Oregon wants prescribing rights for Psychologists

[edieb]

I just think that for people on this thread to refer to psychologists as quacks is insane and was trying to illustrate that those who live in glass houses shouldn't throw stones... The numbers are the numbers and the data are the data...

1 - Psychiatry can't fill all of the available residency positions
2- Interest in psychiatry continues to dwindle
3 - There is a severe shortage of psychiatrists
4 - Prescribing psychologists have been prescribing in the military for 10 years and in 2 states for 3-4 years, all without incident

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[TheWowEffect]

I just think that for people on this thread to refer to psychologists as quacks is insane and was trying to illustrate that those who live in glass houses shouldn't throw stones... The numbers are the numbers and the data are the data...

1 - Psychiatry can't fill all of the available residency positions
2- Interest in psychiatry continues to dwindle
3 - There is a severe shortage of psychiatrists
4 - Prescribing psychologists have been prescribing in the military for 10 years and in 2 states for 3-4 years, all without incident

Man, I can't believe I am being drawn into this stupid argument-

1. This is so false. Psychiatry has been filling every year, including in 2009 when only 11 spots remained which filled within hours in post match. If you are using match stats, no specialty fills fully during the match and that includes surgery, internal medicine, radiology, ER etc. You probably have no idea how the match process works.

2. Interest in psychiatry is at an all-time high among medical students. Just go talk to them.

3. There is shortage of all kinds of doctors in rural and some other underserved areas. Data from NM and LA shows that RxP psychologists are not really working in underserved areas.

4. This is another false and ridiculous statement I have seen being used. Someone told me other day that psychologists use the argument that they have written 20,000 prescriptions without side effects. Can anyone claim here that their patients never had any side effects from psychotropics? These are potent medications and they WILL have side effects. I am shocked how they get away with this false argument.

 

[Therapist4Chnge]

1. This is so false. Psychiatry has been filling every year, including in 2009 when only 11 spots remained which filled within hours in post match. If you are using match stats, no specialty fills fully during the match and that includes surgery, internal medicine, radiology, ER etc. You probably have no idea how the match process works.

I think he is referring to the initial match numbers (listed below), and the inordinately high % of FMGs matching into psychiatry each year, as AMGs seem to be looking elsewhere.

General: 61.7 (AMG)
Family: 54.5 (AMG)
Neuro: 66.7 (AMG)

Obviously these statistics need to be taken with a grain of salt as there are a number of factors at play (AMGs being placed into a higher non-psychiatry placement, highly competitive FMGs taking AMG spots, etc), though I believe the overall inference is that there is less interest for AMGs to going into psychiatry as there are consistantly a large % of spots that need to be filled post-match.

2. Interest in psychiatry is at an all-time high among medical students. Just go talk to them.

While annectdotally you may see this, the match numbers don't seem to support this opinion. The exception being at some ultra-competitive psychatry placements (particularly in research heavy programs), as there always seem to attract a wide range of applicants.

3. There is shortage of all kinds of doctors in rural and some other underserved areas. Data from NM and LA shows that RxP psychologists are not really working in underserved areas.

Citation?

From my understanding, Louisiana as a state has a severe shortage of mental health providers (including prescribing professionals), so while there is a relative cluster of prescribing psychologists in the larger cities, there is still a severe shortage of overall services in the state, including in the larger cities.

I cannot speak to NM, as I do not know much about the prescribing psychologists out there.

4. This is another false and ridiculous statement I have seen being used. Someone told me other day that psychologists use the argument that they have written 20,000 prescriptions without side effects. Can anyone claim here that their patients never had any side effects from psychotropics? These are potent medications and they WILL have side effects. I am shocked how they get away with this false argument.

No, but there haven't been an malpractice claims or reports of problems with the psychologist prescribers. "Safety" is the straw man of the majority of people opposing psychologist prescribers. There has been ZERO evidence that psychologist prescribers pose a threat to the public, and in fact there has been research SUPPORTING their abilities to prescribe safely.

 

[whopper]

I just think that for people on this thread to refer to psychologists as quacks is insane and was trying to illustrate that those who live in glass houses shouldn't throw stones... The numbers are the numbers and the data are the data...

I was one of those telling those medstudents & psychiatrists out to scold psychologists as a whole to dampen their responses because it was unfair & ignorant. In fact the main person who was doing so apologized for what was said in the thread.

And I'll point that just as much to your own post.

1 - Psychiatry can't fill all of the available residency positions

Wrong, this year every spot was filled. Don't believe me? Check out the ACGME data.

2- Interest in psychiatry continues to dwindle

Wrong. Public perception of psychiatry in the last few years has improved. Number of applicants into residency programs have increased. The result of the last MATCH showed a great increase in the # of applicants. This data was published in the APA's newspaper & was based on studies.

3 - There is a severe shortage of psychiatrists

This is true depending on the region, and I have never denied this. In fact I even stated to psychiatrists to take this into account when making judgements on the issue.

4 - Prescribing psychologists have been prescribing in the military for 10 years and in 2 states for 3-4 years, all without incident

I already addressed this issue in a previous post, and from GAO studies into this situation--it was determined that psychologists being able to prescribe did not improve the readiness & availability to those in need of psychotropics, the cost of using psychologist prescribers was 7% higher vs the usual psychologist working with a medical doctor model, and psychologist prescribers were found to be lacking in medical knowledge.

However it was also true that the psychologists in the GAO study did work well with their colleague psychaitrists, & were able to add something to the table with their training which differs from psychiatrists.

This was already mentioned in a previous post, which referenced data from NAMI & the GAO. Both of which are credible sources of data.

I suggest you check your sources before you give data that is not true.

Therapist4Change is a psychology student who has responded quite appropriately so far in this thread, but also in general for the past few years on this thread.

And just so you know...I have a bachelor's in psychology, my wife is getting a degree in counseling & is considering getting a Psy.D. or Ph.D in psychology or counseling, and I'm a member of Psi Chi, National Honor Society in Psychology.

 

[Doctor Bagel]

Wrong. Public perception of psychiatry in the last few years has improved. Number of applicants into residency programs have increased. The result of the last MATCH showed a great increase in the # of applicants. This data was published in the APA's newspaper & was based on studies.

So true.

Anecdotally, there are 5 people in my class of 29 students who are interested in psychiatry. These aren't bottom of the barrel types of people either. 13 out of 140+ in our total campus went into psychiatry this last year. Maybe dwindling interest was an issue in the past, but it wasn't true this year and likely won't be true next year either.

 

[chameleonknight]

This year's match had about ~100 more AMGs apply than last year. ALL residency slots are more competitive (except possibly family medicine) since there has been a large increase in medical students in recent years without a corresponding increase in residency slots.

 

[Therapist4Chnge]

This year's match had about ~100 more AMGs apply than last year. ALL residency slots are more competitive (except possibly family medicine) since there has been a large increase in medical students in recent years without a corresponding increase in residency slots.

This speaks more to, "a rising tide lifts all boats", instead of an actual increase in psychiatry interest. Overall I think it is inconsequential as there are still really strong areas where psychiatry is alive and well, in addition to large areas of need (even with current mid-levels churning out more graduates each year). I think prescribing psychologists will only ever be a small fraction as the #'s that go into psychology are probably <10% compared to mid-level providers, and only a fraction of them will actually go through the additional training.

I think having the AMA involved in the legislative process will be a good thing in the long run because they will push higher standards, even though we may disagree with the outcome (more states granting prescription privileges to properly trained psychologists).

 

[zihuatanejo]

This speaks more to, "a rising tide lifts all boats", instead of an actual increase in psychiatry interest. Overall I think it is inconsequential as there are still really strong areas where psychiatry is alive and well, in addition to large areas of need (even with current mid-levels churning out more graduates each year). I think prescribing psychologists will only ever be a small fraction as the #'s that go into psychology are probably <10% compared to mid-level providers, and only a fraction of them will actually go through the additional training. I think having the AMA involved in the legislative process will be a good thing in the long run because they will push higher standards, even though we may disagree with the outcome (more states granting prescription privileges to properly trained psychologists).

