Medical Psychologists on path to getting prescribing privileges, AMA/APA oppose

[PsychNOS]

Public Health:

I understand where you're coming from, but having a special program separate from medical school distances the mental health profession from other fields of medicine. Part of the goal of medical school and residency is to acquire a shared body of knowledge and experience with other medical specialists. The point of this is to know how to recognize pathology outside of your field of expertise and when to refer.

I know that the program that you are proposing may cover some of these concerns. However, as I've been stating, why replicate a parts of a curriculum that already exists within medical school and residency? I realize that medical school and psychiatry residencies are deficient in areas where clinical psychology are strong, namely psychotherapy and psychometric testing. But why not improve these compenents within psychiatric residencies rather than embarking on a radical campaign to create a new degree? Or, why don't we just allow clinical psychologists to continue doing what they do, but with more collaboration with psychiatrists?

You seem to like my idea of expanding medical school seats in rural areas as a means to expand mental health care coverage. I'm glad that there are rural DO branches, but what i think we also need to do is to recruit existing medical students into psychiatry and to provide financial incentives for physicians in general to practice in rural areas (e.g., loan forgiveness, better compensation, etc.).

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[thethrill]

First there is no place in medicine for individuals with a "God Complex". Furthermore I have no beef against midlevel providers, they serve a great need. However, there needs to be strict standards for patient care or they will get hurt/dead. My wife is an optometrist and one of my best friends is a psychologist who inspired me to go into psychiatry. There is simply no comparision in the training between psychologist and psychiatrist. Just look at the curriculum and the amount of time spent in the clinical setting. I know, my friend is a psychologist he golfed his way through his PhD program and was home by at least 6pm every day and always slept in his own bed. My point about FMG's is that all residents know that residency programs prefer US Grads because they get more funding for US Grads and much less funding if any for FMG's. FMG's mainly just fill spots. You can easily judge the status of a residency program by the number of FMG's. Finally I love being a doctor and nobody would ever accuse me of having a "God Complex", I am however extremely passionate about medicine/psychiatry. I am almost always the first one at clinic or the hospital and usually one of the last to leave at the end of the day. I have been given numorous awards for teaching nurses, medical students and residents. I strongly believe psychologist are not prepared or qualified to prescribe medications. I can understand PA's and NP's doing it under a physicians guidance. I even support psychologist doing certain med rechecks under a physicians guidance but, the law passed in Louisiana gives psychologist complete autonomy and over sight by their own governing body which has never prescribed a medication. Medicine is dangerous. This is life and death we are talking about and the law makers are letting this happen like it is a great experiment. I agree a degree that combines medicine, research, psychotherapy, and psychopharm would be great, fortunately someone already thought of that. It's called a psychiatry residency. We do a lot of psychotherapy as a matter of fact that is most of what we do, we all have to do a research project to graduate, and we do a preliminary year of medicine. The answer is not giving psychologist prescription rights the answer is to make psychiatrist more available and to increase reimbursements so that medical students with and an average debt close to $200,000 can consider do psychiatry. I appreciate everyone's place in medicine, I insisted our program invite the hospital cafeteria staff to our graduation party. I do however believe there needs to be the highest of standards when it comes to patient care. All mentally ill patients deserve to be seen and evaluated by a medically trained PSYCHIATRIST. There are no short cuts in medicine. Short cuts kill patients. Well gotta go admit another patient...

 

[Anasazi23]

...Why not create a rigorous program that allows students who have an interest in psychopharmacology, psychotherapy, and psychiatric/psychologic research to pursue an advanced degree that would allow them to function as comprehensive behavioral healthcare providers, and if so inclined, researchers?

The program you propose is interesting. And if it was well received and established, I may have sought out such a program at one time. However, (and people can't stand it when I do this - they call it a 'logic flaw,'" where will these boundaries end? This slippery slope makes me envision a world of medicine where everyone is trained in one specific area, without a generalized view of the entire spectrum of medicine and surgery.

Why not train people just to deal with womens' health and delivery issues? Why not train people to just do laparoscopic cholecystectomies? Why not train people just to read radiologic films? Why not train people just to recognize and treat illness and disease in children? Why not train people just to perform ORIFs?

Said trained people may perform well with the right training, but they lack an overall view of human medicine. It would be interesting to see how such a system would affect the overall quality of healthcare in the United States. I suspect that in the long run, it wouldn't be time-saving or money-conserving. I imagine it may well result in the opposite due to medical error, complications, and the like.

 

[PsychMD]

This is why I was thinking earlier that the "real" issue to be actually solved by our Public Health institutions is how to improve the qualitative delivery of health-care, including mental health-care to the public. I think this is the main problem we are probably struggling with at this time, at a national level. Quality is perceived by many as going down, while the system seems to be overwhelmed by demand vs. the available resources.
First of all, I want to emphasize that this is a perception, not necessarily a truism, although I have just seen this recent article too http://www.rand.org/news/press.04/05.04.html
(so maybe indeed quality is going down).
Second of all, how can one deliver high-quality en masse? I have no idea. I don't even have the tools needed to even study this question, since I am not a specialist in public health delivery issues.
Third, re. this narrow focus on who prescribes psychotropics, at this time we don't necessarily need MORE prescribers; we need BETTER prescribers. What makes one a BETTER prescriber? Typically, training and experience, built upon a required base of general medical knowledge. Furthermore, in our current mental healthcare delivery system, which is indeed in shambles, as seen from ground-level (by experts, physicians, and public all alike)- who rx.'s psychotropics is only ONE of the multitude of problems. Most of the problems have to do with funding for community supportive services. Don't forget, in Psychiatry, the very vast majority of patients DO NOT have any insurance, nor any means to pay for anything themselves. So even if proponents of psychologists prescribing psychotropic meds say that "psychiatrists are just afraid of psychologists encroaching on their turf", this is a baseless argument.
Psychiatry is about delivering health-care to patients with psychiatric problems. Even now, the quality of psychiatric care is probably poor across the board, because the demand for services outstrips the resources. Psychiatric patients typically also have multiple medical co-morbidities due to self-neglect, lack of supports, and difficulty in accessing primary care services too.
Increasingly, the problem of QUALITY vs. QUANTITY has been cropping up...not just in Psychiatry...but across the board, for Medical care for our public, in general. (The psychologists prescribing promoting groups are just exploiting this current crisis to further their own agenda.). What REALLY worries me, as a physician and as a psychiatrist, is that the people who are "in charge" re. legislating the system or re. proposing regulatory issues or system reform issues, are seemingly promoting narrow agendas with actual disregard for the well-being of our own public.
I realize, for our younger colleagues in training, this may sound like a discouraging and/or possibly depressing point of view. Actually, at an individual level, a psychiatrist's job is still AT THIS TIME one of the most interesting and challenging jobs there is. And it's FUN too. Just BECAUSE it combines knowledge from various fields of medicine, allows for continued study opportunities, satisfies the deep needs (experienced by MOST physicians by virtue of their make-up) for fulfilling intellectual curiosity, abnegation, variety of work settings and situations. Psychiatry is NEVER "boring". And most definitely IS NOT just about psychotropic prescribing, although we are indeed fortunate at this time to have a wide array of psychtropic tools that can be helpful and even life-saving IF used appropriately, judiciously, AND drawing upon our best of medical knowledge accumulated during medical school.
IMHO, the current challenges for Psychiatry seem to be almost like a warning bell, or like a mirror, for the current challenges of our overall health-care delivery system in general.
Also, re. the perceived need for overwhelming demand vs. lack of resources in psychiatry...I really encourage our younger colleagues to brainstorm, to become educated in political, administrative, and public health issues...because it is up to you, ultimately, to help promoting an improved system, improved clarity of the nosology and problems to be solved, improved quality of psychotropic management AND other tx. modalities that are to be delivered.

 

[Svas]

http://www.sq.4mg.com/IQ-jobs.htm

 

[Svas]

at this time we don't necessarily need MORE prescribers; we need BETTER prescribers.

I completely agree. However, I don't think that the model of improving the ability of the FP will meet the demand. I don't recall the exact figure, but someone in another post pointed out that there are 400+ counties nationwide with no psychiatrists. Around here, there's a 3 to 6 month waiting list to get an appointment with one.

Psychologists who are far better trained mental health professionals than any other non-physician (and it's simply arguable whether physicians are better trained in mental health issues), and are far better trained in mental health than FP's, PA's and NP's. To suggest otherwise is silly. A psychologist who correctly makes a diagnosis of a mental health patient, often must continue to support the patients that NEED medication, but without psychiatric support. So, in order to adapt, most of them refer to FP's and then they TELL THE FP WHAT AND HOW MUCH TO PRESCRIBE. Aren't we aware that this is what is happening all around us?

A worse scenario: the FP who gets a psychiatric patient and decides to treat it him or herself without competent mental health care support (either because of being inaccurately self-assured or because it's not available).

Come on . . . *we* can train psychologists to do a good job with a limited formulary. We can argue for a collaborative model that will support our model, support the patient, and support the US health care delivery system. A collaborative model, and not an indentured slave model, *that WE suggest and recommend*, I believe, would be acceptable to them. It would fly through legislatures and we would have some control over the outcome. Otherwise, this is going to occur in our faces and without our input. The options look obvious to me.

S

 

[Andrew_Doan]

All of you complaining here should be sending letters to congress and money to the AMA!

I'm a member of the AMA and send money to AMPAC. We must stand together as physicians to prevent back door non-physicians becoming medical doctors and surgeons. This is scary! If psychologists want to prescribe systemic medications, then they should go to medical school.

Ophthalmology is in a constant battle with optometrists:

http://forums.studentdoctor.net/showthread.php?t=119156

 

[sasevan]

thethrill's post is a remarkable push-me pull-you. You remember the beast of the kids stories who wanted to go in two different directions at once?

Thethrill's world here is all about superiority; psychologists are "dumber" than MDs. FMGs (infering from the context in which they're mentioned in the post) also inferior to US allopaths. (and fair enough, IMGs are in gerenal smaller currency come residency time-but not always). But note that in the doctoring world of stereotypes, psychiatrists are viewed often as the one's who couldnt hack it as "real doctors". But its ok! We can still feel superior! the thrill turns this one around by mentioning all that we know about the real complexity of the field. So we like the superiorty notion a lot, but when we are on the wrong end of that stick we just turn it around to show you how the other guy really just got that one wrong. Whew. Sounds more like a politician than a doctor.

Yes I agree psychologists, who dont study medicine in general and neuro in particulary shouldn't perscribe. And psychiatry is an amazing field. But anyone still looking at the world in terms of who they're better than really hasn't made it too far out of adolesence, emotionally. And I'm sure a good psychiatrist would have something to say about that.

