Psychopharmacology/Advanced Practice Psychology

[nitemagi]

Do I really need to quote myself quoting myself?

Give all the anecdotes you want. I have plenty too (including of psychologists with masters in pharmacology) that paint a darker picture. But anecdotes are not data. And the loopholes in the law and the strong opposition in the psychiatric community clearly DOES make supervision by PCP's a reality.

Yawn.

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[AcronymAllergy]

Do I really need to quote myself quoting myself?

Give all the anecdotes you want. I have plenty too (including of psychologists with masters in pharmacology) that paint a darker picture. But anecdotes are not data. And the loopholes in the law and the strong opposition in the psychiatric community clearly DOES make supervision by PCP's a reality.

Yawn.

I will say that even from what I've seen in Louisiana, the psychiatric opposition isn't nearly universal (or potentially even strong), although I haven't looked at any survey numbers (if they exist) to see what the overall sentiment is. Nationwide vs. in Louisiana might also be another issue, although in truth, the only people currently affected (both practitioners and patients) are those living in Louisiana or New Mexico. Not that I'm doubting there are many psychiatrists opposed to it, but I've definitely spoken with psychologists who work with psychiatrists who are happy to have the extra help.

Although as another poster mentioned, it may be semantics, but the law doesn't require "supervision" by a physician. Rather, it requires that the psychologist collaborate with each patient's PCP for the first few years when prescribing; in the event that the patient has no PCP, the psychologist cannot prescribe to him/her. I would imagine this type of collaboration is helpful even when not required, and so including it as a necessity early on and developing a habit of seeking it out probably isn't a bad thing.

 

[doctorpsych]

Do I really need to quote myself quoting myself?

another example that occurred last week, I get a consult request by another pcp re a 57 y/o male coming in a routine exam. Pt's MD (MD covering pt's pcp) notices that the pt has been taking lorazepam 2mg bid for over a year and he request more refills. I examined his records, as suspected pt. have been chronically attempting to get lorazepam early than indicated on prescription. We did labs, elevated lfts galore and other abnormal findings, pt. also looked jaundice... needless to say, pt. is alcoholic, admitted last drink approx 1 wks ago... Pt also had hx of seizures in the past (unclear whether due to past etoh withdrawal or independent of etoh). Provided recomendation to MD on how to titrate off from benzo (as surprisingly, MD did not know), switched to klonopin and provided titrate off schedule, MD did his thing, put pt on seizure med with less involvement on liver.... Enaged pt in motivational interviewing, set him up with substance abuse tx... most likely will be going inpatient somewhere... pt wins...

yes, keep reapeating yourself, I know it makes you feel better


yes please do, it must make you feel better

 

[nitemagi]

another example that occurred last week, I get a consult request by another pcp re a 57 y/o male coming in a routine exam. Pt's MD (MD covering pt's pcp) notices that the pt has been taking lorazepam 2mg bid for over a year and he request more refills. I examined his records, as suspected pt. have been chronically attempting to get lorazepam early than indicated on prescription. We did labs, elevated lfts galore and other abnormal findings, pt. also looked jaundice... needless to say, pt. is alcoholic. Pt also had hx of seizures (unclear whether due to etoh withdrawal or independent of etoh). Provided recomendation to MD on how to titrate off from benzo (as surprisingly, MD did not know), switched to klonopin and provided titrate off schedule, MD did his thing, put pt on seizure med with less involvement on liver.... Enaged pt in motivational interviewing, set him up with substance abuse tx... most likely will be going inpatient somewhere... pt wins...

Wow. Thank you for illustrating my point on your bravado without recognition of ignorance.

While it's nice you identified an alcoholic, there's so many problems with your management. Elevated LFT's indicate liver damage, not liver function. Jaundice is another monster, and should have further been a sign for a hepatitis panel. More importantly Klonopin is not only MORE metabolized by the liver than ativan, but has a significant P450 interaction that may be of concern with other meds and any other anti-epileptics he might be put on. Even medical students know a simple mnemonic for benzo's with limited hepatic metabolism considered safe in those in liver failure (LOT - Lorazepam, Oxazepam, Temazepam). Apparently you didn't know this, so instead put him on one of the longest acting benzo's around, which if he has liver failure could stack in his system (especially with his history of abusing benzo's) and lead to coma and death. So nice work. But the patient likely didn't know how bad your decisions are, so you'll squeak by unscathed. And you could have made equally bad decisions. Hopefully you at least assessed the amount of lorazepam he was using before concocting your cross-titration schedule and set up frequent follow-ups to make sure he didn't have severe withdrawal since benzo equivalencies have broad ranges.

Regardless of your number of anecdotes, the most you're illustrating is that you know a lot of bad PCP's, and that your judgement is equally bad.

So I refer you to the bolded.
He who knows not and knows not he knows not: he is a fool-shun him.
He who knows not and knows he knows not: he is simple-teach him.
He who knows and knows not he knows: he is asleep-wake him.
He who knows and knows he knows: he is wise-follow him.
-Persian Proverb

 

[doctorpsych]

Wow. Thank you for illustrating my point on your bravado without recognition of ignorance.

While it's nice you identified an alcoholic, there's so many problems with your management. Elevated LFT's indicate liver damage, not liver function. Jaundice is another monster, and should have further been a sign for a hepatitis panel. More importantly Klonopin is not only MORE metabolized by the liver than ativan, but has a significant P450 interaction that may be of concern with other meds and any other anti-epileptics he might be put on. Even medical students know a simple mnemonic for benzo's with limited hepatic metabolism considered safe in those in liver failure (LOT - Lorazepam, Oxazepam, Temazepam). Apparently you didn't know this, so instead put him on one of the longest acting benzo's around, which if he has liver failure could stack in his system (especially with his history of abusing benzo's) and lead to coma and death. So nice work. But the patient likely didn't know how bad your decisions are, so you'll squeak by unscathed. And you could have made equally bad decisions. Hopefully you at least assessed the amount of lorazepam he was using before concocting your cross-titration schedule and set up frequent follow-ups to make sure he didn't have severe withdrawal since benzo equivalencies have broad ranges.