I believe that you are wrong on many of your facts. The percentage of AMGs entering psychiatry increased by almost 6% this year (about 60-70 spots). There are very few, if any, other specialties with similar increases this year. Neurology actually only has slightly more than 50% AMGs rather than the 66% figure that you mentioned earlier. Some of the neurology programs have integrated internship years whereas others require a separate preliminary year. You need to add up both types of position to get an accurate match percentage. If it is true that "a rising tide lifts all boats," why have there been no similar increases in AMGs going into internal medicine, family medicine, neurology, pathology, and PM&R.

I am not sure why you feel the need to come on a psychiatry board and denigrate a specialty that you are not a part of. I don't feel a similar need to denigrate your field on the psychology board because I am secure and content with my choice and don't feel any sense of jealousy or superiority/inferiority towards any other field.

I don't mind psychologists prescribing as long as they go through just as rigorous and long a training period as psychiatrists today. If psychologists do the equivalent of four years of medical school with the same level of rigor, four years of residency, take all the USMLE steps, and pass the equivalent of the psychiatry boards, then they should be allowed to prescribe if they desire to do so. I hope that the APA, AMA, and physicians in general rally and take a stand against the infiltration of midlevel providers into what should be the exclusive domain of physicians, who have toiled for years and incurred hundreds of thousand of dollars in debt for that privilege. We should make politicians accountable for their actions and protect our interests as assiduously as do trial lawyers, insurance companies, hospitals, and pharmaceutical companies.

 

[Therapist4Chnge]

I am not sure why you feel the need to come on a psychiatry board and denigrate a specialty that you are not a part of.

I don't believe I have "denigrated" your specialty in any way with my posts. I have been lucky enough to work with some great psychiatrists over the years, and I have nothing but respect for the vast majority of your field. My comments stick to areas at which I have interactions/insight....as the rest aren't really of interest for me. I find having an open dialogue across disciplines helps everyone, and discouraging it tends to speak more about the separatists than the people wanting to share.

I don't feel a similar need to denigrate your field on the psychology board because I am secure and content with my choice and don't feel any sense of jealousy or superiority/inferiority towards any other field.

....but you still have a health amount of passive-aggressiveness present in the above sentiments. For the record, medical school was an option for me, but I declined it for clinical psychology because I found a better research fit and path.

As for the topic at hand, I agree that training is important when working in a specialty area. I've seen many psychiatrists and neurologists attempt to administer and interpret neuro psych assessments with little to no formal training. For those that go through the appropriate training, I welcome their input and insight.

 

[zihuatanejo]

I don't believe I have "denigrated" your specialty in any way with my posts. I have been lucky enough to work with some great psychiatrists over the years, and I have nothing but respect for the vast majority of your field. My comments stick to areas at which I have interactions/insight....as the rest aren't really of interest for me. I find having an open dialogue across disciplines helps everyone, and discouraging it tends to speak more about the separatists than the people wanting to share.


I think that you might be an intelligent person but I could be wrong based on your idiotic and unintelligible blathering. Reread your previous post, and then tell me again with a straight fact that you were not "denigrating" psychiatry when you attempted to argue that the NRMP data from this year don't really demonstrate an increase in interest in psychiary but merely demonstrate "a rising tide lifts all boats" phenomenon. If that is the case, why did fewer AMGs go into internal medicine or general surgery this year? Why wasn't there a concomitant increase in interest in other specialties such as family medicine, neurology, pathology, and PM&R?



....but you still have a health amount of passive-aggressiveness present in the above sentiments. For the record, medical school was an option for me, but I declined it for clinical psychology because I found a better research fit and path.


Yeah right. You have much too high an opinion of yourself. If you are as happy and content with your choice of psychology as you claim to be, then you would not feel the need to denigrate another specialty or justify your reasons for choosing your field to anyone. I don't feel the need to justify my choice of psychiatry to you or anyone else.



As for the topic at hand, I agree that training is important when working in a specialty area. I've seen many psychiatrists and neurologists attempt to administer and interpret neuro psych assessments with little to no formal training. For those that go through the appropriate training, I welcome their input and insight.

I never claimed that psychiatrists were greater experts in neuropsych testing than psychologists. I think you are reaching for straws with that argument.

 

[BobA]

I think he is referring to the initial match numbers (listed below), and the inordinately high % of FMGs matching into psychiatry each year, as AMGs seem to be looking elsewhere.

General: 61.7 (AMG)
Family: 54.5 (AMG)
Neuro: 66.7 (AMG)

Obviously these statistics need to be taken with a grain of salt as there are a number of factors at play (AMGs being placed into a higher non-psychiatry placement, highly competitive FMGs taking AMG spots, etc), though I believe the overall inference is that there is less interest for AMGs to going into psychiatry as there are consistantly a large % of spots that need to be filled post-match.

This is really twisting statistics. First, it doesn't say anything about psychologists prescribing, which is what this thread is about.

The truth is that there are a lot of spots in that match and that the system is set up so that AMG's have some choice. Overall there are many more residency positions in the match then there are AMG's so you'd expect the fill rate with AMG's to be less than 100% in any field. Psychiatry happens to have a lot of spots. Again, this has little to do with how qualified psychologists are to prescribe.

 

[BobA]

If there was consultation required, would you be okay with psychologists prescribing?

I might be OK with psychologists prescribing a limited formulary if there was some supervision. After all, I think the mid-level model can serve as a standard of care. If we expect supervision of them, and they have more medical training, shouldn't we expect the same from a psychologist?

But let's not beat around the bush:if you wanted to prescribe medications why didn't you go to medical school or NP school after a PhD? Would that have been too rigorous?

 

[ronin12]

it is very interesting to observe this nonsense thrown at us by psychology students/psychologists/wanna be prescribers. Mr and Ms know it all. They are passing judgments on field of medicine, psychiatrists, AMA, residency, FM'gs.
ironically they claim more knowledge and authority over field of medicine/residency/psychiatry then physicians.
Dont they have anything better to do, other then obsessing about doctors.

leave us alone!!!

 

[Therapist4Chnge]

I think that you might be an intelligent person but I could be wrong based on your idiotic and unintelligible blathering.

Please refrain from insults, as this is a professional forum.

 

[billypilgrim37]

Please refrain from insults, as this is a professional forum.

For people just showing up here, T4C has been one of the most valuable members of this forum for years. There have been some other psychologist (and psychiatrist) flame throwers on this thread, but he ain't one of them.

 

[benjee]

I am not sure if psychologists only believe in therapy instead of chemicals/medicine. If they do, then why suddenly they prescribe medicine?? let's say all psychologists can /are allowed prescribe medicine independently , I really doubt they ,with non-medical training, can do it safely. I don't ignore their years of training , but is it better ??if they just stick to what they are trained for instead of crossing and touching other areas, eg prescribing , interpret labs/EKG which they definitely not able to . If i have illness, i would not want non-MD to treat me when i need medicine.

 

[silas2642]

Not to be incendiary, but psychologists, who have doctorates, are hardly "mid-level providers." NPs and PAs are masters level. Psychologists are responsible for many, if not most, of the innovations in the mental health field. For example, DBT and most of the research into FAS were done by psychologists.

Second of all, I don't know why some of you think you are so much better than psychologists when your own field is dying a slow death and, as a whole, standards for admission into psychiatry residencies are laughable. Just look at your boards for verification of this. At the medical school I work at, not one psychiatry resident went to a US medical school. As the DOT said, she had to fill all 20+ slots with FMGs because they cannot get US med students to fill the psychiatry slots. Doctoral-level psychology programs are MUCH more selective than medical schools, as a whole, and MUCH MUCH more selective than psychiatry residencies. So who are the "quacks?"