Stephew,
Those posts were just absurdly funny
Prejudice againsts osteopaths (or allopaths), FMGs (US or otherwise), or allied healthcare profesionals, in my opinion has no place in medicine.
It's actually a little bit disconcerting that someone who is so prejudiced is a physician since it reveals very poor scientific reasoning. Anyway, enough about that.
The real issue is under what circumstance should psychologists (PhD/PsyD) be permitted to prescribe (RxP)?
I fully support PhD/PsyD having RxP for those who are appropriately trained.
I myself am completing my psychology residency after four years of working with psychiatric and medical patients, including a year long C-L rotation, however, I do not believe that I am at this point prepared to prescribe.
The big APA (the psychology one has 150,000 members as opposed to the little APA-the psychiatry one has 35,000 members) agrees and so it proposes a post-doc masters program to train licensed clinical psychologists to become psychopharmacotherapists.
Like you, the big APA would have PhD/PsyD study (and practice under physician supervision) medicine before gaining RxP.
There are currently different models as to just how this post-doc masters program of study and practica will look, among these are the DoD, the NM, and the LA.
I think the future of mental health is both exciting and a little bit confusing.
From PhD/PsyD's point of view the issue is whether healthcare providers can become prescribers without going to med school; study medicine yes, med school no. As the DoD project and NP practice indicate the answer is "yes."
BTW, I myself intend to become a psychiatrist; along with completing my psych residency I am doing my pre-med reqs-don't ask
I want to be able to fully function as a psych PhD/PsyD as well as a psych MD/DO. However, though that is my path I don't believe that it has to be everyone's. I believe that diversity, biological and otherwise, is good and that ultimately mental health will benefit from both psychologists and psychiatrists capable of functioning as psychotherapists and psychopharmacotherapists. While both disciplines will have similar tools at their disposal each will utilize these in the context of different philosophical perspectives.
As a soon to be psychologist (and a future psychiatrist) all that I ask of open minded physicians such as yourself is to consider the scientific evidence; I believe that those who do so will not prematurely conclude that med school is the ONLY or even the best route to prescriptive authority for all providers.

P.S. Please don't forget to include a clinical health psychologist in your future oncology practice.

 

[Htowngsp]

Before medical school, I was a Psychology major, my wife is PhD candidate in Psychology, and my dad is a Psychotherapist here in Texas, so I am aware of the issues surrounding this debate. About a year ago, my dad got a flier froma course offering a psychotropic pharm seminar to PhD's in Psychology (who've never had any such training). He went to this weekend course to get some CEs, just because, having seen patients on these drugs, he had little understanding of them pharmacologically. He came back and told me that he was shocked by the implication made at the conference that someday Psychologists might prescribe, as this was a two-day seminar on anti-depressants only. The main deterrent most noted by his colleagues: malpractice costs.

Oddly, when I talked to my wife she agreed that the practical risks are too high for most PhD's to do prescribing. Psychotropic meds can have negative side effect profiles, and PhDs are even more scared of lawsuit than we are., and their current malpractice rates can be laughable. For example, my wife pays $800 for malpractice insurance annually.

Also, she told me that PhDs in big cities don't want to move to the psysician economic model of 15 minute visits. She makes $150 an hour, fee for service (no insurance taken) as a PhD candidate here in Houston. With a doctorate, she can clear $200. Most M.D.s make 60-100 per consult, or $400 an hour, but that is a fast pace to see patients, and overhead, malpractice, etc. that PhDs don't have. PhDs, if they could prescribe would have to compete in the marketplace, and, frankly, most folks who go into PhD programs aren't looking to work 70-80 hour weeks. So to me, the threat is pretty small.

The bigger threat, IMHO, is FPs prescribing psychotopic willy nilly. Here in Texas, even where there are Psych folks, a lot of our patients seem to turn up with meds prescribed by FPs only...

 

[DrFocker]

I completely agree. However, I don't think that the model of improving the ability of the FP will meet the demand. I don't recall the exact figure, but someone in another post pointed out that there are 400+ counties nationwide with no psychiatrists. Around here, there's a 3 to 6 month waiting list to get an appointment with one.

Psychologists who are far better trained mental health professionals than any other non-physician (and it's simply arguable whether physicians are better trained in mental health issues), and are far better trained in mental health than FP's, PA's and NP's. To suggest otherwise is silly. A psychologist who correctly makes a diagnosis of a mental health patient, often must continue to support the patients that NEED medication, but without psychiatric support. So, in order to adapt, most of them refer to FP's and then they TELL THE FP WHAT AND HOW MUCH TO PRESCRIBE. Aren't we aware that this is what is happening all around us?

A worse scenario: the FP who gets a psychiatric patient and decides to treat it him or herself without competent mental health care support (either because of being inaccurately self-assured or because it's not available).

Come on . . . *we* can train psychologists to do a good job with a limited formulary. We can argue for a collaborative model that will support our model, support the patient, and support the US health care delivery system. A collaborative model, and not an indentured slave model, *that WE suggest and recommend*, I believe, would be acceptable to them. It would fly through legislatures and we would have some control over the outcome. Otherwise, this is going to occur in our faces and without our input. The options look obvious to me.

S

From my experience working in many FP rotations, the FP's had no problems doing psych pharm. If they felt like more counselling was needed which they didn't have time for they would refer to a Psychologist. Psychologists may be more trained in psychotherapy than physicians, however they ARE NOT MORE TRAINED IN MEDICINE THAN NURSES, PA's, and PHYSICIANS. You're suggesting since a Psychologist may be better trained in psychotherapy, that translates into better pharmacotherapy. You continue to ignore the potential side effects/interactions along with co-morbid conditions. How are psychologists that aren't trained in Physical diagnosis, reading EKG's, Labs, etc., etc., going to function without seriously hurting or killing people? Just look at the side effects and potential lethality of TCA's, Lithium for example.

Your worse case scenario is that the FP has NO CLUE how to treat mental health care and therfore the patient suffers from bad mental health care. First of all, that is not only insulting but ignorant. FP's deal with Psych issues EVERY DAY and have done superbly in dealing with them. Shouldn't the worse case scenario be a Psychologist with script rights prescribes Drug X and causes toxic levels of Drug Y. Are they going to know to order a CBC and how to read it for a patient on Clozaril, or do a physical exam and detect potentially fatal Myocarditis on Clozaril? Will they know how to read an EKG and know how to look for ST-T wave changes? My worse case scenario is the PhD KILLING a patient because he/she cannot perform physical diagnosis and doen't have the MEDICAL knowledge necessary to prescribe SAFELY. YOU CANNOT PRESCRIBE WITHIN A VACUUM. If patients only presented with mental health problems and the drugs had no side effects or interactions with other drugs, then you could prescribe within a vacuum. This is simply not the case. I understand your bias having children with Psych PhD's, but as the scientist you claim to be, you simply keep ignoring FACTS.

 

[PublicHealth]

It seems to me that the postdoctoral psychopharmacology programs are lacking. Courses every other weekend, pass/fail courses, disreputable institutions, etc. As indicated by Anasazi and others, psychologists who want to prescribe should receive a comprehensive medical education. Due to the seemingly poor quality of existing postdoctoral psychopharmacology programs, which lack emphasis on general medicine (e.g., http://www.cps.nova.edu/programs/PostdocMasterPsychopharmC7.html), why don't psychologists seeking to prescribe become PAs or NPs? Granted, these programs will require more time, but they will provide psychologists with more comprehensive medical training that is recognized in virtually every state, and that will allow them to function as psychotherapists and psychopharmacotherapists under the supervision of trained psychiatrists. Problem with this for psychologists is that they will have to be supervised and reimbursements will be less. However, malpractice will likely be less of an issue in this case as opposed to having psychologists prescribe on their own.

 

[Anasazi23]

Interesting post, PH.

It's disheartening at best, and frightening, at worst to see that the complex issues related to cardiac disease, pulmonary manifestations, skin conditions, blood dyscrasias and related disorders, genetic susceptibilities, the neurological patient, and of course, the ever complex obstetrical patient will all be covered in the course entitled: "Introduction to Physical Assessment & Laboratory Exams."

Wow.

What also bothers me is the arrogance of the American Psychological Association in allowing said Master's degrees in psychopharm to be conducted without a universal acceptance for this model not only within its own profession, but the assumption that this coursework is sufficient for psychologists in these states to prescribe based on their preconceived course outline.

 

[PublicHealth]

It gets worse...

http://www.alliant.edu/cspp/postdocmsppharm.htm

http://www.alliant.edu/download/2003/pubs/CA_RxP_Brochure0403.pdf

 

[Svas]

How are psychologists that aren't trained in Physical diagnosis, reading EKG's, Labs, etc., etc., going to function without seriously hurting or killing people? Just look at the side effects and potential lethality of TCA's, Lithium for example.
.

Today I pulled 3 NP's, 4 3rd year FP residents (getting ready to be done here), 4 psych residents (3y) and 2 PA's into my clinic office early this morning on a whim and gave them 4 EKG strips, 6 sets of CBC/CHEM25's, a couple RIA's and UA's. They all agreed to be part of a VERY small test sample and I did not "select" these folks. They happened to be near one another in the hallway and lounge.

All these from 4 separate patients.

Number of diagnoses: 5. Number correct: 0 Number of correct recomendations: 3 All of the FP's correctly read the EKG.

Number of the cases that that could have *easily* been correct from the lab data alone: 100%.

What am I trying to prove with this - exactly what you think I'm trying to prove. We have a pretty big problem with inter-rater reliability.

By the way, the most embarrasing problem: ALL of the psychiatric residents missed the cardiac arrthymias in all 4 cases and 2 misidentified the problems with the labs so completely that I'm calling a meeting with the training directors. Only one person correctly put together all of the data correctly, even though the ultimately conclusion was incorrect (I was still please with her thinking and she would have gotten to the correct diagnosis quickly. She was an FP.)


S

 

[stephew]

"Prejudice againsts osteopaths (or allopaths), FMGs (US or otherwise), or allied healthcare profesionals, in my opinion has no place in medicine.
It's actually a little bit disconcerting that someone who is so prejudiced is a physician since it reveals very poor scientific reasoning. Anyway, enough about that."

I can't tell if you think I am the prejudiced one or not. If so, Ill point out that my post was actually in condemnation of that attitude, and that I actually am an IMG (see sig). If not, well then I'm agreement with you.

In either case there are plenty of mental health workers at the hospital I'll be working at.

 

[mdblue]

Today I pulled 3 NP's, 4 3rd year FP residents (getting ready to be done here), 4 psych residents (3y) and 2 PA's into my clinic office early this morning on a whim and gave them 4 EKG strips, 6 sets of CBC/CHEM25's, a couple RIA's and UA's. They all agreed to be part of a VERY small test sample and I did not "select" these folks. They happened to be near one another in the hallway and lounge.

All these from 4 separate patients.

Number of diagnoses: 5. Number correct: 0 Number of correct recomendations: 3 All of the FP's correctly read the EKG.

Number of the cases that that could have *easily* been correct from the lab data alone: 100%.

What am I trying to prove with this - exactly what you think I'm trying to prove. We have a pretty big problem with inter-rater reliability.

By the way, the most embarrasing problem: ALL of the psychiatric residents missed the cardiac arrhymias in all 4 cases and 2 misidentified the problems with the labs so completely that I'm calling a meeting with the training directors. Only one person correctly put together all of the data correctly, even though the ultimately conclusion was incorrect (I was still please with her thinking and she would have gotten to the correct diagnosis quickly. She was an FP.)


