Psychopharmacology/Advanced Practice Psychology

[CGOPsych]

I'm disgusted with the repeated accusations of doctor's protecting their "turf". That is so not the case and you know it. Honestly, if it was up to me, I would decrease psychiatry reimbursements further just to keep unscrupulous people like you from wanting to practice medicine illicitly. But in anycase, there are wide-open mid-level programs for you to engage in to practice medicine already even if you don't want to do all the training necessary to become a physician.

Common sense says that physicians will not lose income because of RxP. However, this IS a turf war in the sense that the RxP campaign's mission is to expand political and economic opportunities by taking over another profession's area of expertise without having to undergo the proper training to do so.

RxP leader Robert McGrath has written in the NJ psych association's newsletter that RxP can bring psychologists significant and vital improvements in their financial outlook. In fact, he goes so far as to say that the future of psychology is only assured in the two states that allow RxP. This is arguably a grossly inaccurate assessment of the professional future of psychology. However, it is an honest acknowledgement of the real motive for spending millions of dollars to get prescription pads. I don't think any RxPer can say with a straight face that this massive, two-decade-old campaign's primary purpose is to improve the mental health system. The alternatives are far safer, non-controversial, more effective and immediately implementable ... but they don't bring the political and financial opportunities that RxP would.

RxP is, in a word, shameful. It makes us look like a bunch of greedy, naive, and dishonest lowlifes who value money and power over patient safety, quality in training, and scientific standards. And this shoddy over-reach for money and power has the full backing and official endorsement of the association that claims to represent us all, which just adds to the shame. I didn't become a psychologist to lie, deceive and put people at risk of injury just to make money.

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[WisNeuro]

Are you being serious? Translating the unnecessary academic journal language (we can easily translate it- but we find it pompous and annoying)- are you now arguing that RxP is a beter training "modality" then LCME medical school and ACGME psychiatry residency? p.s. you are somewhat misusing the word "model" (though I'm guessing you just want to sound "fancy")

Such wanton anger and misinterpretation. Where did I argue that it is a "better" training model? And since when is using the word model "fancy?" Also, we should use more "air quotes." Now that's "fancy."

As for the turf war, continue with your faux outrage and disgust. It's a part of the equation and you very well know it.

 

[WisNeuro]

who value money and power over patient safety, quality in training, and scientific standards.

Where is the data on this quality of training and scientific standards, again?

 

[smalltownpsych]

These last few posts are a bit over the top. Wisneuro has some valid points about why a prescribing psychologist would have to attain a higher bar than other prescribers and to pose the question of what would be adequate training. I can't tell if you (freemontie and cgopsych) think RxP is a bad idea regardless of how it is constructed or if you think the training requirements need to be improved from what is being proposed in states. Two very different arguments. You also seem to conflate players on here who are thinking about these issues with other people who are proponents.

 

[PikminOC]

Are you being serious? Translating the unnecessary academic journal language (we can easily translate it- but we find it pompous and annoying)- are you now arguing that RxP is a beter training "modality" then LCME medical school and ACGME psychiatry residency? p.s. you are somewhat misusing the word "model" (though I'm guessing you just want to sound "fancy")

That is exactly what they are saying. I have talked to some of the psychologists in IL regarding their thoughts on the legislation. They don't think psychiatrists are good enough. They have come up with "psychopharmacologists" who should be teaching it and are using this terminology. One of the "psychopharmacologists" I know who is teaching this is a psychiatrist with a major substance abuse history who has board action. But hey, he's a psychopharmacologist!

 

[PikminOC]

Such wanton anger and misinterpretation. Where did I argue that it is a "better" training model? And since when is using the word model "fancy?" Also, we should use more "air quotes." Now that's "fancy."

As for the turf war, continue with your faux outrage and disgust. It's a part of the equation and you very well know it.

So why not have social workers undergo the RxP training? There's no evidence they can't do it or are unsafe practitioners..

 

[PikminOC]

Where is the data on this quality of training and scientific standards, again?

Why don't you show us the evidence? The Hawaii DOD has data out there. And that is a well integrated area, not like the psyd who want to set up PP as soon as they are done with training....

 

[PikminOC]

The PEP exam sample questions are verbatim out of the psychiatry board exam prep materials....

That should tell you about the content of the exam.

But hey, it must be just an easy made up test.

So memorize answers to a test. A high school student can do that.
Doesn't make them competent.

 

[Therapist4Chnge]

So memorize answers to a test. A high school student can do that.
Doesn't make them competent.

Is that how they teach physicians to pass a test?

Sadly, in many cases that is exactly what happens. Applied and working knowledge of a subject is where the rubber hits the road, and that should probably be the bigger focus.

