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Psychologists Defeated in Hawaii Again

Anasazi23

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    Fine, but still no details.

    Think about what a psychiatrist does from start to finish. How they find out if medication is working, how the med check progresses. Think about the elicitation of symptoms, the reasons a person started a medication to begin with, how it interacts with their lives, and how some (many) symptoms are not changed by medication alone, but through changes in life circumstances. How they can deal and cope with these changes.

    Sounds a lot like some sort of psychotherapy, doesn't it?
     

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      Some people WANT to go in for a 15 minute med check. If the patient wants to discuss their treatment, bring up a new problem, etc etc it's not as if the doctor is going to say, "no no no, we only have 2 more minutes make a new appointment".

      If someone wants to bring up something else we simple bill for an extended appointment.

      Psyclops said:
      I don't know if this will help with the ongoing arguemtn or not, but I think everyone will agree with me that when people point to the 15min med checks that are performed by psychiatrists, and use it as a pejorative description of thier practices, it is with the assumption that those are the only services being provided. Ignoring the actual state of affairs of the mental health field right now, I think all would also agree that for the most part, MH services consumers should receive more contact with providers than 15min/month on a med check. I think all would also agree that the expression of these disorders is not best targeted by purely pharmacological interventions. But maybe I'm wrong, maybe people disagree with the above statements. The question then becomes how is treatment being administered? Are psychiatrists really only doing 15min med checks? I know those on this board would disagree, but I don't think that stereotype was conjured up out of thin air either. I also want to know whether the psychiatrists (i.e., those in residency, after, or practicing) on this board feel that they are representative of psychiatrists as a whole, or are they more informed than your average practicing psychiatrist. These are real questions not intended to be loaded in any way.
       
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      Psyclops

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        Anasazi23 said:
        PsychEval,

        What do you feel about patients that only WANT 15 min med checks a month?

        Believe it or not, I have quite a few patients that fit into this category.

        My name's not PsychEval, but I'm going to answer anyway. Like most questions the best answer I've got is: depends. Many clients either don't require and probably wouldn't benefit from, or don't require and could probably benefit but arean't interested in psychotherapy. I can think of some examples of people I know, highly functioning idividuals who are aware of all of thier treatment options, have tried them and feel that they benefit most from the 15min/month check. The person I'm thinking of is intelligent, aware of wht bothers her, takes the weeklong extended release fluoxetine, and loves it. I personally think she could probably go off it and be fine too, but it helps her be the way she wants to. No issues there. I would contrast that with the client who comes in and demands a "quick fix" to their problem, is generally very entitled, not willing to explore various treatment options, often times is more interested in making recommendations for treatment to the doctor than accepting reccomendations from him/her. Or for example, if a client were to come in for an evaluation, the MD says oh yes you are depressed, here is a green and white pill, see you next month.
         
        Anasazi23 said:
        That, I believe, had nothing to do with what Pterion was referencing. I believe he/she was referencing the notion that psychiatrists are nothing but pill-pushing, non-inclusive, money hungry physicians that know of nothing but medication management.
        That is exactly the propaganda to which I referred. Such imagery is so insidious that it has emboldened those extremists at the fore of the expansion movement, as they seem to take this to mean that because psychiatrists don't do it, they won't need to either. A non-sequitur built on a misperception.

        It is my belief that responsible use of pharmacology is impaired without physiology and biochemistry - and several years of supervised practice. This is not unique to psychiatry. Lest I fall into a fallacy of infinite regression I will concede that some medications do not require such indepth understanding for usage. But even aspirin can kill if you're stupid or suicidal.

        Of course the stereotype came from somewhere. There are bad psychiatrists - no one disputes that. But there are also bad psychologists, not to mention the growing population of diploma mill graduates who think transference is a way to send money by wire. One might hope their log phase is over.

        In response to PublicHealth: you are right, med school is not the only way. ARNP's, PA's are possibilities. The only PCP's I know who are at all enthused about these groups are those in rural areas who hire several, "supervise" them and take 50%. Little (public) attention is paid to quality of care, only quantity. That's the core of my problem with expansion. There simply no basis from which to claim that psychologists will be "better" at treating the "whole patient". Such foot stamping reeks of narcissistic injury. At this med school, psychiatrists are taught psychotherapy, case conceptualization and different theories by the same people who taught me in grad school. Do they have more hours of "psychotherapy" training than I did? No. Would a 2 year MS and 100-500 hours of supervised practice give me as much training in medical management? No. As for the military - it was only recently that you even needed a license to practice as a federal doc. Don't get me started on the kinds of docs I saw when I worked for Uncle.

        Collaboration with a PCP seems the least of a bag of evils. I talked this over with a buddy of mine in IM, who said "So, what - now it will take two professionals to do the work of one psychiatrist?" I liked that. Just humor, don't mean to flame.

        Better go - ironically I have a pharm quiz tomorrow. Antivirals and antineoplastics (fun).
         

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          Anasazi23 said:
          PsychEval,

          What do you feel about patients that only WANT 15 min med checks a month?

          Believe it or not, I have quite a few patients that fit into this category.

          To a certain extent, it depends on the diagnosis and symptoms. Not all mental illness is created equal. However, it may be difficult to determine where we draw the line. As I have said before, I think managed care has trained psychiatrists to over prescribe, and psychologists to over pathologize. I am interested in RxP, so I certainly have no problem with a person who has ADHD coming in for meds only. Your not a pill pusher, and I’m not a therapy pusher.
           

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            Pterion said:
            As for the military - it was only recently that you even needed a license to practice as a federal doc.

