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Psychologists gaining prescribing right?

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Pharmohaulic

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How do you feel about psychologists getting additional training to become midlevel prescribers and working under a psychiatrist or physician where the prescribing psychologist would take the less challenging patients and refer to the PCP or Psychiatrist for more complicated cases or those with comorbid illness? It would work in reverse too where psychiatrists would refer to the psychologist for advice with therapeutic interventions

I was not so sure how I felt about this at first as I thought that psychologists did not have the proper medical training to do so, however when I looked at the programs they are pretty in depth, provide medical training, order/ interpreting labs, how to identify illness presenting with psychiatric symptoms, biochemistry, etc. These programs looked on par with NP or PA programs but more mental health oriented.

Here's an example, take a look and tell me what you think:

https://hilo.hawaii.edu/catalog/ms-clinincal-psychopharmacology
 

northernpsy

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Here is the problem that most politicians and non-physicians don't realize: Practicing medicine is easy...until it isn't. We train as long as we do so that we can pick up on the nuances of prescribing and recognize problems that can come up at any time even in a case that might start off seeming "easy".
Oh yeah and we also train so long because sometimes what looks like a psych problem is actually a totally different medical issue altogether, or the patient has a medical issue that is complicating their psych problem...or a medical problem that just needs to be addressed in its own right regardless.

Hey, I had a pretty good rotation in ob/gyn back in med school and my license does say that I can practice both medicine AND surgery, so I bet if I did a little reading to brush up I could deliver babies and most of the time it would go ok. The problem is that sooner or later there would inevitably be a case where I'd be in over my head. Welp, let's just cross our fingers that I'll realize I'm in over my head before I've caused serious harm.

I have seen a lot of lousy psychopharmacology choices even from other doctors, let alone midlevels. Iatrogenic addiction is devastating many communities as we speak. More prescribers are NOT always a good thing if they are not prescribing judiciously.
 
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randomdoc1

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Here is the problem that most politicians and non-physicians don't realize: Practicing medicine is easy...until it isn't.
More prescribers are NOT always a good thing if they are not prescribing judiciously.
These two points. Haven't read about what specifically the programs have to offer, so I can't really make a well informed argument on how I feel about psychologists developing prescribing rights. However, I totally agree with what is quoted and points that like should be factored in strongly before deciding to extend prescribing privileges to others. Prescribing is a whole 'nother story. I also have to admit that I get quite annoyed when people still think I'm a "psychologist" and not a psychiatrist. My husband still thinks I'm a "therapist" (that I just listen to people complain while they lay on a leather couch and maybe throw an occasional antidepressant at them) and that infuriates me. I do purely med management too.
 
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Pharmohaulic

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Here is the problem that most politicians and non-physicians don't realize: Practicing medicine is easy...until it isn't. We train as long as we do so that we can pick up on the nuances of prescribing and recognize problems that can come up at any time even in a case that might start off seeming "easy".
Oh yeah and we also train so long because sometimes what looks like a psych problem is actually a totally different medical issue altogether, or the patient has a medical issue that is complicating their psych problem...or a medical problem that just needs to be addressed in its own right regardless.

Hey, I had a pretty good rotation in ob/gyn back in med school and my license does say that I can practice both medicine AND surgery, so I bet if I did a little reading to brush up I could deliver babies and most of the time it would go ok. The problem is that sooner or later there would inevitably be a case where I'd be in over my head. Welp, let's just cross our fingers that I'll realize I'm in over my head before I've caused serious harm.

I have seen a lot of lousy psychopharmacology choices even from other doctors, let alone midlevels. Iatrogenic addiction is devastating many communities as we speak. More prescribers are NOT always a good thing if they are not prescribing judiciously.

As it stated though, these people will be able to recognize differential diagnosis and when to refer out.
 

DD214_DOC

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They can't do much worse than a lot of the psychiatrists I've seen, so why not? I've had a discussion about this many times, and I find it very difficult to defend a position that we should reserve this privilege for physicians when so many in my own profession are doing whacky **** all the time.
 