Regardless of your number of anecdotes, the most you're illustrating is that you know a lot of bad PCP's, and that your judgement is equally bad.

So I refer you to the bolded.
He who knows not and knows not he knows not: he is a fool-shun him.
He who knows not and knows he knows not: he is simple-teach him.
He who knows and knows not he knows: he is asleep-wake him.
He who knows and knows he knows: he is wise-follow him.
-Persian Proverb

wow, the wrath of a little judgmental resident... look, my decision was made after consultation with a full fledged university level psychiatrist and while collaborating with another full fledged family medicine MD. You just couldn't help let your need for validation cloud your impulse control couldn't ya?... you think just because I didn't spell out CYP 450 I didn't learn it? which points at how little you know about our training... I don't need to justify every little decision to a resident but to make a point here I will...I choose relatively equivalent dosage of klonopin for it's strong anti-seizure properties to cover his potential for withdrawal with the reasoning that the pt. is going to be admitted into an inpatient unit. As the MD that I collaborated with felt that the risk of acute liver damage from the dosage was lower than having seizures. Serax is not a very good anticonvulsant and temazepam doesn't last that long... you didn't know that DA?

 

[nitemagi]

This is hilarious. Wrath?

"Relative equivalent" in a patient with major liver impairment, and you want to manage without even seeing if the patient is in withdrawal? The pt. needs an ED eval or at minimum a clinic eval first. Prescribing a long-acting benzo to an alcoholic benzo with possible liver failure is quite risky.

The point of the mnemonic is that lorazepam (which is glucoronidated by the liver) is considered safer in liver impaired pt's than klonopin. Oxaz and Temaz are used, but not usually in a detox setting. If you review the literature, there are no studies that, even amongst experts, that give actual benzo "equivalencies." The most you can hope for is to ballpark it, which is why the pt needs close monitoring and not prescribing 3rd-hand via recommendations to a covering physician for their pcp.

BTW, every "resident," which is hilarious that you use the term in an inferior fashion, has at more than twice the medical education you do, and residents within my year have at least twice the psychopharm training with good supervision. But clearly You must be superior.

I don't really care if you "justify every little decision," or any decisions at all. But you're the one posting anecdotes showing your great medical knowledge and ability to handle psychopharm better than physicians. So you're opening yourself up to scrutiny. It's just that at the moment I'm the only one pointing it out. Probably because it's wiser to let you just diddle on, rather than expect you to admit there's any problems with RxP. Diminishing returns at this point.

 

[stigmata]

You obviously care a lot as you keep posting as if we care?? Weird.

 

[nitemagi]

To continue to voice a counterpoint to unopposed anecdotal "evidence."

 

[stigmata]

And your point is both a biased opinion as well as anecdotal.

 

[nitemagi]

Pot...kettle..again.

Yes having my own training biases my interpretation of your anecdotes.

My arguments about benzo's are steeped in medical facts.

 

[doctorpsych]

This is hilarious. Wrath?

"Relative equivalent" in a patient with major liver impairment, and you want to manage without even seeing if the patient is in withdrawal? The pt. needs an ED eval or at minimum a clinic eval first. Prescribing a long-acting benzo to an alcoholic benzo with possible liver failure is quite risky.

The point of the mnemonic is that lorazepam (which is glucoronidated by the liver) is considered safer in liver impaired pt's than klonopin. Oxaz and Temaz are used, but not usually in a detox setting. If you review the literature, there are no studies that, even amongst experts, that give actual benzo "equivalencies." The most you can hope for is to ballpark it, which is why the pt needs close monitoring and not prescribing 3rd-hand via recommendations to a covering physician for their pcp.

BTW, every "resident," which is hilarious that you use the term in an inferior fashion, has at more than twice the medical education you do, and residents within my year have at least twice the psychopharm training with good supervision. But clearly You must be superior.

I don't really care if you "justify every little decision," or any decisions at all. But you're the one posting anecdotes showing your great medical knowledge and ability to handle psychopharm better than physicians. So you're opening yourself up to scrutiny. It's just that at the moment I'm the only one pointing it out. Probably because it's wiser to let you just diddle on, rather than expect you to admit there's any problems with RxP. Diminishing returns at this point.

humm, let me see... you know more about the pt. than I do because you are a 2nd year resident? I'm assuming you finish your internship, now that's hilarious and yes, I am more superior than you little resident. I'm directing it at you. I know that's eating you up right now. BTW that pt that you know more than I do just got sent off to an inpatient substance abuse treatment. If I wasn't there, he would still be somewhere doing real damage to his liver, possibly seizing, etc. So that's a huge plus for our increasing presence and the pcps want us there. You really think anybody gives two cents about your self indulgence rants? You just couldn't help try to show to us all that you know a little about drug metabolism couldn't ya?...and assume that we lowly medical psychologist would be at awe at your grand knowledge...so use your superior resident training and tell us all about the need of a psychiatric resident who feels compelled to post provocative statements toward medical psychologists? keep up the good need for validation, that will do wonders for your ability to work with others.

 

[nitemagi]

I'm really not in need of validation. But you clearly need to rant. So rant on. I clearly hit a nerve by questioning your medication expertise in a case.

And I'm finishing my 4th year of residency, thanks.

 

[stigmata]

Great, so real soon you will be a fledgling psychiatrist who will begin to learn what the real world of clinical practice is like. Let's chat in 10 years when you have more knowledge and less narcissism.