            Regardless of whether or not army psychologists should have been given the right to rpescribe meds, now that they have does anyone know the outcome? This is true question, I don't know the answer? Although how well they did would point to how well psychologists in general could do. If they did resonably well, that would certainly hurt the argument that RxP shouldn't be granted. Theoretically, if prescribing can be safely done (or as safe as an MD) without the training of an MD, then one needn't get the same training as an MD. The same goes for therapy, it used to be only the domain of MDs, but psychologists showed that they could do it just as well, and now Master's level therapists are able to perform well enough that no one is suggesting that they not.
             

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              Psyclops said:
              Regardless of whether or not army psychologists should have been given the right to rpescribe meds, now that they have does anyone know the outcome? This is true question, I don't know the answer? Although how well they did would point to how well psychologists in general could do. If they did resonably well, that would certainly hurt the argument that RxP shouldn't be granted. Theoretically, if prescribing can be safely done (or as safe as an MD) without the training of an MD, then one needn't get the same training as an MD. The same goes for therapy, it used to be only the domain of MDs, but psychologists showed that they could do it just as well, and now Master's level therapists are able to perform well enough that no one is suggesting that they not.


              I think he meant psychiatrists in the army, not psychologists?
               

              Anasazi23

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                Psyclops said:
                Regardless of whether or not army psychologists should have been given the right to rpescribe meds, now that they have does anyone know the outcome? This is true question, I don't know the answer? Although how well they did would point to how well psychologists in general could do. If they did resonably well, that would certainly hurt the argument that RxP shouldn't be granted. Theoretically, if prescribing can be safely done (or as safe as an MD) without the training of an MD, then one needn't get the same training as an MD. The same goes for therapy, it used to be only the domain of MDs, but psychologists showed that they could do it just as well, and now Master's level therapists are able to perform well enough that no one is suggesting that they not.

                A line from the Boondocks cartoon (Adult Swim) comes to mind:

                The absense of evidence does not equal the evidence of absense.

                Not to sound demeaning or devaluing, but safety does not equal efficacy, or efficiency, or imply a full understanding of the patient.

                Just because either Seroquel or Geodon will get a person better certainly does not mean that both can be given interchangeably. Psychiatrists will always be better equipped to make this clinical decision. Regardless of what outcome data reports. To refute this is to ignore the face validity of the entire concept.

                The next question therefore becomes: what do patients deserve? Or the game we play in medicine (the residency axiom)....if this were your mother, what would you do? The answer ususally involves less sleep.

                If my mother, who is chronically hypotensive, became depressed with psychotic features, there's no way in hell I'm sending her to a rxp psychologist.
                 

                Psyclops

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                  Anasazi23 said:
                  A line from the Boondocks cartoon (Adult Swim) comes to mind:

                  The absense of evidence does not equal the evidence of absense.

                  Not to sound demeaning or devaluing, but safety does not equal efficacy, or efficiency, or imply a full understanding of the patient.

                  Just because either Seroquel or Geodon will get a person better certainly does not mean that both can be given interchangeably. Psychiatrists will always be better equipped to make this clinical decision. Regardless of what outcome data reports. To refute this is to ignore the face validity of the entire concept.

                  The next question therefore becomes: what do patients deserve? Or the game we play in medicine (the residency axiom)....if this were your mother, what would you do? The answer ususally involves less sleep.

                  If my mother, who is chronically hypotensive, became depressed with psychotic features, there's no way in hell I'm sending her to a rxp psychologist.

                  I don't think you were demeaning at all, in fact you supported my point in my opionion. The quote could go the other way supporting RxP. As for your argument that you are better equipped regardless of what outcome data report? This is just arguing from a vacuum my firend. I don't know the result of the outcome data, nor do I have time to look it up today, but if it were to show that psychologists were safely and effectively prescribing medication, then your arguments would fall apart. Such is the nature of science. Please read House of Cards by Robyn Dawes for an in depth review on arguing against research findings. As for seroquel and geodon it's possible that neither would get the person better you might have to give 'em clozaril...and as you might imagine, I would always send my mother to a PhD first rxp or not, although I get your point about her being hypotensive.
                   

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                    Pterion said:
                    That is exactly the propaganda to which I referred. Such imagery is so insidious that it has emboldened those extremists at the fore of the expansion movement, as they seem to take this to mean that because psychiatrists don't do it, they won't need to either. A non-sequitur built on a misperception.

                    It is my belief that responsible use of pharmacology is impaired without physiology and biochemistry - and several years of supervised practice. This is not unique to psychiatry. Lest I fall into a fallacy of infinite regression I will concede that some medications do not require such indepth understanding for usage. But even aspirin can kill if you're stupid or suicidal.

                    Of course the stereotype came from somewhere. There are bad psychiatrists - no one disputes that. But there are also bad psychologists, not to mention the growing population of diploma mill graduates who think transference is a way to send money by wire. One might hope their log phase is over.

                    In response to PublicHealth: you are right, med school is not the only way. ARNP's, PA's are possibilities. The only PCP's I know who are at all enthused about these groups are those in rural areas who hire several, "supervise" them and take 50%. Little (public) attention is paid to quality of care, only quantity. That's the core of my problem with expansion. There simply no basis from which to claim that psychologists will be "better" at treating the "whole patient". Such foot stamping reeks of narcissistic injury. At this med school, psychiatrists are taught psychotherapy, case conceptualization and different theories by the same people who taught me in grad school. Do they have more hours of "psychotherapy" training than I did? No. Would a 2 year MS and 100-500 hours of supervised practice give me as much training in medical management? No. As for the military - it was only recently that you even needed a license to practice as a federal doc. Don't get me started on the kinds of docs I saw when I worked for Uncle.

                    Collaboration with a PCP seems the least of a bag of evils. I talked this over with a buddy of mine in IM, who said "So, what - now it will take two professionals to do the work of one psychiatrist?" I liked that. Just humor, don't mean to flame.

                    Better go - ironically I have a pharm quiz tomorrow. Antivirals and antineoplastics (fun).

                    What the F? As related to psychology, those who can do, those who can’t teach or cave and go to med school. Just humor, don’t mean to flame.
                     

