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Psychopharmacology/Advanced Practice Psychology

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by 50960, Dec 6, 2005.

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  1. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    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?
     
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  3. CGOPsych

    CGOPsych 5+ Year Member

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    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.
     
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  4. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    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?
     
  5. CGOPsych

    CGOPsych 5+ Year Member

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    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.
     
  6. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    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).

    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?
     
  7. freemontie

    freemontie Banned Banned

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    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.
     
    Last edited: Apr 28, 2015
  8. freemontie

    freemontie Banned Banned

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    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.
     
    Last edited: Apr 28, 2015
  9. freemontie

    freemontie Banned Banned

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    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.
     
    Last edited: Apr 29, 2015
  10. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    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"?
     
  11. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    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.
     
  12. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    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.
     
  13. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    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.
     
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  14. freemontie

    freemontie Banned Banned

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    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.
     
  15. freemontie

    freemontie Banned Banned

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    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.
     
    Last edited: Apr 28, 2015
  16. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    I did say that they were somewhat arbitrary, due to a lack of data that is now being requested. I think that having that data is actually a good thing. It should be required across disciplines, be it MD, NP, PA, RxP, etc. There's nothing wrong with evidence based medicine, I advocate for it daily in my practice. But, I don't think groups can demand it from others, yet claim that they are exempt from it. But, if it pleases you, keep beating that "minimum standard" strawman. He's looking a little thin though, you should add some more straw.
     
  17. freemontie

    freemontie Banned Banned

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    I don't understand. You don't want to find what the minimum is but you do think we should test to see if standards lower than mid-levels is OK? I don't think there is much room for disagreement here other than the fact that you don't like the fair characterization of "trying to find the minimum." Because I assure you that whatever this theoretical minimum is- it would be higher than RxP in it's current form. And like I said before, I don't think there is anything unfair of wanting a new much lower standard to prove its efficacy and, more importantly, safety. If RxP wasn't so wanting (e.g. if it was a track of PA school and they weren't seeking independent practice rights) then maybe there wouldn't be as much of a clamor for it.
     
  18. freemontie

    freemontie Banned Banned

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    Maybe if clinical practice was mostly about evaluating research. o_O
    Honestly I'm amazed that despite being psychologists some of you overestimate your ability to safely practice outside of your training or with only little add-on training. You overestimate the value of your psychology training and underestimate medical training.
     
  19. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    I'm saying that there needs to be some way of evaluating efficacy competency in this area other than "the way we do it now is the way that works, because.....just because." These ways of evaluation and evidence based medicine could be very important to the field of mental health as a whole. Maybe there are much more efficient and safe ways to deliver psychopharmacological services than what we already utilize. Maybe we can improve the way we train current providers (e.g., training them to evaluate pharma research) that can improve the way that they prescribe. Clinical practice should definitely involve knowing how to evaluate research. Look at the money spent doing things like prescribing aricpet and like drugs for MCI. Guess what the overwhelming consensus about that is according to the research? It's sad to see providers across a range of fields deride EBM for tradition and arbitrary dogma.
     
  20. freemontie

    freemontie Banned Banned

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    You don't think academic psychiatry is evidence-based and evolving? A psychology PhD can be great research training, but I don't think psychiatry departments need non-medical practitioners to come in and teach them evidence based medicine. Some of what you said isn't so much from lack of research as it is self-interested behavior; something RxP would only add to.
     
  21. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    I think academic psychiatry is far removed from clinical psychiatry. Just as I think academic (insert field here) is different from clinical (insert field here). It happens across disciplines. And, this rhetoric of "we don't need to prove what we do works, but you do" just adds to this divide. It should be something we strive for, across medical and mental health disciplines. We can just assume that what we are doing in medicine works, because it's the way we've always done it. Or, we can actually examine if there are better ways to do it. Better ways to deliver care. Ways that are both safe, efficacious in terms of functional outcomes, and cost effective. Or, we can stay embroiled in pointless turf warfare.
     
