Psychologists Get Prescription Privledges

[Stillfocused]

<a href="http://www.nytimes.com/2002/03/26/health/psychology/26MENT.html" target="_blank">http://www.nytimes.com/2002/03/26/health/psychology/26MENT.html</a>

This seems to me like a very unfortunate precedent for medicine, psychology and the public.

Do any of you think that someone can learn enough medicine to safely prescribe with 450 hours of classroom instruction and 400 hours of clinical training (requiring only 100 supervised cases)?

By my estimation, this would amount to less than a full academic year of classroom instruction and the equivalent of less than two robust medical school rotations. This program also has no basic science requirements.

Unlike NPs and PAs or even EMT-P physician extenders, these practitioners would seem to have virtually no training in other aspects of clinical medicine. How can someone with this level of experience begin to make an accurate differential diagnosis or manage a complex drug reaction?

Do you find it ironic that the last twenty years of neuroscience research has led informed, well-meaning practitioners to conclude that brain diseases can be easily separated from the rest of the body?

Does this program suggest that are we now using a profoundly flawed model to understand mental illness?

Doesn?t this also turn clinical psychologists away form what they are actually quite expert at; i.e. research, assessment and therapy.

I am astounded that the AMA and the AOA have let this occur. Do any of you think that this development will hold up over time or continue to expand to other states?

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[Shark]

I had a pharmacologist (PhD) in med school that always said "If you want to prescribe meds, go to medical school." Most of the other professions that are seeking prescribing privileges do really know a lot about SOME drugs as INDIVIDUAL DRUGS, but are not trained to look at the whole picture (i.e. managing a pt. with several issues and on several meds.) Someone needs to let these people know that medical training is not a minimum of 7 years for nothing!!

 

[Kluver Bucy]

Sounds like they're taking the "New" out of "New Mexico"

 

[ckent]

I actually responded to a similar thread in the pre-med forum, but I wanted to post what I had to say over here too. I can't think of any reasons why psychologists should not be allowed to prescribe some psychiatric medications. They should at least be able to prescribe the SSRIs, they are probably the easiest drugs to prescribe (few interactions, no blood work necessary, relatively benign drugs). Psychiatrists don't do anything special when they are prescribing drugs, they aren't supposed to do a physical for obvious reasons, they just ask patients if they are taking any other medication and then go by the patient interview to decide what drugs might help their patient. These days it's getting even easier with computers, all you have to do is type in two different medications and you can get whether or not the drugs are contraindicated together, special dosing, etc. SSRIs, TCAs, MAOIs, and even some antipsychotics would probably be perfectly safe for psychologists to prescribe. On a side note, I think that the whole field of psychiatry should be disbanded in my opinion, the specialty is waste of a medical education. You really don't need the medical training of medical school to be a psychiatrist, and psychologists spend their training time more efficiently learning how to take care of patients right away whereas psychiatrists have to wait until residency and get a shorter training. The specialty is a magnet for doctors who are either mentally ill themselves or incompetent clinicians anyways. I'm sure that there are exceptions, but that's just my general impression of the field.

 

[cchoukal]

It's a lot to think about. It seems like, at least in the New Mexico case, that the decision was borne partly out of really poor access to psychiatric care. If psychologists (who are apparently more accessible) can fill some of that gap, maybe their medication management (which may or may not be substandard relative to that of an MD) is better than nothing. A number of states have defeated similar legislation, but maybe New Mexico will stand as an experiment to see if this kind of thing can work. Actually, the military has been training psychologists to prescribe drugs for years, and I'm not sure how that's worked out.

 

[Shark]

Heelpain,

I don't care if it takes 30 years to get a PhD!
You're still not a Doc. They don't call it med school for nothing. When was the last time you heard someone say: "Grandma's sick! we better call the psychologist!" They have their place but they should stay within their realm. 7 years of research doesn't equal all of the medical school hours and then residency, trust me!!

 

[Starflyr]

Just a note:

MAOIs are some of the most dangerous drugs out there. Nardil and Parnate are NOT "simple drugs with no interactions" (neither are TCAs for that matter). Nardil and Parnate cannot be taken with most OTC drugs, they cannot be co-prescribed with other antidepressants. Patients must also follow a VERY strict diet (no tyramine - which means cheese, alcohol, and a bunch of other things) unless they want to risk death. I am not comfortable with non-physicians prescribing them. SSRIs, well, maybe. And I hope that the prescriptive rights are limited to simple cases of depression or anxiety. Psychologists are not qualified to pharmacologically treat bipolar people or schizophrenics, for example.