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                      Psyclops said:
                      I don't think you were demeaning at all, in fact you supported my point in my opionion. The quote could go the other way supporting RxP. As for your argument that you are better equipped regardless of what outcome data report? This is just arguing from a vacuum my firend. I don't know the result of the outcome data, nor do I have time to look it up today, but if it were to show that psychologists were safely and effectively prescribing medication, then your arguments would fall apart. Such is the nature of science. Please read House of Cards by Robyn Dawes for an in depth review on arguing against research findings. As for seroquel and geodon it's possible that neither would get the person better you might have to give 'em clozaril...and as you might imagine, I would always send my mother to a PhD first rxp or not, although I get your point about her being hypotensive.


                      You would send your mom to a PhD if she had psychotic features?
                       
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                      Anasazi23

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                        Psyclops said:
                        I don't think you were demeaning at all, in fact you supported my point in my opionion. The quote could go the other way supporting RxP. As for your argument that you are better equipped regardless of what outcome data report? This is just arguing from a vacuum my firend. I don't know the result of the outcome data, nor do I have time to look it up today, but if it were to show that psychologists were safely and effectively prescribing medication, then your arguments would fall apart. Such is the nature of science. Please read House of Cards by Robyn Dawes for an in depth review on arguing against research findings.

                        Again, I don't mean to be demeaning, and am sincerely glad that you didn't take my last post as such, since it wasn't intended.

                        But,
                        Psychiatry, unlike some other medical specialties, cannot rely completely on objective criteria for every and all things related to diagnosis. When hearts fail, we see ekg changes, echo changes. When the liver fails, we can track its status via LFTs and coags. When the kidney fails, we can track BUN/Cr, electrolytes, and even acid-base status.

                        When the brain fails, it is manifested through thought processes, speech, behavior, and practical change in functioning. Research findings and pencil-and-paper tests, while valuable, cannot objectify measure all these domains and more importantly, cannot absolutely dictate treatment. Multiply these with comorbid medical problems, and the picture is now quite complicated.

                        As for seroquel and geodon it's possible that neither would get the person better you might have to give 'em clozaril...and as you might imagine, I would always send my mother to a PhD first rxp or not, although I get your point about her being hypotensive.

                        That's just messed up and in some cases, would border on malpractice.
                         

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                          PsychEval said:
                          What the F? As related to psychology, those who can do, those who can’t teach or cave and go to med school. Just humor, don’t mean to flame.

                          Just to be sure everyone is "flamed". In psychology those who can do research, those who can't practice.
                           

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                            Anasazi23 said:
                            But,
                            Psychiatry, unlike some other medical specialties, cannot rely completely on objective criteria for every and all things related to diagnosis. When hearts fail, we see ekg changes, echo changes. When the liver fails, we can track its status via LFTs and coags. When the kidney fails, we can track BUN/Cr, electrolytes, and even acid-base status.

                            When the brain fails, it is manifested through thought processes, speech, behavior, and practical change in functioning. Research findings and pencil-and-paper tests, while valuable, cannot objectify measure all these domains and more importantly, cannot absolutely dictate treatment. Multiply these with comorbid medical problems, and the picture is now quite complicated.


                            Fair enough, we are now having the elusive mature argument. I just want to point out that you are arguing from a vacuum. You say even if the research supports one thing, in this case psychologists adequately prescrbing medication, it doesn't matter because we are not properly operationalizing the constructs. Well, then tell me, how should it be put to a test? If psycholgoists were to effectively and safely prescribe medication, that wouldn't be a proper operationalization of the construct of pharmacological treatment of psychopathology?

                            And I agree that the picture becomes complicated very quickly! And clinical judgement is great if you have it. But as you know the point of research is to objectively measure those things that are indicative of the brain failing in certain ways as you like to put it. I think that biological bases of behavior and cognition can be useful at times in treating a patient, they most certainly are not the end all be all of human mentations and behavior. The brain is a delightful piece of machinery, and is succeptable to influce from all sorts of vectors, chemical and behavioral.

                            As for the comment about my mother I was kidding, I couldn't help myself.
                             

                            Anasazi23

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                              Not so much a vacuum as an appreciation for the fact that not all things related to patient care can be operationalized.

                              While psychologists will scoff at this statement, I stand by it.

                              Either you believe that the extra years of medical training will have some positive impact on psychiatric patient care, or you will not. Rare side effects and medical conditions are by definition, rare.

                              It just seems to me that the psychology camp is spouting ridiculous, equally unscientific 'data' (10 million prescriptions written without one bad side effect!). This doesn't even make statistical sense. Number needed to treat, time in treatment, medications and dosings used, psychologists being supervised by physicians, economic feasibility, medication class used, length of stay, discovery of serious medical conditions, management of adverse effect, and myriad other conditions are all part of a patient whole. To artificially pick one or two of these variables and measure it is not a real-world, useable or useful result.

                              Psychologists are very good at what they do. But in large part, I don't need what they want to tell me as far as managing my patient. Psychologists get on psychiatrists for not obsessing over the correct diagnoses, for example. While diagnosis is important from an academic standpoint, we are trained in medicine to treat symptoms. If you don't fully meet criteria for a particular DSM disorder but have a significant symptom(s) that's causing a problem - we treat it. As the picture changes, we treat the changing picture.

                              As a side note, I rarely go to the psychology forum, as it really has little to no information pertinent to me, but when I do, I see that it's filled with erroneous info and misinformation about psychiatrists. For example, the reason psychiatrists are "so excited about genetics" as posted in the psychology thread, is because we're soon going to be ordering genetic testing via dna analysis that will enable to tailor specific protein couplers and gene modifiers in the form of medication to most effectively treat psychiatric illnesses. We're not just running around 'excited about genetics' because we have nothing better to do or saw a special on the Discovery Channel. :rolleyes:
                               

                              Anasazi23

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                                PsychEval said:
                                What the F? As related to psychology, those who can do, those who can’t teach or cave and go to med school. Just humor, don’t mean to flame.