  22. freemontie

    freemontie Banned Banned

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    I'm not against doing research, so you don't have to convince me of that. If you want physicians to prove their efficacy then that is beyond fair. Though from my understanding its already a common topic in psychiatry especially.
    Now if you want to question physicians' efficacy/safety in comparison to RxP- then that is also fair but a little silly. One is the pinnacle of its' medical area and evolved over decades to have a precise and comprehensive body of knowledge and very closely regulated training and the other is a relatively short online program with less-regulated physician shadowing as it's main clinical training.

    EDIT: But I think the continued "turf war" comments should stop since there is no evidence of it. The only way I could definitively buy that is if RxP approximated the duration and rigor of med shcool/psychiatry residency and they still didn't want you to practice.
     
    Last edited: Apr 28, 2015
  23. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    This is exactly the problem. This statement has no objective basis, yet it has been stated over and over again in this argument.

    As far as the turf war comments. This is a part of most fields of healthcare. Feel free to pretend it doesn't exist all you want, it doesn't change the fact that it's there.
     
  24. freemontie

    freemontie Banned Banned

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    OK, it's the pinnacle in that it has the hardest, longest and most comprehensive training by a significant margin. If you want people to favorably compare RxP to physician training then you're facing an impossible political campaign.
     
  25. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    http://www.tampabay.com/news/educat...lp-for-him-months-before-the-shooting/2207514
    FSU shooter's friends tried to get help for him months before the shooting
    Six months into his job as a prosecutor in the Dona Ana County District Attorney's Office in New Mexico, May couldn't concentrate.
    The 31-year-old had become so distractible, he told his friends, that he had decided to see a psychologist. He emerged from the appointment with prescriptions for an antidepressant and an attention deficit drug, which he took faithfully until, about three weeks later, he suffered a panic attack at work.
    When another attack followed a week later, he returned to his psychologist and had his medication adjusted, said Nixon, a doctor. May was on a combination of Wellbutrin and Vyvanse — drugs that, in rare cases, can cause paranoia.
    By late summer, May had begun acting strangely, his friends said. He was worried his neighbors were watching him. He heard them talking about him through the walls of his apartment.
    It was alarming to his friends, but it was nothing, they said, compared to what was still to come....
    Unsettled now, May's friends contacted his psychologist's office. They said they told her that May was paranoid, that he was hearing voices, and that he had talked about buying a gun and getting even with his neighbors.
    The psychologist made an appointment with May, they said, met with him for about an hour and then declared him to be fine. Nixon and the others were frustrated....
     
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  26. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    So, it's the pinnacle by subjective means? Regardless of whether or not it is necessary or sufficient to meet a certain need (e.g. delivery of psychopharmacological treatment )? I will agree that it is the longest, but that may be where the agreement ends. I can design a program that takes 20 years to complete. Does that make it better? Does that make it the only and best way to have something done?
     
  27. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    They want to show that it is better than physician training.
    In IL, the psychologists were really pissed they couldn't prescribe stimulants. That's what they want to prescribe the most.
     
  28. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Grover, so, if I find one case of psychiatrist misconduct, does it make the whole field obsolete?

    Also, after reading the story, it's not clear that there was misconduct at all in this case. Without reading the details of the case, it's all speculation. Especially when it comes down to statutes of suicidality/homicidality.
     
  29. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    You're a neuropsychologist. You may even be board certified.
    Would you like anyone dumbing down your education?
     
  30. freemontie

    freemontie Banned Banned

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    No, but given the tiny sample size of prescribing psychologists this anecdotal case doesn't bode well. You and others can't declare there are no adverse effects from RxP in NM (as if there was a documented study) and then belittle an example case. Most cases though don't involve high profile actors like the FSU shooter and will thus never come to light by themselves.
     
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  31. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    The Rxp'ers are the ones saying there are no complications with their psychologists prescribing.
    You are not using correct logic regarding the psychiatrist misconduct. I never said psychiatrists don't have misconduct.
     
  32. CGOPsych

    CGOPsych 5+ Year Member

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    RxPers in Illinois and across the country were extremely upset over the IL bill that became law because it makes them get the same training that anyone else would have to get to practice psychiatric medicine. Talk about unfair (excuse the sarcasm).