Star

 

[leorl]

As much as a like psychologists, I think allowing them to prescribe meds would be a very dangerous thing. Psychologists in PhD training don't receive all the necessary biochem/biological interaction and function training necessary to really know what they're doing. Besides physiological psychology, most of them don't even have a passable knowledge of basic biology! I just talked to a cognitive psychologist who teaches at Wash U, who thought the A T G C base pairs were full amino acids! If their biology is lacking that much, there's no way in hell they should be allowed to prescribe meds unless they undergo years of further training equivalent to what med students receive..then heck, they might as well be psychiatrists. As the above poster pointed out, MAOIs have interactions with a huge variety of other drugs. Even if someone has in-depth knowledge concerning MAOIs, he/she really needs a more complex understand involving other areas of medicine. giving them free reign like that is most unwise.

 

[ckent]

•••quote:•••Originally posted by Starflyr:
•Just a note:

MAOIs are some of the most dangerous drugs out there. Nardil and Parnate are NOT "simple drugs with no interactions" (neither are TCAs for that matter). Nardil and Parnate cannot be taken with most OTC drugs, they cannot be co-prescribed with other antidepressants. Patients must also follow a VERY strict diet (no tyramine - which means cheese, alcohol, and a bunch of other things) unless they want to risk death. I am not comfortable with non-physicians prescribing them. SSRIs, well, maybe. And I hope that the prescriptive rights are limited to simple cases of depression or anxiety. Psychologists are not qualified to pharmacologically treat bipolar people or schizophrenics, for example.

Star•••••Don't mean to pick on your post or anything, but what do you think a physician can do that would be any different then a psychologists in prescribing any of those drugs? A psychologist could just as easily tell a patient taking an MAOI to avoid tyramine as a physician. A psychologist would probably spend more time telling a patient what foods to avoid eating then a physician. It's very easy for anyone who can read to tell patients what drug interactions to avoid or what foods to avoid while taking a particular drug and what side effects to watch out for. It's just a matter of looking it up and reading the information to a patient. I don't think that physicians receive any "special" training that makes them more qualified to prescribe many of the psychiatric medications. The decision to prescribe is based on the patient interview and psychiatric diagnosis, which psychologists can do, and anything complicated (eg an elderly patient or a patient with renal/liver failure) can always be referred to an internist for help with making a prescription. But the vast majority of problems you have indicated with psychologists prescribing are the same problems physicians face when prescribing those drugs, and all it takes is an open book (a PDR) to make those decisions and to educate the patient. How long did it take you to learn those things about those drugs? I don't imagine that it would take a psychologist much longer to learn the same things.

 

[maverickDO]

The lawyers will help work this out. When the psychologists see how much legal liability there is for making errors in medical decisions, they will probably run from it. Prescribing medication is a medical decision. Yes, there are many situations that are elementary. But there are also many other situations that are not simple where medical training is necessary. Refering to a medical specialist may be too late.

Many psychiatric medications require regular blood tests. How are the psychologists going to deal with that? If you say "well, they will just refer to a specialist" would it not be easier for the patient to have all of the necessary skills in one person?

As I stated before, when the psychologists see the potential legal liability for medical mistakes, they will think twice.

 

[ExistentialistPhilosopher]

Actually, the pilot program that was used apparently put the psychologists through all of the basic science training given in med school and a year or so of clinical rotation. Of course, this program was successful, but the law that was passed in New Mexico is much too lenient in terms of required training, etc.