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whopper

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This was debated several times on this forum.
I don't mind a psychologist working with a PCP or psychiatrist on considering medications. It's good treatment team management. IMHO the psychologist prescribing with a licensed physician double checking everything and requiring that doc's signature isn't too far removed.
But psychologists prescribing clozapine or on that matter any antipsychotic? No. Lithium? No, doing psychiatry consults in a hospital NO-NO-NO! That would be dangerous. An Oregon bill that was vetoed a few years ago would've allowed all of those.
The recent Illinois bill where psychologists have limited prescription power is more acceptable. That is the psychologist could prescribe very limited meds that are on the safe side. I'm neutral on this. I have several concerns with it but I do think it's worth a try to see where it goes for a few years. IMHO, and I completely admit I haven't recently seen the list of meds I would recommend against any TCA, MAO-I, antipsychotic, mood stabilizer, benzo, well heck anything other than SSRIs or SNRIs, Wellbutrin, mirtazapine, or buspirone.
 
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notdeadyet

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Prescribing rights thread? It must be a day that ends in "y"...
 
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Extralong

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Here is the problem that most politicians and non-physicians don't realize: Practicing medicine is easy...until it isn't. We train as long as we do so that we can pick up on the nuances of prescribing and recognize problems that can come up at any time even in a case that might start off seeming "easy".
Oh yeah and we also train so long because sometimes what looks like a psych problem is actually a totally different medical issue altogether, or the patient has a medical issue that is complicating their psych problem...or a medical problem that just needs to be addressed in its own right regardless.

Hey, I had a pretty good rotation in ob/gyn back in med school and my license does say that I can practice both medicine AND surgery, so I bet if I did a little reading to brush up I could deliver babies and most of the time it would go ok. The problem is that sooner or later there would inevitably be a case where I'd be in over my head. Welp, let's just cross our fingers that I'll realize I'm in over my head before I've caused serious harm.

I have seen a lot of lousy psychopharmacology choices even from other doctors, let alone midlevels. Iatrogenic addiction is devastating many communities as we speak. More prescribers are NOT always a good thing if they are not prescribing judiciously.

Very good quote. Physicians length of training is not for the 99% simple situations, it's for the emergency/complicated 1% of issues that occur. That's why non-physicians tought that their outcomes are so great, because the physician steps in for the complex issue and non-physicians don't deal with them, or miss them.

Psychologists should NOT prescribe medications, instead, go to training in a medical profession.

Psychologists are NOT medical professions and should NOT prescribe.

Secondly, I would not want to supervise psychologists prescribing, because if there is a serious error, and it's missed due to so a certain amount of chart reviews, or whatever, it's my ass on the line and not the psychologist's.

My opinions are not to offend anyone, but I am pretty direct and don't play around with patients health. Naturopaths in eastern part of Canada prescribe medications, including mental health medication, yet they have no f**king clue what the hell they are doing. The next epidemic after the opioid epidemic is improperly trained non-medical providers prescribing medication epidemic.

Say what you will, but I think patients are suffering already and will suffer much more if laws continue to promote prescription rights to everyone.
 
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Dharma

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One week into my psychiatry residency... I ain't worried. If they think they can do it as well as a trained psychiatrist, go for it. Let the results speak for themselves.
 

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I think that it would be reasonable if we had a shortage of all prescribers (nurse practitioners / PA included) but I'm not aware that we do (someone correct me if I'm wrong). As far as I know, We just have a shortage of physicians. A better result would be for psychologists to do what they do best, assess and provide therapy, so that the psychiatrists / PCP in collaboration with them will need to spend less time with stable / uncomplicated patients. As an aside, I'm also not in favor of NPs prescribing controlled substances because I see too many of them running pill mills (some unknowingly, as they trained under physicians that run pill mills and think that is how things are supposed to work) but we've already lost that battle. I'd hate to imagine the psychologist-run Stimulant mills that will pop up if we lose this one.