 

[PikminOC]

Is that how they teach physicians to pass a test?

Not at all.
You are welcome to go to medical school.
No one is stopping you.

 

[CGOPsych]

So why not have social workers undergo the RxP training? There's no evidence they can't do it or are unsafe practitioners..

This is another issue that the RxPers don't want to talk about. Social workers are licensed to practice psychotherapy. And since prescribing drugs is so easy that you can learn everything you need to know with 8.8 internet courses, it shouldn't be any more of a problem for them to. And why not licensed counselors and school psychologists?

 

[WisNeuro]

Why don't you show us the evidence? The Hawaii DOD has data out there. And that is a well integrated area, not like the psyd who want to set up PP as soon as they are done with training....

I'm just commenting on the fact that if opponents to the notion of RxP want to require "data" about safety and efficacy that they claim is only attainable if one goes through the equivalent of med school training, they should have some data to back that up. Otherwise, it's all arbitrary. If there is no objective standard available in the first place for those who prescribe, how can you mandate if for others? This should be data that a field should have regardless of the RxP issue. Why are people so against accountability in their own fields?

 

[freemontie]

These last few posts are a bit over the top. Wisneuro has some valid points about why a prescribing psychologist would have to attain a higher bar than other prescribers and to pose the question of what would be adequate training. I can't tell if you (freemontie and cgopsych) think RxP is a bad idea regardless of how it is constructed or if you think the training requirements need to be improved from what is being proposed in states. Two very different arguments. You also seem to conflate players on here who are thinking about these issues with other people who are proponents.

Let's not kid ourselves. You, Wisneuro and others are far from unbiased players who are simply "thinking about these issues." If left unchecked, you'd still be patting yourselves on the back over RxP's "x hours of training" "national board exam" "years under a physician" "training modality" or other duplicitous qualifications. The image that comes to mind is makeup artists for a farm pig.

You asked me if I'm against RxP regardless of how its constructed. Yes and no. Yes, because the very existence of it is an attempt to shortcut medical education/training for the political/monetary benefit of the practitioners who create it and ardently fight in congress for it. If RxP were a track of PA school and training, then would there be any impetus for it to exist?

 

[Therapist4Chnge]

I'm just commenting on the fact that if opponents to the notion of RxP want to require "data" about safety and efficacy that they claim is only attainable if one goes through the equivalent of med school training, they should have some data to back that up. Otherwise, it's all arbitrary. If there is no objective standard available in the first place for those who prescribe, how can you mandate if for others? This should be data that a field should have regardless of the RxP issue. Why are people so against accountability in their own fields?

They tried the same approach with NPs….*rabble rabble patients will die! rabble rabble*.

The data isn't there, at least none that I've seen.

 

[PikminOC]

I'm just commenting on the fact that if opponents to the notion of RxP want to require "data" about safety and efficacy that they claim is only attainable if one goes through the equivalent of med school training, they should have some data to back that up. Otherwise, it's all arbitrary. If there is no objective standard available in the first place for those who prescribe, how can you mandate if for others? This should be data that a field should have regardless of the RxP issue. Why are people so against accountability in their own fields?

See the Hawaii DOD information re: psychologists prescribing.
There is a reason this bill has failed there numerous times.

 

[freemontie]

In the spirit of just "thinking about the issues," why do you (proponents of RxP) think there aren't many studies in medicine generally to suss out what further education/training shortcuts can be "OK"? Why don't we have post-college "surgeon school" to teach just procedural surgeries? Or "radiology school" to teach just medical imaging interpretation? The answer is obvious but I look forward to RxP's interpretation- I'm guessing something about "turf."

And therapist4change, have every RxPers' patient be re-evaluated by a proper medical practicioner. Hiding behind sub-clinical results, excessive physician consults and tiny sample sizes will prove nothing. If they think they can practice medicine safely APART from the existing medical community- then it is on them to prove it.

 

[CGOPsych]

See the Hawaii DOD information re: psychologists prescribing.
There is a reason this bill has failed there numerous times.

RxP bills have failed 36 times in Hawaii, and there are two more bills looking to go to the fail column when the legislature adjourns on June 7.

 

[PikminOC]

With NP/PA the collaborating doc takes the hit.
The same with Rxp.

 

[WisNeuro]

See the Hawaii DOD information re: psychologists prescribing.
There is a reason this bill has failed there numerous times.

I've read the original DoD report. How does that relate to my original point of no set guidelines established for efficacy/safety?

 

[freemontie]

They tried the same approach with NPs….*rabble rabble patients will die! rabble rabble*.

The data isn't there, at least none that I've seen.