S

With due respect, Dr. Svas what' s your point?
There are good doctors and there are bad docs. Also there are good therapists and there are bad therapists. This AM I was in a group tx for DD substance users w/ a Clinical psychologist(a PhD). She was unable to answer my questions about the nature/goal/intervention techniques about the so-called therapy session. And I've seen multiple of therapists like her. It hardly proves that in general, therapists are incompetent and/or unsafe for clinical work.
Today psychiatry is another medical specialty and all residents should be trained in medicine and neuro to be board-certified. If someone lacks skills in these fields it reflects personal and/or training program deficit, and they should work to improve that. However, I do think it's a legacy from 60s and 70s in psychiatry wrt psych-med dichotomy. It's unfortunate but I've seen it in a lot of senior attendings who emphasize mind over body and gets carried over to the extent that they refuse to do a physical.
Just my 0.02c.

 

[sasevan]

"Prejudice againsts osteopaths (or allopaths), FMGs (US or otherwise), or allied healthcare profesionals, in my opinion has no place in medicine.
It's actually a little bit disconcerting that someone who is so prejudiced is a physician since it reveals very poor scientific reasoning. Anyway, enough about that."

I can't tell if you think I am the prejudiced one or not. If so, Ill point out that my post was actually in condemnation of that attitude, and that I actually am an IMG (see sig). If not, well then I'm agreement with you.

In either case there are plenty of mental health workers at the hospital I'll be working at.

Hi Stephew,
No, I didn't mean you; on the contrary.
I am in complete agreement with your post and in fact have found many of your previous posts both here at StudentDoctorNetwork and at ValueMD to be very informative and balanced.
I believe you are very open minded physician and a credit to St. George's program.
Best of luck on completing your residency.

 

[thethrill]

I think the prejudice thing was directed at me. My parents are foreign (muslim) and my dad's name is muhammed, but I was born in America. I apologize if I affended anyone with the Muhammed, Muhammed, and Muhammed comment. I guess I thought it was funny since I am muslim and so many muslims are named Muhammed. Poor taste, sorry. Anyways, my point was that residency status can easily be evaluated by the number of FMG's in a program. I work with and hang out with many FMG's everyday and the ones that are here definitely earned their ways here they are usually very, very intelligent. I am not prejudice. But I think that midlevel providers are just that, midlevel providers. They are not the real deal. There is no substitute for a US trained MD/DO. Anyways I have given a lot of thought to psychologist get prescription writing priviledges and after a year of busting my ass in my first year of residency saving lives. Yes it's true psychologist we spend the night in the hospital every 3rd or 4th night, usually working 80 hours a week sometimes more despite the new laws and attend many lecture and do dozens of presentations. I realize that there is very little that can be done to stop the political machine and the downward spiral of Mental Health Care. I was offered a EM residency spot today and will be jumping ship to emergency medicine. I would love to be a psychiatrist, but I feel the fight to save the integrity of psychiatry is already lost. I know I am not the only young physician to leave to field of psychiatry secondary to concerns about the future of psychiatry. It seems there are many more psychologist on this post than psychiatrist. Psychiatry has taken a bashing on this and other posts which is unfortunate considering psychiatrist tend to be the most compassionate and intelligent physicians with the least interest in power and financial gain. Psychiatrist probably helped created this problem by trying to educate psychology so that we could work side by side, hand in hand. Unfortunately some psychologist took advantage of this commadarie and are trying to gain more power than they have earned. Ultimately patient care will suffer. I believe my psychiatric training will serve me well in EM. If you knew me you would know that I have many friends of many colors and races and that I work hard every day with a smile on my face because I love medicine. It is sad to see psychiatry start to fall a part the way it is, this could have been handled much more professionally. Not with the speed and haste in which the Louisiana bill was passed. That bill was handled in a wreckless, sleazy fashion. As a young physician with a beautiful wife and a $200,000 debt I can not afford to take a chance on the future of psychiatry. Food for thought, On call last night a patient came in with nausea and vomiting and no chest pain. An EKG was ordered. The patient was admitted to the hospital thus I went to the ED to do the admission. So I was looking at this diabetics labs and then the EKG before I went to see the patient. The EKG had a slight ST segment elevation in the inferior leads that was missed by the EM physician. I called the cardiologist and sent the pt straight to the cath lab. That patient had bypass surgery that night. How bout that a diabetic with a silent MI diagnosed by a psychiatry resident or now a EM resident.

 

[stephew]

Hi Stephew,
No, I didn't mean you; on the contrary.
I am in complete agreement with your post and in fact have found many of your previous posts both here at StudentDoctorNetwork and at ValueMD to be very informative and balanced.
I believe you are very open minded physician and a credit to St. George's program.
Best of luck on completing your residency.

In that case I admire your fine insights

Also I dont think its surprising for a psychiatrist to dx other physiologic conditions- heck you went to med school.. hopefully the ER doc can note psychiatric condintions on occasion in return...

 

[PsychMD]

Svas, re. your ad-hoc experiment:

I felt extremely uncomfortable reading your post about your real-life "experiment" involving junior trainees in the hospital you are currently working in.

I truly hope that your experiment idea using real-life trainees who are under your supervision was not generated by an individual impulse to try to "prove a point" dear to you, but rather by a desire to teach and/or devise methods for improving your supervision and the overall teaching quality on your service. And that such impromptu "grillings" are just not exceptional or generated impulsively and infrequently, but are just part of other routine teaching methods that you employ as part of your job, as a teacher/attending in that hospital, if indeed you are their direct supervisor in the course of their training.

What I actually fear that may have happened sounds much worse: if you just pulled aside randomly some unsuspecting trainees who are not even under your direct supervision and "forced" them to participate unwittingly in an impromptu experiment devised by you impulsively just to "prove a point to yourself" or to us here, knowing that they couldn't even refuse because you are somehow in a superior position of "power" in that hospital, moreover, penalizing and singling out the psych. residents who "failed" your little test by "reporting them" to their program director(what about the other participants who failed too?)...then you have crossed an important boundary and have acted out inappropriately and unethically by USING trainees which are in an inferior position of power to you...in order to satisfy your own needs and ideas.

Please clarify this VERY important point here and re-assure us about the exact circumstances of your described "experiment".

 

[Svas]

Svas, re. your ad-hoc experiment:

I felt extremely uncomfortable reading your post about your real-life "experiment" involving junior trainees in the hospital you are currently working in.

I truly hope that your experiment idea using real-life trainees who are under your supervision was not generated by an individual impulse to try to "prove a point" dear to you, but rather by a desire to teach and/or devise methods for improving your supervision and the overall teaching quality on your service. And that such impromptu "grillings" are just not exceptional or generated impulsively and infrequently, but are just part of other routine teaching methods that you employ as part of your job, as a teacher/attending in that hospital, if indeed you are their direct supervisor in the course of their training. .

This method is part of our regular training activities. I simply added the NP's and PA's because they were around. We grill our residents constantly. Further, the opportunity is not designed to humiliate, but to provide teaching opportunities. I suppose that I could loan them my computer and let them tell you about the experience. But I am certain that all of them experienced it as positive, but given your concerns, I'll raise it with them on Monday when they are all there again and I'll let you know what they thought of the exercise.

Given my "senior status" and that I have been reasonably frequently awarded the "favorite instructor/professor" awards here, I can promise you that I did not engage in any activity that would have either been inappropriate or demeaning to the trainees (or frankly that different from what I do on a weekly basis). It did, however, expose some weaknesses in our training model for them.

BTW, the above issue aside, would you have been concerned about their performance if you had been the proctor?

S

 

[Svas]

From AAMC

Educational Strategies
Modification of Existing Pedagogy

During the clinical years, the questions asked on ward rounds must proceed
beyond the usual recollection of known facts (i.e., ?What are seven causes of atrial fibrillation?? ?What are the Ranson Criteria??), and should ideally incorporate questions of mechanism and of investigative approach (i.e., ?Why might infection have led to atrial fibrillation in this patient, and how would you study this?? or ?Why should this patient with pancreatitis exhibit hypperglycemia, and how could this theory be tested??). While it may be more comfortable to stick with questions of fact, for which there are arguably pre-existing sets of ?correct? answers, such an approach ultimately does a great disservice to both student and patient.


Case Studies
Consideration of existing educational strategies suggests that, while ultimately
an experiential approach is best, an effective way to familiarize students with the power and range of clinical research is through case studies.
A broad and diverse range of case-studies must be developed, highlighting a
range of approaches (from DNA analysis through population-based studies), a
range of medical disciplines, a range of research quality (from exemplary to deeplyflawed), and should ideally include both historical and contemporary examples, from industry as well as academia. Cases should focus on research that resulted in:

1. the development of a new diagnostic or therapeutic approach
New diagnostic approaches might include the use of CT imaging to diagnose
pulmonary embolus, and the use of MRI in stroke. New therapeutic approaches
might include GnRH for premature puberty, and thrombolytic therapy for strokes.
2. a change in practice Examples include how the approach to myocardial infarctions has evolved over the last several decades, from bed rest for 6 months to diagnostic tests then home with rehab in a day. Another example includes the use of routine screening colonoscopy as part of good primary care/preventive medicine.

3. an ethical dilemma
Examples can include the implications associated with most genetic testing,

e.g., testing healthy people for Huntington?s or hemochromatosis.

4. the introduction of a new experimental approach or study design

The use of gene chips and the application of knowledge about population
genetics.

5. the introduction of a new technological innovation Examples include cardiac catherization, laproscopic surgery, and artificial skin
for burn victims.

6. the development of a new outcome measure or surrogate marker

An example is looking at troponin to assess myocardial infarctions.
The case studies are expected to introduce students to the ?process? of developing questions, as well as to illustrate the range of questions possible for a given clinical conundrum. The case studies will enable students to develop and hone their critical appraisal skills, and learn how to formulate and frame ethical, scientifically useful questions. Case studies will also emphasize the role of the patient as partner in discovery, and will highlight the role of communication as an essential aspect of both medical practice and clinical research.

 

[PsychMD]

Svas, thank you for clarifying. I'm not against "grilling" as a method within the regular teaching activities. (I was just getting anxious about the way the first post sounded to me, but now that you've clarified the situation, I understand what you mean.)

Re. concern about performance...yes...I do have concerns about the quality of Academic Medicine too, and the way Academic Medicine's influence and respectability has also diminished; in Psychiatry, especially, Pharma encroachement via $$$ is, IMHO, exceeding proper levels. Basically, it seems that there is no "independence"/boundary from corporate influence, and/or that boundary has been breached quite severely, in both Academic Medicine and even national research...see NIH "scandals". http://www.biomedcentral.com/news/20031210/06 is just one of the "examples".

But to me it seems, and correct me if I am wrong...that you might be coming from the approach "if you can't beat 'em, join 'em", or the "change from within" strategy. Or "this is the way things are evolving"...just jump on the bandwagon and try to be a Player in the system at all cost". I'm not sure if this is the RIGHT way to go, ethically or even practically. The thing is, within this corporate-influence system of funding for Academia and Research, where the major players are basically Insurance co's, and Pharma co's...with their very powerful lobbies, and agendas, and clout...I just see this slippery slope getting more slippery by the minute, and us tumbling down on this path. Even the most well intentioned ones among us. Physicians seemingly HAVE NO SAY re. administrative/funding/policy issues...horror of horrors...even in Academic Medicine! But maybe this is an OLD conflict...and I'm just seeing it now. It just seems pretty blatant nowadays...almost like there's no checks and balances in Medicine anymore. That's mostly what I worry about. But I confess...this is a PERSONAL view, and I admit, I AM biased. I just can't help it. But I do try to be VERY careful about what I post in a public forum frequented by my younger colleagues and doctors to be.