 

[nitemagi]

Your dismissals of my "lack" of experience continues to show the lack of actual evidence to your side of the debate, and is humorous that as your lack of education as critiqued, the best you can respond with is that I must not have enough experience.

Nurses have education as well, yet those who've practiced for 20 years in psychiatry don't have the psychopharm knowledge of any level resident. So your years in the field, IMO, is moot.

And even those nurses have more medical training than a "medical psychologist."

Is this seriously the most substance to your argument? Anecdotes and critiquing the credentials of those who actually Do have psychiatric training?

 

[doctorpsych]

I'm really not in need of validation. But you clearly need to rant. So rant on. I clearly hit a nerve by questioning your medication expertise in a case.

And I'm finishing my 4th year of residency, thanks.

no, it's your condescending tone... it might help to develop some insight too buddy...FYI: many find you insulting... keep up the good work... and "really" really? do you "really" need to qualify your lack of need for validation? really, really?

 

[nitemagi]

Yes I must really only be the one using a condescending tone in this thread. Hubris permeates us all here.

 

[doctorpsych]

Yes I must really only be the one using a condescending tone in this thread. Hubris permeates us all here.

yes Tonto... it's a reaction to you my friend

 

[nitemagi]

yes Tonto... it's a reaction to you my friend

Yes that's right, it's clearly all about me. The fact that I'm only a resident means I have no right to voice an opinion or question your expertise.

You are superior and without issue in your decisions. Your training is obviously superior to anyone with traditional medical training or specialty trained.

Glad we cleared that up. It was all my fault to ask for actual data to support your argument. I should just have taken your word for it because you're an elder in the field.

 

[dl2dp2]

another example that occurred last week, I get a consult request by another pcp re a 57 y/o male coming in a routine exam. Pt's MD (MD covering pt's pcp) notices that the pt has been taking lorazepam 2mg bid for over a year and he request more refills. I examined his records, as suspected pt. have been chronically attempting to get lorazepam early than indicated on prescription. We did labs, elevated lfts galore and other abnormal findings, pt. also looked jaundice... needless to say, pt. is alcoholic, admitted last drink approx 1 wks ago... Pt also had hx of seizures in the past (unclear whether due to past etoh withdrawal or independent of etoh). Provided recomendation to MD on how to titrate off from benzo (as surprisingly, MD did not know), switched to klonopin and provided titrate off schedule, MD did his thing, put pt on seizure med with less involvement on liver.... Enaged pt in motivational interviewing, set him up with substance abuse tx... most likely will be going inpatient somewhere... pt wins...

This case is actually sounds very complicated and demonstrates very well why psychologists make very bad medical doctors. If someone's LFT's out of whack and is on benzos and has a history of EtOH abuse, do you automatically chalk him up to alcoholic steatohepatitis? The answer is no. And is his cirrhosis compensated or decompensated? Perhaps he also has chronic HCV/HBV (not uncommon). If you MISS this, and stopped his benzos but don't temporize his portal hypertension (or know who or when to refer him) he might get a massive variceal bleed and die. If you feel comfortable handling that kind of legal onus, then you don't need PCP supervision.

There is a MEDICAL WORKUP for abnormal LFTs. PCPs know how to do it. PSYCHIATRISTS know how to do it. This is covered in USMLE step 1 2 and 3 over and over. Someone on high dose benzos chronically or any number of potentially hepatotoxic drugs may get LFT abnormalities, but people who aren't trained medically are not going to be very proficient in systematically diagnosing these issues--or even know how to triage the problems that come up.

Related and relevant issues in other parts of psychiatry/psychopharmacology include EKG abnormalities, renal failures, neutropenia, HIV, on and on. It's highly unlikely that non medical trained professional would be able to handle any number of these situations, and it does argue for PCP oversight.

You may feel that psychiatrist are "narcissistic", and I'm telling you you haven't seen anything yet. Wait till you have to call a cardiology consult for your patient who's on Adderall and has triple vessel disease (hopefully you WILL call), and stumble on the plethora of acronyms. Good luck with that. I'll tell u off the bat that cardiologists have much less patience than psychiatrists do.

The other thing is high acuity patients. Are you really comfortable with dosing people's antipsychotics? Are you really comfortable with involuntarily admitting people for acute suicidality--can you defend your clinical decision in court? When do u refer for ECT? When is inpatient hospitalization necessary? When is someone psychotic vs. malingering? Are you comfortable doing a suicide risk assessment? What about for a bipolar on lithium? These bread and butter psychiatry issues are never brought up in RxP training and never will be--because it's not psychopharm. It's PSYCHIATRY--the good old fashioned, insane asylum-derived medical specialty called psychiatry that only psychiatrists--and really no one else in the world--have access to.

It seems to me that it's highly highly unlikely that RxPs would be able to handle either inpatient or consult psychiatry. In terms of outpatient psych, anything that deals with complicated drug regimens likely RxPs won't be able to handle (i.e. any drug beyond PCP's purview). Most RxPs would likely not touch antipsychotics, mood stablizers or tricyclics, drugs most PCPs don't feel comfortable with. They likely won't have any in on specialized niche disorders like pharmacologic management of borderline/PTSD, or severe OCD or eating disorders. Nor would RxPs touch forensics, state hospitals, addiction etc. So the only niche I can come up with is a certain overlap of the cash-only, high functioning, SSRI only, worried well pool that everyone's competing for. Sadly, in that scenario, the rich would rather squander their money on someone who has more of a pedigree. And the poor and worried well likely won't be able to augment your salary that much...