    To add a little more perspective, the IL RxP campaign was looking at certain, massive defeat for the 15th year. So the highly controversial individual leading the campaign, acting alone, accepted the year-old offer of the medical people, who had said that PA-level training would be acceptable since they accept it as the minimal necessary for prescribing medications, along with medical supervision. The training requirements alone make it highly unlikely that any psychologists will prescribe in Illinois as psychologists. Even if an RxP program can be developed (also very unlikely but possible) then the first one would not be writing scripts for about six years, and that's if they apply themselves to full-time education and practicum training.

    The law specifically prohibits the prescription of benzodiazepines and a list of other drugs. It also limits the patients to be treated by the RxPers to persons 17-65 years old who are not pregnant or have a major medical illness or developmental disorder. So the IL law may become the perfect barrier to RxP, forcing people to actually get a medical education rather than be the 8.8-class internet prescribing wonders they hope to be.
     
  33. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    If someone showed that they could adequately do the job with less training, thereby making it more efficient. I would have no argument.

    First, this seems to be more of a Tarasoff deal rather than mis-management of meds. Additionally, which provider is at fault is difficult to tell from the story. It seems multiple ones are involved, and who knows what information was made available to each. I do not belittle a sample case, I just caution against drawing wild conclusions from it with a dearth of details involved.

    And you are not using correct logic here in making fairly significant circumstantial leaps based on little evidence. Perhaps some negligence happened here, but there is far too little information to make the conclusions that you are making.
     
  34. CGOPsych

    CGOPsych 5+ Year Member

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    Hmm, now wait a minute. Isn't that what we've been saying about RxP? Do I sense a double standard here when it is your area that may be under threat by under-trained wannabes?

    I wonder if you would be thus agree that if weekend-wonder neuropsychologists, getting their education through an internet lecture or by taking a couple of seminars, have not been sued or hit with ethics complaints, that would be acceptable evidence that their training is sufficient to do the work of a board-certified neuropsychologist.
     
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  35. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Well, we have a lot of outcome data to show. So, no, no double standard. I am not claiming that neuropsychologists are exempt from showing that we contribute to certain things (e.g., diagnosis, prognosis, etc). That data exists. Your claim has no standing here.

    Also, the weekend warriors already exist, and we already deal with mid-level providers (SLP, OT) using npsych instruments. There is a reason they are not getting our referrals though, poor quality of reports when they use those things, because they do not know how to interpret them.
     
  36. CGOPsych

    CGOPsych 5+ Year Member

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    So the operational definition of certain neuropsychologists practicing ethically, safely and effectively is that they person have not been sued or had a complained filed against them, regardless of how little training they've had?
     
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  37. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Once again, mis-characterization of statements to try to prove a point. I have offered that up as one point of evidence, I have even said it is not great evidence and more was needed. I then said that current prescribers should be beholden to the same level of evidence that they are demanding, otherwise they are setting up a bar that they themselves have not yet reached.
     
  38. CGOPsych

    CGOPsych 5+ Year Member

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    Translation: You won't answer the question. And I don't blame you. The standards that RxPers want to be judged by are those they would never allow others to use.

    I also don't blame the RxPers who never respond to the analogy of social workers doing the work of psychologist (or better still, neuropsychologists) based on training that almost all of us would consider insultingly insufficient. I imagine many shiver at the thought of SWers calling themselves "Psychological Social Workers" (as opposed to "Medical Psychologists") and practicing all forms of psychology independently under their SW licenses, supervised and licensed by the SW board, educated by SW schools, etc.
     
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  39. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    I did answer the question, you just refuse to acknowledge it to willfully mislead.
     
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  40. wesleysmith

    wesleysmith LLMSW 2+ Year Member

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    ...at least we can all unite in our equal disdain for those offensively undereducated social workers! lol
     
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  41. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    It's ok Wesley, you've still got some time. We don't burn the effigies of social workers until the Summer Solstice.
     