What do we teach our students then? Do we even have a duty re. educating re. policy matters, which are political more than medical? How do we encourage students to learn to make their own decisions, WITHOUT introjecting our own biases and prejudices into the mix? HOW do we DO that?

Since it is obvious that some of the participants in this forum are not just residents but "older" physicians in practice too...personally I would like to hear from the "older" and presumably more experienced participants, but I also think that there is a responsibility here towards our younger colleagues in training.

 

[sasevan]

Hi folks,
I'm really glad that so many here are beginning to be less vitriolic and more constructive; in line with that I'd like to share some random thoughts on the points raised by Svas and Sanman and the proposals suggested by PublicHealth and Dentite001 as well as to make some suggestions of my own.

Svas and Sanman,

I believe we're all on basically the same page: we can't find any reasonable arguments against RxP for psychologists and sufficient evidence that non-medical professionals can be trained to be safe and effective autonomous pharmacotherapist as demonstrated by psychologists in the DoD and NPs in 11 states and DC; not to mention, dentists, optometrists, and podiatrists.

I think the question that many have, who while being open-minded are honestly concerned about extending RxP to PhD/PsyDs, is: how can the DoD or the NP model be translated for psychlogists not in the DoD who want to extend their scope of practice into psychopharmacotherapy?

PublicHealth,

Like you, when I first saw various post-doc psychopharm program curricula, I become very concerned; at first glance, anyway. For example:

Prepare for your Future
Earn Your MS in Clinical Psychopharmacology in South Florida at the NSU Bimonthly (Fly-In) Program
Five Extended Weekends Per Year For Two Years

When I read "fly-in...five...weekends," I was

But I continued to read.

This model is designed to meet the needs of Licensed Psychologists who would like an opportunity to receive training from an ongoing University-based facility offering a Master of Science Degree in Clinical Psychopharmacology. This curriculum has been successfully used in our ongoing campus-based program since 1999 and meets all of the requirements of the APA model curriculum. It is now being slightly modified to match criteria proposed in the New Mexico Prescriptive Authority legislation
We are now expanding the program to welcome any licensed psychologist seeking to expand his/her knowledge of Clinical Psychopharmacology.

So, it is based on the APA model curriculum which is based on the DoD model.

The Fly-In Program is currently a 31.5 credit hour program curriculum spread out over two years. Classes meet only FIVE times a year on Thursday, Friday, Saturday, Sunday, Monday and Tuesday, from 9 AM to 5 PM.

31.5 credit hour program actually exceeds the DoD model 30 credit hour program. The weekend is actually Thurs-Tues, in other words longer than the regular work week.

In addition to the classroom activities, chat room and other distance learning techniques will be utilized. Most states allow CE credits for these learning activities. A candidate is expected to complete the Postdoctoral Master's Program in Clinical Psychopharmacology within five years. (SO FAR ALL BUT ONE HAVE COMPLETED IT IN TWO)

So, completion of this program generally takes 2 years while the DoD one took only 1.

Faculty is drawn from the Nova Southeastern University Schools of Psychology, Pharmacy, and Medical Sciences and is supplemented by adjunct professionals with special skills. Quality Intensive Learning in a Relaxed Atmosphere.

Speaks for itself.

Clinical Training

The clinical portion of the program provides students with assessment and intervention experience in a practicum setting. Students residing close to the Nova Southeastern's Community Mental Health Center may take their practicum at the clinic. Distance students may arrange acceptable practicum arrangements closer to their home.

This is in addition to the 31.5 credit hour didactic training. More below:

The practicum is one of the most important elements of the curriculum. This comprehensive program provides each student with practical experience with patients of various ages and varied diagnoses. The curriculum requires a minimum of two; 100-hour intensively supervised clinical experiences, ordinarily scheduled in the summer terms, where a minimum of 50 patients is seen during each practicum. To comply with APA recommended standards, each student should have a minimum of two hours per week of individual supervision.

Students are expected to spend 100 hours or more with their qualified mentor, usually a boarded psychiatrist or an otherwise qualified medical practitioner. The student observes the psychiatrist/patient interaction, his/her clinical evaluation; treatment (medication) prescribed and understands the justification for the treatment protocol. It is preferred that the supervisee is able to follow patients over time to observe long-term effects. In general, each student should spend sufficient hours each week with a supervising psychiatrist (or other accepted provider) to complete his or her practicum hours in a reasonable time frame (usually 8-12 weeks). The specific hours per week are arranged between the student and the approved practicum mentor.

A case seminar overseen by a qualified proctor is scheduled for clusters of students in the summer of the second semester. As part of the practicum training process, students are expected to present clinical cases. Seminar hours are considered part of the required 100 hours. We are currently scheduling four days for a case-based seminar: June 17, 18, 19, 20 2005. However, if students are interested we could extend the seminars for two additional days.

In review, the clinical rotation will consist of two, approximately 100 hours practica, including observation and clinical discussion of fifty patients. The goal is for students to observe a diverse group of patients with a variety of symptoms over the course of several weeks of treatment and to be able to observe the clinical effects of psychotropic medications developing over time.

Students must keep a complete log of their clinical activities as part of the record of their training. The log should include, but is not limited to: each patient?s concise biopsychosocial history; medical and psychiatric history; medications that the patient is currently taking; allergies; foods and beverages that might suggest negative drug interactions; current DSM diagnosis; indications and counter-indications regarding the psychotropic medication(s) currently prescribed and; drug-drug interactions. Each patient?s log will conclude with a one-paragraph summary.

It is our intention for students to develop appropriate practicum arrangements that rival supervision in our own clinical facilities, if it is not practical for them to arrange their schedule to receive supervision at our clinic.We will work with each student to help him/her locate training supervision from a qualified mentor at a site closer to heir residence that can be approved by the director.

Prerequisites for Practicum I and Practicum II are successful completion of all prior courses.

Again, I think it speaks for itself.

So, program length all together, didactic and practicum, is at least four years.

Grading Policy

Grades for course work are assigned according to the following system: P, F or PR (in progress). A grade of I (incomplete) is given only with instructor's approval and under exceptional circumstance. Our goal is to have our students complete the program successfully. Faculty and the director will make every reasonable accommodation to accomplish this goal.

From my understanding many med schools use this grading system; please correct me if I'm mistaken.

I know that this sample program when taken by itself still compares unfavorably with medical school as far as length of training.
HOWEVER, the post-doc psychopharm program is just that, a post-doc program that builds on psychology school training.
In other words, students admitted to this 4 year program already have at least 6 years of grad psych education and probably at least 1 year of licensed psych practice.

Another point is whether med school length of training is necessary for psychopharmacotherapy.
In other words, are 8 years of training necessary to become a competent and ethical psychotherapist/psychopharmacotherapist.
DoD psychologists had far less med training than that and still were impartially evaluated to be so considered; same for psych NPs.

So, maybe, just maybe, it is not the length of training that matters but the depth; not QUANTITY but QUALITY of training. Just maybe

To be continued...

 

[sasevan]

Continued

PublicHealth,

You mentioned the possibility of PhD/PsyDs becoming NPs in order to gain RxP. Some psychologists are going that route but while it solves some problems it creates some others, such as:

1. PhD/PsyDs would be prescribing as NPs thus keeping psychology as a discipline on the periphery of the healthcare field; this is unacceptable to the big APA because it is very committed to expanding psych presence from academia to healthcare, including primary as well as specialty care beyond mental health.
2. NPs have RxP in all 50 states but only autonomous authority/full formulary in 11 states and DC; big APA is committed to the DoD model which is independent practice.
3. Psychologists entering nursing school for the sole purpose of becoming prescribers presents obvious ethical challenges as I'm sure you can envision.

PublicHealth and Dentite001,

I'm running out of time here so instead of commenting on your respective proposals I'd rather echo Svas' evaluation of them which I think is very well thought out and he is someone who is much better informed and articulate than I.

Instead, I'd rather share some reflections and ask for your and others' responses.

Should med psych be:

1. a clinical psych spec, such as neuro psych, health psych, forensic psych, etc, or
2. should it be a hybrid of med school and psych school training?

The big APA supports the former, the little APA opposes both, and I am open to either. I also believe that both of your respective proposals tend to lean towards the latter so I'd like to begin a discussion on that.

First some history, and then a rumor.

HISTORY

PhD-to-MD Program

The PhD-to-MD Program was a special program started by the University of Miami School of Medicine in 1971. It was an innovative and extremely selective program in which students holding the PhD degree could earn the MD degree in just two years.

The program was discontinued in 1987 at the request of the Liaison Committee for Medical Education. Since this organization accredits all medical schools in the United States and Canada, there are no other programs like the PhD-to-MD Program in North America.

RUMOR

psych PhD/PsyD entering a shortened DO program resulting in a psychologist-psychiatrist practitioner.

I presume that the AMA would be opposed just on the basis that the little APA is vehemently opposed to PhD/PsyD gaining RxP without going through an additional 8 years of training and most psychiatrists are MDs, but what about the AOA?

perhaps that shortened DO program could include 2 years of med science, 1 year of clerkship, and 2 years of psychiatry residency, including rotations in IM, neuro, and C-L as well as outpatient and inpatient mental health.

of course, this would be in addition to an also shortened PhD/PsyD program that could perhaps include 3 years of behavioral science and 2 years of psychology residency.

Any thoughts???

Peace to all.

 

[PublicHealth]

RUMOR

psych PhD/PsyD entering a shortened DO program resulting in a psychologist-psychiatrist practitioner.

I presume that the AMA would be opposed just on the basis that the little APA is vehemently opposed to PhD/PsyD gaining RxP without going through an additional 8 years of training and most psychiatrists are MDs, but what about the AOA?

perhaps that shortened DO program could include 2 years of med science, 1 year of clerkship, and 2 years of psych residency, including rotations in IM and C-L as well as outpatient and inpatient mental health.

Any thoughts???

Peace to all.

Sign me up! Where did you hear about this rumor? I described something along these lines in previous posts. With several DO schools opening branch campuses across the country, and a national shortage of psychiatrists, I'm surprised that a program like this has not been implemented. Interesting posts...

 

[thethrill]

SVAS and everyone else, do you believe psychiatrist should be replaced by psychologist? I have not heard SVAS say one positive thing about psychiatrist and you profess to be a psychiatrist. If not, what role do you see psychiatrist playing in the future if psychologist do everything done by current psychiatrist.

 

[PsychMD]

OK, I need some term definitions, and some clarifications here, because I am getting confused by your last post, sasevan.

I have never heard of the terms "big APA" and "little APA". I have to infer from the last post that Sasevan defines "little APA" as being the American Psychiatric Association, and to presume that the qualifying adjective "little" refers to the total number of members, which indeed is lower within the APA (as compared with the number of psychologists who are members of the A. Psychological Assoc.). Am I correct?