 

[AcronymAllergy]

The other thing is high acuity patients. Are you really comfortable with dosing people's antipsychotics? Are you really comfortable with involuntarily admitting people for acute suicidality--can you defend your clinical decision in court? When do u refer for ECT? When is inpatient hospitalization necessary? When is someone psychotic vs. malingering? Are you comfortable doing a suicide risk assessment? What about for a bipolar on lithium? These bread and butter psychiatry issues are never brought up in RxP training and never will be--because it's not psychopharm. It's PSYCHIATRY--the good old fashioned, insane asylum-derived medical specialty called psychiatry that only psychiatrists--and really no one else in the world--have access to.

It seems to me that it's highly highly unlikely that RxPs would be able to handle either inpatient or consult psychiatry. In terms of outpatient psych, anything that deals with complicated drug regimens likely RxPs won't be able to handle (i.e. any drug beyond PCP's purview). Most RxPs would likely not touch antipsychotics, mood stablizers or tricyclics, drugs most PCPs don't feel comfortable with. They likely won't have any in on specialized niche disorders like pharmacologic management of borderline/PTSD, or severe OCD or eating disorders. Nor would RxPs touch forensics, state hospitals, addiction etc. So the only niche I can come up with is a certain overlap of the cash-only, high functioning, SSRI only, worried well pool that everyone's competing for. Sadly, in that scenario, the rich would rather squander their money on someone who has more of a pedigree. And the poor and worried well likely won't be able to augment your salary that much...

I won't touch the earlier comments in your post, as I'm not medically nor RxP trained, so I have no ability to make an informed comment. However, I will say that many of the statements made in the above paragraphs are incorrect.

The majority of research in malingering (cognitive and psychiatric) currently being conducted is by clinical psychologists, and the majority (perhaps all, although I'm not sure) of the widely-used and well-normed and validated assessment measures of malingering were developed by psychologists. Given that it's been shown clinical judgment is not in and of itself adequate to reliably identify a malingering (or less-than-effortful) patient, I'm shocked at the number of mental health providers who don't include these measures in their assessments. In fact, I would make the argument that psychologists can often be more confident in court than other mental health providers who eschew (or are not aware of) these measures, as their judgments are backed by ever-expanding volumes of research in these areas.

In terms of acute suicidality, again, many of the current assessment measures of suicidality were developed by psychologists. Additionally, psychologists in I believe all states are legally able to PEC clients (without oversight) when necessary. As a graduate student, I've had to handle that situation more than once, in addition to having worked in inpatient settings both forensically and civilly. And my experiences are not at all unrepresentative of many other trainees at my level. Clinical psychologists are quite comfortable, and have generally received significant experience, working with SMI populations in addition to receiving significant didactic training in the theory of severe psychopathology. Some individuals may shy away from it for personal reasons (psychiatrists and psychologists alike), but as a field, we do not.

In terms of where RxPs work, the majority whom I know of personally do indeed work in state hospitals and community mental health centers. I only know of a handful who prescribe exclusively in private practice.

 

[stigmata]

This case is actually sounds very complicated and demonstrates very well why psychologists make very bad medical doctors. If someone's LFT's out of whack and is on benzos and has a history of EtOH abuse, do you automatically chalk him up to alcoholic steatohepatitis? The answer is no. And is his cirrhosis compensated or decompensated? Perhaps he also has chronic HCV/HBV (not uncommon). If you MISS this, and stopped his benzos but don't temporize his portal hypertension (or know who or when to refer him) he might get a massive variceal bleed and die. If you feel comfortable handling that kind of legal onus, then you don't need PCP supervision.

There is a MEDICAL WORKUP for abnormal LFTs. PCPs know how to do it. PSYCHIATRISTS know how to do it. This is covered in USMLE step 1 2 and 3 over and over. Someone on high dose benzos chronically or any number of potentially hepatotoxic drugs may get LFT abnormalities, but people who aren't trained medically are not going to be very proficient in systematically diagnosing these issues--or even know how to triage the problems that come up.

Related and relevant issues in other parts of psychiatry/psychopharmacology include EKG abnormalities, renal failures, neutropenia, HIV, on and on. It's highly unlikely that non medical trained professional would be able to handle any number of these situations, and it does argue for PCP oversight.

You may feel that psychiatrist are "narcissistic", and I'm telling you you haven't seen anything yet. Wait till you have to call a cardiology consult for your patient who's on Adderall and has triple vessel disease (hopefully you WILL call), and stumble on the plethora of acronyms. Good luck with that. I'll tell u off the bat that cardiologists have much less patience than psychiatrists do.

The other thing is high acuity patients. Are you really comfortable with dosing people's antipsychotics? Are you really comfortable with involuntarily admitting people for acute suicidality--can you defend your clinical decision in court? When do u refer for ECT? When is inpatient hospitalization necessary? When is someone psychotic vs. malingering? Are you comfortable doing a suicide risk assessment? What about for a bipolar on lithium? These bread and butter psychiatry issues are never brought up in RxP training and never will be--because it's not psychopharm. It's PSYCHIATRY--the good old fashioned, insane asylum-derived medical specialty called psychiatry that only psychiatrists--and really no one else in the world--have access to.

It seems to me that it's highly highly unlikely that RxPs would be able to handle either inpatient or consult psychiatry. In terms of outpatient psych, anything that deals with complicated drug regimens likely RxPs won't be able to handle (i.e. any drug beyond PCP's purview). Most RxPs would likely not touch antipsychotics, mood stablizers or tricyclics, drugs most PCPs don't feel comfortable with. They likely won't have any in on specialized niche disorders like pharmacologic management of borderline/PTSD, or severe OCD or eating disorders. Nor would RxPs touch forensics, state hospitals, addiction etc. So the only niche I can come up with is a certain overlap of the cash-only, high functioning, SSRI only, worried well pool that everyone's competing for. Sadly, in that scenario, the rich would rather squander their money on someone who has more of a pedigree. And the poor and worried well likely won't be able to augment your salary that much...