However, if psychologists were required to go through the equivalent of the first three years of medical school, wouldn't they be basically qualified to prescribe medication? Especially considering that they have also gone through post-doctoral internships in hospitals, working alongside doctors, psychiatrists, and social workers. I know the basic argument is that if you want to prescribe medicine, you should go to med school, but most (good) psychologists don't want to go into medicine or usurp the role of the doctor; they want to be able to provide more for their mentally ill patients. Psychologists often have much more extensive training in interacting with mentally ill patients, yet psychiatrists are still allowed to provide psychotherapy, even with their rudimentary knowledge of psychotherapy. There is a double standard there. If the law is to provide more stringent requirements for psychologists wishing to prescribe, to the point of putting them through med school courses, this would provide psychologists to fill the shortage of psychiatrists in rural areas, not to mention the extreme shortage of child and adolescent psychiatrists. I agree that New Mexico's law is too lenient. But it does not mean that there should be no opportunity for qualified, rigorously trained psychologists to prescribe. Psychiatry has long since ceded to the biomedical perspective, due to the highly biological nature of medical training and the refusal of HMOs to provide adequate psychotherapy to its clients(though there are a few old-timers who still cling to psychoanalysis), while psychologists have remained relatively attached to the idea of psychotherapy's effectiveness. However, any thorough approach to mental illness requires both medicine and psychotherapy. This separation of tasks is not always healthy for the patient, who is bounced around from caretaker to caretaker for different purposes. Although psychiatry used to be the profession that combined both medicine and therapy in its practice, this role may now have to be passed on to the profession of psychology.

Just my two cents.

 

[Vader]

•I don't think that physicians receive any "special" training that makes them more qualified to prescribe many of the psychiatric medications. ...But the vast majority of problems you have indicated with psychologists prescribing are the same problems physicians face when prescribing those drugs, and all it takes is an open book (a PDR) to make those decisions and to educate the patient. How long did it take you to learn those things about those drugs? I don't imagine that it would take a psychologist much longer to learn the same things.•

Why do you think the proposal includes a provision for additional training? There is a void in a psychologist's knowledge base that necessitates extra study. I'm sorry, but it takes more than opening a PDR to do what is best for a patient. Often, patients will have concurrent medical conditions that a psychologist would not have the training to properly diagnose or treat. There is a whole realm of clinical reasoning, organ physiology, anatomy, pharmacology, pathology, etc that is gained through a medical education. Psychiatrists DO in fact receive extensive training which allows them to diagnose, prescribe medication, and deal with complications/side effects that arise. There are cases of depression and psychosis that are secondary to a neurological problem or that are drug induced that a psychologist may not be able to recognize. On the surface, it may seem easy to write out prescriptions, but in fact a lot goes into the decision making process other than simply choosing the right drug and signing your name.

 

[Hamster]

I wasn't able to access the article. But I have posted on this topic previously. I admit, I didn't really see the 'other' side represented very well in the pre-med forum. And even the arguments presented so far for the psychologists just aren't very sound.

Like I mentioned before, if the reasoning is a lack of psychiatrists in New Mexico. Then just recruit more psychiatrists to this area instead of lobbying for prescription privleges. I mean, entire medical schools were founded on the philosophy of increasing healthcare access to certain populations! This leads me to believe that the issue is money, not quality of care.

Let's Not mention the lack of training, Yes most people can look up drug interactions and side effects in a PDA and memorize lists to pass some tests--but this does not make up for the knowledge of how the entire body works, the understanding of exchange that occurs between different biochemical pathways not unique to one organ system. One academic year, by Stillfocused's estimates, or a couple of tests is just not enough. These ideas need constant reinforcement ...which is ( unfortunately ) why medical school consists of classwork and clerkships in addition to residency training. Therefore a psychiatrists training may appear shorter and limited to a residency, but infact it is not.
What if the computer was down? A PDA was stolen? Would the psychologist be able to reason out the meaning behind his patients side effects then?
BTW, I can look up stock quotes on the internet. Can I borrow $500,000 from ya' to trade?

You would think malpractice is enough to pesuade any successful psychologist otherwise, but I guess it doesn't work for us medical students so why should it work for them But I must ask who would the liability fall on? I guess we won't know until something goes wrong.

Even procedure-oriented me understands how hard it is have an appreciation for fields that don't produce a tangible result. But I don't think this cause for the entire specialty to be disbanded. Maybe Psychiatry does attract "incompetent clinicians and the mentally ill" . So what, similar claims can be made about derm attracting the money hungry, surgery attracting the uncaring etc. Residencies should screen better OR these stereotypical clinicians are doing such a good job they are right for the part. :wink:

I agree if you want to give your patients drugs, go to medical school. You might like it!

 

[cchoukal]

I don't think anyone's arguing that a psychologist right out of their doctoral training is qualified to prescribe, but 450 hours of training seems like a lot. I was thinking about what a given medical school course entails. At the U of MN, our courses have varied from 40-80 lectures/hours per semester, meaning at 450 hours of training, these psychologists are undertaking the equivalent of 5-10 semesters worth of coursework. In the military program, this work includes pharmacology, biochem, physiology, etc. It may be that the training would not be as inadequate as many predict.