I certainly wouldn't say that the field of psychiatry is a slowly dying field-- it's in its infancy and from talking to professional psychiatrists and through observation it is a field of medicine that seems to be alive and well and only growing.

As far as IMG's and FMG's being in the field of psychiatry, I'm sorry that your opinion of your colleagues is so low. One of the best preceptors that I've had so far in my short career was an FMG-- he was patient, brilliant, kind, and a wonderful teacher. The fact that he made it to the US to practice to me is a testament of his perseverance-- I don't think that I could do it.

 

[Therapist4Chnge]

I am not sure if psychologists only believe in therapy instead of chemicals/medicine. If they do, then why suddenly they prescribe medicine??

I don't believe it is an "either / or" scenario. Research is showing that there are some Dx's that have more of a defined biological basis (where a pharmacological approach is more appropriate), while others require a psychosocial approach with talk therapy.

I look at prescribing as "another tool in the toolbox". The DoD study speaks to this by citing the prescribing psychologists actually prescribing less often (compared to their psychiatry counter-parts). Obviously there are many factors at play, but I think one could theorize that the prescribing psychologist may have looked at other factors before reaching for the prescription pad. I don't mean to imply the psychiatrists did not consider other options, but it was noted in the study that the prescribing psychologists offered a unique perspective because of their strong basis in behavioral studies and related areas.

let's say all psychologists can /are allowed prescribe medicine independently , I really doubt they ,with non-medical training, can do it safely.

The GAO study (1999) speaks specifically to this and summized, "these graduates full or partial independent status indicates hospital officials' belief that the graduates need no more supervision than do other prescribing providers."

I don't ignore their years of training , but is it better ??

No one is claiming it is better (I think you are thinking of the NP study that came out awhile back claiming "better service" than PCPs). The published studies all seem to come to the conclusion that services were on par with other providers, and did not speak to "better", which would be a hard thing to quantify anyway.

if they just stick to what they are trained for instead of crossing and touching other areas, eg prescribing , interpret labs/EKG which they definitely not able to.

This is already happening. Colleagues in NM, LA, and the armed services are doing this on a daily basis. Clinical psychologists come right out of graduate school (without the addition RxP training) would not be prepared to interpret the labs, but after the additional academic training, clinicals, and supervision they have shown an ability to do just that.

 

[benjee]

I just think that for people on this thread to refer to psychologists as quacks is insane and was trying to illustrate that those who live in glass houses shouldn't throw stones... The numbers are the numbers and the data are the data...

1 - Psychiatry can't fill all of the available residency positions
2- Interest in psychiatry continues to dwindle
3 - There is a severe shortage of psychiatrists
4 - Prescribing psychologists have been prescribing in the military for 10 years and in 2 states for 3-4 years, all without incident

I don't refer psychologists as quacks when they do therapy only instead of prescribing something that they are not trained for.
Even with these unfilled slots in psych. residency and shortage, there is nothing to do with psychologists to demand in prescribing .These psychologist still not capable of prescribing medicine safely since they have no training in it.
The main problem is psychologists not seeing prescribing medicine as part of intergration of medical knowledge which requires medical schoool , and residency training where they face different medical emergency,interpret labs/EKGs indicating different medical problems causing mental status changes..etc.
psychologists prescribing medicine is like a licensed murderer.

 

[Bluemirage]

This is already happening. Colleagues in NM, LA, and the armed services are doing this on a daily basis. Clinical psychologists come right out of graduate school (without the addition RxP training) would not be prepared to interpret the labs, but after the additional academic training, clinicals, and supervision they have shown an ability to do just that.

Just because they are it doing right now doesn't mean they should be nor is it safe to, especially given the loose standards that are currently in place. Even you had admitted in your earlier posts that alot more extensive training and physician supervision is warranted for safe psychologist RX'ing. I do appreciate your more objective and level-headed responses though as compared to your colleague edieb who is giving psychologists a bad rap and hurting your cause with his ignorant extremism (who ironically toyed with the idea of going to medical school a few years ago but decided not to go through the work and sacrifices to do so).

If psychologists are only wanting "mid-level" type RX'ing responsibilities with physician supervision, then I'm sure most physicians won't have a problem with this, if they are at least trained to the same standards (which they are currently not...their training is about 30% less than PA's/NP's. The only exception are the DOD folks who have nearly the same training as PA's/NP's but admit that even their training is insufficient). However, psychologists are not just pushing for "mid-level" type RX'ing privileges; they are wanting independent prescription rights without psychiatry supervision (like the CRNA's of anesthesiology). I think this is what most psychiatrists have a problem with. When you boil down to it, it is pushing to have the privileges of prescription and medical practice without having to go through the hard work and training(MD degree). Like I alluded to in my earlier post, if the training is a 3 year residency and passing the USMLE was a requirement(like the MD/DDS folks-dentists with full RX privileges) , psychologists would be very much welcomed. If the dentists had to do it, why shouldn't psychologists?

 

[whopper]

psychologists prescribing medicine is like a licensed murderer.

Though I am against psychologists prescribing most medications, this is the type of comment that opens the door to name callling. Please no comments calling one profession or the other quacks.

I have not seen anything in google news concerning this issue since it was posted on the forum.

 

[benjee]

The GAO study (1999) speaks specifically to this and summized, "these graduates full or partial independent status indicates hospital officials’ belief that the graduates need no more supervision than do other prescribing providers."

I still don't buy this, if this is valid, then there should be no more medical schools or any residency training. why bother??And let all the sickness seek help from non -mds.

 

[Therapist4Chnge]

psychologists prescribing medicine is like a licensed murderer.

MOD NOTE: This comparison is offensive. Please consider this a formal warning to keep this a professional discussion, and not one that devolves into name calling, as that violates SDN Policy. -t4c

Even you had admitted in your earlier posts that alot more extensive training and physician supervision is warranted for safe psychologist RX'ing. I do appreciate your more objective and level-headed responses......

I wouldn't characterize my statements as "a lot more extensive training", but I believe if programs tightened up their curriculums by adding more clinical and supervision hours, I'd feel much more confident about the training across the board.

If psychologists are only wanting "mid-level" type RX'ing responsibilities with physician supervision, then I'm sure most physicians won't have a problem with this, if they are at least trained to the same standards.......

It seems that most psychiatrists are against it, while many PCPs, FPs, etc are supportive...though I haven't sampled a large N. Of the PCPs and FPs I've spoken with, the majority welcomed the idea of collaboration, as it offers a middle ground so that their patients don't need to travel 30+ miles for service and/or wait 4-6+ weeks for an appointment.

The only exception are the DOD folks who have nearly the same training as PA's/NP's but admit that even their training is insufficient).

I haven't seen/read/heard that before.....

However, psychologists are not just pushing for "mid-level" type RX'ing privileges; they are wanting independent prescription rights without psychiatry supervision (like the CRNA's of anesthesiology).

My reservation to independant prescribing is two-folk:

1. A lack of uniformity across programs. I feel like while many can be successful in independant prescribing, I'm not sure if across the board everyone will be successful under the current training standards. While there are guidelines set, I'd like to see a bit more uniformity and more clinical and supervision hours.

2. Collaboration benefits the pt. I believe a collaborative approach provides the best care for the majority of patients, and there should be a really good reason for independance....and I just don't see it in this case. 95% of the patients out there probably would be fine, but I think collaboration would help that 5% that may have more complexity that would be better addressed through collaboration.

I see collaboration as a fair compromise between the sides, particularly in regard to more "rural" areas where there may be a PCP or two servicing an entire area. The PCP could provide the referral, and 95% of the time it is a quick review. For those few instances where more collaboration is needed....it is built into the system, instead of leaving it up to the prescribing psychologist to independantly seek out a consult.