                                I can take a joke - and know that this particular one is directed at me. But let me ask. Do you really consider those who 'cave' and leave psychology for psychiatry to be one who can't hack it in psych grad school, or are too stupid to get through the classes?

                                If so, why?
                                 

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                                  Anasazi23 said:
                                  Not so much a vacuum as an appreciation for the fact that not all things related to patient care can be operationalized.

                                  While psychologists will scoff at this statement, I stand by it.:

                                  I don't scoff, but I will say that we need to strive to operationalize all that we can, but in general the idographic view makes a valid point, each patient is more complicated than a research agregate.


                                  Anasazi23 said:
                                  It just seems to me that the psychology camp is spouting ridiculous, equally unscientific 'data' (10 million prescriptions written without one bad side effect!). This doesn't even make statistical sense. Number needed to treat, time in treatment, medications and dosings used, psychologists being supervised by physicians, economic feasibility, medication class used, length of stay, discovery of serious medical conditions, management of adverse effect, and myriad other conditions are all part of a patient whole. To artificially pick one or two of these variables and measure it is not a real-world, useable or useful result.

                                  I've heard those numbers as well, I don't know what's behind them. They might show that psycholgists are idiots when it comes to prescribing meds (I doubt it) but if the reserach shows that they aren't I think you should conceed that they can do a fine job and consider endorsing RxP.


                                  Anasazi23 said:
                                  Psychologists are very good at what they do. But in large part, I don't need what they want to tell me as far as managing my patient. Psychologists get on psychiatrists for not obsessing over the correct diagnoses, for example. While diagnosis is important from an academic standpoint, we are trained in medicine to treat symptoms. If you don't fully meet criteria for a particular DSM disorder but have a significant symptom(s) that's causing a problem - we treat it. As the picture changes, we treat the changing picture.:

                                  The problem with treating the symptoms as far as I see it is that different disorders might cause the same symptoms. While youmight not think that matters, it matters if their are differnt etiologies, and thus differnt treatment suggestions. For example, dperession, as you know some patients respond better to ssri's and other to nor-epinephrine drugs like bupropion. That suggests to me that there might be differnt etiologies, or at least varied etiologies. I think we should strive as a field to unlock that secret.


                                  Anasazi23 said:
                                  As a side note, I rarely go to the psychology forum, as it really has little to no information pertinent to me, but when I do, I see that it's filled with erroneous info and misinformation about psychiatrists. For example, the reason psychiatrists are "so excited about genetics" as posted in the psychology thread, is because we're soon going to be ordering genetic testing via dna analysis that will enable to tailor specific protein couplers and gene modifiers in the form of medication to most effectively treat psychiatric illnesses. We're not just running around 'excited about genetics' because we have nothing better to do or saw a special on the Discovery Channel. :rolleyes:

                                  Believe me when I say I know why you are so excited. But are those drugs on the horizon? The reason I scoff at this is because it seems so basic, that how could it have been missed for so many years. It seems to be to be a no-brainer (pun intended) that behavior, mood, personality, etc. will have a genetic component to it.

                                  Aside from assessemnt and testing I have little interest in practicing. By from an academic standpoint MH is very ntresting, and that includes how services are administered. I've worked along psychiatrists for years, quite closely too. I see ways they could improve in thier service delivery. I also enjoy to discuss this stuff. I'm learning as I go along. Just to let you know where I am coming from.
                                   

                                  Anasazi23

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                                    Patients are difficult to operationalize. That we agree on.
                                    That said, I won't endorse psychologist rxp until the training because it's simply sub-par compared with the gold standard (medical school and residency). For the reasons listed above, research will be biased toward the psychologists because a) they will be the ones conducting it b) they know how to skew data in their favor and refuse to account for confounds that are inconvenient for them. As you know, it's quite easy.

                                    You say you see how psychiatrists can improve their practice. Not to be rude, but how are you qualified to make this assertion? How do you know what they need to know and what their responsibilities entail?
                                     

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                                      While it is true that one must walk a mile in a man's shoes to truly understand what they are going through, it is also true that one doesn't have to have children of their own to realize that someone is a bad parent.

                                      As for what I'm basing my opinion on? I've worked in two psychiatric hospitals for three years, I've worked on inpatient child, adult, adolescent, chronic and acute stabalization units. I've also worked residential treatment. I've worked in crisis (both phone and mobile) and would coordinate admissions with the MDs, I would also coordinate outpatient care with MDs and every other level of provider. I've worked addmissions, doing assessments and coordinating with the Docs. I think alot of times the MDs are under pressure to practice in ways they wouldn't neccessarily choose, or I would hope they wouldn't. I understand the imense pressure that 3rd party payers can put a doctor and hospital under. From my vantage point, things need to change.

                                      Edit: I forgot to mention a couple of things. One: For the last year I've been working in a Psychiatry Department of an Ivy League University, doing behavioral genetics of all things. Two: My brief resume here was not meant in any way to be bragadocious or anything, I just want you to know I'm making what I consider informed decisions. It also is true that just because somone has worked in psychiatric hospitals for years it doesn't mean they know much about psychiatrists. Except I strove to learn as much about everything as I could, I would attend tx team, discuss patients with the MDs, etc. Also working in addmissions, I who have no liscence whatsoever would give the initial diagnoses, which is how I learned that the DSM isn't worth the paper it's printed on. I get frustrated when some of those just finishing med school and haven't hit the street yet lambaste me for my posts, but I don't mean to be condescending or inflamatory (most of the time), I enjoy the bilateral discussions.
                                       

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                                        Anasazi23 said:
                                        The absense of evidence does not equal the evidence of absense.