There is data that NPs use more resources (ordering tests and asking for physician consults), over-prescribe, and have higher misdiagnosis rates in controlled experiments (of the top of my head there was one about otitis media- simple ear infection. You'd expect almost anybody to be able to diagnose it, but the misdiagnosis rate was higher nevertheless) But you're right that there are no real-world studies. We can't exactly let patients suffer to prove a point. And the minority of NPs who are both in states that have independent NP practice rights, and really function solo, aren't forthcoming with their documented failures, nor should they be (from a medicolegal standpoint).

And anyway, I'd like to point out that RxP as it stands isn't even comparable to NPs yet. So I don't know why we're even talking about that. And, like I said, it is up to RxPers to prove their "modality" is good enough as compared to the education/training LCME/ACGME has created as the standard in America. Not the other way around.

 

[WisNeuro]

And anyway, I'd like to point out that RxP as it stands isn't even comparable to NPs yet. So I don't know why we're even talking about that. And, like I said, it is up to RxPers to prove their "modality" is just as good as the education/training LCME/ACGME has created as the standard in America. Not the other way around.

The problem with that is, opponents will use that as a moving target. Advocates can point at the DoD data, and lack of reported adverse events in LA and NM as evidence. Opponents have already disregarded those as sources of information. So, Advocates may ask, if that is not good evidence, what would constitute adequate evidence? What was used as adequate evidence for other prescribers? Without having some operationalized target, you will just keep moving the bar, regardless of what people give you as data. I doubt this data existed for other prescribers (NPs, PA's, optometrists), yet I don't see active efforts to take away their prescriptive authority. Which is why I return to the turf war. That turf has already been lost, so protect what turf you have left. As long as you insist on different rules for different parties, I don't see how people cannot see it this way.

 

[freemontie]

The problem with that is, opponents will use that as a moving target. Advocates can point at the DoD data, and lack of reported adverse events in LA and NM as evidence. Opponents have already disregarded those as sources of information. So, Advocates may ask, if that is not good evidence, what would constitute adequate evidence? What was used as adequate evidence for other prescribers? Without having some operationalized target, you will just keep moving the bar, regardless of what people give you as data. I doubt this data existed for other prescribers (NPs, PA's, optometrists), yet I don't see active efforts to take away their prescriptive authority. Which is why I return to the turf war. That turf has already been lost, so protect what turf you have left. As long as you insist on different rules for different parties, I don't see how people cannot see it this way.

First, stop with the DoD report. Throw that out of your argument once and for all because most prospective psychologist prescribers aren't going to be treating young healthy soldiers with MD consults close by. As far as simply "a lack of reported adverse events" in LA and NM- (A) you don't know that and (B) it's completely meaningless as evidence of anything given sub-clinical effects and medicolegal barriers. Actually- I bet I can find anecdotal evidence against them (LA/NM RxPers) fairly easily, despite their small sample size.

Anycase, to answer your question- I don't know what "good enough" would look like in terms of numbers. I'm not even sure if its possible- it would have to be a huge controlled study, and repeated. I agree that we are going by intuition that medical education/training lower than even existing mid-levels is not safe or well-intentioned. And I agree that nobody but RxPers themselves are going to have any interest in doing it e.g. "Let's try to suss out the very minimum amount of education/training I need to probably not pose a danger while making more money ASAP." So I agree you have your work cut out for you, but I'm not exactly sympathetic.

 

[WisNeuro]

Anycase, to answer your question- I don't know what "good enough" would look like in terms of numbers. I'm not even sure if its possible- it would have to be a huge controlled study, and repeated. I agree that we are going by intuition that medical education/training lower than even existing mid-levels is not safe or well-intentioned. And I agree that nobody but RxPers themselves are going to have any interest in doing it e.g. "Let's try to suss out the very minimum amount of education/training I need to probably not pose a danger while making more money ASAP." So I agree you have your work cut out for you, but I'm not exactly sympathetic.

Well, as long as we are in agreement that there is a double standard here, and that the opposed side is not basing their argument on any actual data, we finally agree on something

 

[freemontie]

Well, as long as we are in agreement that there is a double standard here, and that the opposed side is not basing their argument on any actual data, we finally agree on something

Yes, but I disagree with your claim of a "double standard". Since RxP is well below existing midlevels in education/training, you can't fairly compare it to that. And besides, the jury for them (NPs) is still out as well as they fight for independent practice rights and the right to prescribe some controlled substances like painkillers in certain states. To date, only 18 states allow them to be reasonably independent- and they are mostly low-population states.