 

[Therapist4Chnge]

The GAO study (1999) speaks specifically to this and summized, "these graduates full or partial independent status indicates hospital officials' belief that the graduates need no more supervision than do other prescribing providers."

I still don't buy this, if this is valid, then there should be no more medical schools or any residency training. why bother??And let all the sickness seek help from non -mds.

Because the other 98% of medicine is outside of this realm, and they still very much need MDs/DOs to provide services. There were ~2,700 psychology interns matched this year, with only a small fraction even being interested in prescribing, so I wouldn't worry too much about the numbers. I can't speak to mid-level providers, though Hooker & Berlin (2002) wrote an article on the topic: "Trends in the supply of physician assistants and nurse practitioners in the United States." They estimated ~100k NPs & PAs as of 2001, and about 12,000 new ones per year.

 

[Bluemirage]

I haven't seen/read/heard that before.....

My reservation to independant prescribing is two-folk:

1. A lack of uniformity across programs. I feel like while many can be successful in independant prescribing, I'm not sure if across the board everyone will be successful under the current training standards. While there are guidelines set, I'd like to see a bit more uniformity and more clinical and supervision hours.

2. Collaboration benefits the pt. I believe a collaborative approach provides the best care for the majority of patients, and there should be a really good reason for independance....and I just don't see it in this case. 95% of the patients out there probably would be fine, but I think collaboration would help that 5% that may have more complexity that would be better addressed through collaboration.

I see collaboration as a fair compromise between the sides, particularly in regard to more "rural" areas where there may be a PCP or two servicing an entire area. The PCP could provide the referral, and 95% of the time it is a quick review. For those few instances where more collaboration is needed....it is built into the system, instead of leaving it up to the prescribing psychologist to independantly seek out a consult.

I guess I should have been more specific and clarified that the DoD's felt their training was insufficient for independent practice outside of their military medical infrastructure. Their training is just fine in a "mid-level" role for prescribing purposes. I would have to agree with this. Their training was twice the amount that the current APA (psychology) model suggests and so they should be able to prescribe like PA's and NP's under physician guidance. (Please refer to the powerpoint file I have attached earlier for more sources).

In regards to lack of uniformity in the quality of training across the different programs, I totally agree with you. That is why there exists a very uniformed test/measure of medical aptitude/competency/understanding called the USMLE for all independent prescribers. If psychologists want universal recognition of their competence in prescribing safely and effectively they need to complete a residency training (with similar hours and vigor as medical residencies) and pass all the relevant steps of the USMLE. The dentists who have independent prescribing privileges have to pass the USMLE, so should psychologists who want these same independent practice rights.

I agree with the collaborative model. Psychologists have a unique and valuable skillset to contribute to patient care. As long as the RX training model increases the rigor to that of a PA/NP, I think most physicians are ok with them RX'ing with MD/DO supervision. However, the push for independent RX'ing does not really come across as a desire for collaboration to me. More like a push to directly compete to get more pieces of the economic pie.

Let's face it, most non-MD's/DO's (CRNA's, NP's, Psychologists) that are aggressively pushing for independent RX practice are wanting it for economic reasons involving the least amount of effort possible. They want the income and privileges that come with practicing medicine without wanting to go through the hard work and sacrifice that comes with getting a medical education.

 

[grandslam521]

MOD NOTE: This comparison is offensive. Please consider this a formal warning to keep this a professional discussion, and not one that devolves into name calling, as that violates SDN Policy. -t4c

Wow this is harsh! I don't really think that his statement was "name calling". He was making an unfair comparison, but it wasn't directed at anyone in particular.

 

[BobA]

Let's face it, most non-MD's/DO's (CRNA's, NP's, Psychologists) that are aggressively pushing for independent RX practice are wanting it for economic reasons involving the least amount of effort possible. They want the income and privileges that come with practicing medicine without wanting to go through the hard work and sacrifice that comes with getting a medical education.

I have to disagree with this. It is clearly about the patients. The patients need them so much that they can't wait for them to go to NP or PA school, or even be supervised.

 

[benjee]

Because the other 98% of medicine is outside of this realm, and they still very much need MDs/DOs to provide services.

This is what exactly i tried to point out. Psychologists do not see prescribing medicine as an integral part of medical knowledge.When they prescribe medicine independently , they do not consider other possible complicated medical conditions that a client can have and what needs to be followed up or monitor and that's the part I am concerned. Let's take a cancer pt , with history of schizophrenia on clozapine, currently on chemo... this takes medical knowledge and training to monitor this kind of pts.Prescribing medicine is not a simple task actually but legislation/laws make it soo simple and easy for different non-MDs professions .

 

[Faebinder]

It truly takes some excellent medical knowledge to manage psych medications long term. Patients don't just have mental disorders, they come with all sorts of complications/comorbidities.

A bipolar 60 year old with a broken hip which has a very high morbidity and mortality rate... did you cause this with your lithium? (Low lithium to hypothyroid chronic to osteoperosis to broken hip).

A 40 year old male with 20 years schizophrenia and sleep apnea... you increase his antipsychotics due to increased symptoms and poor sleep (not realizing it's the sleep apnea) and he ends up with lowered life spam.

A 55 y/0 male with depression on 30 years of SSRI, slowly increased doses running with low Hgb... never realized he has occult bleeding due to the SSRI and now has an early cardiomyopathy. Add to that he is a drinker and more likely to get the cardiomyopathy early.

A 42 y/0 male doing great on zyprexa or depakote or clozapine or seroquel.... developed diabetes... at what point will you decide to switch to something else?

Psych meds are not benign to the body.

 

[whopper]

Psych meds are not benign to the body.

Agree.

Which is why if there were any case where a psychologist prescriber wasn't watching the medical stuff--they'd be under a lot of pressure.

Even the more benign meds--the SSRIs have possible side effects--SIADH, weight gain, sedation, discontinuation syndrome. Are psychologist prescribers ruling out hyper/hypothyroidism, hyper/hypocalcemia & other medical causes to psychiatric disorders?

Someone with the equivlant of 3.5 weeks of pseudo residency training cannot compare to a psychiatrist with 4. When I say pseudo, that's not meant as disrespect because simply working under a doctor in a unstructured setting vs a residency program with ACGME guidelines, further standardized testing, frequent reviews, attendings who have to be board certified or actively pursuing academic pursuits such research, a call schedule, scenarios where extreme medical cases are reviewed (e.g. C/L, ICU, ER) can't be compared to simply just being under a doctor or NP for a few weeks.

If psychologist prescribers did C/L, lithium, Clozapine, Depakote, Trileptal prescriptions, and as I mentioned have to do the ADA guidelines on antipsychotics that wouldn't even meet standard of care in most states. Nurses get more medical training.

I'd advocate psychiatrists need to use psychologists more often in their own practice or actively pursue more psychotherapy training, but prescribing without medical doctor supervision with the current level of training? I disagree with that.

 

[benjee]

"Because the other 98% of medicine is outside of this realm"
The problem is psychologists consider the meds they prescribe only constitute 2 % of medicine ( the psych part only), they chop medicine into percentage instead of taking it as a whole and all related. In medicine, no matter what specialty, they are all related, there is no way or should not treat medicine as percentage. Like a cardiologist, he/she still need to know basic aspects in surgery at least, even not as good as surgeons.

 

[whopper]

In medicine, no matter what specialty, they are all related, there is no way or should not treat medicine as percentage.

Exactly. Would a psychologist prescriber know that lithium mixed with motrin can disrupt the metabolism & excretion of these medications & thus change the lithium level? How many people on lithium can also have osteoarthritis or any other situation where they take motrin on a daily basis?

Would a psychologist prescriber dare tackle a case of someone in need of antipsychotics who has a history of heart disease & is on multiple non psychiatric meds?

