Psychiatry won't exist?

[Ibid]

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Majesty

Tut tut name calling. Your problem is a parochial perspective. In most of the world you can get Clozapine over the counter. In that context the whole argument becomes absurd in any case.

 

[Manicsleep]

Right. There has to be some standard and the current standard is so weak that its downright pathetic.

I am actually not entirely against psychologists prescribing through a manner outside of medical school. DoD psychologists got 2 years of training and they still limited themselves. 300 hours is just pathetic and insulting to patients.

The reckless follow up to this is that you can get clozaril OTC somewhere? I will let whopper talk with ibid.

 

[Ibid]

Manic

It’s a salient point because in some jurisdictions you must be a psychiatrist to prescribe it and in others primary care physicians can prescribe it, else where you can get it over the counter.

I am actually not entirely against psychologists prescribing through a manner outside of medical school

Why you don’t just post what you opinion is straight off the bat instead of doing the dance of the seven veils over several posts is just a mystery.

Congratulations btw on posting the single most weird and creepy thing I have ever read on the internet. Chief Complaint Thread post #107. It’s not the frankly ordinary content that’s disturbing but your need to repeat it in such a salacious manner. I find it very peculiar but I suppose its just something that has stuck with you. Each to their own, humour being quite a personal thing.

 

[whopper]

How would you judge the expertise of this person?

Why not independent prescription? If they are capable, why do they have to go through you?

Good question and one I intentionally didn't answer because I don't have an answer.

I know several incompetent doctors even though they overcame all the obstacles to get a license to practice. I know some doctors that performed poorly on a board exams yet they are better doctors than others I know that scored well but will not be touched by others. What is the needed standard to make sure a practitioner is competent? That's tough to answer.

The bottom line is they would have to go through me or any other medical professional because there has to be a legal and professional standard as to who has the final say and is ultimately responsible for the treatment decisions.

If, for example, a psychologist prescriber didn't have to get any medical professional to work with (and so far all laws required the cooperation of a medical professional, even the Oregon law, for the psychologist prescriber to practice), fine, I have no responsibility. In that case, the question is, would the psychologist prescriber as a professional whole be able to accomplish this responsibility given their training? IMHO no based on the curriculums I've seen, though I do think they could if there was a medical professional overseeing their work. I don't know what can be done to make every practitioner competent, but I can certainly say that the curriculums I've seen for psychologist prescribers are so minimal in comparison with that of say a psychiatrist, I couldn't endorse that as good enough to prescribe medications without direct oversight.

But it appears the backers of psychologist prescription movement and the laws that have so far passed require some type of medical professional cooperation. For that reason, my previous paragraph is practically moot other than that it more clarifies my own position.

 

[Manicsleep]

Good question and one I intentionally didn't answer because I don't have an answer.

I know several incompetent doctors even though they overcame all the obstacles to get a license to practice. I know some doctors that performed poorly on a board exams yet they are better doctors than others I know that scored well but will not be touched by others. What is the needed standard to make sure a practitioner is competent? That's tough to answer.

The bottom line is they would have to go through me or any other medical professional because there has to be a legal and professional standard as to who has the final say and is ultimately responsible for the treatment decisions.

If, for example, a psychologist prescriber didn't have to get any medical professional to work with (and so far all laws required the cooperation of a medical professional, even the Oregon law, for the psychologist prescriber to practice), fine, I have no responsibility. In that case, the question is, would the psychologist prescriber as a professional whole be able to accomplish this responsibility given their training? IMHO no based on the curriculums I've seen, though I do think they could if there was a medical professional overseeing their work. I don't know what can be done to make every practitioner competent, but I can certainly say that the curriculums I've seen for psychologist prescribers are so minimal in comparison with that of say a psychiatrist, I couldn't endorse that as good enough to prescribe medications without direct oversight.

But it appears the backers of psychologist prescription movement and the laws that have so far passed require some type of medical professional cooperation. For that reason, my previous paragraph is practically moot other than that it more clarifies my own position.

You are familiar with the "advanced practice" psychologists in LA?
They require no prior or ongoing consultation with a psychiatrist or PCP to practice. They work just like any other consultant and copy notes over to the PCP. The training required for this is 100 cases over 3 years. I see more than that in a week.

My point is that lines will continue to get pushed and boundaries blurred. By the time you realize that "ok this is too much" it will be too late. One of the things we need to learn as physicians, especially as psychiatrists, is patterns of behavior. I think the pattern of what is being attempted here is very evident.

