Psychiatry needs to reinvent itself because of psychologists?

[Anasazi23]

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.

Hello Svas (and others),
I have a question for you regarding what I perceive as your excited support for behavioral neurology. I was introduced to the topic some years ago in grad school, but am revisiting it now to refresh. Although you and I apparently differ in our acceptantce of psychologists prescribing and "taking over" psychiatry as we know it, how do you envision behavioral neurology as the white knight that will re-invigorate the profession, and (perhaps more importantly for new graduates) provide for billable procedures/assessments? It seems to me that behavioral neurology seems to be more like neuropsychology, and that psychology is trying to become more like the current practice of psychology. Do you think this quid pro quo switch will succeed for our profession?

I completely agree with you that psychiatry should be "re-medicalized." I suspect that both you and I are disappointed that this loss of medical inclusion has even happened in the first place. However, prescribing psychologists also feel that they will be/are now competent in reading said lab values, and even are putting stethescopes on people's chests in an attempt to hear cardiac murmurs in medical patients.

The recent bill in LA states that a psychologist must 'consult' with a physician before an Rx is allowed to be written by a psychologist. Do you honestly think that if a physician is uncomfortable in prescribing a certain medication, that the psychologist will not simply obtain approval from another physician? How does this improve patient care? My point is that psychologists are themselves attempting to "medicalize" their own profession - this is evident in the misleading title "medical psychologist" and in their pursuit over the years of admitting privilages, and now their right/?ability to order and interpret any lab test, order procedures, and write prescriptions from a "limited formulary."

I am still in contact with many of my friends/colleagues that completed psychology graduate programs from around the country. And although some are doing well, either in psychology or neuropsych, the general consensus remains the same, which was why I left the field. The payments are difficult to procure, the testing is repetitive, lower-level providers seeking parity in treatment/billing, etc, etc. I worry that price undercutting by psychologists will result in a bleaker picture for the future of psychiatry, thus causing less gradutes to seek a career in this field.

I do not disagree that behavioral neurology is very interesting, and I have been reading quite a few abstracts/articles as of late, but I fear that it seems to be of a more scientific, rather than clinical interest. Or at least, one that would take quite a long time to establish as a legitimate clinical speciatly within traditional medicine/surgery.

I know the slippery slope argument is hated by all, but what were to stop the psychologists from taking behavioral neurology in a few years, when the reality of increased susceptibility to lawsuits, skyrocketed malpractice, etc., sobers them to the pitfalls of current psychiatry practices? Neuropsychologists could even effectively argue that they are already qualified to function as behavioral neurologists with their current training. I find it hard to envision satisfaction in a profession constantly under attack by providers in other health care fields looking for expanded scopes of practice.

I simply feel that to lie down and give up an important part of our practice may be the wrong thing. And to say that psychologists are seeking Rx privilages to serve the underserved is simply naive. As a psychologist on the Rxp listserve put it, it's really so that they can "get a piece of the financial pie."

Medical fundamentalism and other arguments aside, this profession is one that is obtained after the most comprehensive biological/medical training model. The field has evolved over time, for better or worse, so that medications are a vital part of the treatment process. Plastic surgeons are not lying down to let dentists perform face-lifts (and one could argue that this 'treatment' is much less altruistic than that of psychiatry). Opthalmologists are not lying down to let optometrists perform Lasik. Why should psychiatry lie down for psychologists who want "a piece of the financial pie," whilst letting psychiatry scramble to completely reinvent itself? Given an inch, psychology and other mid-level providers will attempt to take a proverbial mile. They have already demonstrated this propensity in current legislative battles.

I feel that psychiatry may have shot itself in the foot with the plethora of more recently approved fellowship programs. A fellowship in C/L psychiatry? This field should no doubt be core to evey psychiatrist - as we are medical doctors first, and psychiatrists second. Should every psychiatrist feel that they should complete a C/L fellowship to use their medical knowledge with inpatients? What then of those who worked so hard to complete their C/L fellowships? They would understandibly be upset at the practical abolishment of their 'subspecialty.'