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H

HarryMTieboutMD

This thread is rehashed every few months, but here are my thoughts:

Psychologists: Absolutely not. Psychologists do extensive training and have an amazing skill set. I have learned A LOT from the experienced psychologists in our department, but they are not physicians and should not be prescribing medications. Agreed with above about learning how to manage crisis situations during residency. Also, since most of our drugs have noticeable side effects, anyone who prescribes them should have them at the forefront of their mind and how to quickly evaluate and address them. For example, in clinic I had a patient on a MAOI complaining of stiffness and diaphoresis, and though his vital signs are stable I knew automatically I would have to look at reflexes, bowel sounds, etc. (pt did not have serotonin syndrome btw, just a little anxious). This is pretty basic for any doctor because even in 2016 when physical exams are hardly valued, we still know the basics. However, this is not in line with psychologists' training. They can take all the psychopharm courses available, but the absence of clinical experience of being responsible for medically ill patients (learned during medicine months on intern year), prescribing rights should be limited to physicians

Midlevels: Useful for clerical work where you need someone to sign off or make basic dose adjustments. One of our attending only clinics is set up like this and works pretty well. The attending is responsible for the initial management and sees the patient every few months, but the NP does most of the grunt work. I would not trust an NP with starting clozapine, lithium, MAOI, TCAs etc

I think one of the great myths perpetuating our field is that psychopharmacology is "easy." Yes, treating a psychiatric patient involves much more than just treating symptoms with medication, but using medications correctly (especially more complicated meds with potentially significant side effect burdens) requires considerable training, thinking, and reading of the literature. For example, I regularly think about fundamental pharmacokinetic (half life, volume of distribution, clearance) and pharmacodynamic principles and how they might influence drug choice/response in a given patient. Academic psychologists may consider these issues in prescribing (but lack the clinical medicine experience to understand how loosely they sometimes apply), but I doubt an NP would even think about them beyond (oh check xxx level after 5 days because this is what I head someone else do) I also regularly read both the old and new literature to understand phenomena I didn't expect and various nuances to prescribing.

There are obviously plenty of lazy, board certified psychiatrists who make egregious mistakes: when I was covering the ED a few weeks ago I had to see an OSH transfer because an RN who was a licensed "psych evaluator" noted that the patient was "manic", "delusional," and had "flight of ideas" (none of which were accurate btw, he was delirious), but in looking at the history the patient was recently hospitalized for delirium 2/2 hyponatremia and a psychiatrist tapered of his Xanax 4mg TDD (probably had been on this for years) using 2x Klonopin equivalents in 4 days... so he was in benzo DTs. However, I think in the academic bubble things like this are magnified 10x and are mostly the exception rather than the rule (and happen plenty in most other specialties, btw). And I find fallacy in the claim that the existence of incompetent doctors justifies psychologists and midlevels to prescribe. Hopefully with higher quality medical students choosing psychiatry this becomes less of an issue...
 
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hamstergang

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And I find fallacy in the claim that the existence of incompetent doctors justifies psychologists and midlevels to prescribe.
It is a rather ridiculous thought -- some psychiatrists practice poorly, therefore we should allow others with less training to prescribe as well?? Is there any good reason to think that the only psychologists who go through the psychopharm programs will be the ones that do not worse than average work?
 
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TexasPhysician

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As it stated though, these people will be able to recognize differential diagnosis and when to refer out.

That is where we disagree. Without extensive medical training, it is difficult to accurately identify the lack of knowledge.

I've seen NP's and PA's result in pulled physician licenses due to a lack of oversight and the midlevel overstepping. Very dangerous slope.
 
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randomdoc1

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I'm relatively new to this forum obviously and was browsing old threads on this topic. It's definitely interesting to see physicians and psychologists discuss this topic together. Just wanted to share that I saw a psychologist say that SSRIs are now prescribed for depression in a "cookbook" fashion anyways...that is certainly oversimplifying it.
 

MamaPhD

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I was not so sure how I felt about this at first as I thought that psychologists did not have the proper medical training to do so, however when I looked at the programs they are pretty in depth, provide medical training, order/ interpreting labs, how to identify illness presenting with psychiatric symptoms, biochemistry, etc. These programs looked on par with NP or PA programs but more mental health oriented.

Without rehashing everything I've written about this topic in other threads, if these psychopharmacology master's programs overlap so much with NP or PA programs, then I become very skeptical of the need for them.
 

Pharmohaulic

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Without rehashing everything I've written about this topic in other threads, if these psychopharmacology master's programs overlap so much with NP or PA programs, then I become very skeptical of the need for them.