Sasevan also notes that several participants to this discussion forum (which is primarily a forum for Psychiatrists in training, although we have also some graduated Psychiatrists participating here as well) are "all on the same page" regarding the appropriateness of psychologists prescribing dangerous substances. Indeed this may be the opinion of a few participants, (Svan, Sanman, Public Health), however none of these posters are either Psychiatry residents nor Psychiatrists currently in practice, nor do they seem to be medical students or other specialists aspiring to apply for an ACGME accredited Psychiatry residency training program. Please correct me if I am wrong.

 

[sasevan]

OK, I need some term definitions, and some clarifications here, because I am getting confused by your last post, sasevan.

I have never heard of the terms "big APA" and "little APA". I have to infer from the last post that Sasevan defines "little APA" as being the American Psychiatric Association, and to presume that the qualifying adjective "little" refers to the total number of members, which indeed is lower within the APA (as compared with the number of psychologists who are members of the A. Psychological Assoc.). Am I correct?

Sasevan also notes that several participants to this discussion forum (which is primarily a forum for Psychiatrists in training, although we have also some graduated Psychiatrists participating here as well) are "all on the same page" regarding the appropriateness of psychologists prescribing dangerous substances. Indeed this may be the opinion of a few participants, (Svan, Sanman, Public Health), however none of these posters are either Psychiatry residents nor Psychiatrists currently in practice, nor do they seem to be medical students or other specialists aspiring to apply for an ACGME accredited Psychiatry residency training program. Please correct me if I am wrong.

Hi PsychMD,

Sorry about the confusion
Here's the clarification:
1. Yes, big APA refers to the American Psychological Association and little APA to the American Psychiatric Association.
2. Yes, the adjectives are in reference to the number of members: the big APA has about 150,000 and the little APA has about 35,000.
3. The terms are not meant to be derogatory in the least; as I noted in the same post, at least for me, length of training is not as important as depth of training, quantity is not as important as quality, in other words I'm not using those terms in any way to degrade psychiatry as size is not that important to me; I think this sounds kind of funny More importantly, though, I'm not in any way degrading psychiatry since I eventually want to be a psychiatrist myself though I will be a psychologist in about 3 months. In the med center where I am a number of providers are both psych PhD/PsyDs and psych MD/DOs.
4. It is really cumbersome to keep writing the full name of both associations every time I refer to them.
5. Big APA, little APA is used by some psychologists to differentiate in informal settings while APA (PhD/PsyD), Apa (MD/DO) is used in more formal ones.
6. I believe some psychiatrists do the inverse, please correct me if I'm wrong.

As far as Svas, Sanman, PublicHealth, etc. I believe they better than I should respond to your questions/comments about their respective disciplines.

My comment about being on the same page was directed to Svas and Sanman and not to anyone else on this forum.

Neither the moderators of the Psychiatry nor the Clinical Psychology forums have limited posts to the practitioners or students of those respective disciplines. Neither have any other moderator of any other forum.

Due to recent events there has obviously been an incredible desire to vent, celebrate, condemn, and more recently to dialogue among individuals very concerned about the future of both psychiatry and psychology. Thus, the increase number of cross-postings. If you go to the Clinical Psychology forum you will see plenty of posts from psychiatry residents and med students just as you've seen in the Psychiatry forum the inverse. I actually think its a good thing

 

[Svas]

SVAS and everyone else, do you believe psychiatrist should be replaced by psychologist? I have not heard SVAS say one positive thing about psychiatrist and you profess to be a psychiatrist. If not, what role do you see psychiatrist playing in the future if psychologist do everything done by current psychiatrist.

I've answered this before. I think that the current field described as psychiatry should probably evolve into behavioral neurology. I think that psychologists will ultimately replace psychiatry.

Then again, I could be wrong.

As to what my discipline is: I'm a psychiatrist (and before that I was a chemist for Dow).

S

 

[thethrill]

SVAS

Where I'm from we are proud to be psychiatrist. I would hate to be in your residency program if you are indeed a psychiatrist, which I very much doubt. You are a psychiatrist that doesn't even believe in your own profession, your colleagues and residents would be embarassed if they knew your thoughts. Behavioral neurologist?!? way to recreate the wheel. Neurology, psychotherapy, research and medicine all in one program = psychiatry residency. There are no short cuts. I agree somethings could be tweaked but I think medical school is a great/necessary evil. Again, psychologist does not equal psychiatrist. You should not be working with residents if you don't believe in psychiatry. Any other residents think this?

 

[PublicHealth]

Sasevan also notes that several participants to this discussion forum (which is primarily a forum for Psychiatrists in training, although we have also some graduated Psychiatrists participating here as well) are "all on the same page" regarding the appropriateness of psychologists prescribing dangerous substances. Indeed this may be the opinion of a few participants, (Svan, Sanman, Public Health), however none of these posters are either Psychiatry residents nor Psychiatrists currently in practice, nor do they seem to be medical students or other specialists aspiring to apply for an ACGME accredited Psychiatry residency training program. Please correct me if I am wrong.

Call the SDN Police! Non-psychiatry residents have invaded the Psychiatry Forum! Seriously, if you're so opposed to psychologists gaining prescription privileges, your time would be better spent writing your state politicians instead of policing online forums.

 

[Svas]

SVAS

Where I'm from we are proud to be psychiatrist. I would hate to be in your residency program if you are indeed a psychiatrist, which I very much doubt. You are a psychiatrist that doesn't even believe in your own profession, your colleagues and residents would be embarassed if they knew your thoughts. Behavioral neurologist?!? way to recreate the wheel. Neurology, psychotherapy, research and medicine all in one program = psychiatry residency. There are no short cuts. I agree somethings could be tweaked but I think medical school is a great/necessary evil. Again, psychologist does not equal psychiatrist. You should not be working with residents if you don't believe in psychiatry. Any other residents think this?

I'm attempting to answer the question of where I *think* psychiatry *will* evolve. I suspect that behavioral neurology is a larger umbrella. It's okay not to agree, Thrill. However, what you have suggested about psychiatrists being competent at neurology is way off base. Most psychiatrists are very weak at functional neurology and VERY weak in the required biochemistry for this field. The average psychiatrist is a very poor reader of MRI's and most can't get through an EEG without pulling Aminoff off their shelves (presuming they know where it is).

As to whether or not I'm a psychiatrist - well, that's silly. You've thrown a philosophical gauntlet down that is ridiculous & without much merit. What your essentially saying is : "Anyone who doesn't see the world my way is probably not what I am." The flaws to that argument are so apparent that I won't bite. That other trainees would agree with you is beside the point. After being out, practicing and teaching for this long, *I'm* pretty certain of what I see happening.

Now, do I think that my fellow psychiatrists like this position? No. Do I advertise that I'm in favor of this adaptation? Not really. Will I explain it in a public forum if asked. Sure, I've done this. However, I've got a couple of more years to put in here before I can be as vocal as I'd like to be regarding the changes that I think psychiatry needs to address in order to survive.

Are my resident's embarrassed? No. Would I teach in an MS Psychopharm program? Absolutely. Why? Because I can do a better job of insuring that their training is more complete if I (as a psychiatrist) actively train them versus their getting their training from someone who is NOT a psychiatrist.

BTW, I love what I do as well. I identify with being a psychiatrist, although I'm boarded in neurology too. It's readily apparent from my teaching and consultation practice. However, I'm also open to new ideas and professional opportunities.

 

[sasevan]

Sounds to me that as the stigma of mental illness declines there will be an increased demand for assessment and treatment, possibly further taxing psychiatry's efforts to provide mental healthcare. The relief for this situation may well be psychology's procurement of RxP.
In the 1950s and 1960s psychiatry argued that psychology was an academic disciplined and social science and that as such it could not provide medical evaluations and interventions such as diagnosis and psychotherapy.
In the 1990s and currently psychiatry's arguments against the expansion of psychology's scope of practice into psychopharmacotherapy is much the same.
Maybe we can learn from history and combine our efforts not to fight with one another but rather to fight together to achieve parity in healthcare funding and to develope ever more effective means of primary, secondary, and tertiary prevention.
Psychology is just as concerned about patient care as is psychiatry and there are plenty of patients to go around, in fact, far too many who want services but can't afford them and/or can't find a provider.

Please see below. Peace.

APA POLL: MOST AMERICANS HAVE SOUGHT MENTAL HEALTH TREATMENT BUT COST, INSURANCE STILL BARRIERS

--------------------------------------------------------------------------------

WASHINGTON -- Nearly half of Americans have had someone in their household seek mental health treatment, but most still perceive cost and lack of insurance coverage as barriers according to national poll results released today by the American Psychological Association (APA). The poll also shows that stigma about seeking mental health treatment is increasingly less of a barrier to getting treatment.

Nearly half (48%) of American households have had someone see a mental health professional and nine out of 10 Americans say they are likely to consult or recommend a mental health professional if they or a family member are experiencing a problem.

Those polled say lack of insurance coverage (87%) and concerns about the cost of treatment (81%) are important reasons not to seek help from a mental health professional. More and more Americans (85%) think health insurance should cover mental health services, up from 79% when asked the same question in December 2000. And access to those mental health services is very important to 97% of those polled, although only 70% say they feel they have adequate access to mental health care.

The poll shows that only 30% of Americans say they would be concerned about other people finding out if they saw a mental health professional and only 20% believe there is any stigma associated with therapy. Nearly half (47%) say that the stigma surrounding mental health services has decreased in recent years, and the media gets the most credit for that (35%), although society in general (25%) seems to be more accepting as well.

?We?ve made progress in people?s attitudes toward getting mental health treatment, or seeking it for their loved ones,? said Russ Newman, PhD, JD, APA?s executive director for professional practice. ?But cost, lack of insurance, and access still can be barriers for people in getting the help they need.?

Lack of access can range from health care plans whose criteria make it nearly impossible to have adequate mental health treatment, to scarcity of qualified health care professionals. For example, in Louisiana, waiting time to see a psychiatrist averages as long as six months. That state?s governor last week signed a law allowing specially-trained psychologists to prescribe medication to people with mental health disorders in mental health treatment, thereby, expanding the pool of qualified medical professionals who can prescribe psychotropic medicines to those in need.

The survey of 1,000 Americans was conducted by Penn Schoen & Berland on January 26-27. All respondents were between the ages of 18 and 64 years old. The margin of error for the study is ? 3.1 at the 95th percent level.


--------------------------------------------------------------------------------

The American Psychological Association (APA), located in Washington, DC, is the largest scientific and professional organization representing psychology in the United States and is the world?s largest association of psychologists. APA?s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its 53 divisions and its affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science and profession, and as a means of promoting health, education, and human welfare.


--------------------------------------------------------------------------------

 

[Svas]

Call the SDN Police! Non-psychiatry residents have invaded the Psychiatry Forum! Seriously, if you're so opposed to psychologists gaining prescription privileges, your time would be better spent writing your state politicians instead of policing online forums.

From the FAQ page:

Organizational Relationships

SDN has regular contact with many organizations within the medical education community. However, SDN serves as an independent site and has no direct relationship with any school, professional organization, or company, other than its parent organization, The Coastal Research Group, a 501(c)(3) charitable educational organization.

The Student Doctor Network is an entirely volunteer resource. SDN is run by a small group of unpaid volunteers that are dedicated to providing students unbiased information. SDN is here to tell you the real story about the health professions and help you reach your goals.