As team leaders, psychiatrists and most physicians too often try to make everyone happy. However, this can be at the detriment of our own profession and the degradation of the health field's standards. I think you have a lot to offer because you can talk (read..are willing to talk) to 'certain' people because of your views. My views are a little more cynical and perhaps as you participate more in your regional scene you may become like me or you may think like Carlat. Then again, you may choose your own route.

 

[whopper]

LA

Are you referring to Louisiana? I read the state by-laws on this, and according to their wording, there had to be medical oversight on what the psychologist prescriber did. What you are describing does not sound like there is oversight going on. It could be that these practitioners aren't following the rules or there is more to this than I know.

As for Carlat, I disagreed with him on the Oregon bill. If there is no physician oversight going on in Louisiana, then I'd disagree with that type of practice.

 

[Manicsleep]

Are you referring to Louisiana? I read the state by-laws on this, and according to their wording, there had to be medical oversight on what the psychologist prescriber did. What you are describing does not sound like there is oversight going on. It could be that these practitioners aren't following the rules or there is more to this than I know.

As for Carlat, I disagreed with him on the Oregon bill. If there is no physician oversight going on in Louisiana, then I'd disagree with that type of practice.

I haven't been on a GRC in a few years but that was my understanding of it. I can try to find out and get back to you. Someone else on here may have a better understanding of the way the law is written. Not to say that you don't, its just not the way I understood it. But I could be wrong, which would be great.

Also, physician oversight could be a very loose term. Technically, every consultant has physician 'oversight' by the PCP. So perhaps it is in that sense. You are aware that there are 2 types of medical psychologists in Louisiana now right?

 

[edieb]

As someone who lived in Louisiana during and after the bill passed, I can tell you the oversight was very loose. The psychologist would meet with the overseeing physician once/month or so so the prescriber's notes could be reviewed.


The law in LA was recently changed to resemble that or NM: after an allotted time period, the psychologist has complete autonomy. The law was further changed to allow psychologists to prescribe in all state run facilities and subsume the roles of psychiatry if the Board of Psychologists deemed that no appropriate psychiatrist could be employed in the public facility. This is to address the shortage of psychiatrists.

I know the LA Psychological Association (LPA) is getting ready to introduce a bill to allow appropriately trained psychologists to administer somatic treatment, such as ECT, in state facilities. Furthermore, LA and NM are talking about increasing the scope of medications psychologists can prescribe to help address the side effects of psychoactive medications. I imagine there will be more training needed for this and I believe the American Psychological Ass'n is about to start working on the training model. They didn't begin sooner because the Practice Directorate was working on a credentialing system for psychopharm training that would give RxP bills more momentum in the upcoming legislative session (watch Oregon and Wisconsin)

I believe the motto of the LPA when the bill was passed was just to get a bill through, prove yourself and then refine the bill as needed

 

[Manicsleep]

As someone who lived in Louisiana during and after the bill passed, I can tell you the oversight was very loose. The psychologist would meet with the overseeing physician once/month or so so the prescriber's notes could be reviewed.


The law in LA was recently changed to resemble that or NM: after an allotted time period, the psychologist has complete autonomy. The law was further changed to allow psychologists to prescribe in all state run facilities and subsume the roles of psychiatry if the Board of Psychologists deemed that no appropriate psychiatrist could be employed in the public facility. This is to address the shortage of psychiatrists.

I know the LA Psychological Association (LPA) is getting ready to introduce a bill to allow appropriately trained psychologists to administer somatic treatment, such as ECT, in state facilities. Furthermore, LA and NM are talking about increasing the scope of medications psychologists can prescribe to help address the side effects of psychoactive medications. I imagine there will be more training needed for this and I believe the American Psychological Ass'n is about to start working on the training model. They didn't begin sooner because the Practice Directorate was working on a credentialing system for psychopharm training that would give RxP bills more momentum in the upcoming legislative session (watch Oregon and Wisconsin)

I believe the motto of the LPA when the bill was passed was just to get a bill through, prove yourself and then refine the bill as needed

The board of psychology has no say anymore.
I am interested to see psychologists' practice patterns however. I think the APA should follow the AAFP's lead and commission a study of their own to compare psychiatry practice patterns vs. those of psychologists.