Wow, thank you for this post! While I agree with very little that you say, it very clearly illustrates how psychiatrists have isolated themselves from the majority of mental health providers, primary care, and almost all outpatient health-related treatment providers. You clearly have no idea what training clinical psychologists have if you think we can't/don't do suicide assessments, involuntarily commit patients, make level of care decisions, do forensic work, provide consults in hospitals etc... This has nothing to do with RxP training, it is basic stuff we all get and are competent with. Myself and other RxP psychologists frequently use APs and mood stabilizers, and frequently un-prescibe said drugs when they have been inappropriately used due to lack-luster diagnosing...often by psychiatrists. There will always be a need for psychiatrists to treat the severely ill patients, and I refer to them all the time for this purpose. I agree that psychiatrists are the best for inpatient psychiatric care and will always be. However, the remaining 90% of the population with lesser problems need care too, and we provide it competently.

 

[nitemagi]

And yet the critique of the medical workup is sidestepped in your response.

And prescribing those meds or "unprescribing" them doesn't mean one is doing that well or competently.

Misdiagnosing abounds throughout all of mental health. Besides your anecdotal report that psychiatrists are so often misdiagnosing, do you have any data on this? Or we should just take your word for it?

And can you show how forensics or suicide risk assessment is a required competency for psychology boarding?

 

[stigmata]

Or we should just take your word for it?



Yep, just like you expect us to do with your "opinions". I can provide data, but don't have the time, energy or motivation to do so. I don't much care.

 

[nitemagi]

Such clear evidence psychologists are 'scientists'. You make bold statements about your expertise, but when prompted for any evidence, just don't care.

I call your bluff.

 

[stigmata]

Oh you got me. This isn't work, it is a message board and I am off today

 

[doctorpsych]

Yes that's right, it's clearly all about me. The fact that I'm only a resident means I have no right to voice an opinion or question your expertise.

You are superior and without issue in your decisions. Your training is obviously superior to anyone with traditional medical training or specialty trained.

Glad we cleared that up. It was all my fault to ask for actual data to support your argument. I should just have taken your word for it because you're an elder in the field.

let me make it simple for you, problem= your narcissistic pompous tone. Do I need to clear anything else up for you?

 

[nitemagi]

let me make it simple for you, problem= your narcissistic pompous tone. Do I need to clear anything else up for you?

I love it!

Despite your posting your superior psychopharm and medical knowledge to physicians here, here, here, here, here, here, and here, I'm the one who's pompous?

It isn't pompous to question the safety or efficacy of someone with training less than the gold standard, and ask for actual data to support inflated claims given only by anecdote. I have many psychologist colleagues I collaborate with and respect immensely, and they pride themselves on working from an evidence base. As another psychologist said in a thread recently:
"Psychologists are scientists, plain and simple. It's what we do, it's how we're trained, and it's how we treat our clients and inform our professional decision making."

All I'm asking is that if it is so true display it with actual evidence. RxP has been around for 10 years? No studies yet? The DoD study says RxP from their program (which is way more rigorous than current training programs) had their people functioning at a 3rd year med student level. The Institute of Medicine has plenty of numbers on medical errors and problems in physicians with even more training than that. Do most residents in medical specialties get sued? No. So I think lack of lawsuits in RxP is a pretty low level of evidence for proving lack of errors, or any level of competency in practice.

You may view my challenging your beliefs as pompous, and I'm sorry to hear that. But if you really don't have anything more substantive to support your argument of your being superior than a host of anecdotes, that's too bad.

It's also too bad you have to now play victim that I'm the big bad mean doctor picking on you when not so many posts ago you were ridiculing my lack of training since I'm "only" a resident.

And narcissistic usually refers to a sense of superiority over everyone. I have no such belief nor intention of that in my tone. I do feel quite justified in questioning your medical training or lack thereof, and the very real risks inherent in current legal loopholes that allow such practice, without evidence to support its safety and with a very real body of evidence showing major risk of harm in those with a much more medical training than you.

 

[doctorpsych]

I love it!

Despite your posting your superior psychopharm and medical knowledge to physicians here, here, here, here, here, here, and here, I'm the one who's pompous?

It isn't pompous to question the safety or efficacy of someone with training less than the gold standard, and ask for actual data to support inflated claims given only by anecdote. I have many psychologist colleagues I collaborate with and respect immensely, and they pride themselves on working from an evidence base. As another psychologist said in a thread recently:
"Psychologists are scientists, plain and simple. It's what we do, it's how we're trained, and it's how we treat our clients and inform our professional decision making."

All I'm asking is that if it is so true display it with actual evidence. RxP has been around for 10 years? No studies yet? The DoD study says RxP from their program (which is way more rigorous than current training programs) had their people functioning at a 3rd year med student level. The Institute of Medicine has plenty of numbers on medical errors and problems in physicians with even more training than that. Do most residents in medical specialties get sued? No. So I think lack of lawsuits in RxP is a pretty low level of evidence for proving lack of errors, or any level of competency in practice.

You may view my challenging your beliefs as pompous, and I'm sorry to hear that. But if you really don't have anything more substantive to support your argument of your being superior than a host of anecdotes, that's too bad.

It's also too bad you have to now play victim that I'm the big bad mean doctor picking on you when not so many posts ago you were ridiculing my lack of training since I'm "only" a resident.