When I was in training to be a psychologist (I was in a doctoral program before going to medical school; no, I'm not going into psychiatry...), we oftened debated this topic. Most of my professors were against the idea because it took psychologists out of their expert role as testors, evaluators, assessors, counselors, etc. and made them mere 3rd class citizens (behind psychiatrists, the 2nd class citizens) in the "House of Medicine." Despite what the effect is on the psychologists, I predict that, at least in areas w/o sufficient access to psychiatrists (BTW, it's not always that easy to recruit more. rural areas have always been underserved by many types of physicians), this program will probably help most people. This may sound heretical, but sometimes I think that's as much as we can hope for.

 

[Stillfocused]

The prospect of a psychologists doing differential diagnosis scares the crap out of me.

Even what might appear to be "garden variety" depression and/or anxiety could very well be a seizure disorder, cardiovascular disease, metabolic disorders or even metastasis CA. Or, more terrifyingly, consider a patient with a combination of any of these conditions. <img border="0" title="" alt="[Eek!]" src="eek.gif" />

It?s so weird that instead of solving the philosophical, Cartesian dualist mind/body problem the "decade of the brain" amplified it.

If New Mexico was serious about treating the rural mentally ill they could boost its number of MSN, RNCNS with scholarships, signing bonuses and other incentives.

And, if psychologists really wanted safe, adequate training for prescription privileges they could do one of the intense three year BA to MSN programs like the one at Yale.

Do not be assume that a clinical PhD necessarily has more psychotherapy training than a psychiatrist; it really depends on the respective
programs and the individual student's interests.

PhD clinical psychologists are largely trained for academic/research careers. Those who practice clinically mainly do neurospsych testing. PsyD clinical psychologists, the DO's of psychology, have a much deeper training in psychotherapy. In fact, LICSW level clinicians, not psychologists, practice most of the ?therapy? that is done these days.

Psychiatrically ill patients are already given the hind tit in medicine and in life. They really need access to highly trained medical specialists.

There used to be a great model for training these specialists; it was called psychiatry. Managed care, a moribund attachment to psychoanalysis, research driven by drug company funding and over-prescription destroyed it.

Mental health care parity would a helpful step in begining to deal this crisis not psychologists with prescription pads.

 

[maverickDO]

Hamster has a very good point. The state of New Mexice could just as easy use the money to recruit more Psychiatrists rather than establish new programs for Psychologists. It's all about money. Prescribing privelidges means more money for Psychologists. It would not take much money to recruit psychiatrists to the needy areas.

It's the same story all over again as the CRNA's and Nurse Practitioners, they just want to get a "piece of the pie"!!!

Yes, there is no denying that there are areas in desperate need of Psychiatrists. But giving out prescription pads is not the answer. Many states have successful programs to recruit primary care physicians. They could do the same for psychiatrists.

Another point, how come the University of NM medical school is not turning out many psychiatrists that stay in NM??? The school needs to do more to sell students to stay in NM and pursue specialties of need. So part of the problem is poor recruiting of medical students with potential of helping NM.

 

[leorl]

Agree as well. why give psychologists the ability to prescribe meds, leaving a whole lot of room for dubiousness and malpractice, when you've already got psychiatrists in the field? 450 hours is not a lot, it's not even a year, if those guys have training for 2 hours a day every day. I mean, school learning is not practice either...maybe they can train for a year in academic subjects, but they need a whole lot more clinical time or simulated clinical studies to prove proficiency.

 

[Shark]

heelpain,

I'm not on a high horse my friend. Lets get one thing straight. The term "Doctor" is used by many different people. It is really a generic term when you think about it. I personally know people who studied history, politics, accounting, economics etc. who call themselves "Doctors." So you're right, psychologists are "Doctors" as well as chiropractors, optometrists and podiatrists. However, there are only two types of "Doctors" that are fully permitted to practice medicine and surgery and to prescribe meds. MD's and DO's. If you want to play on the words lets use the term "Physician." Nobody ever confuses that term! You see, you are assuming that I am looking down upon psychologists. I never claimed that people who go to med school are smarter than those who might choose psychology. I know a couple people who almost went to med school but said that they didn't want to go that long without money or deal with the long hours that med school and residency demands, or wanted to start a family under less harsh circumstances. I don't claim to be any smarter than them. I just chose a different route. To each his/her own. My only point is that there are limits on each profession. There are reasons why psychologists should not be prescribing meds. To the notion that prescribing responsibility is as easy as looking in the PDR is ridiculous. True, some drugs are so safe that it really doesn't matter, but many drugs require that the clinician have a strong understanding of pharm, biochem, physio, and even anatomy. Also, and perhaps more importantly, the clinician needs to have had a period of time where they practiced prescribing under direct supervision, i.e. residency!!

