How do you feel about Psychologist prescription privileges?

[WisNeuro]

That's just the thing, we can come up with plenty of assumptions, but with no data to back anything up, those are just assumptions. What's the base rate of certain complications with existing providers? Does it differ depending on background (NP vs PA vs MD vs DO, etc)? Most of these we don't know, we just assume. This is an inherent problem in the healthcare system as a whole, and highlights the need for advocacy in healthcare outcomes research at all levels. Is the care we deliver effective, and can it be delivered at a similar level of effectiveness at a lower cost?

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[Ceke2002]

The obvious route is to give air traffic controllers prescribing privileges.

"TTC 110 Heavy, understand you're declaring an emergency, turn left heading 220, cleared to land on any runway. Ativan authorisation code being sent through now."

"TTC 110 Heavy, Ativan unsuitable at this time, request Haldol, repeat, request Haldol."

"TTC 110 Heavy, understand you're requesting Haldol. Keep left heading 220, Ativan authorisation code has been cancelled, resending authorisation for Haldol, still cleared to land any runway."

And now I really want to hear a conversation between IM and Psychiatry that actually sounds like this.

 

[deleted343839]

No. I have no desire to practice medicine. If that desire changes... well, I live within driving distance of a few medical schools.

I think there are certain contained systems (the military springs to mind) where a well integrated psychologist could do first-line prescribing under a protocol in a very cost-effective manner. Likewise, I think most psychologists could offer even more than NPs if they were the front line providers in, say, a stepped care program for depression within an integrated healthcare system. But in general, out there in the private practice world? I think it's a terrible idea and would further splinter the profession.

 

[nitemagi]

That's just the thing, we can come up with plenty of assumptions, but with no data to back anything up, those are just assumptions. What's the base rate of certain complications with existing providers? Does it differ depending on background (NP vs PA vs MD vs DO, etc)? Most of these we don't know, we just assume. This is an inherent problem in the healthcare system as a whole, and highlights the need for advocacy in healthcare outcomes research at all levels. Is the care we deliver effective, and can it be delivered at a similar level of effectiveness at a lower cost?

This is a rehash of everything in the RxP sticky.

The Institute of Medicine has clear data and conclusions. Less training = more errors and problems. Furthermore the DoD training program said the trainees topped off at the level of 3rd year med students.

This is real data but the RxP choose to ignore data for the sake of their agenda.

 

[WisNeuro]

Can you post the IOM data? I have not seen any objective data to this point yet, only subjective things.

 

[nitemagi]

Can you post the IOM data? I have not seen any objective data to this point yet, only subjective things.

There are IOM reports going back over a decade showing more medical errors for those with less training. They have a public website.

 

[WisNeuro]

I'm aware of IOM, and have read countless IOM articles, I'm just interested in the objective data that is being purported here, because it's not one that I've seen. If anything, I've seen many reviews that NP's and PA's have ADE error rates comparable to other prescribers.

 

[notdeadyet]

There are IOM reports going back over a decade showing more medical errors for those with less training. They have a public website.

I've seen this too, but the studies I've seen are typically comparing training level within a training path. Third year medicine residents make fewer medical errors than interns.

Have they looked specifically at NPs/PAs/RxPhDs committing more medical errors than MD counterparts for comparable tasks? That'd be great ammo for those against encroachment of MD scope or practice.

But if they haven't studied this, to say that the IOM has "clear data and conclusions" about NPs/PAs/RxPhDs vs. MDs is inaccurate. If they haven't studied it, they haven't studied it.

I hope they have or will. The data would sure be interesting.

 

[birchswing]

Almost every practice that accepts insurance has one in my area.

That's interesting.

I've been to a lot of outpatient practices with psychiatrists/psychologists and never come across one with a NP, either of the general or psych variety. A number of PCP offices have NPs, though. I wonder if the offices around here don't have psych NPs out of custom or lack of psych NPs. Given that many psychiatrists aren't taking new patients, it's not due to lack of need.

 

[nitemagi]

I've seen this too, but the studies I've seen are typically comparing training level within a training path. Third year medicine residents make fewer medical errors than interns.

Yes. While this isn't directly MD vs. RxP data, there's no evidence that LESS medical training leads to less errors, which is what RxPs have -- less training.

IOM data is specifically correlating training hours to errors. I've read many RxP proponents say there's no reason to think X number of hours is essential to reduce errors or create a good standard. Well actually, there is.