 

[WisNeuro]

How can it not be a double standard? You are saying that RxP has to demonstrate something that no other prescriber has had to do? It's a "you have to prove that you can do this, and just assume that we can just fine, because it's always been this way, so there." And, this is done in an arbitrary way, there is no established standard of training to prove competence/efficacy/safety, etc. Without any sort of data driven guideline, you've set up an impossible task. A bar which can move at a whim.

 

[smalltownpsych]

Let's not kid ourselves. You, Wisneuro and others are far from unbiased players who are simply "thinking about these issues." If left unchecked, you'd still be patting yourselves on the back over RxP's "x hours of training" "national board exam" "years under a physician" "training modality" or other duplicitous qualifications. The image that comes to mind is makeup artists for a farm pig.

You asked me if I'm against RxP regardless of how its constructed. Yes and no. Yes, because the very existence of it is an attempt to shortcut medical education/training for the political/monetary benefit of the practitioners who create it and ardently fight in congress for it. If RxP were a track of PA school and training, then would there be any impetus for it to exist?

First off, I am not a proponent of RxP. I have serious concerns about how this would affect the practice of psychology and the care of my patients. You are completely misconstruing my position on this. I do know that my community has not been able to recruit a psychiatrist in the past two years and that our NP has an extremely simplistic layman's understanding of mental illness. As far as her medical knowledge goes, I have no idea and leave that up to the many family docs, IM docs, and EM docs who are here to backstop the medical. The community mental health NP is the other prescriber of psychotropics in our community and I have limited knowledge of her level of ability. I am not sure what the solution is and am open to the possibility of psychologists being in that role. I know that I can't and don't want to advise the medical doctors which medications they can prescribe and they ask me all the time because they recognize my level of knowledge of mental health issues and psychotropic medications. So I guess you are right that I am not unbiased as I clearly have a vested interest in resolving this dilemma for my patients and the medical providers who are consulting me.

 

[CGOPsych]

The DoD demonstration project is an inappropriate comparison. True, they only treated people 18-65 who did not have serious mental or medical illnesses, and in medical center contexts, surrounded by opportunities for consults that were free. The 10 carefully selected participants were trained in a university setting, essentially 1-2 years of medical school. At the end, the report on the project said that "virtually all" of the 10 agreed that a short-cut civilian version (just as RxP is now) would be "ill-advised."

It is remarkable that RxP advocates say there have been no adverse events reported by RxPers' prescribing. Adverse events occur all the time. Thus, on its face this is false or misleading.

Of course safety and efficacy can be studied. Those are outcome studies. The participants of the DoD demonstration project were studied by an outside organization, the American College of Neuropsychopharmacology. Such a study could be conducted for these persons. It would be easy to study if RxPers' patients have more adverse events requiring additional treatment (e.g., ER visits) than other prescribers.

Furthermore, appropriateness of education can be reviewed by experts in that field. APA has not sought any such review.

RxPers can be tested on their knowledge of prescribing in ways that can easily be compared to those in other professions.

Agreed, freemontie, that the necessity of establishing safety and efficacy is significant because the RxP model is such a drastic reduction in what has been accepted as minimally appropriate. Again, we're talking about the difference between 8.8 courses on the internet with somewhat dubious conditions such as open-book tests that can be easily cribbed, with the IL-physician assistant model that requires 28 courses in an independently accredited program. Also, the APA-RxP model calls for a practicum supervised by another psychologist in a private office, writing scripts for 100 patients. The IL-PA model calls for a 14-month full-time practicum consisting of medical setting rotations. Huge difference.

Then there are major concerns about the practice conditions of RxPers, already noted above.

Therefore, it is incumbent on the RxPers proposing such a massive downgrade in quality and quantity to show that this is appropriate. Instead, no such data are gathered, no such reviews have been passed. RxP has been successful only because of the massive amount of money poured into the political process in two states early in the campaign before opponents could understand and formulate a response to such an onslaught of political capital.

 

[freemontie]

How can it not be a double standard? You are saying that RxP has to demonstrate something that no other prescriber has had to do? It's a "you have to prove that you can do this, and just assume that we can just fine, because it's always been this way, so there." And, this is done in an arbitrary way, there is no established standard of training to prove competence/efficacy/safety, etc. Without any sort of data driven guideline, you've set up an impossible task. A bar which can move at a whim.

My understanding of a double standard is applying a different set of principles to two SIMILAR situations. If RxP approximated other mid-level programs in education/training and the public demanded RxP to prove their worth more so than the other mid-levels- then that would be a double standard. As it stands RxP is not similar to existing midlevels, not even close.

 

[WisNeuro]

My understanding of a double standard is applying a different set of principles for two SIMILAR situations. If RxP approximated other mid-level programs in education/training and the public demanded RxP to prove their worth more so than the other mid-levels- then that would be a double standard. As it stands RxP is not similar to existing midlevels, not even close.