Because they are tailored to the "prescribing psychologist" and not to the PA or NP with minimal psych training at best.. The psychopharmacology post doctoral masters will teach them how to recognize alternative diagnosis/ companies medical issues and when to refer out, but won't teach them how to actually treat them because that is not what a prescribing psychologist will be doing. Also, prescribing psychologist will be only prescribing a limited set of drugs whereas NP's and PA's prescribe all drugs.
 

splik

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I was not so sure how I felt about this at first as I thought that psychologists did not have the proper medical training to do so, however when I looked at the programs they are pretty in depth, provide medical training, order/ interpreting labs, how to identify illness presenting with psychiatric symptoms, biochemistry, etc. These programs looked on par with NP or PA programs but more mental health oriented.

Here's an example, take a look and tell me what you think:

https://hilo.hawaii.edu/catalog/ms-clinincal-psychopharmacology
if you think an online course is pretty in-depth you havent looked very hard or have a very odd idea of what indepth is. also these websites don't tell you what they are actually teaching so how could you have a sense other than very superficially. The APA RxP requirements are a joke, and many psychologists feel very despondent about this movement which degrades the field
 
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SmallBird

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if you think an online course is pretty in-depth you havent looked very hard or have a very odd idea of what indepth is. also these websites don't tell you what they are actually teaching so how could you have a sense other than very superficially. The APA RxP requirements are a joke, and many psychologists feel very despondent about this movement which degrades the field

Agreed.

It is possible a psychologist could learn a bunch of relevant facts. But the clinical heuristics which allow for effective prescribing practices are distinct from those which are prevalent (and appropriate) to most tasks done by clinical psychologists. I am impressed by my psychology colleagues who talk about patients in terms of dimensions of impairment, go beyond a simple description of depression to highlight key vulnerabilities and recurrent thought patterns that are of relevance to a patient, and tailor psychological interventions in a sophisticated manner. None of this is relevant to psychopharmacology, and in fact thinking this way is counterproductive. Clinical data for medication is based on treating categorical diagnoses is specific populations, and the task of determining whether your patient is likely to benefit from a medication involves a process of evidence appraisal and judgement that is quite specific to medical training. There may come a time when we understand the role of medication in such a fine grained way that it becomes appropriate to identify the nuance in a clinical presentation that means the time for pharmacological intervention has arrived; we do not possess such knowledge currently or imminently. A critical aspect of deciding to use medication involves acknowledging only a moderate likelihood of a positive effect and balancing that with associated medical risk. In order for a psychologist to do this effectively, they would need to attend medical school.
 
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Pharmohaulic

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if you think an online course is pretty in-depth you havent looked very hard or have a very odd idea of what indepth is. also these websites don't tell you what they are actually teaching so how could you have a sense other than very superficially. The APA RxP requirements are a joke, and many psychologists feel very despondent about this movement which degrades the field

I dont see how it's degrading... Also, when I went into the website I clicked on each class individually and read the... They are not all online and they have clinical rotations with doctors.
 

Pharmohaulic

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Agreed.

It is possible a psychologist could learn a bunch of relevant facts. But the clinical heuristics which allow for effective prescribing practices are distinct from those which are prevalent (and appropriate) to most tasks done by clinical psychologists. I am impressed by my psychology colleagues who talk about patients in terms of dimensions of impairment, go beyond a simple description of depression to highlight key vulnerabilities and recurrent thought patterns that are of relevance to a patient, and tailor psychological interventions in a sophisticated manner. None of this is relevant to psychopharmacology, and in fact thinking this way is counterproductive. Clinical data for medication is based on treating categorical diagnoses is specific populations, and the task of determining whether your patient is likely to benefit from a medication involves a process of evidence appraisal and judgement that is quite specific to medical training. There may come a time when we understand the role of medication in such a fine grained way that it becomes appropriate to identify the nuance in a clinical presentation that means the time for pharmacological intervention has arrived; we do not possess such knowledge currently or imminently. A critical aspect of deciding to use medication involves acknowledging only a moderate likelihood of a positive effect and balancing that with associated medical risk. In order for a psychologist to do this effectively, they would need to attend medical school.