The GAO did their own review of the DoD RxP program and found it wasn't cost effective. http://www.gao.gov/archive/1997/he97083.pdf
The American College of Neuropsychopharmacology did an independent review and found the RxP's functioned well when directly supervised by a psychiatrist (which NO state RxP programs involved, rather having them supervised by PCPs with their advanced psychopharm knowledge), and that they had the experience of a third year med student.
Volume 6, Number 3 - American College of ...

Considering most state programs have far less training than even the DoD program, far less supervision by non-specialists, it's unclear on what basis they can claim any level of safety or efficacy.

That's the data I have on the prior programs. To my knowledge no other studies have been done on the existing programs, though I did review the New Mexico RxPs and nearly all are in urban areas (therefore not fulfilling their claimed goal of rural coverage).

 

[TexasPhysician]

That's just the thing, we can come up with plenty of assumptions, but with no data to back anything up, those are just assumptions. What's the base rate of certain complications with existing providers? Does it differ depending on background (NP vs PA vs MD vs DO, etc)? Most of these we don't know, we just assume. This is an inherent problem in the healthcare system as a whole, and highlights the need for advocacy in healthcare outcomes research at all levels. Is the care we deliver effective, and can it be delivered at a similar level of effectiveness at a lower cost?

There is no data to support that psychiatrists have better results than electricians at treating anything. Why not them too?

We should be asking "where is the data to support prescribing psychologists"?

The data is about equal to electricians. It is completely insufficient.

 

[westlaker]

There is science and there is common sense. We don't need to find a study or studies to support the hypothesis or idea that elementary teachers do know more than their students, do we?

 

[westlaker]

Knowing what to prescribe is easy, knowing how to identify a rare side effect requires extensive training. It takes a lot of practice to know what is normal before you are able to see the abnormal.

I always tell my medical students, being trained as a physician means you are always looking for and be prepared for the zebra. Let the NP/PA/(you fill the blank) take care of the horses. Well, at least true in most of the academic hospitals

 

[DD214_DOC]

I think until psychiatry as a field starts holding accountable those within our ranks who practice completely silly and irrational things, it's quite difficult for us to reasonably criticize the clinical acumen of others.

 

[WisNeuro]

There is no data to support that psychiatrists have better results than electricians at treating anything. Why not them too?

We should be asking "where is the data to support prescribing psychologists"?

The data is about equal to electricians. It is completely insufficient.

It's more about changing goalposts to some arbitrary standard. If you can't point to an empirical standard of what is sufficient in terms of training, you're simply picking guidelines out of the air because it's "kind of" worked before. And that way you can protect your turf without really having to do anything to prove superior efficacy. Your field isn't alone in that, we've had our own battles with mid-level encroachment, and I think if we want to take a firm stance, we have to actually prove that our expertise leads to differences in efficacy and outcomes from an empirical perspective.

 

[nitemagi]

It's more about changing goalposts to some arbitrary standard. If you can't point to an empirical standard of what is sufficient in terms of training, you're simply picking guidelines out of the air because it's "kind of" worked before. And that way you can protect your turf without really having to do anything to prove superior efficacy. Your field isn't alone in that, we've had our own battles with mid-level encroachment, and I think if we want to take a firm stance, we have to actually prove that our expertise leads to differences in efficacy and outcomes from an empirical perspective.

It only became arbitrary when non-physicians called it arbitrary. Before that we called it a GOLD STANDARD.

 

[WisNeuro]

A gold standard based on what, exactly?

 

[nitemagi]

A gold standard based on what, exactly?

Do some research on gold standard.
Then read about standard of care.

In the progression of the field you do not first have to prove that the standard of care is good enough. You prove that the new intervention is comparable to the standard.

RxP has no data to show that. The burden of proof isn't on me, it's on you.

 

[WisNeuro]

I've published on gold standards before, quite familiar with the concept. There is already plenty of data suggesting that alternative methods of training (PA, NP) lead to similar outcomes in clinical studies, suggesting that the gold/silver/bronze standard isn't all that shiny and immutable. I'm a firm believer that the onus is on providers to prove their worth in this overpriced marketplace, rather than sitting back complacent with our arbitrary standards of what we think is the only way to reach adequacy. Otherwise we're just being lazy and making people suffer for our meaningless turf wars. And yes, that extends to my profession as well. It's why we've funded a sizable research grant to fund clinical outcomes research within several of our large orgs.