You failing to acknowledge the similarity is all based on opinion. Once again, you are establishing a precedent built on arbitrary standards. While, I will agree that some proposals for RxP are lacking, I feel that opponents will not accept anything short of PA or NP training, which is arbitrary and could also be argued that these are not similar situations (e.g., treating a wide variety of medical conditions vs. treating only psychological). These are all emotion based arguments. There is a lot of rhetoric about lack of data and dismissing what is there, but the opposing side is only countering with rhetoric and 0 data of its own, trying to build false equivalencies.

I will remind once again, that this point stands for the notion of RxP, not the proposals that are out there at the moment (some of which I would not support as they stand).

 

[smalltownpsych]

My understanding of a double standard is applying a different set of principles for two SIMILAR situations. If RxP approximated other mid-level programs in education/training and the public demanded RxP to prove their worth more so than the other mid-levels- then that would be a double standard. As it stands RxP is not similar to existing midlevels, not even close.

That is true. It isn't even close. The existing midlevels don't know much about psychopathology or treatment at all. They seem awfully susceptible to sales pitches from pharmaceuticals as they don't understand research data very well either.

 

[smalltownpsych]

...and their knowledge of legal and ethical issues in mental health is abysmal, but I guess none of that has to do with prescribing psychotropics.

 

[freemontie]

You failing to acknowledge the similarity is all based on opinion. Once again, you are establishing a precedent built on arbitrary standards. While, I will agree that some proposals for RxP are lacking, I feel that opponents will not accept anything short of PA or NP training, which is arbitrary and could also be argued that these are not similar situations (e.g., treating a wide variety of medical conditions vs. treating only psychological). These are all emotion based arguments. There is a lot of rhetoric about lack of data and dismissing what is there, but the opposing side is only countering with rhetoric and 0 data of its own, trying to build false equivalencies.

I will remind once again, that this point stands for the notion of RxP, not the proposals that are out there at the moment (some of which I would not support as they stand).

The dissimilarity isn't opinion- it's based on the specifics of education/training formally required of RxP vs. other midlevels. We've gone from comparing it to physicians to mid-levels that themselves are still suspect as evidenced by lack of universal independent practice rights or prescription privileges of certain controlled substances.

Funny story: I once taught an undergraduate chemistry lab (TA). At the beginning of the semester I told them that I would bump a 3.49 to an A (usually 3.5+ is an A). At the end, a student with a 3.48 came to me with much of the same argument. Yes, it's less than a 3.49, but that's just an arbitrary standard I created, isn't it? In the end, I gave it to him because withholding an "A" is not a big priority for me. In this case though, the stakes are much higher and to extend the analogy- RxP is coming to lawmakers with a dressed-up 2.0 asking for the "A."

 

[freemontie]

That is true. It isn't even close. The existing midlevels don't know much about psychopathology or treatment at all. They seem awfully susceptible to sales pitches from pharmaceuticals as they don't understand research data very well either.

I don't know what to tell you. If you think PMHNP (Psych NPs)'s psychology or psychotropics knowledge is deficient then advocate to stop NPs from increasing their practice rights further or otherwise increase their education/training. But if you're attacking them as an argument to give yourself what would effectively be a full medical license, then you should stop as it's unconvincing.

 

[WisNeuro]

Many would argue for the similarities of some of the proposed training models, but still not the issue I was talking about. Anecdotes and analogies are great, but they still don't mask the lack of data or acceptable level of evidence for any provider, long established, or newer. As long as we're using partially relevant analogies, no one can win at the game you propose if you never tell them what the rules are, or how they can score, at the same time not explaining how your own points got on the scoreboard.

 

[freemontie]

Many would argue for the similarities of some of the proposed training models, but still not the issue I was talking about. Anecdotes and analogies are great, but they still don't mask the lack of data or acceptable level of evidence for any provider, long established, or newer. As long as we're using partially relevant analogies, no one can win at the game you propose if you never tell them what the rules are, or how they can score, at the same time not explaining how your own points got on the scoreboard.

The rules are very clear- they are the specifics of medical school or midlevel school (if you want to practice as a midlevel). A more apt analogy is you're trying to change the rules by arguing that something that's much less might be good enough. (Also its not a "game." I wouldn't use that in my analogy.)