 

[AcronymAllergy]

The board of psychology has no say anymore.
I am interested to see psychologists' practice patterns however. I think the APA should follow the AAFP's lead and commission a study of their own to compare psychiatry practice patterns vs. those of psychologists.

While I don't know that I have any particular interest in securing prescription privileges myself at any point, I'd be interested in this as well, if for no other reason than to simply have the information available. I directly know of perhaps a half-dozen psychologists who've secured privileges, but it seems as though only roughly 1/3 are actively prescribing, or plan on prescribing in the future.

 

[whopper]

Also, physician oversight could be a very loose term. Technically, every consultant has physician 'oversight' by the PCP. So perhaps it is in that sense. You are aware that there are 2 types of medical psychologists in Louisiana now right?

It could be very loose. Hell, I know a lot of doctors that do subpar practice and have for years and get away with it because no one pressed the right levers to get them investigated. Even when that did happen, it's a slow process and can take years. Often times by then the original complainant gives up because it could require that person go to court for years.

As for the two differing types--I do recall that, but then again I haven't read the Louisiana laws for a few months. As Edieb mentioned there apparently has been some refinements.

I believe the motto of the LPA when the bill was passed was just to get a bill through, prove yourself and then refine the bill as needed

Well this gets to something I criticized before. If you're going to subject someone into a medical treatment that could have disastrous consequences on health, you have to make sure it's safe. This sounds more like opening something to the public that is highly experimental. As I've written before about the DOD report, that's the only one that's been spinned as "proof" that psychologist prescribing was somehow considered to be "safe" yet that same report stated that it should not be used as a measure for psychologist prescribing in the community and it found bad as well as good things with psychologist prescribers.

While the DOD report did bring some interesting points that IMHO could open one's mind to a psycholgoist prescriber, that was it. It's not proof the practice is safe, and to claim it is proof is a stretch of the truth at best. At best, it should be a stepping stone to open the door to more investigation.

That IMHO is pretty ridiculous if that's the only evidence that could be presented, and so far, that's all I've seen. That's a reason why IMHO there needs to be physician oversight. If a medical doctor is irresponsible enough to allow for patients to get a medication without properly reviewing the case, then the law is not bad, it's a case of a bad physician. There are plenty of those and there always will be--but the law is not at fault in that situation.

As I've written before, there has to be data on this..so why it's not being brought to the public forum is something I find very interesting. While I have no idea what that data is (heck for all I know it suggests psychologist prescribing is very safe), the fact that it's not being presented IMHO begs the question that it perhaps is not as safe practice in comparison with the other providers of psychotropic medications. That is more true if the claims are correct that the insurance provider for psycholgist prescribers is connected with the APsychologicalA. Again, I think the answer here is to analyze that data and go with what those results are, after all, are we not scientists? I do not know for a fact if the APsychologicalA controls psychologist-prescriber insurance as has been written on this board in the past by psychologists.

Am I being unreasonable? Hmm, a doctor here wants empirical data showing with reasonable medical certainty that a practice is safe before it should be given to the public. That doesn't sound unreasonable to me.

 

[loveoforganic]

How are physicians reimbursed for that type of oversight and what kind of liability to they hold? What liability do the psychologists hold?

 

[whopper]

Someone else on here may have a better understanding of the way the law is written.

I reviewed the laws less than a year ago from a Louisana government website. When I reviewed it and I did post it on this forum with links, that law specifically stated there had to be oversight from a medical professional and that medical professional had the final say. That said, things could've changed.

How are physicians reimbursed for that type of oversight and what kind of liability to they hold? What liability do the psychologists hold?

Physicians are reimbursed either through insurance, the government, or out of pocket pay. The liability they hold is the following (and I'm citing this off the top of my head so it may not be complete)...

1) Physicians are expected to practice under the standard of care.
2) " are expected to practice under the guideilnes of state and federal laws. This specific category is large and exhaustive with the number of details that could be discussed. For example, doctors as specificied by a Supreme Court case are mandated to explain to a patient the reason for the treatment, the risks and benefits, and the alternatives. Many doctors I know do not do this even though they are supposed to do so.
3) If physicians do not follow the rules, their license to practice can be suspended by the state medical board. Further, several other authorities such as private insurance and the government could revoke someone's method of reimbursement. E.g. an insurance company could refuse to pay a doctor unless he/she meets their criteria of an acceptable physician. E.g. Several companies will not accept physicians that are not board-certified. Others will not accept doctors if that doctor has a history littered with questionable practice.
4) Physicians could be sued if they commit malpractice or other types of unacceptable practice such as abandonment.
5) Physicians could face problems getting a new job if they have a littered history. E.g. Most employers and insurance companies will demand a list of any malpractice cases, cases where a doctor was investigated by the state board, etc. Most will demand the doctor to provide at least 3 professional references to back that the doctor is of good character and professional standards.