 

[Therapist4Chnge]

While I support it in theory, if not in current practice, I would not be likely to pursue it if it made it's way to my state. At the places I've worked, prescribers are almost solely med management, and that's not how I want to spend my day.

I support it in theory, but the training requirements need to be improved. I want more clinical/supervision hours and I want a truly collaborative model for prescribing, not the loosy-goosy approach that happens w. most NP setups (in non-ind prescribing states). I completed the training a number of yrs ago at a residentially-based program, completed the clinicia practica w an excellent mentor, and still wanted (and needed) more supervision and training to feel comfortable. I pursued the training to inform my research efforts, though I definitely see the value in the clinical side of my work.

I believe there will be a lot of pressure for ppl to prescribe FT, which really takes away from our primary skill sets. I still support the idea of psychologists prescribing, but there needs to be some changes in the training and some discussion within our profession about the best way to utilize the training in conjunction w our other skill sets and not in place of them.

 

[nitemagi]

I've published on gold standards before, quite familiar with the concept. There is already plenty of data suggesting that alternative methods of training (PA, NP) lead to similar outcomes in clinical studies, suggesting that the gold/silver/bronze standard isn't all that shiny and immutable. I'm a firm believer that the onus is on providers to prove their worth in this overpriced marketplace, rather than sitting back complacent with our arbitrary standards of what we think is the only way to reach adequacy. Otherwise we're just being lazy and making people suffer for our meaningless turf wars. And yes, that extends to my profession as well. It's why we've funded a sizable research grant to fund clinical outcomes research within several of our large orgs.

And yet conveniently no outcomes research on RxP.

 

[Extralong]

I have so many concerns for psychologists prescribing meds.
I think that if they want to prescribe, they should become a PA or an NP or go to medical school. There is no substitution in proper training. Medications interact with other medications, can cause metabolic disturbances, hormone irregularities, etc. This is only understood by not only studying the material but seeing the gross form of it during training and knowing how to catch medical issues.
Also there is a reason why we have entrance exams for PA, NP, or medical school. To make sure you not only can manage the material, but willing to place the effort in studying all of it. Taking to time to study and take the entrance exam, and interview for schools, puts some stake in what your doing. If you spend most of your time becoming a non-medical provider, thats what you decided to do, and if you want to become a medical provider, go through it just like the rest of us prescribing medication that can alter body chemistry and have medical side effects.

 

[notdeadyet]

We should be asking "where is the data to support prescribing psychologists"?.

yes, this I agree with. And the little data I've seen from the DoD study was not promising (and that program had much more robust training than what most proposals have for prescribing psychologists).

I just disagree with taking data about outcomes comparing junior doctors and senior doctors and generalizing it to non-MDs.

Sure, it's good horse sense, but it's not science.


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[TexasPhysician]

It's more about changing goalposts to some arbitrary standard. If you can't point to an empirical standard of what is sufficient in terms of training, you're simply picking guidelines out of the air because it's "kind of" worked before.

There were no studies performed by RxP demonstrating benefit of themselves. DoD studies have shown that complications increase with less education. What more is needed?

Just because RxP created themselves doesn't justify it.

Comparing RxP to a FDA approval process. I could invent snorting certain spiders as a treatment for the flu. As there are no studies demonstrating it to be false, it should be approved.

 

[WisNeuro]

I understand the fear of doing outcomes research as an excuse for the indolent attitude towards the subject, really. It's easier to fight the turf war when you never define the justification for the bar or what constitutes adequacy. I'm talking more about the idea that prescibing privileges do not require "going to med school" as an arbitrary metric. We've already seen that NP's and PA's, to some extent, seem to be able to do it just fine from the little research that exists. The sky has not fallen in NM and LA. I think you guys should be more worried about holing up your turf fort and letting others do the outcomes research, rather than taking the lead on it.

 

[deleted343839]

There were no studies performed by RxP demonstrating benefit of themselves.

Based on what I've seen, the RxP movement is dominated by people who are probably incapable of designing a solid clinical trial. The profession is really much more divided on the RxP issue than those on the outside seem to think.

I have so many concerns for psychologists prescribing meds. I think that if they want to prescribe, they should become a PA or an NP or go to medical school.

A few years back the American Psychological Association published a profile of a psychologist who became a nurse practitioner in order to expand his scope of practice in a rural community. This seems like a reasonable alternative to the RxP model.

