctor’s expertise, that is why patients see me, a Psychologist. Like many of the psychiatrists who have helped to train me, I love what psychiatry could be, but I am very disappointed in what psychiatry has become.

Psychiatry continues to develop new treatments, publish much relevant and useful research, and manage its patients effectively. Sorry about your disappointment. I can't say that psychiatrists are disappointed in psychologists...the topic doesn't even seem to come up.

 

[50960]

You are right Anasazi, psychiatrists do not need psychologists, it is all the other docs and mids that do. Most places I work would use a psychiatrist if they had one available, but do not. This is why the so called turf war is stupid. Psychologists are not trying, nor will they ever replace psychiatrists, we are simply filling in where you are not. To do this we need medical training of some flavor for sure. I think all psychologists should have a min of an RN level of science and medicine, and all who wish to work in medical settings quite abit more. This is my soapbox, much more than RxP.

 

[ProZackMI]

...and chiropractors, podiatrists, psychologists, and naturopaths are all DOCTORS in their respective professions.

Please don't belittle healthcare professions as subordinate if you do not know what they're about.

Well, chiropractic and naturopathic practitioners are questionable, but I agree that pharmacists, psychologists, podiatrists, dentists, and vets are DOCTORS.

Then again, one could argue, from a technical basis, that holders of PhDs in any field, EdDs, lawyers (with JDs), and clergy with doctorates in ministry/theology, are all "DOCTORS" too.

What really bothers about posts like this one, in general, is that so many physicians readily attack psychologists by citing to their non-medical backgrounds, yet have no problem with dentists, podiatrists, and <<<shudder>>> optometrists writing scripts, performing limited surgeries, and even serving on hospital staff rosters.

I really believe that doctorally prepared psychologists, who have also been trained in psychopharmacology, medical assessment, and other clinical procedures, and who are properly monitored, should have RxPs and hospital privis. Like it or not, managed health care has taken some power and prestige away from allopathic medicine and given some of it to other professions like psychology, optometry, and podiatry. Other professions have latched on to changes in medicine and the increase in pharmaceutical interventions and used these changes to advocate for expanded scopes of practice and educational changes (e.g., converting from a 5 year BS in pharmacy to a PharmD degree; changes in a BS or MS in PT to a professional DPT in physical therapy; converting from an MA in audiology to an AuD in audiology).

It's a changing world out there. NPs and PAs are encroaching into GP, IM, and pediatric practices. PTs and Chiros are trying to move into PM & R. PTs now want primary care status (bypassing MD/DO referrals). AuDs want to become like ODs (since there is a parallel) and garner RxPs and increased autonomy. ODs are encroaching into ophthalmology by looking into increased RxPs and surgical residencies/training. Midwives --> OB-GYN. CRNAs --> anesthesiology. Many PharmDs with post-doc residencies are collaborating with physicians in practices and many states like WA have created clinical pharmacist practitioners who can Rx under physician protocols. There are even PharmD-PA programs like the one at UWash.

Times are changing. As a younger physician, and psychiatrist, some of this scares me, but in general, I think things will work out in the long run. It'll be interesting to see where things change. It makes you wonder, though, if PhD/PsyD psychs get RxPs and eventually other medical privileges, will MSWs start filling in the void in psychometrics/long term therapy?

Everyone wants a piece of the pie. We sure live in interesting times! 🙂

 

[Anasazi23]

I see delerium cases quite often in a psychiatry department (so it's not because of lack of available psychiatrists). Most of the time it's because the referring physician is not sure what is going on, so they want a diagnostic evaluation to assist with differentials. I've diagnosed many inpatient deleriums.

With respect to panic attacks, there are several effective treatment options for clinical psychologists that reduce frequency of panic attacks and limit the development of agoraphobia. Again, there is a clear role for psychology here. Also, true with severe anxiety. Behavioral programs also help schizophrenics on daily living skills and other important issues.

I don't doubt any of this. But it doesn't fly when a beligerent, agitated delirious guy is tearing up the telemetry unit at 3 in the morning, or throwing a fan through the ER glass door (happened recently).

I'd be the first to refer to psychologists specializing in these types of interventions while I handled other parts of patient care...believe me.

 

[Hurricane]

Unfortunately, I'm very much in the 'real world.' What I see there is why I got out of psychology as a profession...I saw it being destroyed by itself. I'm afraid that as more and more psychologists bill themselves as mini-psychiatrists, that the severe problems they have with their own profession (unchecked overgrowth, low reimbursement, overwhelming feminization of the profession, and many others) will leach into psychiatry. That's something we can't afford.

Unchecked overgrowth and low reimbursement sound bad. But feminization? I'm guessing you didn't mean that women should leave psychiatry to the menfolk. So what do you mean exactly?

And what is the current male:female ratio in psychiatry anyway? I tried googling for it, and came up empty. At my institution, it appears to be male > female, but not overwhelmingly so.

 

[PublicHealth]

Unchecked overgrowth and low reimbursement sound bad. But feminization? I'm guessing you didn't mean that women should leave psychiatry to the menfolk. So what do you mean exactly?