This all said, I've seen several physicians do very poor practice and get away with it. The primary reason is that patients don't know what options they have or if the practice was wrong. I've had, for example, several patients that tell me that their physician got them hooked on opioids and/or benzos and were never given a warning of the addictive and dependence potential of these medications. Further, in several of those cases, I've seen specific evidence to back it up. I've even called up those doctors and the doctor refused to discuss the case with me. Usually the patient does not want to make a case against the doctor because they're already embaressed over the situation and just want to get on with their lives. Unless I specifically see the problematic behavior with my own eyes, I can't do much other than encourage the patients to contact the state medical boards themselves which isn't exactly good business on my end if I want to get more referrals (and by the way I do encourage my patients to do this when they tell me of previous care that meets malpractice standards). I've seen several doctors not explain the minimum required (reason for treatment, alternatives, and risk/benefits).

The best analogy I can give is speeding. Yes there's laws against it but there are several who still speed and get away with it. It's usually only the very chronic and very dangerous speeders that get caught to the point where they have their license supsended, and often, it's usually only after they've broken the law several times and have caused egregious harm.

To quote a former program director where I did general residency, it's hard as hell to get a license to practice, but once you get it, it's hard as hell to lose it. He specifically mentioned it when we discussed a case where we knew of an attending who was having sexual relations with dozens of his patients. It took one of those specific people over fifteen years of lawsuits to get that doctor to have his license removed. Most people would've given up.

 

[loveoforganic]

Sorry you typed all that out Whopper, I think you misunderstood me.

I meant - is there an insurance/medicare/medicaid code for physician oversight of psychologist prescriptions? If so, how does this work? Set value/prescription written?

If the supervised psychologist writes a crappy prescription that results in a poor outcome for a patient, to what extent are that psychologist and the supervising physician held liable? What if the psychologist's notes were inadequate to make a judgment on the prescription?

 

[whopper]

I meant - is there an insurance/medicare/medicaid code for physician oversight of psychologist prescriptions? If so, how does this work? Set value/prescription written?

If the supervised psychologist writes a crappy prescription that results in a poor outcome for a patient, to what extent are that psychologist and the supervising physician held liable? What if the psychologist's notes were inadequate to make a judgment on the prescription?

I don't know how specifically the billing works because I do not work in a state where psychologist prescribers are accepted.

If the psychologist's notes are inadequate to make a judgment, then IMHO the physician should not approve the prescription. A physician, by signing his or her name is putting themselves at liability and making a statement that giving the person the medication meets acceptable practice.

That written, and being somewhat redundant, I see several doctors not following proper guidelines. I've known of psychiatrists that, for example, give out lithium, even for years, without ever ordering a lab for it.

A psychologist prescriber could latch onto a specific medical doctor who does poor care and will approve each and every prescription the psychologist makes without even reviewing the case. It makes sense too. I've seen too many physicians "fast food" and "assembly-line" their patients by simply giving a prescription without explaining anything or even talking to the patient. Each time that happens, the doctor can bill and makes more money. It's not surprising or hard to extrapolate that a medical doctor would do this if they were the person that was supposed to approve the work of a psychologist prescriber. I've seen several attendings do this type of practice with residents. They simply sign the notes and orders without even reading it.

Who would be at fault in this situation? IMHO mostly if not completely the medical doctor, though one could also find fault in the psychologist prescriber if that prescriber knew this M.D. was not doing his job and continued to work with him anyway because he was "easy."

If I were to work with a psychologist prescriber, ideally, I'd want to be under the same roof so I could work hand-in-hand with the prescriber and approve things on-the-spot with the psychologist prescriber there so we could get these things easily out of the way. I could realistically see several logistical problems if the medical doctor and psychologist were at different locations that could lead to poor care.

 

[Manicsleep]

While I don't know that I have any particular interest in securing prescription privileges myself at any point, I'd be interested in this as well, if for no other reason than to simply have the information available. I directly know of perhaps a half-dozen psychologists who've secured privileges, but it seems as though only roughly 1/3 are actively prescribing, or plan on prescribing in the future.