In short, what would you say to psychiatry residents concerned about the encroachment upon their profession by mid-level providers (psychologists), and about the ability to pay back loans, etc? How can behavioral neurology be the best way to reinvent the profession? Should we even be obligated to change the clinical face of the profession simply because others feel they are entitled to its practice modalities?

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[Svas]

I have only a few seconds to reply:

Who is doing heart surgery these days?

Cardiovascular surgeons?

Cardiothoracic surgeons?

Nope. Cardiologists are replacing them because of Stents. In the the next two years, who will be doing them??? Radiologists (and as we all know, radiology is not going to stop there. I predict their next major domain will be orthopedics).

We have this infighting going on elsewhere *inside* medicine. We either adapt, grow, engage in the "verticle and horizontal" integration of news skills, or we become defunct. (I don't think that we actually become defunct, but rather that the social pressures are like physics. What's happening is akin to our having moved around enough so that we're evolving into the most economical shape. For us (IMO), spherical=behavioral neurology.


Have a great day!

S

 

[PublicHealth]

I have only a few seconds to reply:

Who is doing heart surgery these days?

Cardiovascular surgeons?

Cardiothoracic surgeons?

Nope. Cardiologists are replacing them because of Stents. In the the next two years, who will be doing them??? Radiologists (and as we all know, radiology is not going to stop there. I predict their next major domain will be orthopedics).

We have this infighting going on elsewhere *inside* medicine. We either adapt, grow, engage in the "verticle and horizontal" integration of news skills, or we become defunct. (I don't think that we actually become defunct, but rather that the social pressures are like physics. What's happening is akin to our having moved around enough so that we're evolving into the most economical shape. For us (IMO), spherical=behavioral neurology.


Have a great day!

S

In my limited experience, I have noticed that neurologists seem to be at odds with psychiatrists, and vice versa (interesting because they're boarded in both fields). Sure there are conditions defined by neurologic and psychiatric complications (e.g., dementias), but how would the "turf" of neurology and psychiatry be divided or shared? Also, what role would clinical neuropsychologists, who may ultimately gain prescription privileges, play in behavioral neurology?

 

[Thewonderer]

In my limited experience, I have noticed that neurologists seem to be at odds with psychiatrists, and vice versa (interesting because they're boarded in both fields). Sure there are conditions defined by neurologic and psychiatric complications (e.g., dementias), but how would the "turf" of neurology and psychiatry be divided or shared? Also, what role would clinical neuropsychologists, who may ultimately gain prescription privileges, play in behavioral neurology?

I do not feel that there is a "turf" war between psychiatrist and neurologist. Other than dementia, I do not see a lot of overlaps. Psychiatrists do NOT like what neurologists do while neurologists do NOT like what psychiatrists do. It is more of a mutual dislike rather than a turf war.

 

[Anasazi23]

I have only a few seconds to reply:

Who is doing heart surgery these days?

Cardiovascular surgeons?

Cardiothoracic surgeons?

Nope. Cardiologists are replacing them because of Stents. In the the next two years, who will be doing them??? ......

I see your point, but it begs another question. Although I can understand that cardiothoracic/cardiovascular surgeons could be upset at the scope of cardiologists expanding what was their traditional scope of practice in performing these procedures, I'm not quite sure it's the same as if a mid-level provider did the same thing.

For example, the scenario might be much different if EKG techs somehow obtained the ability to install cardiac stents.

Also, the encroachment of psychologists seeking Rx privilages is, for lack of a better word, a stab at what is now the heart of psychiatry. Cardiothoracic surgeons may not be putting in as many stents, but they have a multitude of other procedures that will keep them as a unique specialty - one needed by the medical world and by patients. Right now, from a practical standpoint, I'm not sure if psychiatry has this same luxury.

It's no secret that psychologists feel that psychiatrists are hurried pill pushers that do not have a complete understanding of the human psyche like they do. As one visiting Yale psychologist professor told our grad school class, "...to psychiatrists and neurologists, if the patient wakes up from surgery [neuro], the operation was a success. We, of course, know better, and only we are the ones capable of fully assessing and rehabilitating these patients. The psychiatrist doesn't care if you can't speak as well as you could before the surgery....psychiatrists don't know anything about the brain anymore - that is our job."