And what is the current male:female ratio in psychiatry anyway? I tried googling for it, and came up empty. At my institution, it appears to be male > female, but not overwhelmingly so.

Feminization refers to clinical psychology, not psychiatry.

 

[Anasazi23]

Unchecked overgrowth and low reimbursement sound bad. But feminization? I'm guessing you didn't mean that women should leave psychiatry to the menfolk. So what do you mean exactly?

And what is the current male:female ratio in psychiatry anyway? I tried googling for it, and came up empty. At my institution, it appears to be male > female, but not overwhelmingly so.

Some articles to get you started (some scientific, some not):
http://www.nytimes.com/specials/women/nyt98/21caro.html
http://www.findarticles.com/p/articles/mi_qa3711/is_200111/ai_n9007774
http://www.apa.org/monitor/nov99/nl15.html
http://www.apa.org/monitor/feb01/facts.html

There was also an American psychological association task force report dealing with the feminization of psychology a few years ago, but I can't find a link.

 

[PublicHealth]

Some articles to get you started (some scientific, some not):
http://www.nytimes.com/specials/women/nyt98/21caro.html
http://www.findarticles.com/p/articles/mi_qa3711/is_200111/ai_n9007774
http://www.apa.org/monitor/nov99/nl15.html
http://www.apa.org/monitor/feb01/facts.html

There was also an American psychological association task force report dealing with the feminization of psychology a few years ago, but I can't find a link.

What about clinical neuropsychologists? I have a feeling that there is a fairly even, if not more male, representation in this subspecialty.

 

[ProZackMI]

What about clinical neuropsychologists? I have a feeling that there is a fairly even, if not more male, representation in this subspecialty.

I've never thought about that, but you're right. In Michigan, all but one of the neuropsychologists in the metro Detroit area, that I work with, are males. Good point!

 

[Anasazi23]

What about clinical neuropsychologists? I have a feeling that there is a fairly even, if not more male, representation in this subspecialty.

I remember having discussed this quite a while ago. I do believe that your statement is true, but is slowly changing as well - I think more as a function of women increasingly dominating the applicant pool of psychology in general than men seeking out neuropsychology in particular. I don't have any hard numbers though. I'm sure they're out there.

 

[Hurricane]

Some articles to get you started (some scientific, some not):
http://www.nytimes.com/specials/women/nyt98/21caro.html
http://www.findarticles.com/p/articles/mi_qa3711/is_200111/ai_n9007774
http://www.apa.org/monitor/nov99/nl15.html
http://www.apa.org/monitor/feb01/facts.html

There was also an American psychological association task force report dealing with the feminization of psychology a few years ago, but I can't find a link.

Thanks for the articles. Interesting reading. I'm still a little unclear on exactly what aspect of feminization you fear leaching into psychiatry though.

This, from the first article?

The difference in the training and methods of researchers and many therapists has grown so wide that psychologists now speak of the "researcher-practitioner gap."
<snip>
The feminization of psychology has been accompanied by the "feministization" of the field, which widened the researcher-practitioner gap. "Feminists brought an important critique of science to psychology," said Letitia Anne Peplau, a psychology professor at the University of California, Los Angeles, and a leading scholar in gender research. "They questioned its assumption of cool neutrality and identified its entrenched biases against women."

In some quarters, Dr. Peplau said, the criticism of science led to a rejection of scientific methods themselves, which were seen as male tools that oppress women.

(Just have to interject here: as a female soon-to-be MD/PhD, I find the notion of the scientific method as "male tools that oppress women" ridiculous!)

Or are you afraid of this, from second article:

It is interesting to note that just at a time when women now outnumber men in the academy, at least at the undergraduate level, there has been a concomitant reduction in the value of university degrees. We are familiar with the phenomenon that when women have attained a numerical majority in a field or discipline, the prestige of the occupation or field and the associated income declines (Eliasson, 1998; Touhey, 1974). Gaskell, McLaren, and Novogrodsky (1989) make the point that, in general, whatever females do tends to be devalued relative to whatever males do and this applies in the school system where courses and programs dominated by women are treated differently and seen as less prestigious than those dominated by men.

If it's the former, then I don't agree that an influx of women is necessarily the root of the problem. Rather, from the same article:

The researcher-therapist gap has been institutionalized by the rapid rise of free-standing schools of therapy not connected to university psychology departments. Graduates of these schools typically learn only to do therapy and seldom learn about other areas of psychology relevant to their work -- like the limitations of hypnosis, the fallibility of memory or the normal process of suggestion in therapy.

Another contribution to the scientific illiteracy of many therapists is the proliferation of certification programs in special methods. For example, therapists can take a six-day course in "heart-centered hynotherapy" or a two-day workshop in "thought field therapy." These programs appeal to therapists who are desperate to survive in a crowded market and whose livelihoods are being jeopardized by managed care.

That sounds like the problem is widely divergent training, not gender per se. Psychiatrists, on the other hand, must complete accredited residency training programs and pass standardized licensing exams. Maybe I'm just naive, but doesn't that ensure that all practicing psychiatrists have the same core training, which includes both clinical and research education?