And narcissistic usually refers to a sense of superiority over everyone. I have no such belief nor intention of that in my tone. I do feel quite justified in questioning your medical training or lack thereof, and the very real risks inherent in current legal loopholes that allow such practice, without evidence to support its safety and with a very real body of evidence showing major risk of harm in those with a much more medical training than you.

wow... keep on spending your precious time coming up with verbose responses to my one lines... you really love to self indulge don't you? again, I don't know how else to help you understand... your TONE is insulting... you are entitled to your beliefs but how you express them is the PROBLEM... trace it back and you'll see why people are firing back at you... and I highly doubt your colleagues respect you for that...that is, if they do... and to clear things, I never said that medical psychologist are superior than psychiatrists, what I said is that medical psychologist have more training in psychotropics, therefore can handle them more effectively than pcp's... and again, they welcome our help...that's the crux... you are spinning it, and I can't help think that your underlying 'issues' are driving your distorted perception... again, I hope you realize that before you get out to the real world...

 

[Zigman]

The majority of research in malingering (cognitive and psychiatric) currently being conducted is by clinical psychologists, and the majority (perhaps all, although I'm not sure) of the widely-used and well-normed and validated assessment measures of malingering were developed by psychologists. Given that it's been shown clinical judgment is not in and of itself adequate to reliably identify a malingering (or less-than-effortful) patient, I'm shocked at the number of mental health providers who don't include these measures in their assessments. In fact, I would make the argument that psychologists can often be more confident in court than other mental health providers who eschew (or are not aware of) these measures, as their judgments are backed by ever-expanding volumes of research in these areas.

This is absolutely correct. To suggest we are ignorant of such matters, is itself reflective of ignorance. I too am a graduate student and have helped produce this research (including several presentations, a publication in press and another one nearing submission -all pertaining to the validation of novel objective measures of effort/malingering).

And with regard to boarding -it depends on your subspecialty. If one were to seek boarding in forensic psychology OR clinical neuropsychology, one would have to demonstrate expert knowledge in this domain.

 

[dl2dp2]

You clearly have no idea what training clinical psychologists have if you think we can't/don't do suicide assessments, involuntarily commit patients, make level of care decisions, do forensic work, provide consults in hospitals etc... This has nothing to do with RxP training, it is basic stuff we all get and are competent with...

As far as I'm aware, both in the State of Louisiana and Massachusetts, involuntarily committing a patient to a hospital requires signatures of at least 2 physicians licensed to practice in that state. I believe in all 50 states you need at least 1 signature of a physician to involuntarily commit a patient. Psychologists are NOT legally allowed to involuntarily commit patients.

I don't care if you CAN or CANNOT do suicide assessment. You aren't legally authorized to take away people's civil liberties. If I was a patient, I sure as hell will insist on having at least a real PHYSICIAN to commit me.

Again, doing research in a subject and having the legal authority of practicing medicine are two different things. There are world experts on cardiovascular diseases doing research with only a PhD, but they sure as hell will NOT touch a heart attack patient with a five foot pole.

You can argue this all day long, but nobody will ever staff inpatient units or psych ERs with only psychologists. Not here, not in Louisiana, not in New Mexico. Nowhere. Never. LOL.

 

[nitemagi]

X

 

[nitemagi]

wow... keep on spending your precious time coming up with verbose responses to my one lines... you really love to self indulge don't you? again, I don't know how else to help you understand... your TONE is insulting... you are entitled to your beliefs but how you express them is the PROBLEM... trace it back and you'll see why people are firing back at you... and I highly doubt your colleagues respect you for that...that is, if they do... and to clear things, I never said that medical psychologist are superior than psychiatrists, what I said is that medical psychologist have more training in psychotropics, therefore can handle them more effectively than pcp's... and again, they welcome our help...that's the crux... you are spinning it, and I can't help think that your underlying 'issues' are driving your distorted perception... again, I hope you realize that before you get out to the real world...

I live and work in the real world. And the only 'issues' relevant to this thread is how ignoring risk leads to bad outcomes. People are open to healing with crystals too. That doesn't make it effective. In fact it makes one predatory to 'double' your salary as you stated you did above while offering expertise you don't have. The difference between the crystal healer and you is that their risk of harm is much much lower. But clearly that whole line of argument is irrelevant because of my tone. Speake to the content, not the process.

 

[stigmata]

As far as I'm aware, both in the State of Louisiana and Massachusetts, involuntarily committing a patient to a hospital requires signatures of at least 2 physicians licensed to practice in that state. I believe in all 50 states you need at least 1 signature of a physician to involuntarily commit a patient. Psychologists are NOT legally allowed to involuntarily commit patients.

I don't care if you CAN or CANNOT do suicide assessment. You aren't legally authorized to take away people's civil liberties. If I was a patient, I sure as hell will insist on having at least a real PHYSICIAN to commit me.

Again, doing research in a subject and having the legal authority of practicing medicine are two different things. There are world experts on cardiovascular diseases doing research with only a PhD, but they sure as hell will NOT touch a heart attack patient with a five foot pole.

You can argue this all day long, but nobody will ever staff inpatient units or psych ERs with only psychologists. Not here, not in Louisiana, not in New Mexico. Nowhere. Never. LOL.

Well as usual you are wrong. I practice in Colorado and Wyoming where I can involuntarily commit patients by law, and it does not require any physician involvement. I can also admit patients to the psychiatric hospital and the family medicine service floors, and am on the medical staff. Please get a clue....this is getting old.

 

[nitemagi]

Stigmata,

what's the required amount of training in inpatient treatment to get those privileges in Wyoming and Colorado? And are you primary provider on record (typically an attending physician) in the inpatient hospital?

 

[doctorpsych]

I live and work in the real world. And the only 'issues' relevant to this thread is how ignoring risk leads to bad outcomes. People are open to healing with crystals too. That doesn't make it effective. In fact it makes one predatory to 'double' your salary as you stated you did above while offering expertise you don't have. The difference between the crystal healer and you is that their risk of harm is much much lower. But clearly that whole line of argument is irrelevant because of my tone. Speake to the content, not the process.

booohoooo, now you got me with the crystal comment... wow, you are smart... please continue!