Everyone keeps touting about medical school and it's making my head spin.. Neither NP's or PA's go to medical school and they prescribe and nobody says a word about that ... But yet they'll go on to say a psychologist with two years of training (equivalent to NP or PA training mind you) can't prescribe because they didn't go to med school? Am I missing something? If a psychologist can't prescribe without medical school shouldn't then the case be that no one can prescribe without med school?

What I DO disagree with however is PA's, NP's and prescribing psychologists (if passed) getting independent prescription rights. That I can see how it would anger docs and rightly should. These positions are ment to consult with docs. But a prescribing psychologist with appropriate training just like a NP or PA working Under or in COLLABORATION with a doctor... I see no harm in this
 

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So this message board is for psychiatrists, psychiatry residents, medical students and other people considering careers in psychiatry. It's not designed for people who obviously have no interest in becoming a psychiatrist to discuss prescribing rights for other types of providers. What you're doing is essentially trolling. Clearly you have an agenda and are not actually attempting to engage anyone in a discussion about this.
 
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SmallBird

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Everyone keeps touting about medical school and it's making my head spin.. Neither NP's or PA's go to medical school and they prescribe and nobody says a word about that ... But yet they'll go on to say a psychologist with two years of training (equivalent to NP or PA training mind you) can't prescribe because they didn't go to med school? Am I missing something? If a psychologist can't prescribe without medical school shouldn't then the case be that no one can prescribe without med school?

What I DO disagree with however is PA's, NP's and prescribing psychologists (if passed) getting independent prescription rights. That I can see how it would anger docs and rightly should. These positions are ment to consult with docs. But a prescribing psychologist with appropriate training just like a NP or PA working Under or in COLLABORATION with a doctor... I see no harm in this

I didn't give those folks prescription rights. I don't believe psychologists should pursue or be allowed to obtain prescribing rights for reasons I articulated. I feel entitled to express that opinion without analyzing the comparative risks and merits of mid level providers.
 

Pharmohaulic

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So this message board is for psychiatrists, psychiatry residents, medical students and other people considering careers in psychiatry. It's not designed for people who obviously have no interest in becoming a psychiatrist to discuss prescribing rights for other types of providers. What you're doing is essentially trolling. Clearly you have an agenda and are not actually attempting to engage anyone in a discussion about this.

You people are so quick to be all hyper sensitive and immediately toss out the word "trolling." No I'm not "trolling" I am simply inquiring because I know that there's such a debate about it and I'm interested
 

Pharmohaulic

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So this message board is for psychiatrists, psychiatry residents, medical students and other people considering careers in psychiatry. It's not designed for people who obviously have no interest in becoming a psychiatrist to discuss prescribing rights for other types of providers. What you're doing is essentially trolling. Clearly you have an agenda and are not actually attempting to engage anyone in a discussion about this.

Maybe I need to simplify it... My point is if we have mid-levels such as nurse practitioners and physician's assistant, and nobody really says a word about them, then how come it's not okay for psychologists to pursue the appropriate training to become a mid-level themselves?
 

Pharmohaulic

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I didn't give those folks prescription rights. I don't believe psychologists should pursue or be allowed to obtain prescribing rights for reasons I articulated. I feel entitled to express that opinion without analyzing the comparative risks and merits of mid level providers.

Well mine was a legitimate question and so I was entitled for asking it
 

Extralong

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Maybe I need to simplify it... My point is if we have mid-levels such as nurse practitioners and physician's assistant, and nobody really says a word about them, then how come it's not okay for psychologists to pursue the appropriate training to become a mid-level themselves?

Go back to the NP and PA forums and complain there. You heard our opinions. Furthermore, you can use the search function for discussion of NPs and PA to see what has been discussed.
No offense to you, but the term trolling is used for someone like you that has 16 posts, and only wants to argue only one topic and not has contributed to larger, more informative topics. I would recommend taking it easy for now, and see what you can contribute to sdn through your own knowledge base, building a good reputation and see what happens in time. We have had NPs and psychologists discuss this topic many times, and I would recommend reading what they have said, their length of sdn along with contributions and how they post their posts.
 