The whole reason...well the whole propaganda sold by the psychologists...was that they were going to serve the underserved. This has not happened. They want more 'clients.'

I don't know how many are actively prescribing or not but your post doesn't surprise me.

 

[AcronymAllergy]

The whole reason...well the whole propaganda sold by the psychologists...was that they were going to serve the underserved. This has not happened. They want more 'clients.'

I don't know how many are actively prescribing or not but your post doesn't surprise me.

Looking at only my own (very) limited sample, it's essentially a 50/50 split: three prescribe (or are considering prescribing) to underserved populations (rural community mental health and urban low-income/free-care patients), and three prescribe as a part of their private practices with patients who likely would not be considered underserved.

Absolutely no idea what the numbers look like state-wide, though. I've heard of quite a few community mental health-type settings who are hiring MPs, but not sure what sorts of interest they're attracting.

 

[Therapist4Chnge]

A psychologist prescriber could latch onto a specific medical doctor who does poor care and will approve each and every prescription the psychologist makes without even reviewing the case. It makes sense too. I've seen too many physicians "fast food" and "assembly-line" their patients by simply giving a prescription without explaining anything or even talking to the patient. Each time that happens, the doctor can bill and makes more money. It's not surprising or hard to extrapolate that a medical doctor would do this if they were the person that was supposed to approve the work of a psychologist prescriber. I've seen several attendings do this type of practice with residents. They simply sign the notes and orders without even reading it.

The reality is that passive oversight can and does happen with all types of prescribing providers (residents, NPs, PAs, and prescribing psychologists).

Replace "psychologist provider" with "nurse practitioner" or "physician assistant" and you have the same problem, yet those get a pass because...wait for it....those two groups already won prescribing rights. It can be a dangerous way to practice for the physician, not because one group is more likely to make a mistake than another, but they are putting their license on the line without properly reviewing the case. This example could happen in any setting because of the poor oversight of the physician, not because a "psychologist provider".

 

[Manicsleep]

The reality is that passive oversight can and does happen with all types of prescribing providers (residents, NPs, PAs, and prescribing psychologists).

Replace "psychologist provider" with "nurse practitioner" or "physician assistant" and you have the same problem, yet those get a pass because...wait for it....those two groups already won prescribing rights. It can be a dangerous way to practice for the physician, not because one group is more likely to make a mistake than another, but they are putting their license on the line without properly reviewing the case. This example could happen in any setting because of the poor oversight of the physician, not because a "psychologist provider".

There is some truth with this statement although I think there are levels. I completely agree that physicians need to be more vigilant about allowing others to use their license.

In residency, interns are scrutinized pretty closelyand more discretion is given as a resident progresses through training. You can't really compare a PGY3 or PGY4 resident who is supervising interns to a prescribing psychologist, nurse practitioner or PAs.

PAs are rare in psychiatry but those in other specialties get very close to residents in the middle of their careers. They are usually better than a well trained intern. An FP training director puts his PAs at PGY2 level and NPs at late PGY1 level.

Prescribing psychologists are the least well trained, by far, out of all 4 of these groups. An intern on July 1st is much better trained than a prescribing psychologist with regards to danger although they may have better training with respect to psychotherapy than a psychiatry intern.

 

[PsychEval]

What is particularly confusing is that the “least well trained” medical psychologists are taught to follow practice guidelines. Is this taught during residency in psychiatry? Research indicates that when practice guidelines are followed, there are generally better patient outcomes. From what I have seen recently, with a sample size of approximately 2,000 patients, the psychiatrists in my community rarely follow practice guidelines. The norm is off label prescribing, non FDA approved treatments, poly pharmacy with an average of four medications prescribed during a 20 minute 90801 after a 3 hour wait, 80 % have bi polar, and labs are rarely ordered. When does it become unethical to refer to a provider who may hurt your patient? I heard a primary care physician say to a patient who was on lithium for several years with no labs being ordered, “I’m not a psychiatrist, but I sort of remember something about lithium and labs needing to be done when I was in med school, you might ask your psychiatrist about that.” Patient leaves the room, PCP laughs in astonishment. It would be easy for me to dismiss this type of sloppy practice if I hadn’t seen it occur in three different states. My question is, why do so many (not all) psychiatrists rarely practice by the guidelines established by the American Psychiatric Association?