 

[nitemagi]

booohoooo, now you got me with the crystal comment... wow, you are smart... please continue!

So further evasion.

 

[AcronymAllergy]

Responding on my phone, so there may be typos. However, again, I will say that psychologists in Louisiana complete a PEC on a patient without oversight from a physician. As far as I am aware, this is the case in most states. In general, when it comes to non-pharm mental health care, there is little distinction at the state level between psychologists and psychiatrists.

The idea being that unlike many other strictly academic degrees clinical psychology programs require an additional component of significant application and patient care. The concept that medical training is the best, or only, means of acquiring expertise in dealing with mental health issues and treatment was abandoned by states years ago. Both disciplines provide equal amounts of expertise, just from different persepectives

 

[doctorpsych]

So further evasion.

if you want to engage in a discussion, ask away appropriately; but the second you insert asinine self-aggrandizing comments, you will be treated at that grade level...got me?

 

[dl2dp2]

Responding on my phone, so there may be typos. However, again, I will say that psychologists in Louisiana complete a PEC on a patient without oversight from a physician. As far as I am aware, this is the case in most states. In general, when it comes to non-pharm mental health care, there is little distinction at the state level between psychologists and psychiatrists.

This is not what I meant at all, you are obfuscating technicality and practicality. The specific Louisiana state mental health codes specify that certified psychiatrist, psychologist or nurse practitioners have the authority to involuntarily admit patients. However, in PRACTICE, NPs and psychologist do NOT admit patient independently because no ACCEPTING facility would admit patients without physician certification. The reason is accepting facility needs medical clearance before they are comfortable accepting patients.

Again, in some states, psychiatric NPs can provide psychiatric care and prescribe medicine. However, if you argue that there is "little distinction" between NP care and MD care, then I rest my case. And to a certain extent, the entire RxP premise is to transition clinical psychologists to de facto psychiatric NPs--a premise I doubt that most RxPs would accept.

This will be my last post on this thread.

 

[edieb]

This is not what I meant at all, you are obfuscating technicality and practicality. The specific Louisiana state mental health codes specify that certified psychiatrist, psychologist or nurse practitioners have the authority to involuntarily admit patients. However, in PRACTICE, NPs and psychologist do NOT admit patient independently because no ACCEPTING facility would admit patients without physician certification. The reason is accepting facility needs medical clearance before they are comfortable accepting patients.

Again, in some states, psychiatric NPs can provide psychiatric care and prescribe medicine. However, if you argue that there is "little distinction" between NP care and MD care, then I rest my case. And to a certain extent, the entire RxP premise is to transition clinical psychologists to de facto psychiatric NPs--a premise I doubt that most RxPs would accept.

This will be my last post on this thread.

I can attest that the above is completely untrue. I received my Ph.D. in clinical psychology from Louisiana State University in Baton Rouge. In our training program, the supervising psychologist (Phillip Brantley, Ph.D.) frequently admitted patients to Greenwell Springs Hospital and experienced no difficulty in doing so.

 

[nitemagi]

There will be exceptions to every rule.

 

[stigmata]

When I admit to family medicine I turn over attending to the weekly attending physician on the unit. When I admit to the acute psych unit I do so independently unless I feel that the patient needs medical clearance. In that case they go through the ER to get cleared, then I admit, then I had off to one of their psychiatrists.

 

[nitemagi]

So you're the attending on record if they don't need medical clearance[which you determine], that manages them throughout their hospitalization, sees them daily, makes medication choices, and discharges them from the psychiatric hospital?

What qualifies as medical clearance and when it should be required is an ongoing area of dispute, and another turf battle often involving psychiatrists and emergency medicine physicians.

 

[stigmata]

No I said I hand over to the psychiatrist. I am not a hospital employee, just credentialled there.

 

[AcronymAllergy]

This is not what I meant at all, you are obfuscating technicality and practicality. The specific Louisiana state mental health codes specify that certified psychiatrist, psychologist or nurse practitioners have the authority to involuntarily admit patients. However, in PRACTICE, NPs and psychologist do NOT admit patient independently because no ACCEPTING facility would admit patients without physician certification. The reason is accepting facility needs medical clearance before they are comfortable accepting patients.

Again, in some states, psychiatric NPs can provide psychiatric care and prescribe medicine. However, if you argue that there is "little distinction" between NP care and MD care, then I rest my case. And to a certain extent, the entire RxP premise is to transition clinical psychologists to de facto psychiatric NPs--a premise I doubt that most RxPs would accept.

This will be my last post on this thread.

As you've said, I don't think many RxP psychologists would completely agree with your statement--I can see how the training would essentially turn psychologists into psychiatric NPs strictly in terms of medical education (I'm guessing this is what you meant?). However, the psychologist obviously also has the additional training provided by his/her doctorate, hence the reason for disagreement.

As for PECs, I can't speak for every hospital in Louisiana. What I can say, though, is that I've known several psychologists who've PEC'd clients to various hospitals without issue from the receiving facility. I've actually even had to work with an NP to PEC a client when a physician wasn't available, and as far as I know, there were no problems that sprung up there, either. I do understand your point, though, and wouldn't doubt that--at the least--some hospitals would initially provide resistance to any PEC, particularly one initiated by a psychologist. And particularly if that psychologist did not have some type of working relationship with the receiving facility.

 

[doctorpsych]

mom brought 13 y/o boy in, she complained that he has been "very" inattentive, doesn't follow instructions, doesn't socialize with family and friends. His pediatrician (outside of our agency) dx him with "ADD" and rx metadate cd along with Methylin in the pm. Mom complained that her son was getting worse. The pediatrician missed a huge boat, this kid had signs of psychosis/developing schizophrenia. Apparently there was a paternal hx of psychosis and mom also stated the kid is often seen "having conversations with himself", reports having "d'javu" experiences, hears machines and wind "saying words to me". His sx's mostly have been worsened by his misdx and rx.