 

[ckent]

Alright, I'll bite again. I don't think that any of you have given a convincing arguement of why someone needs to go to medical school to prescribe most psych drugs. What knowledege do you guys think that you have that they can't teach a psychologist? You guys are quoting first and second year info from med school like it actually matters in prescribing psych drugs. Biochem? Why, do you actually think that knowing how DNA replicates help you decide what dose of a drug to use? Or what about knowing all the steps in glycolysis, how does that effect your ability to prescribe? Pathology? Well, I've never seen a psychiatrist look at a slide before, so I don't think that psychologists will be lacking in that department. Anatomy? I could think that your heart was in your neck and your liver was down by your foot and still be perfectly competent in writing you script for an SSRI or antipsychotic. Remember that psychiatrists do not conduct physical exams, any physical change in the patient would have to be so obvious that a psychologist or anyone off the street would notice. Physiology? All a psychologist would have to know is when to refer to an internist for script writing (renal or liver problems), and there is nothing wrong with referring those patients, the vast majority of psych patients do not have those problems. How often do you guys think that someone with an underlying medical problem that is causing their psychological problems presents to a psychiatrist? Very rarely. When people feel differently, they don't go straight to a psychiatrist. They go to their internist who evaluates them and then decides if they might be helped by seeing a psychiatrist. Again, psychiatrists do not run blood tests on every patient they see. If a psychologist is going to miss that a physical problem is causing their psychiatric problems, I would bet that a psychiatrist would do the same. You guys are all saying how important your first two years of medical education are in prescribing drugs. Do you know how much of their first two years of medical school a psychiatrist over 40 can remember? None to very little. Nobody seems to have a problem with them prescribing drugs. I'm not saying that psychologists in practice right now can prescribe medication. But if you give them some training (not four years of medical school, more like a month long work-shop), and some supervision while they start, I don't see anything wrong with it at all. Residency is when you really learn how to be a doctor, not medical school. The only reason that psychiatrists need a 3 yr residency program is that they have not gotten nearly the amount of training in taking care of psych patients as psychologists already have when the graduate. Believe me, they don't spend 3 yrs in psych residency teaching their residents how to dose SSRIs every day. They teach how to diagnose, how to talk with and treat psych patients during psych residency. Psychologists already know how to do most of this, it's a short step to teach them the drug part.

 

[Starflyr]

ckent -

Where are you getting all of this crap about psychiatrists? Hm? From things you've "heard"? Have you ever been to a psychiatrist? They do, indeed, do physical exams - no, perhaps not a fully physical, but who does? And I think you need to learn a LOT more about psychopharmacology than what you get 1st and 2nd year in med school to be able to competently prescribe psychoactive meds. Even SSRIs have side effects and interactions that need to be understood. I predict many malpractice lawsuits against psychologists that prescribe meds - half the SSRIs induce/inhibit various liver enzymes that can have wierd effects, some people have different metabolisms. And the antipsychotics??? what planet are you on? they are complex and have even more effects than SSRIs. You think that psychologists should be prescribing medications to people with complex mood disorders and schizophrenia etc? Do you have ANY idea how hard it is to do that? And what making a mistake can do to a person? What if a psychologist prescribed lithium to a bipolar patient but couldnt get blood levels done? And the patient went toxic (say, they took some ibuprofen, which raises lith levels) and came into ER and died (VERY narrow therapeutic index for lith)??? And, BTW many people with psychiatric illnesses DO have comorbid illnesses that require medication.

Star

 

[leorl]

well said Starflyr. Ck, you bring up the point that psychologists don't need the basic bio in order to gain knowledge necessary for prescribing meds. I disagree. The psychology curriculum has almost no biology in it whatsoever. The only things these kids get are "what is a neuron" and maybe neuronal physiology. They might learn a little bit of brain anatomy. How are you going to expect them to suddenly cram in complex mechanisms of drug interaction or effect, which I believe is necessary to understanding why you're prescribing a particular drug, when they have never been taught to handle pathways before? I'm talkin' like cGMP pathway or even krebs cycle stuff...learning these things trains your ability to be able to handle more complex ones in the future. I don't think you can take a psychologist, throw him into a class room , and cram that stuff down his throat and expect him to retain that information. Plus, the old dog new tricks thing. And I maintain that 450 hours is not enough.