If any bad outcome happened, that'd be a lot of reason to legally challenge this type of prescriber.

In the case of Louisiana, I can at least understand it to some degree because psychiatrist in the hurricane devastated regions are extremely rare and that place is in dire need of psychiatrists.

 

[Therapist4Chnge]

This is what exactly i tried to point out. .

My "98% / 2%" comment was in response to benjee's (sarcastic) lament about not needing MD/DO training anymore, and was not meant to imply prescribing being a small part of medicine, but moreso a comment on the providers it would effect if psychologists were to prescribe. I cited the number of total psychologists coming out each year (and the very small % that would even go for the additional training), as well as the Hooker & Berlin article, to put the numbers into perspective.

 

[primadonna22274]

...but without the rigorous pharmacology, physiology, and, um, MEDICINE training that a PA has???
hmmm???

In a medically straightforward pt, I'd rather have a psychologist do the prescribing than an NP or PA. And about on par with a PCP.

At least it'll be by someone with the training and the inclination to get a thorough psych history and actually address the interpersonal, psychodynamic, and cognitive-behavioral issues at work.

 

[maranatha]

Agree.

Which is why if there were any case where a psychologist prescriber wasn't watching the medical stuff--they'd be under a lot of pressure.

Even the more benign meds--the SSRIs have possible side effects--SIADH, weight gain, sedation, discontinuation syndrome. Are psychologist prescribers ruling out hyper/hypothyroidism, hyper/hypocalcemia & other medical causes to psychiatric disorders?

Someone with the equivlant of 3.5 weeks of pseudo residency training cannot compare to a psychiatrist with 4. When I say pseudo, that's not meant as disrespect because simply working under a doctor in a unstructured setting vs a residency program with ACGME guidelines, further standardized testing, frequent reviews, attendings who have to be board certified or actively pursuing academic pursuits such research, a call schedule, scenarios where extreme medical cases are reviewed (e.g. C/L, ICU, ER) can't be compared to simply just being under a doctor or NP for a few weeks.

If psychologist prescribers did C/L, lithium, Clozapine, Depakote, Trileptal prescriptions, and as I mentioned have to do the ADA guidelines on antipsychotics that wouldn't even meet standard of care in most states. Nurses get more medical training.

I'd advocate psychiatrists need to use psychologists more often in their own practice or actively pursue more psychotherapy training, but prescribing without medical doctor supervision with the current level of training? I disagree with that.

I totally agree with this. Before medical school I actually agonized about whether to apply to a clinical PhD program or go to medical school to become a psychiatrist. I heard the debate about potential prescribing rights for psychologist before making my decision and took that into account. Ultimately, I decided that I would never be comfortable prescribing medications without the medical degree...I am so glad I made this decision! For myself, I would never be comfortable with the training that the prescribing psychologists are discussing in this forum. Psychiatry has turned out to have far more overlap with medicine then I anticipated before starting medical school.

I also feel that thus far my psychotherapy training has been pretty good. I'm personally a big supporter of psychiatrist utlizing more therapy into their practice. But if not, we need to work as close to the therapists as possible in order to provide the most complete care for our patients.

 

[masterofmonkeys]

...but without the rigorous pharmacology, physiology, and, um, MEDICINE training that a PA has???
hmmm???

Ok, let's once again point out that these psychologists are going through RxP training to prescribe psych meds. Not everything else.

I pretty much agree with the 'guidelines' that T4C has suggested.

I think there is some scope for clinical psychologists to prescribe psych meds, and I think it fits in perfectly with what most of them do in practice. I.e. outpatient diagnosis, treatment, and management of patients with mood/anxiety disorders, dysmorphias and the like, and some personality disorders.

Should they be involved in inpatient work, consults, or use meds with significant general med issues? Probably not. And if they aren't outright limited from this, I think few would want to do so anyway.

And should they be able to do so without supervision? Probably not. But let's face it, supervision for mid-levels can be something of a joke anyway.

And I absolutely 100% object to calling clinical psychologists mid-level providers. Maybe this is because I owe my undergrad psych professors a ton, and have learned a lot from many PhDs already in my young career. Who knows.

Getting into a psych PhD program is tougher than getting into medical school (or was the last time I looked at the stats) and getting a psyd isn't much easier. They get plenty of education on the biological basis of mental illness and are no doubt better educated in the half of psychiatry known as psychotherapy, in various modalities. Not to mention a stronger education in statistics, which is woefully inadequate for doctors who try to practice evidence-based medicine. 'peer-review' is on guarantee of quality. Calling someone who's an expert in an area, with a doctorate, who is better at psychotherapy than an MD psychiatrist. Who then undergoes a 2 year RxP program a mid-level is kinda dismissive.

Sure, they aren't as well-versed in the medical aspects of their patients, but that doesn't mean they should be lumped in with people who get far less training in psych, overall.

A PA gets anywhere from 2 to 3 years in schooling, most coming somewhere in between. And clinical experience of only a year or so before threy're let loose. with 4 weeks or so of a core psych rotation.

A family doctor gets a 6 week psych rotation in medical school. And that's it as far as psych-specific training.

Are the latter two probably better equipped to deal with medical complications of psychiatric illness and psychopharmocological interventions? Sure. But should patients on lithium or antipsychotics be seeing someone other than a psychiatrist anyway, regardless of medical training? And how many psychologists will be dealing with those entities anyway? Probably not a lot. And I think any kind of prudent guideline on scope of practice would limit that anyway.

Bottom line is that I think a reasonable person would hold that the medical model and symptomatic 'treatment' (god I hate that phrase--it's symptomatic management darnit) is terribly flawed especially when it comes to psych. Is it really ideal to have a patient with psychosocial issues seeing a family physician or PA receiving pharmacological treatment but not having the underlying stressors, cognitive-behavioral issues, and deep-seated psychodynamic issues unaddressed? Even if these mid-levels and generalists did make a apoint of referring all of these patients to a psychiatrsit or a psychologist for a proper psych eval (which many don't), does it make sense to have a population that is already poorly compliant, more likely to have income/transportation/time issues, and likely to have motivation issues have to see two practitioners for complete care?

A reasonable and realistic scope of practice for psychologists (such as T4C is proposing) involves the use of the most medically straightforward pharmacologic agents in the most medically and psychiatrically straightforward patients, who coincidentally are by far the most likely to benefit from any of a number of different psychotheraputic modalities.

And I'm hearing that RxP (with solid training, physician oversight, and a well-delineated scope of practice) is somehow a bad thing?

You have got to be kidding me.

 

[benjee]

And should they be able to do so without supervision? Probably not. But let's face it, supervision for mid-levels can be something of a joke anyway.

And I absolutely 100% object to calling clinical psychologists mid-level providers. Maybe this is because I owe my undergrad psych professors a ton, and have learned a lot from many PhDs already in my young career. Who knows.
No pscyhologists are not midlevels. They should not be compared with midlevels like PA or NPs. they are different entities.
Getting into a psych PhD program is tougher than getting into medical school (or was the last time I looked at the stats) and getting a psyd isn't much easier. They get plenty of education on the biological basis of mental illness and are no doubt better educated in the half of psychiatry known as psychotherapy, in various modalities. Not to mention a stronger education in statistics, which is woefully inadequate for doctors who try to practice evidence-based medicine. 'peer-review' is on guarantee of quality. Calling someone who's an expert in an area, with a doctorate, who is better at psychotherapy than an MD psychiatrist. Who then undergoes a 2 year RxP program a mid-level is kinda dismissive.

Even the admission to PHd program is tougher, it does not mean pscyhologists should prescribe medicine which they are not trained for.

Are the latter two probably better equipped to deal with medical complications of psychiatric illness and psychopharmocological interventions? Sure. But should patients on lithium or antipsychotics be seeing someone other than a psychiatrist anyway, regardless of medical training? And how many psychologists will be dealing with those entities anyway? Probably not a lot. And I think any kind of prudent guideline on scope of practice would limit that anyway.
If psychologists are competent in doing what they request, then why should there a limitations??