I'm amazed on a day to day basis how obvious our services are needed and how little does the 'lack of safety' argument really stands. In the case safety was jeopardized, not by a medical psychologist

 

[nitemagi]

mom brought 13 y/o boy in, she complained that he has been "very" inattentive, doesn't follow instructions, doesn't socialize with family and friends. His pediatrician (outside of our agency) dx him with "ADD" and rx metadate cd along with Methylin in the pm. Mom complained that her son was getting worse. The pediatrician missed a huge boat, this kid had signs of psychosis/developing schizophrenia. Apparently there was a paternal hx of psychosis and mom also stated the kid is often seen "having conversations with himself", reports having "d'javu" experiences, hears machines and wind "saying words to me". His sx's mostly have been worsened by his misdx and rx.

I'm amazed on a day to day basis how obvious our services are needed and how little does the 'lack of safety' argument really stands. In the case safety was jeopardized, not by a medical psychologist

Hmm. I wouldn't call it a closed case yet. As much as can be diagnosed from an internet anecdote, I would be equally concerned for substance induced psychosis, and for seizures (deja vu). 13yo is a bit outside the normal age of onset for schizophrenia, even for most prodromal kids. Someone that age with those symptoms needs a thorough medical w/u - including EEG, MRI, labs (cbc, chem-10 at minimum). Amphetamine induced psychosis also is known to worsen with presence of white noise (wind and machines). Inattention can be a sx of absence sz's, and TLE can cause auditory hallucinations. Improper medical w/u could lead to a lifetime of antipsychotic treatment rather than anti-epileptic tx.

 

[doctorpsych]

I don't have time to write the kids full biopsychoed hx, remember, he came to me at age 13, doesn't me his prodomal sx's began recently, cmp, cbc, tsh--all unremarkable, urine tox ordered but highly doubt will be positive (the latter, waiting for results), he has been already medically evaluated (I'm assuming seizures were ruled out), his current pcp cleared him in terms of medical issues, his sx's were present prior to psychostim tx by pediatrician.

the bottom line is that his pediatrician had been improperly treating him with psychostim, which made his psychiatric sx's worse and further deteriorating his educational and equally important his social fx for years... so at least in this case (and I'm sure other similar ones are out there), potential harm is coming from tx provided by an MD with limited mental health training. now off course, this is not a open shut case, but at least now a medical psychologist is in the picture, which I will be providing the care he needs, including a thorough psychoed eval, implementing/monitoring meds (more frequently than the pediatrician), psychological and educational interventions.

also, we have a new md that started recently... was discussing one of our common pt's, I made recommendations and the md openly stated having little knowledge of psychotropics and would go with my recommendations... this is hardly unusual, pretty much all pcp's that I've encounted gave me the same response and support... I believe my experiences mirrors the general concensus that most pcps support medical psychologist because we are there to help them out...

Hmm. I wouldn't call it a closed case yet. As much as can be diagnosed from an internet anecdote, I would be equally concerned for substance induced psychosis, and for seizures (deja vu). 13yo is a bit outside the normal age of onset for schizophrenia, even for most prodromal kids. Someone that age with those symptoms needs a thorough medical w/u - including EEG, MRI, labs (cbc, chem-10 at minimum). Amphetamine induced psychosis also is known to worsen with presence of white noise (wind and machines). Inattention can be a sx of absence sz's, and TLE can cause auditory hallucinations. Improper medical w/u could lead to a lifetime of antipsychotic treatment rather than anti-epileptic tx.

 

[stigmata]

Boring and stupid...why respond to a constant troll.

 

[nitemagi]

I don't have time to write the kids full biopsychoed hx, remember, he came to me at age 13, doesn't me his prodomal sx's began recently, cmp, cbc, tsh--all unremarkable, urine tox ordered but highly doubt will be positive (the latter, waiting for results), he has been already medically evaluated (I'm assuming seizures were ruled out), his current pcp cleared him in terms of medical issues, his sx's were present prior to psychostim tx by pediatrician.

the bottom line is that his pediatrician had been improperly treating him with psychostim, which made his psychiatric sx's worse and further deteriorating his educational and equally important his social fx for years... so at least in this case (and I'm sure other similar ones are out there), potential harm is coming from tx provided by an MD with limited mental health training. now off course, this is not a open shut case, but at least now a medical psychologist is in the picture, which I will be providing the care he needs, including a thorough psychoed eval, implementing/monitoring meds (more frequently than the pediatrician), psychological and educational interventions.

also, we have a new md that started recently... was discussing one of our common pt's, I made recommendations and the md openly stated having little knowledge of psychotropics and would go with my recommendations... this is hardly unusual, pretty much all pcp's that I've encounted gave me the same response and support... I believe my experiences mirrors the general concensus that most pcps support medical psychologist because we are there to help them out...

Wasn't suggesting he used illicits. Was suggesting that the methylphenidate could be causing the psychosis. And "medically cleared" has no uniform definition, including for psychosis. I think it's great you caught the psychotic sx's, but this is actually where it's important a psychiatrist is involved, because likely if all the pediatrician did was "medically clear" his ADHD, then he's never had a real workup for new onset psychosis. Age of onset for psychosis is usually 20-30 for males. Anyone with onset at any age needs a full medical w/u, including a head scan. Onset outside of that range is much more concerning. Not trying to be oppositional, just pointing out that unless you have an EEG conducted and have documentation of these psychotic sx's (which you noted he had been on for years) prior to the introduction of the stimulant, there's still serious alternatives in the differential diagnosis that need to be ruled out.