                                        Not to sound demeaning or devaluing, but safety does not equal efficacy, or efficiency, or imply a full understanding of the patient.

                                        How can you be sure that psychologist prescribing is not efficacious, efficient, or that prescribing/medical psychologists do not have a full understanding of their patients? There are no data! As you pointed out, the absence of evidence does not equal evidence of absence.

                                        Anasazi23 said:
                                        Psychiatrists will always be better equipped to make this clinical decision. Regardless of what outcome data reports. To refute this is to ignore the face validity of the entire concept.

                                        If my mother, who is chronically hypotensive, became depressed with psychotic features, there's no way in hell I'm sending her to a rxp psychologist.

                                        The issue is not psychiatrist vs. psychologist. It's whether or not psychologists with training in psychopharmacology can prescribe safely and effectively. There is no doubt that psychiatrists are the "gold standard" in biological treatments of psychiatric conditions. But this does not mean that psychologists cannot be trained to treat and manage psychiatric disorders in the context of psychotherapeutic treatment and collaboration with a primary care physician.

                                        If your chronically hypotensive mother with depression with psychotic features lived in a state in which the closest psychiatrist was 100 miles away, had a five-month waitlist, and charged $500 for an initial evaluation, I'm sure you might reconsider a prescribing/medical psychologist. Clearly, this is not the reality in New York City, where you currently work, but the situation is dramatically different in other states, especially in child psychiatry http://www.cnn.com/2006/HEALTH/04/07/child.psychiatrists.ap/index.html. As someone pointed out above, there has been increasing interest in psychiatry among medical students, but will these purported increase really satisfy the demand? Some psychiatrists do not pursue independent practice after residency, opting instead for academia or industry, and most have no interest at all in practicing in rural states where there is a critical shortage of psychiatrists.
                                         
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                                        Anasazi23 said:
                                        Not so much a vacuum as an appreciation for the fact that not all things related to patient care can be operationalized.

                                        While psychologists will scoff at this statement, I stand by it.

                                        Either you believe that the extra years of medical training will have some positive impact on psychiatric patient care, or you will not. Rare side effects and medical conditions are by definition, rare.

                                        It just seems to me that the psychology camp is spouting ridiculous, equally unscientific 'data' (10 million prescriptions written without one bad side effect!). This doesn't even make statistical sense. Number needed to treat, time in treatment, medications and dosings used, psychologists being supervised by physicians, economic feasibility, medication class used, length of stay, discovery of serious medical conditions, management of adverse effect, and myriad other conditions are all part of a patient whole. To artificially pick one or two of these variables and measure it is not a real-world, useable or useful result.

                                        Psychologists are very good at what they do. But in large part, I don't need what they want to tell me as far as managing my patient. Psychologists get on psychiatrists for not obsessing over the correct diagnoses, for example. While diagnosis is important from an academic standpoint, we are trained in medicine to treat symptoms. If you don't fully meet criteria for a particular DSM disorder but have a significant symptom(s) that's causing a problem - we treat it. As the picture changes, we treat the changing picture.

                                        As a side note, I rarely go to the psychology forum, as it really has little to no information pertinent to me, but when I do, I see that it's filled with erroneous info and misinformation about psychiatrists. For example, the reason psychiatrists are "so excited about genetics" as posted in the psychology thread, is because we're soon going to be ordering genetic testing via dna analysis that will enable to tailor specific protein couplers and gene modifiers in the form of medication to most effectively treat psychiatric illnesses. We're not just running around 'excited about genetics' because we have nothing better to do or saw a special on the Discovery Channel. :rolleyes:


                                        I agree with this 100% sazi!
                                         

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                                          PublicHealth said:
                                          How can you be sure that psychologist prescribing is not efficacious, efficient, or that prescribing/medical psychologists do not have a full understanding of their patients? There are no data! As you pointed out, the absence of evidence does not equal evidence of absence.



                                          The issue is not psychiatrist vs. psychologist. It's whether or not psychologists with training in psychopharmacology can prescribe safely and effectively. There is no doubt that psychiatrists are the "gold standard" in biological treatments of psychiatric conditions. But this does not mean that psychologists cannot be trained to treat and manage psychiatric disorders in the context of psychotherapeutic treatment and collaboration with a primary care physician.

                                          If your chronically hypotensive mother with depression with psychotic features lived in a state in which the closest psychiatrist was 100 miles away, had a five-month waitlist, and charged $500 for an initial evaluation, I'm sure you might reconsider a prescribing/medical psychologist. Clearly, this is not the reality in New York City, where you currently work, but the situation is dramatically different in other states, especially in child psychiatry http://www.cnn.com/2006/HEALTH/04/07/child.psychiatrists.ap/index.html. As someone pointed out above, there has been increasing interest in psychiatry among medical students, but will these purported increase really satisfy the demand? Some psychiatrists do not pursue independent practice after residency, opting instead for academia or industry, and most have no interest at all in practicing in rural states where there is a critical shortage of psychiatrists.

                                          I could rehash the same arguments that refute this, but it's old hat. For example: Show me the data that psychologists are willing to move to chronically underserved swamplands that psychiatrists refuse to go to.

                                          The motivation is money, not patient care or access. The stuff coming off of that listserv is sickening. You know this.
                                           

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                                            Anasazi23 said:
                                            The motivation is money, not patient care or access. The stuff coming off of that listserv is sickening. You know this.

                                            Of course. Increased scope of practice is critical to psychology's survival as a healthcare discipline. Money doesn't hurt either. ;) (How's the new beemer, by the way!?). However, I have personally worked with a number of psychologists who could not provide their patients with the comprehensive psychiatric care that they needed because they did not have prescriptive authority. Instead, they had to tell their patients that they would have to wait MONTHS to get evaluated and receive treatment. How would our hypothetical hypotensive patients with depression with psychotic features react to this news? Patient care and access clearly plays a role in the psychologist RxP movement. Psychologists see their patients each week for therapy and often grow interpersonally connected to them. I'm sure some may feel that they fail their patients when they cannot offer the best and most comprehensive combination of psychological treatment and pharmacotherapy.