Bottom line is that I think a reasonable person would hold that the medical model and symptomatic 'treatment' (god I hate that phrase--it's symptomatic management darnit) is terribly flawed especially when it comes to psych. Is it really ideal to have a patient with psychosocial issues seeing a family physician or PA receiving pharmacological treatment but not having the underlying stressors, cognitive-behavioral issues, and deep-seated psychodynamic issues unaddressed? Even if these mid-levels and generalists did make a apoint of referring all of these patients to a psychiatrsit or a psychologist for a proper psych eval (which many don't), does it make sense to have a population that is already poorly compliant, more likely to have income/transportation/time issues, and likely to have motivation issues have to see two practitioners for complete care?
Alot of times, clients do need to see different specialists when needed and generalists are to incorporate all these services.

A reasonable and realistic scope of practice for psychologists (such as T4C is proposing) involves the use of the most medically straightforward pharmacologic agents in the most medically and psychiatrically straightforward patients, who coincidentally are by far the most likely to benefit from any of a number of different psychotheraputic modalities.

I wish human beings can be straightforward. Alot of times, straightforward can be deceiving, humans beings can develop some kind of complicated diseases after psychologists seeing that clients for a period of time and missing some critical /subtle symptoms which he/she may believe the client still fine and straightforward. This not uncommon in medicine world and lawsuits have been happening alot.

 

[masterofmonkeys]

No pscyhologists are not midlevels. They should not be compared with midlevels like PA or NPs. they are different entities.

Agreed

Even the admission to PHd program is tougher, it does not mean pscyhologists should prescribe medicine which they are not trained for.

No one is talking about allowing psychologists to prescribe without training. Straw man.

If psychologists are competent in doing what they request, then why should there a limitations?? [/qupte]
Not sure what you're saying here. I'm saying that I don't think you can have the competency to deal with the medically complex patients or pharmacologic agents without a medical education and residency training. A PA, NP, or family doc technically could prescribe lithium or antipsychotics, etc, doesn't mean they should.

Alot of times, clients do need to see different specialists when needed and generalists are to incorporate all these services.

Again, your point? My point is that generalists and mid-levels handling psych issues is a lot like a generalist or a mid-level handling an arrythmia, or a bone marrow disease workup. Can they? Technically, yes. Should they? Probably not. There is a lot of specialist training that goes into psych, especially in the psychosocial realm. Something that is not part of general medical education. Unless you're arguing that the 4 weeks a PA or the 6 weeks a med student gets in psych is enough to handle a proper psych workup. I don't. Which is why I'm doing a psych residency.

Maybe you're right though. I personally have loved my 'anxiety' patients taking xanax daily (from a PCP) who have a family history of palpitations/tachycardia who are taking in absurd amounts of caffeine. And the 'depressed' patients who show up suicidal because they got the SSRI but the PCP or mid-level never addressed the fact that they're depressed because they feel like they can never measure up, they were sexually abused and find it hard to be intimate, etc (not saying that SSRIs cause suicidality...). God knows how many of those I've seen, and I haven't even started residency yet.

Again, my argument is that psych issues are almost always a specialist-level phenomenon, like addison's or cushing's, as opposed to diabetes. And that it'd be better to have someone who's at least proficient in diagnosis and workup of psych issues doing the prescribing, even if they are more limited in their formulary and medical knowledge than a psychiatrist.

I wish human beings can be straightforward. Alot of times, straightforward can be deceiving, humans beings can develop some kind of complicated diseases after psychologists seeing that clients for a period of time and missing some critical /subtle symptoms which he/she may believe the client still fine and straightforward. This not uncommon in medicine world and lawsuits have been happening alot.

No one's saying an RxP can replace a PCP. At least, I haven't heard that argument made. Lets also not denigrate the Rx-training. I don't know how extensive it is, but lets not pretend that it its lightyears behind the 1 year of clinical supervision that a PA typically gets.

I am merely making the argument that it makes more sense to have an Rx-trained psychologist be the primary mental healthcare giver for patients with the more medically and psychopharmacologically straightforward patients, with appropriate supervision.

 

[benjee]

Agreed



No one is talking about allowing psychologists to prescribe without training. Straw man.
Even they have training to prescribe but is it enough without enough medical knowledge ??It seems many allied health professions focus on prescribing medicine as a single entity without integration of comprehensive medical knowledge which I am against. theoretically, agree with whoever want to prescribe but first they need to go through basic medical knowledge --by medical school and so forth before they enter into prescribing world.

If psychologists are competent in doing what they request, then why should there a limitations?? [/qupte]
Not sure what you're saying here. I'm saying that I don't think you can have the competency to deal with the medically complex patients or pharmacologic agents without a medical education and residency training. A PA, NP, or family doc technically could prescribe lithium or antipsychotics, etc, doesn't mean they should.
I mean why would there be a limitation in prescribing only certain meds instead of full range of psych medicine or medicine for psych. purposes which also can be b blocker..etc ??

Again, your point? My point is that generalists and mid-levels handling psych issues is a lot like a generalist or a mid-level handling an arrythmia, or a bone marrow disease workup. Can they? Technically, yes. Should they? Probably not. There is a lot of specialist training that goes into psych, especially in the psychosocial realm. Something that is not part of general medical education. Unless you're arguing that the 4 weeks a PA or the 6 weeks a med student gets in psych is enough to handle a proper psych workup. I don't. Which is why I'm doing a psych residency.

Actually I never agree what PAs is doing if they allowed no supervision and perform diagnosis, treat and prescribe and work up.
i am trying to point out the difference between Mds and psychologists , not PAs which are not even comparable in that level.For mds , they are least go thru medical school and residency training , even a generalist/FP, who also go thru a longitudinal follow psych pts for 3 yrs and see different cases during training. I don't believe psychologists go thru these .

Maybe you're right though. I personally have loved my 'anxiety' patients taking xanax daily (from a PCP) who have a family history of palpitations/tachycardia who are taking in absurd amounts of caffeine. And the 'depressed' patients who show up suicidal because they got the SSRI but the PCP or mid-level never addressed the fact that they're depressed because they feel like they can never measure up, they were sexually abused and find it hard to be intimate, etc (not saying that SSRIs cause suicidality...). God knows how many of those I've seen, and I haven't even started residency yet.

Again, my argument is that psych issues are almost always a specialist-level phenomenon, like addison's or cushing's, as opposed to diabetes. And that it'd be better to have someone who's at least proficient in diagnosis and workup of psych issues doing the prescribing, even if they are more limited in their formulary and medical knowledge than a psychiatrist.
Even at specailists level, specialists still need to know or have knowledge of basic in primary care, it does not mean they only deal with specialist level and ignore the basics which can be critical in some cases.
The problem is lots of times there are mixture of psych and medical issues in reality and that require a well equipped knowledge to handle it, personally, I don't believe there such a thing of doing a good work up, diagnosis with limitation of medical knowledge and training.smething got to be missing here.lets say a bipolar pt on lithium , develop renal problem, require dialysis, so how a psychologist to adjust the dose as an outpt?? or change to other meds?? what if that pt has other illness ??and what they going to montior??

No one's saying an RxP can replace a PCP. At least, I haven't heard that argument made. Lets also not denigrate the Rx-training. I don't know how extensive it is, but lets not pretend that it its lightyears behind the 1 year of clinical supervision that a PA typically gets.

Again, I would not compare PAs here .

 

[Bluemirage]

And I absolutely 100% object to calling clinical psychologists mid-level providers.

Calling someone who's an expert in an area, with a doctorate, who is better at psychotherapy than an MD psychiatrist. Who then undergoes a 2 year RxP program a mid-level is kinda dismissive.