 

[freemontie]

First off, I am not a proponent of RxP. I have serious concerns about how this would affect the practice of psychology and the care of my patients. You are completely misconstruing my position on this. I do know that my community has not been able to recruit a psychiatrist in the past two years and that our NP has an extremely simplistic layman's understanding of mental illness. As far as her medical knowledge goes, I have no idea and leave that up to the many family docs, IM docs, and EM docs who are here to backstop the medical. The community mental health NP is the other prescriber of psychotropics in our community and I have limited knowledge of her level of ability. I am not sure what the solution is and am open to the possibility of psychologists being in that role. I know that I can't and don't want to advise the medical doctors which medications they can prescribe and they ask me all the time because they recognize my level of knowledge of mental health issues and psychotropic medications. So I guess you are right that I am not unbiased as I clearly have a vested interest in resolving this dilemma for my patients and the medical providers who are consulting me.

I sympathsize with the issue of increasing medical care in rural areas. But the fact that a family medicine physician asks for your opinion on psychology or what you've witnessed of various psych drugs- is not enough of a rationale to confer a medical license to you after very minimal formal medical training/education. And it's not like we can pass a law that only applies to you and other psychologists on a case by case basis either.

 

[Therapist4Chnge]

The rules are very clear- they are the specifics of medical school or midlevel school (if you want to practice as a midlevel). A more apt analogy is you're trying to change the rules by arguing that something that's much less might be good enough. (Also its not a "game." I wouldn't use that in my analogy.)

The current paths for prescribing: medical school, PA, NP, dentists et al., and post-doc psych RxP'ers in certain states/areas. Ok, so of those MD/DO and some NPs have independent Rx. Then the limited formularies and/or collaborative setup is PA, NP, and psych RxPer's. How does this "change the rules" to want additional states have a collaborative setup? How are the LA or NM models a "change" in the rules from what is current existing? It's not. These are all paths that current exist, so there is no "new" path or "change".

Let's consult the mounds of data showing that MD Rx'ing is the ONLY safe way to train and RxP safely. Oh wait, that data doesn't exist. The best I've seen are some studies that look at outcomes of MD/DOs and NPs…and from what I recall it was a wash. Okay, so what other data are out there? Well…DoD was one source, albeit not a great fit for what is "typical". Okay, what else is out there. Let's look at LA and NM. There isn't much there either that looks specifically at prescribing. So do we look at anecdotal data or are there other options?

One way medical systems evaluate the safety of a procedure/program/intervention in their system is to measure how many adverse outcomes per 100 (or 1000) cases. If someone were to believe the (unsubstantiated) claims of anti-psych RxP you'd think that there would be piles of dead bodies everywhere or at least lawsuits for adverse outcomes from all of the medication mismanagement. So….where are they? Tens (hundreds?) of thousands of prescriptions written and….? You'd think that if the training were so inadequate that there would be reports of problem, no?

 

[CGOPsych]

I sympathsize with the issue of increasing medical care in rural areas. But the fact that a family medicine physician asks for your opinion on psychology or what you've witnessed of various psych drugs- is not enough of a rationale to confer a medical license to you after very minimal formal medical training/education. And it's not like we can pass a law that only applies to you and other psychologists on a case by case basis either.

Also, the claim that RxP would enhance access to psychoactive medications in rural areas is not supported by the data. For example, in Illinois, the Baird study found this argument to be hollow because there are virtually no psychologists in the state's rural areas.
An examination of where the RxPers practice in LA and NM (according to office addresses on file with the psychology board) found that, like almost all other professionals, they work where there are the most people.

 

[Therapist4Chnge]

Ok…access to care.

You will always find more clinicians in big cities v. rural areas, that is well known and holds true for almost every specialty area. The thing about "access to care" it isn't just about geographic coverage but it is also about how many patients can be seen. Can more patients be seen if the # of prescribers increased?

 

[CGOPsych]

Ok…access to care.

You will always find more clinicians in big cities v. rural areas, that is well known and holds true for almost every specialty area. The thing about "access to care" it isn't just about geographic coverage but it is also about how many patients can be seen. Can more patients be seen if the # of prescribers increased?

Well, I guess you are conceding that the rural access claim is indeed phony.

As for rural access, the far more appropriate alternative is telepsychiatry, so that far-better trained psychiatrists can cover broad areas. The VA and the Bureau of Prisons are using it a lot. A couple of psychiatrists are covering large swaths of western Nebraska. No need to let internet-trained part-timers prescribe drugs.

 

[Therapist4Chnge]

Well, I guess you are conceding that the rural access claim is indeed phony.