I like these statements, but as we're learning . . . being unbiased is nearly impossible (in anyone).

S

 

[sasevan]

Sign me up! Where did you hear about this rumor? I described something along these lines in previous posts. With several DO schools opening branch campuses across the country, and a national shortage of psychiatrists, I'm surprised that a program like this has not been implemented. Interesting posts...

Remember, its just a rumor

What I've heard is that at a DO setting there have been some physicians exploring that possiblity with some psychologists very much involved in the RxP movement. (I have a psychologist friend who has been asked to give feedback about such a possibility).

Howver, in reality I doubt that given recent developments the big APA would be willing to go that route.
The incoming president of APA, Dr. Levant, has been one of the most committed proponents of RxP since even before the big APA and most PhD/PsyDs were in favor. The big APA wants psychologists to have RxP not to be psychiatrists.
As NM gets ready to go forth with implementation of its RxP legislation and as LA also goes forth with its own RxP legislation based on a model likely to be more acceptable to physicians and legislators (NM provides for independent practice, LA for collaborative) I believe the big APA views RxP as a train that has already left the station.
I also doubt if the AOA would be willing to develope a med specialty that would not be recognized by the AMA (because of the little APA) or if such a discipline would be recognized by the accreditation committee for med edu (both MD and DO) as evidenced by that committee putting an end to the University of Miami's PhD-to-MD program.

 

[thethrill]

The answer to helping more mental health patients is to open more psychiatry residency spots. The government put a freeze on developing new residency spots back in 1997, it is high time to reverse that and open more psych residency spots. Also, sasevan your are right it is near impossible for individuals with mental illness to afford good healthcare and the government nowing this is not helping. If you fart sideways and go to the ER you will get a 3-5 day hospital stay and a million dollar work-up. But if you go crazy the government doesn't recognize this as a serious health issue and greatly limits the amount of money spent on the mentally ill. If you get a nose bleed and go the to ER you'll get a CT of MRI. But it is like pulling teeth to get any imagining on a new psych patient. The main reason the government wants to give psychologist rx priviledges is because they see psychologist as less expensive labor. The government will not reimburse psychologist the same as psychiatrist. SVAS, dude you are smoking down again, psychiatrist don't and shouldn't read EEG's, you need to be a trained neurologist to do that. If you are managing epileptics that is malpractice waiting to happen. Neurology and Psychiatry separated many years ago although our degree is giving as the board of Neurology and Psychiatry. There is no way to combine these fields again it is far too encompassing. These fields split for a reason. I do agree we need more neuro in Psych training, but to read EEG's let's get real.

 

[Svas]

. . . psychiatrist don't and shouldn't read EEG's, you need to be a trained neurologist to do that. If you are managing epileptics that is malpractice waiting to happen. Neurology and Psychiatry separated many years ago although our degree is giving as the board of Neurology and Psychiatry. There is no way to combine these fields again it is far too encompassing. These fields split for a reason. I do agree we need more neuro in Psych training, but to read EEG's let's get real.

My residents CAN read MRI's and EEG's by the time they are done. If the EEG's reflect seizure, they get consults. The consultant either remains a consultant or becomes a co-treating doc. EEG's are pretty simple (pattern recognition & we've proven that HS students can do it effectively). MRI's are more complicated . . . but it's amazing what you can do if you understand both structural and functional neuroanatomy. This really should be required knowledge now in psychiatry - but you may discover that your professors don't know the field very well.

There's NO way to combine these fields again? Surely you jest. You made a case earlier for the fact that psychiatry was already the perfect marriage of these fields.

I gotta go mow the lawn & think about how to help you see that the future is much brighter if you adapt more effectively. Otherwise, you're going to end up only reminding me of that famous line by Danny DiVito from "Other People's Money" regarding the making of buggy whips.

S

 

[sasevan]

PART I



Commentary: The Prescription Jihad
by Ali Hashmi, M.D.
Psychiatric Times July 2001 Vol. XVIII Issue 7


--------------------------------------------------------------------------------
I was compelled to pen this piece after reading yet another opinion on the fierce psychologist-prescribing debate in the Feb. 3 issue of Psychiatric News.
Before I go any further, some disclosures are in order. I am a psychiatrist, employed by a community mental health center in Arkansas, in a 100% outpatient practice. I am one of four psychiatrists (three specializing in the treatment of adults and one in child psychiatry) employed by our center, and we serve a catchment area of seven counties with a combined population of approximately 200,000. Despite having trained in a traditionally psychoanalytic program at Baylor College of Medicine, I was always more comfortable with medication evaluations and with what today would be called the biological aspect of psychiatry. I do very little therapy per se, apart from supportive therapy, some crisis intervention and education. I do, therefore, have a vested interest in keeping prescribing privileges out of the hands of non-physicians.

Having said that, I find it more than a little amusing when I hear all kinds of high-minded arguments being bandied about over what is obviously an economic issue. To quote from the above-mentioned article by Jan Leard-Hansson, M.D., "To prescribe medication properly the physician must know the patient from head to toe?We, as psychiatric physicians, must maintain a steadfast commitment to protecting and providing high-quality patient care."

Admirable sentiments indeed, but when was the last time Leard-Hansson, or any of us, did a rectal examination on a patient? Or auscultated their chest? Or palpated their lymph nodes or liver? Even my colleagues who work in hospital settings routinely defer physical examination to their internal medicine or family practice consultants. The simple truth of the matter is that sub-specialization, by definition, means that most of us lose some of the skills that we learned in medical school, primarily those that we do not use on a regular basis. I know that I would have a tough time picking up a murmur on a chest exam or appreciating a subtle physical finding. It is, therefore, more than a little disingenuous to claim that we, as psychiatrists, know our patients from head to toe. The day-to-day practice of our art demands, in fact, that we concentrate on certain areas and de-emphasize others, referring patients to others with more expertise when necessary. Surely, I find it easier to examine a routine blood report and pick up obvious abnormalities or interpret the results of a computed tomography or magnetic resonance imaging scan, but those are skills that can be learned with time.

Coming back to the main topic of non-physician prescribing, the arguments being put forward by both camps (i.e., physicians and non-physicians--mainly psychologists but soon to be joined, I am sure, by social workers and other clinical personnel) are similar. Each side accuses the other of being petty and money-grubbing, while claiming the moral high ground for themselves.

The Psychiatrists

Psychiatrists claim that the whole psychologist-prescribing effort was born of the drive toward managed care. Managed care organizations are increasingly driving down the rates of reimbursement for both therapy and psychological testing, while farming out therapy to ancillary (read "cheaper") clinical staff such as licensed certified and master's level social workers and associate counselors, or even counselors with only a bachelor's degree.

The managed care trend has also put psychologists in the uncomfortable position of feeling like a fifth wheel relegated to doing psychological and neuropsychological testing, which may also one day be delegated to even less costly technicians. Prescribing ability would ensure a more reliable income stream for psychologists. In addition, prescribing is much less labor intensive than therapy or testing.

The psychiatric community claims, with some justification, that this is uncomfortably similar to the top of a slippery slope. What is next? Prescribing privileges for social workers, marriage, family and child counselors, case managers, and mental health technicians? Where does it stop?

Psychiatrists argue that they oppose this effort purely for the sake of their patients and with the purest motives at heart. (I am exaggerating, of course, but you get the gist.) Psychiatrists are resistant to psychologist prescribing because non-physicians would have a greater risk of missing crucial side effects, drug interactions and co-existing medical conditions, thereby leading to increased morbidity and mortality. There is something to be said for this concern, but it requires a greater leap of faith. Have none of us psychiatrists ever had any patients with bad outcomes? Of course we have, but one learns and moves on and, presumably, non-physician prescribers could do the same.

 

[sasevan]

PART II

The Psychologists

Psychologists, on the other hand, claim that managed care organizations are increasingly restricting access to psychiatrists, preferring that psychopharmacological management is done by primary care physicians.

Also, thanks to managed care, Medicare and the Health Care Financing Administration, recent graduates from psychiatric residency training programs are well-versed in medication evaluation and management but are increasingly unaware of, and uninterested in, therapy skills. This makes psychiatrists little more than "dispensers," diagnosing people through DSM-IV checklists and prescribing the recommended medications according to various algorithms--something that can be done by a simple computer program, and for much less cost than using human dispensers. The move away from trying to understand the inner lives of people and learning how their relationships, families and feelings impact their illness makes today's psychiatrists increasingly expendable and replaceable by family physicians who can do the necessary prescribing while also caring for day-to-day illnesses. Psychologists argue, with some justification, that psychiatrists are already obsolete or will be in short order.

Also, unlike oncological chemotherapy, invasive cardiology or neurosurgery, for example, psychopharmacology is hardly rocket science. There are a limited number of agents, with most belonging to two or three major classes with similar efficacy and side-effect profiles. The safety margins--especially for the newer agents--are wide, with even large overdoses rarely proving fatal. In addition, the proponents of the psychologist-prescribing effort point out that the recently discontinued U.S. Department of Defense program has demonstrated that non-physicians with appropriate training can be just as effective and safe as physicians.

However, psychologists argue that they want prescribing privileges not for the crass purpose of making more money, but because the result would be an increase in the availability of qualified psychopharmacologists in rural areas where the need is still great. This argument flies in the face of several recent papers that have pointed out that, traditionally, doctorate level psychologists tend to cluster in big cities usually in and around universities.

It is the psychologists and their supporters, some say, who are the noble warriors in this crusade, battling against those dastardly psychiatrists (again, I exaggerate, but you get the gist).

Conclusions

As can be seen, there are valid arguments from both sides, and both sides have a vested economic interest in the outcome, which is usually unacknowledged. From personal experience, I have spoken to a number of psychologists on this issue, none of whom were enthusiastic about prescribing. These are qualified, competent people who do therapy, psychological testing, disability evaluations and some administrative work and are well-satisfied with what is on their plate. Most of them were of the opinion that the added monetary benefits of prescribing were not worth the additional risks of making decisions about people's suicidality, proneness to violence and other issues of potential medicolegal consequence, such as the use of psychotropics in pregnancy. They were more than happy to defer such decisions to the physician.

An added disincentive is the attendant deluge of drug-seeking patients, such as those with ill-defined physical conditions (i.e., chronic back pain, fibromyalgia, chronic fatigue) or others with intractable personality disorders who demand benzodiazepines, pain medications and the like. I see a large proportion of such patients in my day-to-day practice, and they are usually the ones I dread.

There are others who are either on, or in the process of applying for, disability. There is, of course, no hope that any of them will ever improve, since substantial improvement would mean loss of benefits. It's like walking on a treadmill. No matter how long you walk, you stay in exactly the same place.

Of course, I practice in a rural area where there are generally more patients than qualified practitioners. The situation is likely different in larger cities where there may be a large number of practitioners and where competition for patients may be fierce.

On the other hand, I have at times wished that there were more of us, simply because the need appears so great. The number of people needing care, from nursing home patients to adults to schoolchildren, means that most of us are booked up to six weeks or more in advance, and at times some extra help would be welcome. Just as family practice doctors often have nurse practitioners or physician assistants who can prescribe under supervision, perhaps a similar system could be devised for non-psychiatric prescribers. The quality and knowledge base would likely vary widely, but in the long term, self-selection would eliminate those with obvious deficiencies.