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Pharmohaulic

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Go back to the NP and PA forums and complain there. You heard our opinions. Furthermore, you can use the search function for discussion of NPs and PA to see what has been discussed.
No offense to you, but the term trolling is used for someone like you that has 16 posts, and only wants to argue only one topic and not has contributed to larger, more informative topics. I would recommend taking it easy for now, and see what you can contribute to sdn through your own knowledge base, building a good reputation and see what happens in time. We have had NPs and psychologists discuss this topic many times, and I would recommend reading what they have said, their length of sdn along with contributions and how they post their posts.

I have 2 posts actually
 
H

HarryMTieboutMD

bush league trolling... nowhere close to Vistaril's level
 
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smalltownpsych

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How do you feel about psychologists getting additional training to become midlevel prescribers and working under a psychiatrist or physician where the prescribing psychologist would take the less challenging patients and refer to the PCP or Psychiatrist for more complicated cases or those with comorbid illness? It would work in reverse too where psychiatrists would refer to the psychologist for advice with therapeutic interventions

I was not so sure how I felt about this at first as I thought that psychologists did not have the proper medical training to do so, however when I looked at the programs they are pretty in depth, provide medical training, order/ interpreting labs, how to identify illness presenting with psychiatric symptoms, biochemistry, etc. These programs looked on par with NP or PA programs but more mental health oriented.

Here's an example, take a look and tell me what you think:

https://hilo.hawaii.edu/catalog/ms-clinincal-psychopharmacology
:beat:
Most psychiatrists are probably not in favor of RxP and depending on how you phrase the question at best 50% of psychologists are in favor of it. I tend to vacillate a bit myself. I would rather that our APA put more effort into dealing with our midlevel problem and reimbursement problem and proliferation of professional schools problem as opposed to trying to become part of psychiatry's midlevel problem.
 
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Therapist4Chnge

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One week into my psychiatry residency... I ain't worried. If they think they can do it as well as a trained psychiatrist, go for it. Let the results speak for themselves.
It's been going on for a decade in some places, so the results may already be talking....?

That said, I only support a collaborative model with more training than is being pushed by the A(Psychology)A. I write this as someone who went through the training and have compared it against NP programs and MD & DO programs.

I believe NPs should have a collaborative setup too, but that horse left the barn already. I believe psychologists with additional training can safely prescribe, though the collaboration adds another layer of support to the process.
 
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Heck, pretty much no one should be prescribing medications.

Patient comes in (inpt medicine) with urinary retention. On a slew of psych meds, including a typical antipsychotic. Also chronically on Cogentin. Given flomax and discharged.

Readmitted a couple days later with urinary retention. Psych consultant (NP) does not mention either the antipsychotic or the cogentin. The outpatient psych (NP) doesn't mention the cogentin when contacted for more info. The admitting medicine resident wants to stop the antipsychotic and continue benztropene.

We stop the benztropene. The patient pees. No EPS.

-_-
 
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DD214_DOC

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Heck, pretty much no one should be prescribing medications.

Patient comes in (inpt medicine) with urinary retention. On a slew of psych meds, including a typical antipsychotic. Also chronically on Cogentin. Given flomax and discharged.

Readmitted a couple days later with urinary retention. Psych consultant (NP) does not mention either the antipsychotic or the cogentin. The outpatient psych (NP) doesn't mention the cogentin when contacted for more info. The admitting medicine resident wants to stop the antipsychotic and continue benztropene.

We stop the benztropene. The patient pees. No EPS.

-_-

Sometimes I really hate my field
 

DD214_DOC

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There's a psychologist here trying to get Rx rights. I've supported it, primarily because he would be in a period of supervision and I can't honestly argue against it when the psychiatrist I replaced routinely did crazy things with meds. I regularly ask him, "why on earth would you WANT rx privileges?", and warn him to be careful what he asks for.

Since leaving training and entering full practice, my most rewarding cases have been those in which I've been able to significantly reduce or completely discontinue a nonsensical and inappropriate medication regimen. It also makes me sad that I have to do this so frequently.
 