Having more prescribers CAN provide rural access to care, the person would just need to travel….like they do to see their CV surgeon, oncologist, etc. As a neuropsychologist I have people travel from around the state and the surrounding 3-4 states to see me. Is that ideal…no, but I can still provide them a serve that they wouldn't otherwise have had access to in their small town. I consulted with a rural hospital that imports specialists on different days so the "locals" can be seen. Mondays are for diabetes-related cases, Tuesdays are for psychiatric cases, Wednesdays are for phys rehab cases, etc. My colleague covers their clinic one day a week and does eval and consultation because there are literally no other providers within 30+ mi for any kind of psychotherapy and 75-100+ for a neuropsychologist (who already has a 2-6+ mon waitlist).

As for rural access, the far more appropriate alternative is telepsychiatry, so that far-better trained psychiatrists can cover broad areas. The VA and the Bureau of Prisons are using it a lot. A couple of psychiatrists are covering large swaths of western Nebraska. No need to let internet-trained part-timers prescribe drugs.

Telehealth…that is one option. Will I concede "far better trained psychiatrists"….no, not based on what I've experienced in 4 different hospital systems across 4 different states. I've worked with some excellent psychiatrists, but I've also worked with psychiatrists who I wouldn't wish upon an enemy. I previously worked with a psychiatrist who was a surgeon in their country and they became a psychiatrist because they didn't match into any surgery residencies and had psychiatry as their backup. Is that a "far better trained" prescriber than a psychologist who went through 4yr undergrad psych, 4-6yr of grad school, fellowship….THEN a MS, more supervision, and then collaborates w. a physician?

 

[freemontie]

The current paths for prescribing: medical school, PA, NP, dentists et al., and post-doc psych RxP'ers in certain states/areas. Ok, so of those MD/DO and some NPs have independent Rx. Then the limited formularies and/or collaborative setup is PA, NP, and psych RxPer's. How does this "change the rules" to want additional states have a collaborative setup? How are the LA or NM models a "change" in the rules from what is current existing? It's not. These are all paths that current exist, so there is no "new" path or "change".

Let's consult the mounds of data showing that MD Rx'ing is the ONLY safe way to train and RxP safely. Oh wait, that data doesn't exist. The best I've seen are some studies that look at outcomes of MD/DOs and NPs…and from what I recall it was a wash. Okay, so what other data are out there? Well…DoD was one source, albeit not a great fit for what is "typical". Okay, what else is out there. Let's look at LA and NM. There isn't much there either that looks specifically at prescribing. So do we look at anecdotal data or are there other options?

One way medical systems evaluate the safety of a procedure/program/intervention in their system is to measure how many adverse outcomes per 100 (or 1000) cases. If someone were to believe the (unsubstantiated) claims of anti-psych RxP you'd think that there would be piles of dead bodies everywhere or at least lawsuits for adverse outcomes from all of the medication mismanagement. So….where are they? Tens (hundreds?) of thousands of prescriptions written and….? You'd think that if the training were so inadequate that there would be reports of problem, no?

Like I said- get RxPers to open up to close scrutiny by the medical community (not to just the APA). I believe you will find a difference in outcomes, most will be sub-clinical but some would be more dire. My prediction is it would be especially bad in terms of delayed diagnosis and resulting delayed appropriate medical care. Right now, nobody is accurately measuring adverse outcomes in RxP and you're taking that to mean it doesn't exist. Likewise, psychiatry has among the lowest malpractice rates because the bad outcomes there are largely sub-clinical and the litigation that happens isn't advertised on banners.

 

[freemontie]

I love it- you guys know bad Psych NPs AND bad psychiatrists. I'm convinced!

But to be more serious- that's why education/training has to be at a level higher than the conclusive minimum that Wisneuro is trying to find. A practicioner's competency in any field is going to be on a normal distribution- there are going to be a few that are relatively disastrous. Can RxPers guarantee that there won't be an opportunist slacker who cheated through a completely noncompetitive online RxP program and had an uneducational paper-pushing experience via an opportunist private practice psychiatrist? Because that BE/BC psychiatrist went through a higher minimum- meaning the disastrous people from that training/education can be bad- but nowhere near as bad.

 

[freemontie]

Ok…access to care.

You will always find more clinicians in big cities v. rural areas, that is well known and holds true for almost every specialty area. The thing about "access to care" it isn't just about geographic coverage but it is also about how many patients can be seen. Can more patients be seen if the # of prescribers increased?

Yes. More patients can be "seen" if the # of prescribers is increased. But they would not be "seen" in a way that is beneficial to anyone but the RxPer. You're not going to be treating difficult psychosomatic cases (Edit: I meant consult-liason cases more generally, or cases difficult for requiring interface between medicine and psych) after RxP training. The more likely scenario is a xanax pill mill for stressed out well-to-do suburban moms, for example. God forbid an RxPer actually practices in a rural area where patients are even more likely to present their related non-psych medical illnesses to the only "doctor" they see.