The absurdity of this statement, methinks, is one shared by a large portion of clinical psychologists and particularly, clinical neuropsychologists. Scarily, I know that many psychologists would not mind the abolishment of the profession of psychiatry all together. I wonder how, if the shoe were on the other foot, they would respond to psychiatrists' expanded scope of practice. What would the response be if psychiatrists started charging $2000 for a complete medical exam, Halstead-Reitan neuropsychological battery, medications and the like? I don't think the response would be a positive one.

p.s. any good true clinician knows and understands that the separation of neurology and psychiatry is an artificial one. The best clinician, albeit rare, knows that these entities are not independent of each other, and takes into account all the functionings of the human CNS when evaluating/treating the patient. In my view, all patients are neuropsychiatric in nature and must be approached as such.

 

[PublicHealth]

As one visiting Yale psychologist professor told our grad school class, "...to psychiatrists and neurologists, if the patient wakes up from surgery [neuro], the operation was a success. We, of course, know better, and only we are the ones capable of fully assessing and rehabilitating these patients. The psychiatrist doesn't care if you can't speak as well as you could before the surgery....psychiatrists don't know anything about the brain anymore - that is our job."

Would you mind sharing the name of this professor? Was it Salovey, Brownell, or Westerveld?

 

[Anasazi23]

Would you mind sharing the name of this professor? Was it Salovey, Brownell, or Westerveld?

none of the above.

Perhaps I should clarify. He was a Yale graduated psychologist, who maintained a teaching position there. Whether or not he was a 'full professor' I'm not sure.

 

[Svas]

. Although I can understand that cardiothoracic/cardiovascular surgeons could be upset at the scope of cardiologists expanding what was their traditional scope of practice in performing these procedures, I'm not quite sure it's the same as if a mid-level provider did the same thing.

In terms of surgery . . .

Don't think, for one minute, that cardiovascular surgeons (or neurosurgeons) don't think of cardiologists (neurologists) as mid-level providers.

[best stated, cardiovascular surgeons think of cardiologists and neurologists . .. and definitely psychiatrists as mid-level providers. They won't admit it at a party . . .but they definitely think it.]

They may laugh this off . . but generally their behavior betrays this. CV-Surgeons around here are suffering as much as a !!!50%!!! reduction in billings. Don't think THAT's not a stab to the heart (so to speak).


S

 

[sasevan]

Why should psychiatry lie down for psychologists who want "a piece of the financial pie," whilst letting psychiatry scramble to completely reinvent itself? Given an inch, psychology and other mid-level providers will attempt to take a proverbial mile. They have already demonstrated this propensity in current legislative battles.

In short, what would you say to psychiatry residents concerned about the encroachment upon their profession by mid-level providers (psychologists), and about the ability to pay back loans, etc? How can behavioral neurology be the best way to reinvent the profession? Should we even be obligated to change the clinical face of the profession simply because others feel they are entitled to its practice modalities?

Psychologists mid-level providers

Aren't all doctoral level healthcare disciplines (e.g., physicians, dentists, optometrists, podiatrists, psychologists) upper-level providers or is it just physicians, I mean, medical fundamentalism aside

The Physician and
the Mid-Level Provider
November/December 1996 - Volume VII, Number 6



Advanced registered nurse practitioners and physician assistants, collectively referred to as mid-level providers, have provided health care in the United States since the 1960s. Today, more and more physicians employ or work with them. Below are answers to our insureds? recent questions about mid-level providers.


Q:
Who are mid-level providers?

A: Mid-level providers are advanced registered nurse practitioners (ARNPs) and physician assistants (PAs). An ARNP is a registered nurse who has completed a graduate degree in advanced nursing practice and has passed a national certifying exam. Washington law recognizes the following areas of specialization for nurse practitioners: family nurse practitioner, women?s health care nurse practitioner, pediatric nurse practitioner, adult nurse practitioner, geriatric nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, school nurse practitioner, neonatal nurse practitioner, and clinical specialist in psychiatric/mental health nursing. Nurse practitioners in Washington are licensed to practice independently.