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smalltownpsych

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There's a psychologist here trying to get Rx rights. I've supported it, primarily because he would be in a period of supervision and I can't honestly argue against it when the psychiatrist I replaced routinely did crazy things with meds. I regularly ask him, "why on earth would you WANT rx privileges?", and warn him to be careful what he asks for.

Since leaving training and entering full practice, my most rewarding cases have been those in which I've been able to significantly reduce or completely discontinue a nonsensical and inappropriate medication regimen. It also makes me sad that I have to do this so frequently.
There are some pretty straightforward psychological reasons why docs get pulled into prescribing these inappropriate medication regimes. It is a huge problem when we don't take into account the interpersonal dynamics for both the patient and ourselves. This is one reason that I think the average psychologist with RxP would be much better suited to this than the average midlevel and potentially even the average FM or IM doc. In a perfect world, the psychologists and psychiatrists team up and support each other's strengths and fight the race to the bottom that the midlevel proliferation represents for both sides of the coin; i.e., medication and psychotherapy.
 
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SmallBird

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There are some pretty straightforward psychological reasons why docs get pulled into prescribing these inappropriate medication regimes. It is a huge problem when we don't take into account the interpersonal dynamics for both the patient and ourselves. This is one reason that I think the average psychologist with RxP would be much better suited to this than the average midlevel and potentially even the average FM or IM doc. In a perfect world, the psychologists and psychiatrists team up and support each other's strengths and fight the race to the bottom that the midlevel proliferation represents for both sides of the coin; i.e., medication and psychotherapy.

You highlight an incredibly salient issue that is seldom discussed. Common issues are a need for the prescriber to have a solution, perhaps due to a savior complex or an intolerance of negative affect, as well as succumbing to a pressure to 'do something' in order to feel responsive to a patient, even when this involves adding a medication that is unlikely to be helpful. People need to be aware of these dynamics and I agree psychologists can play an important role in teams by helping to identify these practices. We have a psychologist on our inpatient unit who frequently helps us discuss these issues, however they do not engage in prescription.

Prescribing medication, in my opinion, remains an activity which requires a firm background in biomedical sciences. This should include basic science coursework, anatomy, physiology, and clinical rotations in a broad set of specialities. This should remain the standard for evaluating for and presenting medication and I don't believe in chipping of certain classes of medication as being suitable for prescription by individuals without this background.
 
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PistolPete

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Heck, pretty much no one should be prescribing medications.

Patient comes in (inpt medicine) with urinary retention. On a slew of psych meds, including a typical antipsychotic. Also chronically on Cogentin. Given flomax and discharged.

Readmitted a couple days later with urinary retention. Psych consultant (NP) does not mention either the antipsychotic or the cogentin. The outpatient psych (NP) doesn't mention the cogentin when contacted for more info. The admitting medicine resident wants to stop the antipsychotic and continue benztropene.

We stop the benztropene. The patient pees. No EPS.

-_-

I find your username and the subject of your post highly amusing.... guess I'm still childish ;)
 

Therapist4Chnge

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...which requires a firm background in biomedical sciences. This should include basic science coursework, anatomy, physiology, and clinical rotations in a broad set of specialities. This should remain the standard for evaluating...

This is where I think most of the current psychology RxP programs and requirements fall short. The NM program has an integrated clinical training program (not sure rotations off hand), though last I checked the other programs do not. Most are setup w. one physician and are PP based. Back when I did my training I was hospital-based and gained exposure across a number of patient populations (psych, TBI, stroke, dementia, with plenty of co-morbid dxs mixed in), but I would have liked to see more of all pt types. If I just did out-patient in an office park and saw medically healthy patients...it would have been far less useful.
 
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smalltownpsych

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This is where I think most of the current psychology RxP programs and requirements fall short. The NM program has an integrated clinical training program (not sure rotations off hand), though last I checked the other programs do not. Most are setup w. one physician and are PP based. Back when I did my training I was hospital-based and gained exposure across a number of patient populations (psych, TBI, stroke, dementia, with plenty of co-morbid dxs mixed in), but I would have liked to see more of all pt types. If I just did out-patient in an office park and saw medically healthy patients...it would have been far less useful.
Completely agree with this and that it can be a weakness of some non-prescribing psychologists as well. I personally sought out inpatient experiences during training so that I would be more comfortable with more serious and complex cases.
 