Sure, they aren't as well-versed in the medical aspects of their patients, but that doesn't mean they should be lumped in with people who get far less training in psych, overall.

A PA gets anywhere from 2 to 3 years in schooling, most coming somewhere in between. And clinical experience of only a year or so before threy're let loose. with 4 weeks or so of a core psych rotation.

A family doctor gets a 6 week psych rotation in medical school. And that's it as far as psych-specific training.

And I think any kind of prudent guideline on scope of practice would limit that anyway.

And I'm hearing that RxP (with solid training, physician oversight, and a well-delineated scope of practice) is somehow a bad thing?

You have got to be kidding me.

I enjoy reading your posts masterofmonkeys and I have alot of respect for you but I'm going to have to respectfully disagree with you on a number of points in your post. I can certainly understand your loyalties to psychologists given your background. I don't believe anyone here is disrespecting the psychologist's role in patient care with regards to their field of expertise: psychotherapy and psychological testing. However, look at their training with regards to RXing (Please see my powerpoint slides of sources from page 1 of this thread created by a Psychologist that thinks it's a bad idea to allow Psychology RX). It will be very clear why their current model of RX training is woefully inadaquate (30% less than PA's/NP's-remember PA's/NP's have biological science and clinical medicine training). It is anything but solid. Even the DoD psychologists (the original successes that the current movement is based on, agree that less training is a bad idea- note they have a ton more medical training than what the current APA model recommends).

Psychologists are not mid-level providers when they stick to their current scope of practice but those that want to RX meds are really pseudo-midlevel providers. What I mean by this is that they are experts in the field of psychology (doctoral level experts who practice independently) but are at the level of medical midlevel providers in their medical training for RXing meds (training less than that of PA's/NP's). They are never going to have the same depth of medical understanding/training unless they go through a residency and USMLE like the MD/DDS folks. As someone that just finished the whole medical school process I am surprised to read your comments.

Remember, the current push by psychologists are not just for supervised RX'ing under MD/DO. They are pushing for independent RX'ing rights to compete with physicians. Make no mistake about it, behind all their smokey mirrors, their real intention is to get MD/DO Rxing responsibilities and the income/privileges that come with it without having to go through a vigorous residency & USMLE process like the MD's/DO's and MD/DDS's. Look at what is happening to anesthesiology. The CRNA's went through a similar process that the current psychologists are doing. It is now a mess where the CRNA's openly declared in their statements through their national organization (AANA) that they are just as good as physicians and that they can safely replace them! The American Society of Anesthesiologists currently launched a national campaign to counter this but it is coming late- after years of CRNA's getting independent practice rights state by state. This can happen to psychiatry too if physicians in this field do not exercise vigilance in protecting their own profession from others who are no adequately trained.

I like you and respect your posts masterofmonkeys and it pains me to have to write this response. As a future MD colleague, I hope this does not personally offend you.

 

[whopper]

Someone with the equivlant of 3.5 weeks of pseudo residency training cannot compare to a psychiatrist with 4. When I say pseudo, that's not meant as disrespect because simply working under a doctor in a unstructured setting vs a residency program with ACGME guidelines, further standardized testing, frequent reviews, attendings who have to be board certified or actively pursuing academic pursuits such research, a call schedule, scenarios where extreme medical cases are reviewed (e.g. C/L, ICU, ER) can't be compared to simply just being under a doctor or NP for a few weeks.

I need to correct myself and state the 3.5 weeks is in comparison with 4 years of residency, not 4 weeks.

As for medically complicated psychiatric cases Master of Monkeys, it happens quite a bit, especially on the mood stabilizers & antipsychotics.

As for SSRIs, it doesn't happen much, but can still happen, and if someone didn't have medical training, they're more likely to miss it. For several on SSRIs, they're fine on them, but you don't know if its going to cause a medical complication until it happens. Further, you need to order labs to rule out medical causes before psychiatric meds are started. I've mentioned before that learning to interpret labs can take months in a residency program--not quite enough training in the current psychologist prescriber programs.

And I'm hearing that RxP (with solid training, physician oversight, and a well-delineated scope of practice) is somehow a bad thing?

I don't agree with the solid training. If you read the guidelines, they are only supposed to work under a doctor for a certain number of hours which equates to 3.5 weeks of residency in terms of their on the job clinical training. That clinical work is also not within the highly structred setting of an ACGME residency. For all you or I know, the guy could show up to the doc's office and just read magazine articles & watch Judge Judy depending on the whim of the doctor.

Same applies to taking medical histories and several other clinical aspects. These are actively tested in medical school, the USMLE, and the CS section. In the psychology prescriber programs, these aspects are not tested. They just have to work under a doc, who like I said is not within the structured guidelines as the ACGME provides.

 

[Bluemirage]

As a follow-up post here is a sample legislative letter created by members of the American Psychiatric Association putting forth the arguments why psychologists should not have independent prescription rights. I know it is biased since psychiatrists put this together but it makes very similar points to the powerpoint file I have attached to page 1 of this thread created by a psychologist. Perhaps there may be some points in this document that some have not thought about.

 

[Therapist4Chnge]

From skimming the letter my first reaction is that it is much more realistic, compared to some of the extremist and (untrue) propaganda out there. Some of the points stray a bit, but if the APA-iatry can accept more clinical hours, a more formalized supervision period, and a collaborative approach....we may actually be able to find a middle ground.

 

[Bluemirage]

From skimming the letter my first reaction is that it is much more realistic, compared to some of the extremist and (untrue) propaganda out there. Some of the points stray a bit, but if the APA-iatry can accept more clinical hours, a more formalized supervision period, and a collaborative approach....we may actually be able to find a middle ground.

I believe this letter was drafted and approved by the American Psychiatric Association for members to write to legislators to oppose Psychology RX in new states. Hence it is less extreme than some of the garbage out there. Like I had pointed out earlier, if psychologists are willing to increase their medical education to that of a PA/NP with strict uniformed standards (and pass licensing exams of PA/NP) and be permanently content with RX'ing under supervision of an MD/DO, I don't think there would be as much opposition. I personally would welcome this collaboration as it would maximize patient access to quality care and RXing would be effective and safe, nobody's jobs are being threatened=everybody's happy.

However, alot of the push out there is for independent RX rights without physician supervision. Even the ones pushing for supervised RXing, many have the ulterior motive of pushing for independent rights further down the line once they have established that supervised RXing is safe. I don't want to sound like a broken record but this does not sound like collaboration to me...more like a move to direct compete and possibly take Psychiatry jobs ala CRNA style without going through the rigors of a formally structured residency program and passing the USMLE.

 

[zihuatanejo]

I believe this letter was drafted and approved by the American Psychiatric Association for members to write to legislators to oppose Psychology RX in new states. Hence it is less extreme than some of the garbage out there. Like I had pointed out earlier, if psychologists are willing to increase their medical education to that of a PA/NP with strict uniformed standards (and pass licensing exams of PA/NP) and be permanently content with RX'ing under supervision of an MD/DO, I don't think there would be as much opposition. I personally would welcome this collaboration as it would maximize patient access to quality care and RXing would be effective and safe, nobody's jobs are being threatened=everybody's happy.

However, alot of the push out there is for independent RX rights without physician supervision. Even the ones pushing for supervised RXing, many have the ulterior motive of pushing for independent rights further down the line once they have established that supervised RXing is safe. I don't want to sound like a broken record but this does not sound like collaboration to me...more like a move to direct compete and possibly take Psychiatry jobs ala CRNA style without going through the rigors of a formally structured residency program and passing the USMLE.