I think prescribing privileges for non-physician personnel are inevitable at some point. If such practitioners would cost less than psychiatrists, you can be sure managed care will be the first to jump on the bandwagon. As psychiatrists, our choice is not between having or not having non-physicians prescribe psychotropics. Our challenge is to engage in this process in a way that is productive and non-confrontational. In the long term, as with managed care, we will gain more by being active and shaping the debate rather than being isolated behind the ramparts of our self-righteousness, firing off shots in the dark.

Dr. Hashmi is a board-certified psychiatrist practicing at Mid-South Health Systems, a community mental health center in Jonesboro, Ark.

 

[PsychMD]

I have a question (and I am NOT trying to be facetiously "naive"; I'm genuinely trying to find out, actually, from a Public Health perspective): why do you think that the demand for mental health treatment has seemingly skyrocketed in the last 2 decades? Is our nation suddenly growing profoundly unhealthy (mental health-wise)? (Understanding "health" as per the WHO definition of a state of physical and psychological balance and well-being). Epidemiologically, the major mental illnesses are still around the same rates, aren't they? I don't really know. I am not trained in public health issues nor in public health policy issues, so probably I don't even have the tools to either ask or answer this question in a meaningful way. I was hoping maybe for some brainstorming here, prompted by the last couple of posts which seem to advocate rx. privileges for psychologists based on this lack of access to much needed care.

I also wanted to observe that treatment for psychiatric disorders does not necessarily equal pharmacotherapy alone, as we all know; most often than not, it's a combination of biological, psychological, AND social treatments (you know, the "old" bio-psycho-social paradigm). Of course, now, with the tremendous advances in psychopharmacology, we have some better tools available, but overall it is indeed true: the demand ouweighs the resources by far, and there seems to be no end in sight. Not even an ARMY of psychologists armed with BOTH psychotherapeutic knowledge AND with rx. pads will satisfy this demand at this time, IMHO.

Maybe I'm just repeating a truism here, but, in my personal experience: most patients who are truly in need of mental health care are CHRONIC, lack any funds, any insurance, most are homeless, most have a multitude of co-morbid substance abuse, and possibly other illnesses as well (with no access to even the most basic primary care either, unfortunately). This is the most underserved patient population of all. Some pills may make them temporarily a little better, during an acute exacerbation maybe, but...what about the tx. setting? Most community hospitals are closing their psych. units in droves, the funding for Community mental health has been declinig precipitously; state hospitals beds are practically almost non-existent relative to the demand (we're talking about really sick people here); a large percentage of the mentally ill are now in the correctional setting, etc. Where are the public health solutions for this increasing demand relative to the meagerness of the resources?

That's why I was saying that this is NOT just about having MORE people able to rx. psychotropics (or even about people being BETTER trained re. psychotropic rx.). Now, especially now...when even most psychiatrists and most Family Practice docs are growing actually INCREASINGLY CAUTIOUS about rx'ing ANY psychotropics, especially antidepressants...because we are starting to learn that psychotropics are in many cases actually potentially detrimental or just don't help more than placebo...especially when it comes to depression, anxiety, that Pharma studies have had problems, etc.

I just wanted to throw this too on the table for further discussion, because the answer to the growing "crisis" in Mental Health tx. access does not seem to be as easy as just having more numbers of prescribers, IMHO.

And...overall...thinking from a historical perspective...psychiatric patients have always had a hard time, even in the pre-Pharma era...I don't really see that much has really improved re. quality of tx. or access to tx. or tx. resources at "mass level" since the Pharma era started either. (Other than Pharma making $ billions).

Are you guys (who are advocating the rx. privileges for non-physicians)...are you sure you're not playing into the hands of Pharma corporate interest, while thinking that you are advocating for better/improved mental health tx. solutions...?

 

[PsychMD]

Not to make light of the situation or distract from the main topic, but I thought this may bring a bit of much needed humorous relief (albeit somewhat bitter too!)
http://www.nytimes.com/2004/05/16/f...00&en=2171dfc250b84b27&ei=5062&partner=GOOGLE

(It's about oral surgeons in CA trying to get privileged to do plastic surgery procedures, rendering the Assoc. of Plastic Surgeons "appoplectic", as quoted in the article!)

 

[PublicHealth]

I have a question (and I am NOT trying to be facetiously "naive"; I'm genuinely trying to find out, actually, from a Public Health perspective): why do you think that the demand for mental health treatment has seemingly skyrocketed in the last 2 decades? Is our nation suddenly growing profoundly unhealthy (mental health-wise)? (Understanding "health" as per the WHO definition of a state of physical and psychological balance and well-being).

http://www.iop.kcl.ac.uk/iopweb/departments/home/default.aspx?locator=528

Is Psychiatry for Sale?: an examination of the influence of the pharmaceutical industry on academic and practical psychiatry

Joanna Moncrieff (foreword by Fuller Torrey)
Institute of Psychiatry, King's College, London

Foreword
Dr. Moncrieff's question has been answered in the United States, where it is clear that psychiatry has already been sold. The buyer was Big Pharma. The sale price has not been disclosed, but rumor has it that the pharmaceutical industry got a bargain.

The author is right on target in her descriptions of the compromise of individual psychiatrists and of drug trials. She is also correct in decrying the extension of psychiatric diagnoses so as to enlarge the markets for pharmaceutical products. It is, in fact, embarrassing to see colleagues who were once respected line up under the banner of limitless "social anxiety" or "subsyndromal depression," then collect their paychecks from pharmaceutical representatives.

Unfortunately, Dr. Moncrieff also throws out the baby with the bath water. Major depressive disorder, bipolar disorder, schizophrenia, and other major psychiatric disorders are brain diseases, and the evidence to support this is overwhelming. They are in exactly the same category as Parkinson's disease and multiple sclerosis. Social factors must be considered in the treatment of all such disorders, but changing social factors will not prevent or cure them. One can criticize the pharmaceutical industry and its compromise of the psychiatric profession without discarding the medical model. Indeed, I am impressed by the large number of truly brain-diseased individuals in the United States who are unable to afford to purchase the drugs they need, because the drugs cost so much. And one reason they cost so much is because the drug companies have purchased so much pizza for psychiatric trainees and so many perks for practicing psychiatrists.

But do not blame Big Pharma-they are just doing what companies are expected to do in a free enterprise society. They are selling their goods in any way they can. Instead, blame our psychiatric colleagues who are colluding in the process and who should know better. We need more young psychiatrists like Dr. Moncrieff to save the profession from degenerating into a pharmaceutical brothel.

Summary
Western society is consuming ever larger quantities of prescription drugs and many of these are for psychiatric complaints. Drugs are central to modern psychiatric practice and to much psychiatric thought about the nature and causation of mental disorders. Psychiatry has therefore become an important target for the large and powerful pharmaceutical industry. Drug companies direct lavish advertising and hospitality towards psychiatrists and provide funding for much medical education and some mental health service initiatives. The industry is now heavily involved in the organisation of research into psychiatric drugs and the dissemination of research findings. This raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. Drug companies also provide funds for pro drug patient and carer groups and address advertising or disease promotion campaigns to the general public. They exert influence at a political level through lobbying and direct funding of political bodies including drug regulatory agencies.

This influence has helped to create and reinforce a narrow biological approach to the explanation and treatment of mental disorders and has led to the exclusion of alternative explanatory paradigms. The coercive function of psychiatry has been strengthened by promoting the idea that psychiatric disorders are akin to medical conditions and that they are amenable to technical solutions in the form of drugs. In addition, alternative treatment approaches are neglected and it is likely that drugs are currently used for overly long periods and in excessive doses. The adverse effects of drugs are neglected.

Psychiatry provides fertile ground for pharmaceutical industry profits because it provides opportunities for expanding definitions of sickness to include more and more areas of social and personal difficulty. This paper gives examples of how the industry has been involved in promoting and expanding concepts such as depression, social phobia, attention deficit hyperactivity disorder and psychosis.

The current extent of drug company influence threatens the integrity of psychiatry and some suggestions are made about steps that could be taken to address this. The influence of the industry must be curbed for political reasons too. We are rapidly becoming a society that seeks a "pill for every ill;" one that looks for simplistic, technical solutions to complex social problems. This helps to divert attention away from the profound social and political changes that have occurred during the last few decades. Psychiatrists should not be colluding in this process.

 

[sasevan]

Not to make light of the situation or distract from the main topic, but I thought this may bring a bit of much needed humorous relief (albeit somewhat bitter too!)
http://www.nytimes.com/2004/05/16/f...00&en=2171dfc250b84b27&ei=5062&partner=GOOGLE

(It's about oral surgeons in CA trying to get privileged to do plastic surgery procedures, rendering the Assoc. of Plastic Surgeons "appoplectic", as quoted in the article!)

That was hilarious. Thanks for the link.

 

[sasevan]

I have a question (and I am NOT trying to be facetiously "naive"; I'm genuinely trying to find out, actually, from a Public Health perspective): why do you think that the demand for mental health treatment has seemingly skyrocketed in the last 2 decades? Is our nation suddenly growing profoundly unhealthy (mental health-wise)? (Understanding "health" as per the WHO definition of a state of physical and psychological balance and well-being). Epidemiologically, the major mental illnesses are still around the same rates, aren't they? I don't really know. I am not trained in public health issues nor in public health policy issues, so probably I don't even have the tools to either ask or answer this question in a meaningful way. I was hoping maybe for some brainstorming here, prompted by the last couple of posts which seem to advocate rx. privileges for psychologists based on this lack of access to much needed care.

I don't know the answer to this question but I suspect that as the stigma of mental illness has declined there has been a proportional rise in patient recognition, reporting, and request for mental health services. As the big APA's article suggested, much of the decline in stigma has been due to media coverage which has perhaps helped to educate patients and their families as to the etiology of much of psychopathology lying not in Mother but in biochemical dysfunction and/or maladaptive cognitive and behavioral patterns.

I also wanted to observe that treatment for psychiatric disorders does not necessarily equal pharmacotherapy alone, as we all know; most often than not, it's a combination of biological, psychological, AND social treatments (you know, the "old" bio-psycho-social paradigm). Of course, now, with the tremendous advances in psychopharmacology, we have some better tools available, but overall it is indeed true: the demand ouweighs the resources by far, and there seems to be no end in sight. Not even an ARMY of psychologists armed with BOTH psychotherapeutic knowledge AND with rx. pads will satisfy this demand at this time, IMHO.

It may not satisfy demand at this time but it would make a dent. There are currently about 60,000 psychology students. Of course, not all or maybe even the majority of these will want to become med psychologists as there are numerous other cl psych spec, such as neuro psych, forensic psych, etc. and there are also many non-cl psych fields such as experimental psych, industrial-organization psych, etc. But some would be willing to undergo the additional training and then go and practice where there is a critical need/financial opportunity, i.e., rural areas and the inner city.