 

[TexasPhysician]

I'm talking more about the idea that prescibing privileges do not require "going to med school" as an arbitrary metric. We've already seen that NP's and PA's, to some extent

Glad to know we do things randomly...

And the data is clear that NP's and PA's don't perform as well. Both through studies and community reports. One of my best referral sources are patients being unhappy with their NP/PA. I enjoy reading their entertaining notes. It's hard to establish the line between lower care vs no care.

Psychologists are already providing good care. I'd argue prescribing has higher risk vs known reward.

As you seem to be well versed in exactly how to draw the scientifically proven prescribing bar, why don't you have it drawn at NP/PA and become famous for setting an objective bar selflessly about yourself. Your name would be known forever.

 

[WisNeuro]

Is the data clear? I have yet to see that definitive review, especially the one refuting the Cochrane review. This is larger than simply RxP, it's about actually looking at our current practices and establishing the balance between safety, efficacy, and cost effectiveness for the patient. Rather than merely looking at our own financial self interests ahead of the patient's care.​

 

[whopper]

Psychologists ought to team up with existing practitioners that can prescribe. As for us psychiatrists that are against psychologist prescribing I say we have to join the bandwagon to address the lack of psychiatric providers in several areas in America and not just argue we don't want psychologists to prescribe. Besides it doesn't seem like that will solve the problem anyway. In the states where psychologists can prescribe on the argument they can service the rural communities most of those psychologists stayed in the urban areas.

 

[WisNeuro]

Psychologists ought to team up with existing practitioners that can prescribe. As for us psychiatrists that are against psychologist prescribing I say we have to join the bandwagon to address the lack of psychiatric providers in several areas in America and not just argue we don't want psychologists to prescribe. Besides it doesn't seem like that will solve the problem anyway. In the states where psychologists can prescribe on the argument they can service the rural communities most of those psychologists stayed in the urban areas.

Yeah, some of the arguments on both sides aren't all that great. As for the rural areas, this is pretty much a problem for most healthcare access. Unless you're from that rural community and want to go back, or are just jazzed about living in the sticks, there's really no great motivator to get providers there.

 

[TexasPhysician]

Psychologists ought to team up with existing practitioners that can prescribe. As for us psychiatrists that are against psychologist prescribing I say we have to join the bandwagon to address the lack of psychiatric providers in several areas in America and not just argue we don't want psychologists to prescribe.

This is already happening. I work with psychologists who are doing very well financially and we have seen excellent results coordinating care. This is absolutely how mental health should be performed. Our practice has added Telepsychiatry to improve care in more rural areas as well.

The only problem is laws preventing Telepsychiatry from expanding. Instead politicians expand prescribing in urban areas which is a failure to fix the problem.

 

[Therapist4Chnge]

In the states where psychologists can prescribe on the argument they can service the rural communities most of those psychologists stayed in the urban areas.

There are a shortage of prescribers in many/most major cities, not just in rural areas, so they are still helping address the overall shortage. If towns/cities want to address critical shortage areas, they need to pay more bc reimbursing Medicaid or Medicare rates won't cut it. I don't know any provider (MD/DO/NP, etc) who can support a practice w. those as the majority payors.

 

[smalltownpsych]

Psychologists ought to team up with existing practitioners that can prescribe. As for us psychiatrists that are against psychologist prescribing I say we have to join the bandwagon to address the lack of psychiatric providers in several areas in America and not just argue we don't want psychologists to prescribe. Besides it doesn't seem like that will solve the problem anyway. In the states where psychologists can prescribe on the argument they can service the rural communities most of those psychologists stayed in the urban areas.

Teaming up with an NP is what we are doing at my current hospital, but there are some significant challenges in that. What I have seen so far is that they don't know their limitations very well and are often defensive in their collaborations. I also have the opportunity to collaborate with psychiatrists who are two hours away and the coordination is improved even when it is only through exchange of notes than it is with the NP down the hall. How an NP could conceivably have the specialized expertise in mental health of either a psychiatrist or a psychologist to practice effectively is beyond me.

 

[nitemagi]

Teaming up with an NP is what we are doing at my current hospital, but there are some significant challenges in that. What I have seen so far is that they don't know their limitations very well and are often defensive in their collaborations. I also have the opportunity to collaborate with psychiatrists who are two hours away and the coordination is improved even when it is only through exchange of notes than it is with the NP down the hall. How an NP could conceivably have the specialized expertise in mental health of either a psychiatrist or a psychologist to practice effectively is beyond me.