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  42. smalltownpsych

    smalltownpsych 2+ Year Member

    And that my friends is a great example of how to protect your turf. No holds barred, take no prisoners, always attack. MDs are way better at this than us. We play too nicely with others. Of course, collaboration with other professionals is part of our skill set so we don't throw the other people in our field under the bus. That includes all the MDs who prescribe opiates and benzos without any awareness of how dangerous these drugs are to our patients. How many physicianss even know that opiates increase risk for falls in the elderly? Why don't physicians seem to know the difference between dementia and delirium? Why do the LCPCs dig up traumatic experiences in my young patients during "lunch group" at school and then send them back to class in a high state of emotional arousal? The more I think about it the more I think psychologists are the premier profession in mental health and if we spent less time eating our own and more time protecting our turf then our patients lives would be a whole lot better.
     
    Last edited: Apr 29, 2015
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  43. Goobernut

    Goobernut LMSW 5+ Year Member

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    As a side note, LCSWs have approximately the same amount of clock hours/training (hours in a graduate program) in their respective fields as NPs do. Basically the same as any mid-level mental health provider, not just to use the example of the horrible social workers.

    I am not for mental health mid-levels prescribing. I hope others don't misconstrue my point.

    Just like to point out again: online direct entry NP programs exist and result in nurses being able to prescribe within their scope. Yet some of you are referring back to them as a "medical model."
     
  44. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    So if there was negligence, is that a considered negative? Or no?
    And if the article is true, a psychiatrist was left cleaning up the mess in the inpatient hospitalization.
    And once again, the same people who argue about physicians and opioids are the first ones to prescribe stims as if they are candy.
     
  45. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    If there was negligence, yes, it is a negative. But this is a far more complicated case than you would have people believe. Ask any SMI provider what it takes to have someone involuntarily committed.

    Second, do you have any data to back up your gross generalization of one case to an entire field? I'd have to do a power analysis, but a n=1 usually has trouble finding an effect.
     
  46. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    So after the Dod report in Hawaii, why wasn't Hawaii passing the bill to let psychologists prescribe?
     
  47. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    Psychologists say there are NO problems or complications with them prescribing. So ONE is all that is needed to refute it.
    And the psychologist in the case did not find a need to involuntarily commit the patient, per the article.
    Can stimulants cause mania or psychosis? Do you know?
     
  48. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    Lobbying money, political pressure, any number of extraneous factors?

    You are assuming the problem was with med management. Has that been irrefutably proven in this case? And, I imagine that the psychologist had no legal standing to involuntarily commit this person. I imagine you have no real idea on how hard it is to involuntarily commit, especially when you are dealing with hearsay. You should look up some state laws sometimes, it's actually pretty interesting. Yes, stimulants have been proposed to cause psychosis. Do you know the base rates on that? And, does that mean that they should never be prescribed?
     
  49. GroverPsychMD

    GroverPsychMD Gold Donor 7+ Year Member

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    According to the article, he thought the patient was fine. Why are you harping on the involuntarily committing point?
    And when it comes to lobbying money, the Rxpers have a great deal. Look at Illinois and how much they spent there.
     
  50. WisNeuro

    WisNeuro Board Certified Neuropsychologist 7+ Year Member

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    What does "fine" mean? That is the writer's interpretation, I am more curious as to what was in the actual patient notes than hearsay twice removed. I am harping on involuntary commitment here because it appears to be the central issue once you consider the facts presented. It's something I've dealt with several times in different states, so I am somewhat familiar with the laws and statutes.

    And, I never claimed that the lobbying was one-sided.
     
  51. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus 10+ Year Member

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    Political motives/forces…just like EVERY OTHER piece of legislation that needs to pass through the system. Trying to tag the RxP bill as an outlier is disingenuous. Horsetrading is required for even the tiniest bit of legislation to get through, so political capital is needed. Whether or not the sponsor/co-sponsor wants/has this to trade…that is why most legislation passes/fails.

    The legislative process is where sausage is made….the process is messy and what goes in is often quite different than what comes out; welcome to our political system.
     
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