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nancysinatra

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I think the way to deal with this is simple. Let's refer to our local psychologist prescribers all our patients who have liver or kidney disease, as well as all our elderly patients, and while we're at it, all our patients who are on high doses of off label meds like clonidine. Refer a few people in alcohol withdrawal so bad they require phenobarbital (preferably outpatient). If you've got a possible lamictal rash coming in, but you're not sure, that's also a good case for your friendly neighborhood prescribing psychologist. Send over a few prolonged QTc's and an EKG machine, and en enrollment in an upcoming ACLS course (at which, any psychologist who is in attendance will probably be in such shock they will need ACLS themselves). Refer over a couple people on coumadin, and let them watch the drug-drug interaction lights go off. Send them anyone and everyone on a beta-blocker or a steroid. The next patient you meet who swears by St. John's Wort with its multiplicity of unknown side effects and drug interactions - refer them too. And of course, send them a few cases of polypharmacy special, which we've all seen - the guy on 17 meds who for some reason still has 20 symptoms. Send them all this and they'll never prescribe again.
 
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Pharmohaulic

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I think the way to deal with this is simple. Let's refer to our local psychologist prescribers all our patients who have liver or kidney disease, as well as all our elderly patients, and while we're at it, all our patients who are on high doses of off label meds like clonidine. Refer a few people in alcohol withdrawal so bad they require phenobarbital (preferably outpatient). If you've got a possible lamictal rash coming in, but you're not sure, that's also a good case for your friendly neighborhood prescribing psychologist. Send over a few prolonged QTc's and an EKG machine, and en enrollment in an upcoming ACLS course (at which, any psychologist who is in attendance will probably be in such shock they will need ACLS themselves). Refer over a couple people on coumadin, and let them watch the drug-drug interaction lights go off. Send them anyone and everyone on a beta-blocker or a steroid. The next patient you meet who swears by St. John's Wort with its multiplicity of unknown side effects and drug interactions - refer them too. And of course, send them a few cases of polypharmacy special, which we've all seen - the guy on 17 meds who for some reason still has 20 symptoms. Send them all this and they'll never prescribe again.

That's an extreme case... I don't think RxP's will be seeing those cases lol
 

Pharmohaulic

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No personally I don't but that seems to be an evolutionary outcome so considering this at the initiation is prudent.

I think the solution would be to refer those cases to the psychiatrist and leave it up to their expertise... This is the perfect example how psychiatrists will still be in demand despite others getting rx rights
 

Jules A

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I think the solution would be to refer those cases to the psychiatrist and leave it up to their expertise... This is the perfect example how psychiatrists will still be in demand despite others getting rx rights

Absolutely and in a perfect world that would happen unfortunately in my experience there is no shortage of cavalier prescribers of the non-MD flavor whether this is due to grandiosity, poor judgement or just not knowing what they don't know. If it was kept to a PA type relationship it would be easier to control but personally many of the psychologists I know already think they are Docs so I question whether their judgement vs their ego would be the most objective if not under some sort of obligation to consult. Not trying to bash any discipline because I have seen as many horrible psychiatrists as I have midlevels however if I were blindly picking someone to prescribe for my family my money would definitely be on a MD simply due to what I believe is a superior education.
 

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That's an extreme case... I don't think RxP's will be seeing those cases lol

Ah. Got it. So what you're saying is that they're not going to be helping contribute to addressing the "shortage" of people who prescribe psychotropics? I guess it makes sense, then, for them to take the people who are straight forward, otherwise healthy and insured. You know, the kind who only need an SSRI and already have access to a PCP .
 
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Extralong

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This is ridiculous. Why are we even discussing the possibility of psychologists having enough MEDICAL knowledge to refer. That bull**** statement of "extreme case" is a waste basket term thrown around for someone that doesn't know wtf medicine is.

Please, please, I urge you all psychiatrists, to NOT be nice, gentle, mellow, and understanding in this matter. There is NO GREY area, and it should not be created. Patients lives are at stake, not just our careers, but even more so, I repeat, human beings that can suffer greatly.
 
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