I'm not saying it can't be done, but why should it? You've already got psychiatrists. The practice of psychology should not be changed to a more medical one. Their therapies (whatever models they choose - cognitive, behavioral, etc) are effective not only in helping their patients overcome whatever problems they have, but also help them deal with the surrounding world. You can't throw meds at someone and suddenly expect them to become a perfectly normal-behaving part of society. I think allowing psychologists to prescribe meds would ultimately deconstruct other approaches to psycho-social issues.

 

[cchoukal]

Sure, why let psychologists prescribe when we've already got psychiatrists? I think the point of the original article, and indeed the point of the legislation is that we DON'T have psychiatrists, at least not enough of them in the right places. I think it raises the larger issue of whether less-than-perfect care is better than no care at all, or drastically delayed care.

There also seem to be some misconceptions about what psychologists are trained for. Clinical and counseling PhD programs around the country vary in the degree to which they are trained for psychotherapy, but it's a dramatic overstatement to say that most clinical PhD's are trained for academic careers and not clinical work. In order to graduate, students need on the order of 1000-2000 hours of supervised clinical work, and earning the PhD requires a 1 year clinical internship. Becoming licensed requires a further 1000-2000 hours (depending on the state) of supervised work. Furthermore, any clinician would be trained in diagnosis according to the 5-axis system in the DSM (put out by the American Psychiatric Assn). There are decision trees and algorithms for psychiatric disorders just like there are for the medical disorders, and these include ruling out physical causes of mental problems.

I believe it could be argued that psychologists have a tougher diagnostic task than their medical counterparts, given the absence of simple tests for common problems. Know too that Axis 3 is reserved specifically for concomitant physical problems. That is, psychologists are trained not to ignore or forget about physiological determinants of mental illness.

Again, I don't know if this experiment is going to work, but I perceive that some of the arguments against it are based on inaccurate of incomplete knowledge.

 

[Kluver Bucy]

Heelpain, what happened to your usual alias of "different strokes" and why is it your mission to preach the virtues, $$$, etc. of psychologists - often out of the blue in non-sequiturs? Are you a psychologist?

Just curious.

•••quote:•••Originally posted by heelpain:
[QB][Where have you been? Psychologists ARE doctors whether you like it or not. And many spend over seven years to get the phd. In a psych program, they must complete coursework, pass exams, if exams are passed, proceed with a dissertation, and COMPETE FOR INTERNSHIP SLOTS TO DO THEIR CLINICALS AND SEE PATIENTS. THEY ALSO TEACH WHILE IN THE PROGRAM. THIS IS ALL DONE WHILE IN THE PROGRAM. Finally the dissertation must be defended. As a phd psych STUDENT, you are a therapist, teacher, student, and researcher.[QB]••••

 

[drusso]

Psychologists shouldn't be allowed to prescribe medicine because prescription privileges are part and parcel of the *PRACTICE* of medicine. A PhD is not a medical degree no matter how rigorous or in depth the coursework and study. I am certain that there are PhD biochemists and PhD pharmacologists out there who have an intricate understanding of lipid metabolism far beyond most internal medicine doctors. This understanding, however, does not qualify them to prescribe cholesterol lowering medication or practice medicine.

No matter how "benign" a drug is, the process of meeting a patient, evaluating them, doing a physical examination, a mental status examination, planning therapy, initiating treatment, and monitoring effects is the practice of medicine. Period. Every time organized medicine (MDs and DOs) lets other health professionals assume larger and larger roles in patient care we essentially send the message that 4 years of medical school and 3-5 years of residency is "no big deal." We devalue ourselves in the marketplace. The marketplace will always be under pressure to reimburse the lowest cost provider. And, it is a fact, that psychologists are less expensive than physicians.

First and foremost, psychiatrists are PHYSICIANS who are also mental health experts trained to take care of patients suffering from MENTAL ILLNESSES and psychiatric disorders. They practice medicine. There are other mental health experts who contribute greatly to the assessment, care, recuperation, and rehabilitation of mentally ill people. But, these other experts are not PHYSICIANS and should not be allowed to practice medicine. Only MDs and DOs can do that.