And yet they have far more training in medicine and medications than RxP'ers. I agree that a psychologist further trained as a NP is a great pathway. That's where the funding should go.

 

[smalltownpsych]

And yet they have far more training in medicine and medications than RxP'ers. I agree that a psychologist further trained as a NP is a great pathway. That's where the funding should go.

Isn't that level of medical training what the Illinois law requires? Regardless, I would not want to be an NP. If I had really wanted to develop more expertise with medications and use in the treatment of mental illness, then I would have become a psychiatrist. Midlevel anything is just not what I aspire to be. Maybe that is just my competitive background where my dad would always tell us that second place meant that you lost.

 

[sunlioness]

Isn't that level of medical training what the Illinois law requires? Regardless, I would not want to be an NP. If I had really wanted to develop more expertise with medications and use in the treatment of mental illness, then I would have become a psychiatrist. Midlevel anything is just not what I aspire to be. Maybe that is just my competitive background where my dad would always tell us that second place meant that you lost.

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[DD214_DOC]

FNP's prescribe and get almost zero psych-related training. It shows.

I have a psychologist in my clinic who went through the DoD Rx program and wants to prescribe. The system is pushing back probably because of guild reasons or who knows. I said I'm all for it, he can't do any worse than the psychiatrist I replaced. Most of what we do with meds isn't rocket science. In fact, it's barely science at all.

 

[TexasPhysician]

I have a psychologist in my clinic who went through the DoD Rx program and wants to prescribe. I said I'm all for it, he can't do any worse than the psychiatrist I replaced.

So now the bar is so low that no one can do worse?

 

[WisNeuro]

I think the issue is that there is no operationalized bar to begin with. In healthcare we tend to just go with tradition and how things have always worked rather than putting in the legwork to show efficacy. Especially in the long-term.

 

[AcronymAllergy]

Isn't that level of medical training what the Illinois law requires? Regardless, I would not want to be an NP. If I had really wanted to develop more expertise with medications and use in the treatment of mental illness, then I would have become a psychiatrist. Midlevel anything is just not what I aspire to be. Maybe that is just my competitive background where my dad would always tell us that second place meant that you lost.

I think the Illinois law incorporates PA rather than NP training, to the extent that (I believe) the RxP program needs approval from either the state's medical board, or some national PA program accreditation body. I believe it also stipulates that the RxP training occur concurrently with the doctoral psych training.

Can't remember the specifics off-hand, though.

 

[Therapist4Chnge]

And yet they have far more training in medicine and medications than RxP'ers. I agree that a psychologist further trained as a NP is a great pathway. That's where the funding should go.

Says who? How many classes/hours do they have specifically studying pharmacology? Hint…a lot less than psych RxP'ers.

 

[nitemagi]

Says who? How many classes/hours do they have specifically studying pharmacology? Hint…a lot less than psych RxP'ers.

Cite your sources, please.

 

[Therapist4Chnge]

Cite your sources, please.

Muse, Mark; McGrath, Robert E. Training Comparison Among Three Professions Prescribing Psychoactive Medications: Psychiatric Nurse Practitioners, Physicians, and Pharmacologically Trained Psychologists. 66 J Clinical Psychol. 2010; 96-103.

 

[nitemagi]

Muse, Mark; McGrath, Robert E. Training Comparison Among Three Professions Prescribing Psychoactive Medications: Psychiatric Nurse Practitioners, Physicians, and Pharmacologically Trained Psychologists. 66 J Clinical Psychol. 2010; 96-103.

That study misrepresents the numbers. 1. It lumps "neuroscience and biochemistry" as one type of hours. 2. Pharmacology as a category. No other areas of training are noted.

The whole point of pharmacology is that it effects many systems of the body, other disease processes, other organ systems. NONE of that training is represented in that paper, and is a core aspect of pharmacology. Per that paper, psychologists have MORE training in pharm than physicians. Misrepresented much?

 

[Therapist4Chnge]

The study isn't amazing, but it is an attempt to quantify some of the similarities and differences in the training. One of the challenges to this work is the goal posts always seem to be moving. My response to you was discussing the role of training involving medications. Yes, there are various systems, disease processes, etc. that need to be considered, but that information isn't taught in a vacuum.