                                            You're right about the listserv. Seems like some folks are growing very desperate. We'll see what happens.
                                             

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                                              PublicHealth said:
                                              Division 55, right?

                                              Duh, gotcha. The argument previously put forth by Ana, about the psychologists not running in droves to the swamplands out there, doesn't make sense to me. NM and LA granted prescriptive authority to PhDs because the were available in those places right? There happen to be more PhDs in any given part of the US, even the remote ass places like Wyoming and hell's next door neighbor LA right?
                                               

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                                                Psyclops said:
                                                Duh, gotcha. The argument previously put forth by Ana, about the psychologists not running in droves to the swamplands out there, doesn't make sense to me. NM and LA granted prescriptive authority to PhDs because the were available in those places right? There happen to be more PhDs in any given part of the US, even the remote ass places like Wyoming and hell's next door neighbor LA right?


                                                Division 55, how clandestine.
                                                 

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                                                  pschmom1 said:
                                                  Hawaii here I come!!! Beautiful weather, beautiful scenery, wholesome atmosphere, and super high demand for psychiatrists? I'm there!!!!

                                                  Hate to bust your bubble. I lived there for three years. Great weather and views, but one backward place with a lot of problems...and expensive! It was, however, a great transition to other third world countries, LOL!
                                                   
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                                                    zenman said:
                                                    Hate to bust your bubble. I lived there for three years. Great weather and views, but one backward place with a lot of problems...and expensive! It was, however, a great transition to other third world countries, LOL!


                                                    As a native Hawaiian I think your post was a little insulting. The problems in Hawaii are not "third world" and your three years there definitely wouldn't make you an expert. If you understood the culture of Hawaiians, you'd realize the issues and problems that appear to be so "unique" to Hawaii are actually problems very common among other NATIVE AMERICAN communities - not THIRD WORLD COUNTRIES :rolleyes: Furthermore, you'd find the same issues in the rural parts of the U.S., far from what I've experienced in third world countries with Hawaii having its own set of problems, often steming from over abundance of drug abuse, limited healthcare options, and poor schooling, as well as a tradition that too many "visitors" exploit without understanding.

                                                    If you were in the military there (which I'm assuming) you had the ultimate in limited exposure since you either lived on base or in one of those crappy areas (which is all that military can afford) so your view isn't comprehensive.
                                                     

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                                                      Psyclops said:
                                                      Duh, gotcha. The argument previously put forth by Ana, about the psychologists not running in droves to the swamplands out there, doesn't make sense to me. NM and LA granted prescriptive authority to PhDs because the were available in those places right? There happen to be more PhDs in any given part of the US, even the remote ass places like Wyoming and hell's next door neighbor LA right?

                                                      There was a study...too lazy to dig it up now, that showed the distribution of psychiatrists and psychologists to be about exactly the same. That is, concentrated in cities.

                                                      In fact, when the whole rxp movement started, one of the provisions was that the psychologists had to remain in an underserved area to practice, since that was their battle cry - underserved populations. Of course, they refused this.

                                                      As for public health's proposition that our hypotensive psychotic mother would need to wait 5 months to see a psychiatrist doesn't really fly either. You're limiting your thinking to outpatient private practice only. A huge part of psychiatry consist of psychiatric clinics, academic centers, and of course hospitals. She would receive treatment at any hospital in the state. It's the law. Again not surprisingly, the psychologists did not include the above mentioned access centers in their recent survey of psychiatrists' offices. Whereafter they claimed that most psychiatrists don't answer their phone, or some such drivel.
                                                       

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                                                        Poety said:
                                                        As a native Hawaiian I think your post was a little insulting. The problems in Hawaii are not "third world" and your three years there definitely wouldn't make you an expert. If you understood the culture of Hawaiians, you'd realize the issues and problems that appear to be so "unique" to Hawaii are actually problems very common among other NATIVE AMERICAN communities - not THIRD WORLD COUNTRIES :rolleyes: Furthermore, you'd find the same issues in the rural parts of the U.S., far from what I've experienced in third world countries with Hawaii having its own set of problems, often steming from over abundance of drug abuse, limited healthcare options, and poor schooling, as well as a tradition that too many "visitors" exploit without understanding.

                                                        If you were in the military there (which I'm assuming) you had the ultimate in limited exposure since you either lived on base or in one of those crappy areas (which is all that military can afford) so your view isn't comprehensive.


                                                        No meant insult. I lived one year each in Honolulu, Kapolei and then bought a house in Waianae. That's right broduh, I was a white boy in Waianae! And my military time was Nam era, not now. I was also given honorary "local boy" status by a Japanese Hawaiian. I was just intending to let the poster know that the grass is not always greener in Hawaii...nor is it any other place. Hawaii would be fine if it was a country and not screwed up by being part of the states...know what I mean! But you guys must do something about those plate lunches...and put some bar-b-que sauce on those damn pigs! :laugh:
                                                         

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                                                          zenman said:
                                                          No meant insult. I lived one year each in Honolulu, Kapolei and then bought a house in Waianae. That's right broduh, I was a white boy in Waianae! And my military time was Nam era, not now. I was also given honorary "local boy" status by a Japanese Hawaiian. I was just intending to let the poster know that the grass is not always greener in Hawaii...nor is it any other place. Hawaii would be fine if it was a country and not screwed up by being part of the states...know what I mean! But you guys must do something about those plate lunches...and put some bar-b-que sauce on those damn pigs! :laugh:

                                                          If you bought a house, you were doing ok - although real estate in local areas is actually very reasonable! Honolulu sucks and is not a reflection at all of Hawaiian culture - that place is just all around crap. Its like visiting disney land, when you should be going to disney WORLD ya know?