 

[snarfer]

. My question is, why do so many (not all) psychiatrists rarely practice by the guidelines established?

You can posed this question to GI, cardio, primary care, neuro, surgery, endocrine, etc. Why do so many primary care clinicians and cardio put pts on 4 antihypertensives, 3 antilipids, etc.? why do GI put pts on H2, PPI and scope them after a 20 min 90801 visit?

As a general rule, psychiatrists tend to get the more complicated pts others can not treat. I have had pts on 4-5 medicines prescribed by NP, PAs. They develop EPS or TD and were referred to me.

If someone is stable for many years on Lithium and has no physical or mental health complaint, sometimes it is well to leave it be. Although many psychiatrists I know would order labs and follow VS even if there are no physical symptoms.

 

[Manicsleep]

What is particularly confusing is that the “least well trained” medical psychologists are taught to follow practice guidelines. Is this taught during residency in psychiatry?

Yes it is taught during residency. Tested during the boards etc
Where is your data that the least well trained LEARN practice guidelines and actually PRACTICE based on them. Show me that 2000 sample size of equivalent patients.

The norm is off label prescribing, non FDA approved treatments, poly pharmacy with an average of four medications prescribed during a 20 minute 90801 after a 3 hour wait, 80 % have bi polar, and labs are rarely ordered.

You have data for this being the 'norm' or this is the norm that has been fed to you.

When does it become unethical to refer to a provider who may hurt your patient?

When the provider has only 300 hours of training is an excellent start.

 

[whopper]

From what I have seen recently, with a sample size of approximately 2,000 patients, the psychiatrists in my community rarely follow practice guidelines. The norm is off label prescribing, non FDA approved treatments, poly pharmacy with an average of four medications prescribed during a 20 minute 90801 after a 3 hour wait, 80 % have bi polar, and labs are rarely ordered.

I've seen the same as well. The problem here, however, is not lack of training. In these cases, psychiatrists most definitely were very well trained. We have to take several exams and there are several layers that put a pressure on us to keep up on the data.

The problem here IMHO is laziness on the part of doctors and the desire to make money.

The bottom line is doctors make more money and/or have to do less work when they spend less time with patients. We see 5 patients in an hour? We can bill 5x. We see 2 patients an hour, we can bill twice. The math here is simple. I've seen medical prescription horror stories and written about them on the forum for years.

This, however, does not justify giving prescription power with even less training requirements because some idiots in the profession choose not to do the right thing. Every profession will have their fair share of good and bad people. By allowing even more people to prescribe with even less requirements will only increase the amount of poor practice.

Even a terrible psychiatrist will have had to gone through some very extensive training to get where he is. The training is to the point where anyone can point out to the doctor and know that he should know better if he is doing poor practice.

You have data for this being the 'norm' or this is the norm that has been fed to you.

Whether or not any data backed this up in a study, I can tell you from personal experience this does happen and may be the norm in a specific locality. The quality of practice can highly vary because of the shortage of psychiatrists. If you practice in Iowa, you may be THE ONLY PSYCHIATRIST in several counties. Basically what that psychiatrist chooses to do there becomes the new standard for that locality.

I can also tell you that in the town where I work in a private practice, there are only 2 other private psychiatrists and I know the quality of their work. It's piss poor. It's so poor that one of those psychiatrists is a poster boy (literally) for the antipsychiatry movement. He's been quoted in their horror examples of poor psychiatric practice. There are 3 psychiatrists in the community mental health center and I know that 2 out of those 3 psychiatrists do poor practice. The third, I'm not convinced yet either way if he is a good psychiatrist or not.

How bad are they? One of them gave rectal exams to all of his patients and has been brought to court several times over it. Another only gives two weeks worth of meds with no refills, forcing the patient to come back so he can bill them for several visits. Another treats her patients using amphetamines for depression, and not as a temporary augmentation agent, I 'm talking chronic and first line treatment. I can give you several other examples but I think you get the point.

How do I know? They've either been in the newspaper, I've taken their former patients and I've read the records of their prior patients.

I've also seen this occur in several localities, even urban ones where there are a more plentiful supply of psychiatrists.

But I repeat, the problem here is not lack of training, it's unethical people who most likely got the proper training but choose to cut corners and be lazy. I see this problem in every field of medicine. Allowing someone with training that barely holds a shadow to existing standards even by non-M.D. standards (e.g. nurse practitioners and physician assistants) to be able to prescribe medications is only going to make the problem worse.