 

[Therapist4Chnge]

The whole point of pharmacology is that it effects many systems of the body, other disease processes, other organ systems. NONE of that training is represented in that paper, and is a core aspect of pharmacology. Per that paper, psychologists have MORE training in pharm than physicians. Misrepresented much?

Misrepresented…I don't think so. If the focus is comparing physicians, psychiatric nursing, and psych trained in RxP…then I think it is accurate. They didn't set out to say board certified psychiatrists, as that level of training isn't required to prescribe. I'd consider it ideal, but not the standard. As others have mentioned previously, FP/GPs prescribe a great deal of psychotropics. How much training in psych meds does the average FP/GP receive?

 

[nitemagi]

Misrepresented…I don't think so. If the focus is comparing physicians, psychiatric nursing, and psych trained in RxP…then I think it is accurate. They didn't set out to say board certified psychiatrists, as that level of training isn't required to prescribe. I'd consider it ideal, but not the standard. As others have mentioned previously, FP/GPs prescribe a great deal of psychotropics. How much training in psych meds does the average FP/GP receive?

It's misrepresentation because neuroscience and biochem are lumped, as if that makes sense as a category. Really that artificially bumps the hours for psychologists and doesn't show the actual biochem they're getting. Or physiology. Or anatomy. Or pathology. Or pathophysiology. Or genetics.

Pharm training isn't in a vacuum, just as drugs don't only go to the brain. Like the liver is kinda important, y'know? If you don't understand hep c, alcoholic cirrhosis, fatty liver disease, alpha-1 antitrypsin deficiency, etc, how are you going to know to adjust your med dosing?

Leaving out all the other hours that RxP aren't getting undermines their conclusions that RxP get more hours training than NPs. Their chart lists hours of training in psychosocial interventions, but not hours of any medical/physiology/pathology training. Which is more relevant for prescribing? It's selective presentation of data to further their agenda.

 

[Armadillos]

On a somewhat related note, I feel like it is really hard to quantify how much training a physician gets on X topic because so much of the training is related to whatever patient is in front of you.

Sure you have years of lectures in medschool to lay the groundwork, but the real learning happens when your a resident, have a patient and you have a highly specific question/situation come up. Then your reading textbooks, calling the pharmacist, discussing with attendings, searching the literature, consulting specialists in other fields related to the specific question, etc to learn the practical application of the years of lectures to innumerable different scenarios. Seems impossible to say physicians get X amount of training on Y topic because we spend so much time under supervision treating (and learning about) whatever walks through the door even if is completely unrelated on paper to whatever service/rotation we are actually on.

 

[smalltownpsych]

It's misrepresentation because neuroscience and biochem are lumped, as if that makes sense as a category. Really that artificially bumps the hours for psychologists and doesn't show the actual biochem they're getting. Or physiology. Or anatomy. Or pathology. Or pathophysiology. Or genetics.

Pharm training isn't in a vacuum, just as drugs don't only go to the brain. Like the liver is kinda important, y'know? If you don't understand hep c, alcoholic cirrhosis, fatty liver disease, alpha-1 antitrypsin deficiency, etc, how are you going to know to adjust your med dosing?

Leaving out all the other hours that RxP aren't getting undermines their conclusions that RxP get more hours training than NPs. Their chart lists hours of training in psychosocial interventions, but not hours of any medical/physiology/pathology training. Which is more relevant for prescribing? It's selective presentation of data to further their agenda.

Completly agree that it is all interconnected and that our edge in understanding the psychological factors is a good thing but that doesn't override the necessity to understand the physiological. I have always advocated for more knowledge of anatomy, physiology, and biochemistry for psychologists. I personally would not support RxP that didn't have equivalent or better training in medicine than a mid-level. Some of that is my own personal interest in the field of medicine in general which has always separated me from many of my colleagues. I would say that most of the psychologists who post on SDN seem to have a similar leaning.

 

[F0nzie]

One thing I am curious about is how exactly do psychologists get exposure to mental illnesses? They are not in the hospital or inpatient units training with us. I have tried collaborating with psychologists in the community but it seems like we're never on the same page. For example a patient is manic and they call it anxiety. Or a patient is psychotic with hallucinations and they call it disassociation. If diagnosis leads to treatment then this is an epic failure.

And what about psychiatric symptoms secondary to medication or medical illnesses. If those cannot be assessed how can it be safe for them to prescribe?

I have worked with NPs and I can't tell you how many times they're like oh I didn't know or I think I read about that once text books… Well they should know that because it could kill the pt. That's all.