Psychologists are using the guise of "access to care" to expand their practice privileges. This debate has been going on for decades. In the late 70's organized psychiatry approached organized psychology with a compromise that would allow PhD level psychologists to essentially function as "psychiatric physician assistants" by completing certain training programs. They would be allowed to prescribe certain drugs under the supervision of a psychiatrist. This would have greatly improved access to care for patients suffering from mental illness. The psychologists rejected this compromise because they want INDEPENDENT authority to prescribe. Why?

Follow the money...

 

[PACmatthew]

drusso,

You are 100% correct, and I can tell that you speak from experience. You said it best when you stated that allied health professionals try to take more and more of the physicians role away by taking it for themselves. As a PA, I understand this statement and have to go agree. It is strange to see myself writing this, but even as I prescribe medications daily I do not always feel I should be allowed to. I think the PA role for instance was founded on the principle of placing non-physician providers in places where docs would not go (primarily underserved areas). I find it hard to believe that I see 40 patients a day in an office next to a competing practice who has docs that aren't half as busy. Should I really be seeing these patients when there are physicians next door who are more qualified than I? I think the lines have been blurred and the reality is that groups hire PA's (who can prescribe) because they are cheaper, and then pass patients off on them with the excuse that their PCP is busy. For this exact ambiguity, I am starting medical school this summer, and I wholeheartedly agree that physicians should stand their ground on issues related to practice rights.

 

[leorl]

Axis 3 does code for comorbidity between mental health and physiological health, I don't think anyone stated that psychologists would not be aware of the parallels and dependence between the two. That's not the point. Sufficient knowledge to prescribe medication is completely different. I do not believe psychologists are incapable of doing it, I just believe much more time has to be spent in training because prescribing meds is completely a different form of treatment than the current therapies, and that drug prescription should remain primarily in the hands of already trained psychiatrists. In the absence of psychiatrists, more should be done to recruit psychiatrists into the area or promote psychiatry residency, rather than giving psychologists the right to practice meds. There is no national shortage of psychiatrists, so they should be utilized. Allowing a psychologist this freedom increases the chance of mis-prescribing a drug, whether there's a comorbidity or not, and that's a risk that shouldn't be taken. Especially when there are so many unknowns already existing with psychological disorders in general. There is no doubt that clinical psychologists would be able to diagnose and decide the best therapeutic treatment for mental illness and comorbidities, but if he/she feels drugs are needed, I believe it would be better for a referral to a medically-trained psychiatrists, rather than having training just added on for a mere 450 hours. And if the latter prevailed, there needs to be strict standardization and certification.

 

[drusso]

•••quote:•••Originally posted by leorl:
• There is no doubt that clinical psychologists would be able to diagnose and decide the best therapeutic treatment for mental illness and comorbidities, but if he/she feels drugs are needed, I believe it would be better for a referral to a medically-trained psychiatrists, rather than having training just added on for a mere 450 hours. And if the latter prevailed, there needs to be strict standardization and certification.•••••There is already a strict standardization and certification process in place: It involves completing four years of education at an accredited school of medicine or osteopathic medicine, passage of three steps of a national licensure examination, and completion of an accredited post-gradutate residency training program. There's also the business of a little oath you take somewhere along the line too. This is among the most tightly regulated professional training experience ever created. Maybe astronauts have more standardized training...

The variability in PhD level clinical psychology programs is enormous. PhD psychologists are not licensed nationally, they are licensed on a state by state basis. I'm skeptical that a 450 hour psychopharmacology course could ever duplicate two years of basic sciences, plus two years of clinical rotations in medical school, plus a 3-5 year residency. Ask yourself this: Is the completion of a 450 hour CME course good health care?

Psychologists want to prescribe medicine because 1)the strict cartesian separation of "mind" and "body" is blurring, mental illnesses and brain illnesses are increasingly seen as two sides of the same coin; 2) managed care has ruined the practice of psychotherapy so much that many therapists feel that doing psychotherapy the managed care way is unethical; 3) new classes of psychiatric drugs have proven to be very effective and psychotropics under development look even more promising; 4) it generates good income to prescribe medicine (4 med checks/hour at $75-$125) versus 1 hour psychotherapy at $65-$95/hour).

Again, I reiterate, just follow the money...