To give an analogy, there are bad police officers. The solution is not allowing more people to have police powers with even less training and qualifications. The solution here is for internal affairs to do it's job and regulate dirty cops.

 

[Manicsleep]

The norm is off label prescribing, non FDA approved treatments, poly pharmacy with an average of four medications prescribed during a 20 minute 90801 after a 3 hour wait, 80 % have bi polar, and labs are rarely ordered.

I've seen the same as well.

If you practice in Iowa, you may be THE ONLY PSYCHIATRIST in several counties.

ugh.

The 'norm' of a group does not refer to 1 psychiatrist out in one locality when the group in question is psychiatrists.

 

[Ollie123]

Could not agree more Whopper. What passes for care in the real world is, quite frankly, frightening and disturbing. The more I get involved in settings outside my university, the more stuff like this I see.

I like the analogy, and agree with it wholeheartedly. Its why, despite being in psychology I have generally been against psychology RxP (at least as they have been proposed). A view that isn't exactly going to win me any popularity contests amongst certain groups in the field, but so be it.

Unfortunately, it feels like the political push has been to "Win" RxP, and to make it as easy as possible. I probably won't be on board with the movement until I see people trying to figure out ways to maximize the training (while still keeping it efficient). I don't see that happening anytime soon. The assumption seems to be that more providers = better care. I'm not convinced that's necessarily the case, and I don't see that question asked often enough.

 

[PsychEval]

This is a complicated issue. To over simplify, Psychiatrists are socialized to be the Captain of the Ship. Psychologists are socialized to be Conscientious. IMHO, this socialization process creates different types of prescribing providers more so than differences in training.

 

[Majesty]

Psychologists are socialized to be Conscientious. IMHO, this socialization process creates different types of prescribing providers more so than differences in training.

I completely agree.
Take Gitmo for example. Very conscienctious indeed. I mean Conscientious with capital letters. Wouldn't want to diminish your accomplishments.

 

[Ollie123]

This is a complicated issue. To over simplify, Psychiatrists are socialized to be the Captain of the Ship. Psychologists are socialized to be Conscientious. IMHO, this socialization process creates different types of prescribing providers more so than differences in training.

I think there's some truth to the fact that the socialization process is dramatically different, and it can have implications for practice. I think part of it is the idea of an academic versus professional model. I'm far more interested in what we don't know about mental health than what we do and my training has focused more on that aspect. I'm not sure that would be true for the average psychiatrist, or even a more clinically-focused psychologist for that matter. It makes sense from a pragmatic standpoint...you can't treat patients with things you don't know yet, and people need help now. That's also certainly an oversimplification...obviously I need to know the background to know how to build on it, and a good clinician needs to know what things are still unproven, but we are talking trends here.

I strongly disagree with the conclusions you are drawing from that though. I'm not sure how conscientiousness factors in at all, and strongly disagree that psychology training emphasizes this anywhere near to the extent that it should. There is way too much non-EBP and other ridiculous practice going on for me to believe that conscientiousness, at least as I define it, is a major factor in training. Unfortunately, I worry that a lot of the backing for RxP seems to be coming from the very groups I trust the least to provide competent, conscientious care (at least on a system-wide level, obviously many within that group are excellent).

 

[whopper]

Someone conscientious who doesn't know how to prescribe is still someone who does not know how to prescribe.

Can psychologist prescribers be safe providers of psychotropic medication? Show me some good data. Until then, it's an untested process. The DOD report doesn't count and I've explained why several times. I've even pointed to sources that could likely provide data but they aren't giving out the data.

By the way, I actually do agree with the "over simplified" analogy that psychiatrists are trained to be Captains of the Ship. Psychiatrists, IMHO, in general (hence the over simplification) tend to treat their patients as if they're patients in other fields of medicine. It's only to be expected when so much of medical training is not based in the behavioral sciences.

Or more correctly....doctors in general treat their patients like machines waiting to be fixed instead of people. We all have our horror stories of doctors who never once explained the risks and benefits of a surgery, then the patient refuses, then they label them as psychotic and demand a psychiatry consult to assess if the patient has the capacity to decide if he needs surgery.

But the bottom line is still the bottom line. No data to support psychologist prescribers as safe in the community? Then it shouldn't be pushed forward until there is data.