If it's the latter... well, I'm not going to alter my career choice just because it dilutes the prestige for my male counterparts. 😉

 

[ProZackMI]

In my psychiatric residency, I was the only American born male. The majority of the residents in my cohort were female. In fact, I was surprised that so many of them were older and had been involved in other careers prior to medical school. I was one of the youngest in my group, which did consist of plenty of traditional post med school age people, but many of my cohort were in their late 30s, 40s, and a few in their 50s. My primary point, however, is that there were maybe 5 males in my group, and I was the only American born of the five.

At my medical school, there were more females than males. I'd guess maybe 60-40 (with 60 being female), but this is a rough estimate. My ex, who was in vet school, said the majority of her classmates were females. In law school, I'd guess there was close to a 50/50 split, but there were more females than I expected.

So, I wonder if that means medicine/law are becoming more "feminized"? If it does, I don't see this as being a bad thing. I never thought of clinical psychology as being feminized. Social work most definitely is, but clinical psychology I've always seen as being neutral and quite scientific. Of course, the Dr. Phil types excluded -- I don't consider those "pop self-help types", regardless of degree/training, to be included in the psychiatry/psychology debate.

 

[Miklos]

Psychologists have accredited programs, residencies, and fellowships as well. Plus, there is a generalized board (APPP) and specific specialty boards.

I (and I'm pretty certain that I'm not alone) take exception to the use of the word 'residency' with regard to training in psychology.

There is some quackery on the periphery of psychology (e.g., though field therapy). But, I think that's true in psychiatry as well.

Medical licensing boards (as well as malpractice lawsuits) seem to do a pretty good job (although far from perfect) of going after quacks. What does organized psychology do?

 

[Miklos]

I really believe that doctorally prepared psychologists, who have also been trained in psychopharmacology, medical assessment, and other clinical procedures, and who are properly monitored, should have RxPs and hospital privis. Like it or not, managed health care has taken some power and prestige away from allopathic medicine and given some of it to other professions like psychology, optometry, and podiatry. Other professions have latched on to changes in medicine and the increase in pharmaceutical interventions and used these changes to advocate for expanded scopes of practice and educational changes (e.g., converting from a 5 year BS in pharmacy to a PharmD degree; changes in a BS or MS in PT to a professional DPT in physical therapy; converting from an MA in audiology to an AuD in audiology).

It's a changing world out there. NPs and PAs are encroaching into GP, IM, and pediatric practices. PTs and Chiros are trying to move into PM & R. PTs now want primary care status (bypassing MD/DO referrals). AuDs want to become like ODs (since there is a parallel) and garner RxPs and increased autonomy. ODs are encroaching into ophthalmology by looking into increased RxPs and surgical residencies/training. Midwives --> OB-GYN. CRNAs --> anesthesiology. Many PharmDs with post-doc residencies are collaborating with physicians in practices and many states like WA have created clinical pharmacist practitioners who can Rx under physician protocols. There are even PharmD-PA programs like the one at UWash.

Times are changing. As a younger physician, and psychiatrist, some of this scares me, but in general, I think things will work out in the long run. It'll be interesting to see where things change. It makes you wonder, though, if PhD/PsyD psychs get RxPs and eventually other medical privileges, will MSWs start filling in the void in psychometrics/long term therapy?

Everyone wants a piece of the pie. We sure live in interesting times! 🙂

I don't think that managed care is the root cause of the problem.

I think that it boils down to a physician (or especially a psychiatrist) shortage. The folks (IMO) most responsible for that are the AMA. Thanks to their past 'successes' in restricting the number of allopathic medical students, market forces are simply responding to the problem.

 

[ProZackMI]

I don't think that managed care is the root cause of the problem.

I think that it boils down to a physician (or especially a psychiatrist) shortage. The folks (IMO) most responsible for that are the AMA. Thanks to their past 'successes' in restricting the number of allopathic medical students, market forces are simply responding to the problem.

Very true. Good point. Today, very few American-educated medical students enter psychiatry. It went from a very prestigious speciality to one of the lower rated ones. Many of my physician friends and colleagues tell me I don't really practice medicine, which of course, is incorrect. In MI, I would guess that the majority of psychiatrists are foreign-born and foreign-trained with US residencies.

 

[PublicHealth]

No insult was meant by use of the term; didn't really think about it. Call it an internship if you'd like. I only used the term because at the medical school I completed my clinical service, I was paid through the graduate medical education program on the PGY system and called a "resident". . . even got all the little medical resident perks offered. I'm still on that system for my fellowship, actually. I don't pretend to be a medical resident. I don't want to be a medical resident. You'd be surprised what my training entailed though. I'm sure you would have been sufficiently stimulated/challenged.

Where are you training?

 

[PsychEval]

It is in every single NYC area hospital I've worked in.


Psychologists do what with the referrals? They cannot manage agitation, psychosis, severe anxiety, panic attacks, delirium or many of the other common hospital referrals. They must be seen by a psychiatrist - most often for medication or alteration of medical management. You can't talk someone out of an agitated psychotic break or delirium. If you say you can, then you have a lot of reading to do.

Anasazi, You have more to offer than just your prescription pad.