 

[Therapist4Chnge]

Yes. More patients can be "seen" if the # of prescribers is increased. But they would not be "seen" in a way that is beneficial to anyone but the RxPer.

So...seeing MORE patients is across the board is not beneficial because....? The wait lists for a psychiatric NP or psychiatrist are often 3-6+ mon, so...,it would not be beneficial to the patient to see a prescribing psychologist sooner?

You're not going to be treating difficult psychosomatic cases after RxP training.

Why do you make that assumption? If anything I think it is BETTER for them to see a prescribing psychologist bc we are often the experts for those kinds of cases. We regularly get them on my unit (neuro/rehab, not psych) and I can work w them in conjunction w a physiatrist/PT/OT/SLP/etc. sending them to an in-pt psych unit would do...? Or out-pt when they can't get an appt for 3+ months?

The more likely scenario is a xanax pill mill for stressed out well-to-do suburban moms, for example. God forbid an RxPer actually practices in a rural area where patients are even more likely to present their related non-psych medical illnesses to the only "doctor" they see.

How is it "more likely"?

 

[WisNeuro]

The rules are very clear- they are the specifics of medical school or midlevel school (if you want to practice as a midlevel). A more apt analogy is you're trying to change the rules by arguing that something that's much less might be good enough. (Also its not a "game." I wouldn't use that in my analogy.)

I would say requiring an undefined level of evidence of safety/efficacy, without requiring it in any other context makes those rules unclear, at best. Disingenuous, at worst. And, please, healthcare can aptly be described as a game at all levels of the system. We all play it every day. We just hopefully treat a few patients along the way as well. Show me a healthcare system in this country devoid of politic and bureaucracy and maybe I'll change my very appropriate analogy.

 

[WisNeuro]

But to be more serious- that's why education/training has to be at a level higher than the conclusive minimum that Wisneuro is trying to find.

Hyperbole, mis-characterization, and ad hominem are terrible ways to pursue an argument. I'd challenge you to find a place where I argue for the bare minimum. Instead, I believe I've said multiple times that I do not like many of the current RxP proposals. I am more arguing for the concept, and against the opposing view of not maintaining any real standard from which to judge competency/efficacy/whatever you want to call it. I am merely stating that it really doesn't matter what the RxP movement does, they'll never really make the opposition happy, they'll just continue to move the bar to keep it just out of feasible reach with arbitrary standards.

 

[WisNeuro]

How is it "more likely"?

Yeah, I would think that having people who know how to evaluate research would actually make that much less likely, given the lack of effectiveness and growing evidence of long-term side effects.

 

[freemontie]

Hyperbole, mis-characterization, and ad hominem are terrible ways to pursue an argument. I'd challenge you to find a place where I argue for the bare minimum. Instead, I believe I've said multiple times that I do not like many of the current RxP proposals. I am more arguing for the concept, and against the opposing view of not maintaining any real standard from which to judge competency/efficacy/whatever you want to call it. I am merely stating that it really doesn't matter what the RxP movement does, they'll never really make the opposition happy, they'll just continue to move the bar to keep it just out of feasible reach with arbitrary standards.

No, that's a very accurate characterization. Were you not stating that the accepted education/training requirements were "abritrary"? Were you not looking to find the minimum? Also, you keep talking about "moving the bar." What bar? You make it sound like RxP at one point satisfied some minimum standards set by the medical community. There is no "moving bar" other than where you want to move it (far downwards)- the standards for what is acceptable for mid-level and physician-level have been static for some time now.

 

[freemontie]

So...seeing MORE patients is across the board is not beneficial because....? The wait lists for a psychiatric NP or psychiatrist are often 3-6+ mon, so...,it would not be beneficial to the patient to see a prescribing psychologist sooner?



Why do you make that assumption? If anything I think it is BETTER for them to see a prescribing psychologist bc we are often the experts for those kinds of cases. We regularly get them on my unit (neuro/rehab, not psych) and I can work w them in conjunction w a physiatrist/PT/OT/SLP/etc. sending them to an in-pt psych unit would do...? Or out-pt when they can't get an appt for 3+ months?


How is it "more likely"?

If the only measurement of what is better is how many patients can be "seen" then you would be right. I disagree. If I agreed with you I would take it further and allow social workers, RNs and others to prescribe after RxP "training."

And I make that assumption (pill mill) because I believe there is a strong correlation between low training/education standards and professional abuse. (I believe that is one of the main reasons we don't allow NPs to prescribe certain pain killers.)

Also consider that most RxPers aren't going to be neuropsychologists in academic hospitals so your experiences are irrelevant. We should only consider the formal requirements of RxP- not what one person (you) have learned or done.