 

[Therapist4Chnge]

I have seen some scary prescribing practices in the community setting, which makes quality providers that much more valuable. It is a shame that many providers get business by default and not because they provide quality services.

Unfortunately, it feels like the political push has been to "Win" RxP, and to make it as easy as possible. I probably won't be on board with the movement until I see people trying to figure out ways to maximize the training (while still keeping it efficient). I don't see that happening anytime soon. The assumption seems to be that more providers = better care. I'm not convinced that's necessarily the case, and I don't see that question asked often enough.

Exactly. Unfortunately it has stopped being a clinical push and is now a political push.

 

[PsychEval]

Someone conscientious who doesn't know how to prescribe is still someone who does not know how to prescribe.

Can psychologist prescribers be safe providers of psychotropic medication? Show me some good data. Until then, it's an untested process. The DOD report doesn't count and I've explained why several times. I've even pointed to sources that could likely provide data but they aren't giving out the data.

By the way, I actually do agree with the "over simplified" analogy that psychiatrists are trained to be Captains of the Ship. Psychiatrists, IMHO, in general (hence the over simplification) tend to treat their patients as if they're patients in other fields of medicine. It's only to be expected when so much of medical training is not based in the behavioral sciences.

Or more correctly....doctors in general treat their patients like machines waiting to be fixed instead of people. We all have our horror stories of doctors who never once explained the risks and benefits of a surgery, then the patient refuses, then they label them as psychotic and demand a psychiatry consult to assess if the patient has the capacity to decide if he needs surgery.

But the bottom line is still the bottom line. No data to support psychologist prescribers as safe in the community? Then it shouldn't be pushed forward until there is data.

A prescribing provider who is highly trained, reckless, lazy, and greedy isn’t safe for a community. I understand the no time limit 90862 dilemma. Just as you are genuinely concerned about patient safety with psychologists prescribing, I know several psychologists who are genuinely concerned about patient safety with psychiatrists prescribing. If we cannot motivate our colleagues to appropriately care for our patients, we get focused on doing it ourselves.

 

[whopper]

Don't agree Psycheval, though I do suspect you may have very good intentions.

There are better solutions to allowing someone with little training psychiatric prescription power. IMHO the standards I've seen for training psychologists to prescribe is quite minimal.

The largest provider of psychotropic medications are not psychiatrists but PCPs (IM, family practice, Ob-Gyn, general practitioners). They usually prescribe SSRIs or SNRIs and leave the more toxic stuff like antipsychotics and mood stabilizers to us psychiatrists.

Handling antipsychotics, mood stabilizers and even SSRIs on some occasions can be quite medically complex.

In prescribing for example Lithium, one must have, IMHO, good medical knowledge on the kidneys, know how to identify renal failure, and know how hypertension and diabetes can affect the kidneys. IMHO, given the level of training I've seen required by psychologist prescribers, their clinical knowledge and required experience is less than that of a medical student who has not yet even entered residency. Medical students cannot prescribe and with good reason. I wouldn't trust a medical student to handle that medication and for the same reason, I'd have even less faith in a psychologist prescriber giving it out as well.

I do think psychologists with the current training offered to psychologist prescribers can be consultants who can help medical professionals in guiding psychotropic prescription but a medical professional has to be a final authority given the possible medical complexities that can occur. Unfortunately that is not what has been pushed forward by the psychologist prescriber movement in several cases as was seen in Oregon. If, for example, a psychologist prescriber had to work in conjunction with an M.D., and the M.D. had the final say over whether the prescription was safe or not I'd be more open to accepting them because there would be oversight from a medical professional should a complex medical problem occur that could be hard to detect.

The debate over this, including on this forum, has become more political than evidenced-based.

I know several psychologists who are genuinely concerned about patient safety with psychiatrists prescribing.

IMHO, the best way for a psychologist prescriber then is to pursue a route such as an N.P. or P.A. Their required clinical experience and training was much more than what I've seen from psychologist prescriber curriculums.

 

[Cinnameg]

Ok, I'm having an acronym problem with this thread -- what does IMHO stand for?

 

[loveoforganic]

In my humble opinion

 

[Manicsleep]

Ok, I'm having an acronym problem with this thread -- what does IMHO stand for?

In my humble opinion

Also:

In My Honest Opinion
In My Holy Opinion
I Must Haughtily Observe

I am sure there are others...