                                                          I agree that Hawai'i has a lot of problems stemming from the Mainland, and ofcourse, it is a tourist environment (but how would Hawaiians survive otherwise?) which just makes the problems worse. I could also argue that any area that has a large service community (even on the mainland) is riddled with problems relating to a large transient population that really doesn't invest in the community. (Take for instance the Fort Jackson,SC area, Fayetville, NC, etc...)

                                                          Hawaii really is a primary site for drug trade, and its monopolized by Japanese ownership - all these things account for the detriment of the local community. There's no real investors that are committed to enhancing education, and assist Hawaiians in the transition from tribal tradition to "mainstream" life. There are also SOOOO many immigrants from actual third world countries, that in retrospect, I can see where you would get that whole "third world country" idea from. But those are the immigrants, not the locals.

                                                          My concern is that so many people think of reservations and islands as vacation places, with no real consideration of the people that make up the backbone of these communities. Whats even sadder is, research has shown (take for instance, the kaui studies) that in order to be successful, most Hawaiians need to distance themselves from their heritage in order to get ahead. Now that is a sad, sad, SAD state of affairs.

                                                          plate lunches ROCK! :laugh:

                                                          and I'd kill for some saimin right now - even if its from McDonalds! :laugh: hey hey, don't knock it til you try it!
                                                           

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                                                            Honestly, just as droves of psychologists may not be packing their bags with plans to move to isolated, rural areas, there are plenty of psychologists who have no intention of pursuing Rx privileges (even if they are ultimately awarded).

                                                            I'm not saying this to suggest these issues are not worth discussing, but rather to highlight the fact that the overall scope of mental health care would probably not change as much as some people (esp the forces in Div. 55) would like you to believe.
                                                             

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                                                              PsychEval said:
                                                              The stereotype is not coming from the competing APA, as public health pointed out:

                                                              Medical students are generally not interested in psychiatry because (1) it's one of the lowest paying specialties; (2) they don't want to work with chronically mentally ill people; and (3) psychiatrists tend to be less respected than other physicians.

                                                              See thread "The Field of Psychiatry" in the General Residency Forum.
                                                               

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                                                                Solideliquid said:
                                                                See thread "The Field of Psychiatry" in the General Residency Forum.

                                                                Hi Solid,

                                                                Interesting. Although, I never said it was a justified stereotype. I was simply suggesting the stereotype is not coming from the APA. I think you would agree that mental health tends to be less valued in society than physical health. This is evidenced with reimbursement rates, reactions from others when you tell them what you do (psychiatrist/or psychologist), etc. As you likely know, many are pushing for parity. It does seem the stigma of mental illness is decreasing, which in turn contributes to all of us being busier. We (psychiatrists/psychologists) get some of the most challenging cases and are frequently in a position to assist someone with getting their life back, pretty rewarding.

                                                                These are some of the things I struggle with:

                                                                It is difficulty to get my patients in for a medication evaluation in a timely fashion on an outpatient basis. The ER is always an option, but over utilization of health care is everyone’s problem. As your tax bracket goes up, you will recognize this even more. It typically takes 2-4 months to get a patient in to see a psychiatrist in my area. 75% of the time, these patients end up seeing a nurse, not the psychiatrist. Consequently, of my patients who require medication, 97% receive meds from their PCP, and only 3% of my patients see a psychiatrist.

                                                                I continue to have a hard time understanding how most on this forum fail to recognize that psychologists with medical training will be in a better position to recognize a medical problem, and make an appropriate referral back to the primary physician if needed.
                                                                 

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                                                                  Jon Snow said:
                                                                  Perhaps this is why psychiatrists are scorned by other physicians. You're trained to treat symptoms? Diagnosis only matters from an academic standpoint? Surely, you jest.

                                                                  This just reaks of inexperience.

                                                                  You don't need what psychologists have to say. Doesn't this entirely depend on setting and population?


                                                                  "If all I saw was perfectly healthy, depressed people, I wouldn't need psychiatrists. "

                                                                  Oh, and the comment about needing two doctors to do a psychiatrist's job. . . A psychiatrist is a specialist. You aren't first in the chain for the most part. Primary care physicians are most often the initial screeners.

                                                                  Access to psychiatrists even in a hospital setting can be difficult for patients with certain insurance coverages and/or lack thereof. I have served a role in the past of rec. medications to a PCP in a hospital setting even though my office was on a freakin' psychiatry wing and there were psychiatrists running around all over the place. They wouldn't see my patient. You guys are difficult to track down.

                                                                  So when do you begin your MS in clinical psychopharmacology? ;)

                                                                  Illinois has some folks active in the RxP movement: http://www.illinoispsychology.org/i...alog=9&parent=top134&do=datePublished&dd=Desc
                                                                   

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                                                                    Ana, if you're interested take a look at that link in the post above this one. It seems to think there are more psychologists in rural areas. And it had occured to me that even if the distribution was relatively the same, or the same, with there being more practicing psychologists out there in general, there would be more in rural and uncerserved areas than there would be psychiatrists.

                                                                    While we are on the topic of availability of services, I think that your suggestion that someone go to the emergency room is not always going to get them service, even if as you say "It's the Law". Insurance companies and psychiatric services ahve a funny way of turning EMTALA rules into gray areas. And our poor suffering depressed psychotic mother might not meet the criteria for a stay in a hospital according to her insurance company, especially if she is keeping up with her ADLs and not overtly suicidal, and the next available intake might be months away. Granted the insurance company is a differnt issue (I think they all worship the devil). But it brings to the forefront the issue of availability of service providers. My experience has been that of intakes taking months to come about.

