Psychiatry post-psychologist prescriptive rights

[Red Beard]

DISCLAIMER: This is NOT a thread to debate whether or not psychologists should have prescriptive rights.

I read the other thread that just got bumped re: psychologist prescriptive rights. I also happen to have lived in Oregon, heard the concern of at least a few psychiatrists there, and read up on the issue a little bit.

The psychiatrists I spoke to are concerned. The number of psychologists in the state is around 1400 vs. 400 or so psychiatrists. Geographically, psychologists are concentrated in the same areas as psychiatrists. The problem of access for the mentally ill is not a lack of practitioners so much as it is a lack of reimbursement.

If the number of providers doubles, but the money to pay them remains the same, then competition will sky rocket and everyone will necessarily make less.

Another feature is that psychologists don't tend to take care of the sickest of the sick, those with severe chronic mental illness that is not amenable to psychotherapy. They take care of those who are more cognitively intact. Translate: a higher proportion of their clients tend to be capable of cash-pay.

These "easy pickings" are what the real competition will be about.

That leaves psychiatrists with the sickest of the sick, a population that reimburses the least.

Psychiatry has for so long offered a great variety of practice options with relative job security to match.

I can understand the concern.

Thoughts?

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[st2205]

DISCLAIMER: This is NOT a thread to debate whether or not psychologists should have prescriptive rights.

I read the other thread that just got bumped re: psychologist prescriptive rights. I also happen to have lived in Oregon, heard the concern of at least a few psychiatrists there, and read up on the issue a little bit.

The psychiatrists I spoke to are concerned. The number of psychologists in the state is around 1400 vs. 400 or so psychiatrists. Geographically, psychologists are concentrated in the same areas as psychiatrists. The problem of access for the mentally ill is not a lack of practitioners so much as it is a lack of reimbursement.

If the number of providers doubles, but the money to pay them remains the same, then competition will sky rocket and everyone will necessarily make less.

Another feature is that psychologists don't tend to take care of the sickest of the sick, those with severe chronic mental illness that is not amenable to psychotherapy. They take care of those who are more cognitively intact. Translate: a higher proportion of their clients tend to be capable of cash-pay.

These "easy pickings" are what the real competition will be about.

That leaves psychiatrists with the sickest of the sick, a population that reimburses the least.

Psychiatry has for so long offered a great variety of practice options with relative job security to match.

I can understand the concern.

Thoughts?

Most prescriptions are being written by PCPs, NPs, or PAs rather than psychiatrists. I think another important question is how many psychologists would pursue the additional training and certification to add psychopharmacology? In my opinion, which I would admit being quite limited, it wouldn't make any appreciable difference considering the above factors.

 

[Red Beard]

Most prescriptions are being written by PCPs, NPs, or PAs rather than psychiatrists. I think another important question is how many psychologists would pursue the additional training and certification to add psychopharmacology? In my opinion, which I would admit being quite limited, it wouldn't make any appreciable difference considering the above factors.

This seems like a reasonable point to me.

 

[Sneezing]

You are thinking about this all wrong. You can't be ready to give up. You know darn well our medical training isn't a waste. Our experiences aren't trivial and residency does a hell of a job producing the pharmacolgic master of psychotropics.

You know it. I know it. We need to grab our kahoonas like the anesthesiologists and start fighting with fire in those states. We are the gold standard and cash paying customers want the gold standard. Many people get refereralls from who? A physician. We know the quality of our training and if I were a PCP, you can bet that I'd want to send my patients to the best, and that is a psychiatrist, not a wannabe.

Psychiatrists in these states will eventually start advertising and pursuing these patients. Eventually, they'll dominate the prime insurance/cash market. Sadly, those with less resources and more debilitating diseases will be left to the psychologists. As they flounder, the morbidity and public outcry will mount. Eventually, within 10-20 years the politicians will realize their folly for messing with medical scopes of practice.

The ensuing morbidity will be on the hands of the politicians.

 

[dl2dp2]

I don't think psychiatrists need to necessarily worry about turf war with psychotherapist. The far future of psychiatry is in procedures and more targeted therapy, like DBS, TMS, DCS, advanced psychopharm (i.e. pharmacogenetics), advanced neuroscience-guided therapy (i.e. virtual reality exposure, computer assisted CBT), advanced imaging interpretation, and in subspecialties, like detox programs, autism/social function disorders, forensics, etc.

In the near future, psychosis/bipolar/severe depression (i.e. suicides and ECT)/severe anxiety will still be very likely strictly psychiatry. How many psychologists are willing/able to do pre-ECT H&Ps? Subspecialties won't be easily replaceable--psychologists can't do detox protocols or manage ADHD meds. C-L is definitely not at risk. Severe eating disorder/borderline disorder would probably not be easily managed by a psychologist. Turf isn't always enforced legally. Any doctor could prescribe anything, but no hematologist will ever manage a lupus patient's steroids. If specialized knowledge is needed, it doesn't matter what is allowed, people just won't do it they don't feel comfortable doing it. That's why medical specialties existed in the first place.

So what you are left with for RxP is mild to moderate depression, well functioning neurosis, marital problems, stable schizophrenics etc. While these things may constitute a big part of the cash-only clientele of MD psychiatrists at the moment, I doubt they'll in the end make a huge difference. As it is, many residency programs are de-emphasizing therapy in training, and I think this trend will only become more and more pronounced, like it or not. Although I think it's likely that psychiatry itself may split into two fields: biological psychiatry might become its own subspecialty in the coming years, then psychotherapy oriented residents can get more time to get trained to do dynamics--in fact this is already happening in psychoanalytic institutes.

What's interesting to me though is that the most prestigious psychoanalytic institutes primarily train MD therapists. Most rich clients prefer MD analysts, even though supposedly MD therapy training is inferior (which I believe personally).