Maybe I'm just repeating a truism here, but, in my personal experience: most patients who are truly in need of mental health care are CHRONIC, lack any funds, any insurance, most are homeless, most have a multitude of co-morbid substance abuse, and possibly other illnesses as well (with no access to even the most basic primary care either, unfortunately). This is the most underserved patient population of all. Some pills may make them temporarily a little better, during an acute exacerbation maybe, but...what about the tx. setting? Most community hospitals are closing their psych. units in droves, the funding for Community mental health has been declinig precipitously; state hospitals beds are practically almost non-existent relative to the demand (we're talking about really sick people here); a large percentage of the mentally ill are now in the correctional setting, etc. Where are the public health solutions for this increasing demand relative to the meagerness of the resources?

I absolutely agree. Here's an issue that psychology and psychiatry could be jointly addressing, and funneling the needed resources to do so effectively, except that we're not able to do so now because we're engaged in a costly war with one another that makes cooperation on other issues difficult if not impossible. Its difficult to dialogue with, much less consider allies, those who state that psychologists are just not smart enough to learn how to prescribe for if they were they would have gone to med school and become psychiatrists in the first place.

That's why I was saying that this is NOT just about having MORE people able to rx. psychotropics (or even about people being BETTER trained re. psychotropic rx.). Now, especially now...when even most psychiatrists and most Family Practice docs are growing actually INCREASINGLY CAUTIOUS about rx'ing ANY psychotropics, especially antidepressants...because we are starting to learn that psychotropics are in many cases actually potentially detrimental or just don't help more than placebo...especially when it comes to depression, anxiety, that Pharma studies have had problems, etc.

Again, I absolutely agree. I believe that when psychologists discuss the biological dimension of mental illness and appropriate chemical intervention for it as well as when psychiatrist discuss behavioral treatments and poorly designed pharmaceutical research, we're seeing really good changes in both disciplines that I believe will lead to increased used of evidence-based medicine both by MD/DOs and PhD/PsyDs.

I just wanted to throw this too on the table for further discussion, because the answer to the growing "crisis" in Mental Health tx. access does not seem to be as easy as just having more numbers of prescribers, IMHO.

Thanks for a very positive post. We may not agree about RxP but we don't have to be disagreeable about it.

And...overall...thinking from a historical perspective...psychiatric patients have always had a hard time, even in the pre-Pharma era...I don't really see that much has really improved re. quality of tx. or access to tx. or tx. resources at "mass level" since the Pharma era started either. (Other than Pharma making $ billions).

I disagree with this. I do believe there have been some needed developments:
1. reduced stigma of mental illness,
2. the re-medicalization of psychiatry (not that I'm anti-psychodynamic, quite the contrary; I just see this as a needed correction to a time when psychoanalysis had a stranglehold on the field),
3. the biochemicalization of psychology (again, not that I'm anti-cogitive-behavioral), and
4. a growing appreciation for evidence-based practice in both disciplines.

Are you guys (who are advocating the rx. privileges for non-physicians)...are you sure you're not playing into the hands of Pharma corporate interest, while thinking that you are advocating for better/improved mental health tx. solutions...?

I believe that research has demonstrated that the best tx is in many cases a combination of both cog-behavioral and bio-chemical interventions.

As Dr. Sammons, one of the first of the DoD program's graduate, stated:

"Only if psychologists directly involve themselves in the prescription of psychotropics can they hope to play a more forceful role in issues such as overreliance on psychotropics, inappropriate use of psychotropic agents in special populations (e.g., children, elderly people), and the neglect of effective behavioral interventions. It represents a surrender to the status quo if psychologists do not intervene and bring a fundamentally different orientation to the prescription of psychotropics-and there is much to suggest that the status quo is not very good."

 

[ace9803]

Just thought I would add a short comment. I think the comment about the media is right on target. Prior to psychotropics being advertised on TV the average person didn't know what many of these disoders were and/or that they even existed. I also agree that this has been influential in reducing the stigma attached to mental illness.

One additional point that should not be overlooked is access to mental health services. You mention the work of psychologist, but how about social workers. MSW's make up a large number of our mental health professionals today. They are often more accessible and equally attractive to managed care panels. Not to mention that many of them are "altruistic" and don't charge the alarmed fees that psychiatrists charge so they are much more accessible to the average person.

I am actually a clinical social worker working in an HIV/AIDS clinic in Manhattan. Someone visiting our clinic from abroad (Nigeria) asked this very same question. Kind of interesting . She too was alarmed at the rate of mental illness seen in the clinic...granted this is a rather unique population and many factors contribute to the comorbidity. Anyway, I think I am rambling....

 

[silbenny]

...got to this thread a little late...

SVAS (you have been quite civil, but nevertheless some things must be said),
Concerning your little experiment, I completely agree with MDBLUE's response. Also, the inability by the psychiatric residents missing the cardiac arrhymias in all 4 cases and 2 misidentifying the problems with the labs may be indicative of a problem in your residency program (and perhaps in your ability as a teacher if you are indeed a psychiatrist- you did say they where third years- what exactly have you been teaching them all this time-perhaps that they have no future as a psychiatrist!). Where I am, we are taught to look at EKG and labs when prescribing- simply secondary to all the potential side effects. As for your residents telling you that it was a positive experience- what exactly did you expect- that you're an a**hole? Not many residents are going to tell their attending anything but how positive their teaching is.
To thethrill- i'll back you up. I pray to god that SVAS is not going to be teaching me when I start my residency in July.

 

[Svas]

...got to this thread a little late...

SVAS (you have been quite civil, but nevertheless some things must be said),
Concerning your little experiment, I completely agree with MDBLUE's response. Also, the inability by the psychiatric residents missing the cardiac arrhymias in all 4 cases and 2 misidentifying the problems with the labs may be indicative of a problem in your residency program (and perhaps in your ability as a teacher if you are indeed a psychiatrist- you did say they where third years- what exactly have you been teaching them all this time-perhaps that they have no future as a psychiatrist!). Where I am, we are taught to look at EKG and labs when prescribing- simply secondary to all the potential side effects. .

Silbenny,

I understand your frustration when looking ahead to residency now, particularly in light of the political climate. Post again in 4 years & let us/me know how things look (in retrospect) Good luck. Depending upon where you go, your psychiatric residency will be challenging and probably an eye-opener.

I don't get the psych residents until they hit their 3rd and 4th years. I'm going to ask my colleagues/residents about the task I presented and get their feedback regarding it's appropriateness - as I already stated I'd do. I'll inform them of the negative reaction you and MDBlue had to it. The task I presented is not different than what I've been doing for the past decade. It *was* unusual for not being attended by a couple of neurology residents who are usually floating through and that I included the PA's and NP's (I have a joint appointment in both departments). Additionally, it's not unusual to have other faculty members sit in on such events (as I do in their seminars, classes, etc.).

Unfortunately, I find that psychiatrists' abilities to understand and engage in "medicine" diminishes badly by the time 2 or 3 years go by after residency, and I think that the problem is perpetuated by our current residency training structure (nationwide). I think that medicine can be a use it or lose it phenomenon. I grow weary of looking at board-certified psychiatrists' eyes glazing over when I begin to lecture regarding pharmacokinetics, and in hearing their stories of "treatment refractory" conditions that were actually produced by drug-drug, drug-food interaction effects or pathophysiologies that I KNOW they should know. I think that re-medicalizing (to quote from a different thread) our psychiatric residencies is one of the changes that will have to be made for psychiatry to survive if it is to remain in its *current* form. It is also why I have generally supported increasing the amount of behavioral neurology that should be required of the residents - and it's why I drill and continue to educate them regarding the value of labwork.

Psychiatry struggles with being an ignored stepchild of medicine. It's a position poorly deserved. I think, though, that psychiatrists are their own worst enemy in that we ended up (for so long) accepting people who could not get any other residencies and for not confronting the pathological narcissism that was a byproduct of compensating for feeling one-downed by our medical colleagues. Now that neurology and psychiatry are clearly beginning to apparently blend (via behavioral neurology), revitalizing the field through increased attention to functional neuroanatomy, biochemistry, imaging, etc., is critical to carry us through this phase. What we CURRENTLY think of as "psychiatry" must change and, yes, I think that medical psychologists are probably going to take over the CURRENTLY perceived model. (I say, let them have it.)

Anyway, my behaviors aren't sadistic, but geared toward making sure that our psychiatrists don't lose touch with being physicians first.

(Now, don't get me started with regard to how little training psychiatrists are getting in terms of psychotherapy. I'm also strongly convinced that psychiatric residents should all be IN individual psychotherapy and group for at least 6 months (each), but that's a personal belief that I would not force-feed to anyone.)

You know, that's a great question: How often are current psychiatric residents encouraged to seek out psychotherapy for themselves for the purpose of self-review and growth (if not for working through some real psychological/characterological issues)? My sense is "not frequently." Does anyone know where I could get stats on such a question?

S

 

[silbenny]

Ah- still civil- one of the redeeming qualities of psychiatrists.
SVAS, I have no problem with your test. It's good to scut a little- best way i remember things. The issue I have is how you were trying to prove your point of the incompetencies of psychiatrists- equating them with the knowledge base of PA, NPs, etc...
As for the training- yes there are inadequacies. However, this is due to the nature of the profession and the residency itself as you have noted. For the 'medicine' part- the question should be- what knowledge is required for the current scope of our profession- many psychiatrist would agree that our knowledge base if sufficient for what is required within this scope. What this scope should encompass is debatable.

The current trend suggests that the scope is getting increasingly small- hence the ability by psychologist to eat away at the things we may not want (therapy). Prescribing privileges has always been within the core of our scope, but that is now being threatened. In my opinion it is being threatened by psychologist and fought by psychiatrist largely for economic issues. (yes I do agree that the patient will suffer in the long run) All professions have to deal with multiple changes and threats and all have the right to fight these changes. In our case, for psychologists, social workers (yes, i always hear them mumbling to themselves that they can do the job of a psychiatrist easily) the saying 'if you can't beat em, join em' doesn't work. We have set a limit on the number of psychiatry residencies and have done little to remedy the shortage. Who really didn't see these things coming- there will always be people who will take advantage of an opportunity if one is presented so clearly- can't blaim the psychologists for trying. Can't blaim the managed care companies for lovin' this- after all, their poor compensation and limits on psychotherapy are driving us away from this element of psychiatry. Now they and others have their eyes set on the prescription element of psychiatry. I have laypeople telling me they only want to go to a medical doctor if they had a mental illness. However, remove the insurance coverage and they'll probably sing another tune. Does this all mean we just lay down and take the beating? Absolutely not- we need to protect what is ours to lose. I for one plan on being actively involved. I can only hope others will be doing the same. For some reason, I get the feeling that you (SVAS) have already moved on- for better or worse- only time will tell.

 

[DrFocker]

Just Curious, everyone is quoting the DOD study as if it is god's justification for allowing Psychologists to prescribe. Am I wrong, but didn't this study have a very limited sample size (like 10 psychologists) and it took place in a military setting versus civilian? These seems flawed in many ways: Limited sample size is obvious, but can results in a military setting expect to be translated to results in civilian life? Also, it's only ONE STUDY so it seems the book is still way out on the safety and efficacy of Psychologists to Rxp. Obviously, Psychologists who lobby politicians without a science background can quote the study to lead credence to their arguement and it appears to be working. After all, how many governors have learned to look critically at scientific studies? Anyway, I guess I'm curious as to the specifics of the DoD study since it's brought out all the time in favor of Psychologists Rxp.