Don't be fooled by the reasonably sounding arguments of Therapist4Change. The so-called collaborative approach of clinical psychologists only prescribing under a physician's supervision is merely a waystation on their pursuit of independent prescription priviliges, which is what they really want and have already achieved in New Mexico. Also check out the recent thread entitled LPCs and SWs getting right to interpret psychological and neuropsyc tests in the clinical psychology forum, wherein Therapist4Change and Edieb, both of whom you should be familiar with from their posts on this thread, argue that LPCs and SWs should be barred from doing neuropsych testing or interpreting psychological tests because they supposedly lack sufficient training and will cut into clinical psychology's share of the economic pie. So it is the height of hypocrisy for these two characters to come on the psychiatry forum and argue that we should happily accept our own displacement. I encourage everyone to contact their state legislators, perhaps using the sample letter submitted by BlueMirage, to oppose allowing any prescriptive authority for psychologists whether supervised or independent. There are other and better ways, from psychiatry's viewpoint, of addressing the legitimate issue of shortage of psychiatrists especially in rural and other underservedareas. One is the phenomenon of telepsychiatry, which is likely to grow in the future, and the other is to give PCPs in underserved areas additional training in psychopharmacology.

 

[Therapist4Chnge]

Don't be fooled by the reasonably sounding arguments of Therapist4Change. The so-called collaborative approach of clinical psychologists only prescribing under a physician's supervision is merely a waystation on their pursuit of independent prescription priviliges, which is what they really want and have already achieved in New Mexico.

There are some who want independent prescribing, but most of the pro-RxP folks want a collaborative approach.

Also check out the recent thread entitled LPCs and SWs getting right to interpret psychological and neuropsyc tests in the clinical psychology forum, wherein Therapist4Change and Edieb, both of whom you should be familiar with from their posts on this thread, argue that LPCs and SWs should be barred from doing neuropsych testing or interpreting psychological tests because they supposedly lack sufficient training and will cut into clinical psychology's share of the economic pie.

If you read the bill the guidelines are akin to, "if you say you are qualified....you are qualified", so there are NO GUIDELINES for administration and interpretation. No required classes, no supervision requirements, no clinicals, no licensure, etc. The argument is apples and oranges.

 

[Bluemirage]

The so-called collaborative approach of clinical psychologists only prescribing under a physician's supervision is merely a waystation on their pursuit of independent prescription priviliges, which is what they really want and have already achieved in New Mexico.

So it is the height of hypocrisy for these two characters to come on the psychiatry forum and argue that we should happily accept our own displacement. I encourage everyone to contact their state legislators, perhaps using the sample letter submitted by BlueMirage, to oppose allowing any prescriptive authority for psychologists whether supervised or independent. There are other and better ways, from psychiatry's viewpoint, of addressing the legitimate issue of shortage of psychiatrists especially in rural and other underservedareas. One is the phenomenon of telepsychiatry, which is likely to grow in the future, and the other is to give PCPs in underserved areas additional training in psychopharmacology.

I totally agree with you. This is what I eluded to in my post as the psychologists with the "ulterior motives" and is what every psychiatrist should be genuinely afraid for. For those that think this is paranoia, it is NOT. I think psychiatrists need to learn from Anesthesiology's mistakes (an anesthesiologist has posted earlier on this thread warning psychiatrists of this threat).

Although to be fair to therapist4change I have not seen extreme posts from him advocating independent RX'ing or psychology superiority and I do not want to jump to conclusions and make judgments about him unless I find out otherwise. His comrade Edieb on the other hand, is a different story. He talked about wanting to attend medical school two years ago because he was "no longer interested in pursuing psychology." He then expressed concerns about the obstacles of going back to school for his prereqs and getting into medical school in his 30's and we have not heard about this since. He definitely fits the mold of a psychologist wanting the income/privilege of RX'ing without wanting to go through the hard work/sacrifice of medical school. That is why his posts are so infuriating and insulting. They lack credibility and are just the rantings/ravings of an MD/DO wannabe.

 

[Therapist4Chnge]

Although to be fair to therapist4change I have not seen extreme posts from him advocating independent RX'ing or psychology superiority and I do not want to jump to conclusions and make judgments about him unless I find out otherwise.

Well that makes two (you and whopper).....

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I'd like to bring this back to the initial discussion, and not make it about individual posters, as that seems to derail threads more often than not.

 

[Anasazi23]

I also don't want to get dragged into this, but here I am again anyhow.

Just a couple points of my own:

1. I absolutely do not believe that psychologist prescribing has not caused adverse effects. The most likely scenario is that they're unable to either ask the correct questions, or make the proper medical observations to note this. Give me 100 patients on meds prescribed by psychologists, and I promise you, I'll find screw-ups in management and adverse effects six ways to Sunday.

2. Bluemirage is completely correct. Leaked emails and the like from the psychologist prescriber advocates make it very clear that their field (psychology) is in dire financial state, and that their turf is quickly being eroded by mid-levels. They want the prescriber piece of the pie, and they're citing underserved areas to get it. Make no mistake, they want full autonomy and have fought bills requiring oversight and limited formulary.

3. The DoD study, commonly cited by psychologists as proof of their safety is, ironically, quite the opposite. It's ironic because one thing that psychology does well, research, was in nearly all ways thrown out the window since they obtained favorable anecdotal results (not data). They prescribed a limited formulary (SSRIs) to non-medically comorbid, non-child, non-geri patients under supervision by a physician. It's completely ungeneralizable.

4. The claim that they're interested in serving the underserved is bogus. In the long run, this will hurt psychiatric patients, as more states adopt this program, causing less med students to pursue psychiatry. The shortage then will get worse, not better.

5. I recently passed the oral boards in psychiatry. I realized once again while studying for this brutal test, the tremendous amount of information that I have yet to study, and how much work I need to feel comfortable. The thought that a non-residency without proper medical training standards amounting to a couple weeks of real residency is atrocious. Add to this the fact that they want to prescribe to children and geri populations and in the hospital (all of which is done commonly with advanced fellowship training AFTER residency in psychiatry) makes it orders of magnitudes worse.

6. There's a lot more, but I just don't want to get into it more than I already have. It's a political move for a field that has problems. In some ways I don't blame them, their niche is eroding, and they don't police their own admission numbers. They need to do something to guarantee an income to the graduates of the phd and psyd programs.

 

[whopper]

While this certainly is an interesting debate & discussion, I think I'm going to take a more passive role. Most of what I think can be said has been said.

And I still haven't heard anything about what's going on in Oregon.

I agree with the above that if the training of a psychologist prescriber was on the order of a NP or PA, I'd be more inclined to feel safer about such a prescriber.

As many of you have probably seen from electives, if you work under a doctor in an unstructured setting, you can get a doctor that'll really teach or a doctor that pretty much just has you follow him around while you sit there like a fly on the wall.

So I am very surprised that the Oregon law, the clinical training pretty much amounts to just being under a doctor/NP for a few hundred hours. What goes on during those few hundred hours--there's pretty much no guidelines as far as I saw (and someone correct me if I'm wrong).

If a psychologist worked under me for a few weeks, I'd doubt they'd see many medically complicated cases, as a result of psyche meds. That's actually saying quite a bit because where I work--we get the most extreme cases--psychotic patients in need of ECT, polypharmacy--even after Clozapine administration.

However so far during this first 10 month period of my experience as an attending, I have had about 15 cases so far where patients had some type of adverse medical reaction to their meds--which if left unchecked would've resulted in possible disaster. Strattera causing HR to go over 150 bpm, Trileptal causing hyponatremia, Clozapine induced tachycardia which could've lead to myocarditis, a patient on Depakote who also had Hep B & C, a pregnant & agitated patient where we had to use lithium, a case of depakote induced neutropenia, a patient who's core body T went below 90F, most likely as a result of antipsychotic tx, etc.

I doubt a psychologist under such conditions could've handled those situations with the training in the Oregon law. I'm actually thinking if they had any of the above cases I mentioned--there would've been a high likelihood of a bad outcome that would've been avoidable with a psychiatrist following standard of care practice.