                                                                    For my own edification, how close are we to ordering genetic testing via dna analysis that will enable to tailor specific protein couplers and gene modifiers in the form of medication to most effectively treat psychiatric illnesses? From my limited kowledge we seem to be pretty far from that bright horizon.
                                                                     

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                                                                      Not that it matters but I agree wholeheartedly with JS's post, I've long been against the idea of psycholgoists practicing until recently that is. But I think JS brings up some very good conditions. They will be a tough sell to the psychological community though. There allready is poor precedent when it comes to specialization.
                                                                       

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                                                                          Psyclops said:
                                                                          Ana, if you're interested take a look at that link in the post above this one. It seems to think there are more psychologists in rural areas.

                                                                          Illinois Psychological Association.
                                                                          Enough said.

                                                                          While we are on the topic of availability of services, I think that your suggestion that someone go to the emergency room is not always going to get them service, even if as you say "It's the Law". Insurance companies and psychiatric services ahve a funny way of turning EMTALA rules into gray areas. And our poor suffering depressed psychotic mother might not meet the criteria for a stay in a hospital according to her insurance company, especially if she is keeping up with her ADLs and not overtly suicidal, and the next available intake might be months away. Granted the insurance company is a differnt issue (I think they all worship the devil). But it brings to the forefront the issue of availability of service providers. My experience has been that of intakes taking months to come about.
                                                                          Of course, insurance companies suck. Period. My experience is very different, since I'm in a major city. I'm not sure if that means that underqualified persons should therefore act as mini-psychiatrists.

                                                                          I watched that insipid video from the Illinois Psychological Association. Again, with poorly selected dire music and all, it amounted to ridiculous propagandized claims that the entire state is going to descend onto psychopathic madness if psychologists don't get prescription privilages.
                                                                           

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                                                                            Jon Snow said:
                                                                            Perhaps this is why psychiatrists are scorned by other physicians. You're trained to treat symptoms? Diagnosis only matters from an academic standpoint? Surely, you jest.

                                                                            This just reaks of inexperience.

                                                                            You don't need what psychologists have to say. Doesn't this entirely depend on setting and population?

                                                                            We are not scorened by other physicians. Scorned? Where the hell did you get that idea?

                                                                            I like how psychologists rail on the DSM, claiming it's useless, created by psychiatrists, for psychiatrists, and that all psychiatric illness exist on a continuum (I agree with the latter). Then, they get enraged at the notion that psychiatrists are not diagnosing as carefully as they. Last time I checked, the DSM was where the diagnosis leads to.

                                                                            Inexperience? Nope. Reality and the medical model.
                                                                            Not rarely, I discharge patients still unsure of what the official 'diagnosis' would be. What I do know is that the pathological elements of their symptom clusters have improved, and they're happy and thankful for it.

                                                                            Diagnosis is from a purely academic standpoint? Perhaps I was being facetious. Of course it's not. But sometimes, it actually is.

                                                                            If all I saw was perfectly healthy, depressed people, I wouldn't need psychiatrists.
                                                                            That's fine. But how would you plan to treat them then? Primary care physicians? I thought they were grossly ******ed vapid folks who wouldn't know an atypical antipsychotic if it slapped them in the face.


                                                                            Oh, and the comment about needing two doctors to do a psychiatrist's job. . . A psychiatrist is a specialist. You aren't first in the chain for the most part. Primary care physicians are most often the initial screeners.
                                                                            [/quote]

                                                                            Access to psychiatrists even in a hospital setting can be difficult for patients with certain insurance coverages and/or lack thereof. I have served a role in the past of rec. medications to a PCP in a hospital setting even though my office was on a freakin' psychiatry wing and there were psychiatrists running around all over the place. They wouldn't see my patient. You guys are difficult to track down.
                                                                            We agree. Insurance companies suck. Sometimes we don't like working without getting paid.
                                                                            Are all psychologists so altruistic?

                                                                            It's a student forum. You're of course correct about the utility of genetic testing and current applied research demonstrating different efficacies for medical treatments. This is the current wave in much of medicine. I know several psychologists working in this arena. Gee, imagine that.
                                                                            I like what psychologists have to offer outside of them playing medicine. I appreciate their contributions to the field, and their expertise in some areas. I don't like when they claim that psychiatrists aren't doing their job, and they they must do it for us - all the while claiming false pretenses (patient access to care vs. desparate attempt to save a troubled field).
                                                                             
                                                                            Jon Snow said:
                                                                            Oh, and the comment about needing two doctors to do a psychiatrist's job. . . A psychiatrist is a specialist. You aren't first in the chain for the most part. Primary care physicians are most often the initial screeners.

                                                                            Missing the point. The comment was an editorial, sardonic view of the psychologist/PCP model. One's a generalist with the same four year initial medical training that all physicians receive compounded with at least three years of directly supervised clinical practice. The other is a specialist with roughly one quarter the medical training and what, 100-500 hours of supervised medical clinical practice? Why would that be better than just referring to a psychiatrist - propaganda regarding "access to care" notwithstanding?

                                                                            Anasazi23 said:
                                                                            We agree. Insurance companies suck. Sometimes we don't like working without getting paid.
                                                                            Are all psychologists so altruistic?
                                                                            Hopefully that will be answered once the cost of the degree(s), malpractice insurance and administrative costs (including the costs incurred just pursuing payment!) rear their collective ugly heads. Since many psychologists do not currently work in medical settings I fear they may misunderstand the "access to care" problem as one originating within psychiatry.

                                                                            Jon Snow said:
                                                                            No, but supply to demand is such in many areas that psychiatrists can afford to stock their practices with self-pay and elite insurance carriers. Personally, that's fine by me. I think government/universal healthcare is all kinds of bullsh!t.
                                                                            Too true. Also true of neurosurgeons, cardiologists, interventional radiologists, orthopaedic surgeons etc. A big "here, here" to your comment on single party payor systems. Ask any Canadian who works for a living.
                                                                             
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