A PA is an individual who has graduated from a physician assistant training program accredited by the AMA and is eligible for the national certifying exam. A PA-C (physician assistant?certified) has passed the national certifying exam. In Washington State law, a PA-C is referred to as a certified physician assistant. All physician assistants in Washington are licensed to practice under a physician?s supervision.


Q:
What are the legal requirements for supervision of mid-level providers?

A: State law requirements for supervision differ depending upon the type of mid-level provider. Nurse practitioners are licensed to practice independently, requiring no supervision under the law. For PA-Cs, the law requires appropriate consultation and review of work by the sponsoring physician. For PAs, the law requires adequate supervision and review of work by the supervising physician.

A physician can supervise or sponsor no more than three PAs or PA-Cs. When a sponsoring or supervising physician is absent temporarily, a designated alternate physician sponsor or supervisor is appointed in any PA?s practice plan.

The underwriting standards of Physicians Insurance require that our policyholders exercise appropriate supervision of any mid-level providers they employ.


Q:
Does a physician have to review and countersign a mid-level provider?s charting?

A: Under the law, no such review and countersignature is required for nurse practitioners or PA-Cs. For PAs, each written entry shall be reviewed and countersigned by the supervising physician within two working days. Most physicians and clinics who employ mid-level providers routinely review a percentage of the mid-level provider?s charts from the standpoint of quality assurance.


Q:
Can mid-level providers write their own prescriptions?

A: All mid-level providers can write their own prescriptions for legend drugs. For controlled substances, PAs and PA-Cs can write prescriptions for schedule two through five controlled substances. Nurse practitioners in general can write prescriptions for schedule five controlled substances. Nurse anesthetists can write prescriptions for controlled substances for patients requiring anesthesia.


Q:
Can a mid-level provider have hospital privileges?

A: Many mid-level providers have privileges at local hospitals. The scope of privileges varies from hospital to hospital.


Q:
What liability does a physician have in working with a mid-level provider?

A: The available national and state malpractice data does not suggest that employing, sponsoring, or supervising a mid-level provider is a significant liability risk to a physician. If the physician is the mid-level provider?s employer, the physician is vicariously liable for the acts of the employee. If the physician is not the employer but sponsors or supervises a mid-level provider, the physician may have minor liability exposure on the issues of delegation, supervision, or oversight of the mid-level provider. In some cases, the physician does not employ, sponsor, or supervise the mid-level provider, but merely consults, accepts patients from, or refers patients to the mid-level provider. For these cases the physician?s minor liability exposure is the same as that of working with any other health care provider in caring jointly for a patient.


Q:
How are mid-level providers covered for malpractice?

A: At this time Physicians Insurance does not write individual professional liability policies for independent mid-level providers. Policies for insured physicians and clinics cover, at a premium charge, the mid-level providers they employ.

 

[Anasazi23]

Psychologists mid-level providers

Aren't all doctoral level healthcare disciplines (e.g., physicians, dentists, optometrists, podiatrists, psychologists) upper-level providers or is it just physicians, I mean, medical fundamentalism aside

A mid-level provider, in medical commonspeak, is generally considered a non-physician provider. This normally refers to a PA or nurse practitioner, but is commonly mentioned in medical circles as a non-physician provider. This designation is made in the world of medicare carriers. They are also known as "NPPs," - non-physician providers. Although very technically, I believe psychologists occupy a unique position as providers - neither non-physicians nor physicians according to medicare.

 

[PublicHealth]

A mid-level provider, in medical commonspeak, is generally considered a non-physician provider. This normally refers to a PA or nurse practitioner, but is commonly mentioned in medical circles as a non-physician provider. This designation is made in the world of medicare carriers. They are also known as "NPPs," - non-physician providers. Although very technically, I believe psychologists occupy a unique position as providers - neither non-physicians nor physicians according to medicare.

You down with NPPs? Yeah, you know me!

Sorry...couldn't resist...