Psycycle

Psychologist, ABPP
10+ Year Member
Jul 9, 2006
540
231
281
Status
Psychologist
So I've been considering going back to school and getting my PA degree, then joining a practice and doing 1/2 therapy 1/2 med management as a longer term career trajectory. I was wondering if anyone might have feedback on if this is a good path to consider? Would like to get away from the turf war, if possible. Obviously I'd be working, in the case of med stuff, under the supervision of a MD or DO.
 

MamaPhD

Psychologist, Academic Medical Center
7+ Year Member
Aug 2, 2010
1,977
1,799
181
Status
Psychologist
So I've been considering going back to school and getting my PA degree, then joining a practice and doing 1/2 therapy 1/2 med management as a longer term career trajectory. I was wondering if anyone might have feedback on if this is a good path to consider? Would like to get away from the turf war, if possible. Obviously I'd be working, in the case of med stuff, under the supervision of a MD or DO.
Well, it sounds good in theory, but is this really a thing? Are there good working models of practicing both as a psychologist and a midlevel in the same position? I'm not saying it can't be done, but it would be an unusual situation and a tricky fit with many practices.
 
  • Like
Reactions: Fan_of_Meehl

Fan_of_Meehl

2+ Year Member
Oct 22, 2014
682
767
81
Status
Psychologist
So I've been considering going back to school and getting my PA degree, then joining a practice and doing 1/2 therapy 1/2 med management as a longer term career trajectory. I was wondering if anyone might have feedback on if this is a good path to consider? Would like to get away from the turf war, if possible. Obviously I'd be working, in the case of med stuff, under the supervision of a MD or DO.
Being in Louisiana, I've (briefly) considered the 'medical psychologist' route. One of the biggest challenges I see for myself would be inhibiting all of those impulses to do in-depth differential diagnostics, cognitive-behavioral case formulation, and cognitive-behavioral interventions that are challenging enough to fit into a 50-55 minute session (and there's no way I could really do any of that in the context of brief med checks). I feel that--in some very real way--I would have to 'kill the old (psychologist) me' and take a completely different approach to interacting with patients.
 

PSYDR

Psychologist
10+ Year Member
Dec 18, 2005
2,605
2,070
281
Status
Being in Louisiana, I've (briefly) considered the 'medical psychologist' route. One of the biggest challenges I see for myself would be inhibiting all of those impulses to do in-depth differential diagnostics, cognitive-behavioral case formulation, and cognitive-behavioral interventions that are challenging enough to fit into a 50-55 minute session (and there's no way I could really do any of that in the context of brief med checks). I feel that--in some very real way--I would have to 'kill the old (psychologist) me' and take a completely different approach to interacting with patients.
I have this fantasy of the old school psychoanalyst who occasionally prescribes something. Don't think it works like that unless you have an established private practice.
 

AcronymAllergy

Neuropsychologist
Moderator
Gold Donor
7+ Year Member
Jan 7, 2010
7,194
1,494
281
Status
Psychologist
Yep, the only folks I know who are actually able to practice that way are in PP. I also wonder about the issues related to practicing at the doctoral/LIP professional in one sense, and in what's technically been considered a mid-level role under the supervision of a physician in another sense.
 

Psycycle

Psychologist, ABPP
10+ Year Member
Jul 9, 2006
540
231
281
Status
Psychologist
Thanks for the feedback. Yeah, I'd want to be in private practice doing this route. I am really drawn to the flexibility of private practice, but I don't want to be doing therapy all day. I like therapy, but I can't fathom 8 hours of it each day. A half day of therapy, half day of meds, some teaching, some research - that sounds far more ideal to me. I also love physical medicine.

What I'm less certain about is whether it would be financially worth it.
 
  • Like
Reactions: Fan_of_Meehl

erg923

Regional Clinical Officer, Centene Corporation
10+ Year Member
Apr 6, 2007
9,734
3,404
281
Louisville, KY
Status
Psychologist
Thanks for the feedback. Yeah, I'd want to be in private practice doing this route. I am really drawn to the flexibility of private practice, but I don't want to be doing therapy all day. I like therapy, but I can't fathom 8 hours of it each day. A half day of therapy, half day of meds, some teaching, some research - that sounds far more ideal to me. I also love physical medicine.

What I'm less certain about is whether it would be financially worth it.
I actually think an MBA would create more financial ROI (its the only degree I would remotely entertain doing 5 years post phd) , but only if you are interested/willing to get out of doing primarily clinical service work.
 
Mar 24, 2014
4,393
3,838
81
Rural Area Medical Facilty
Status
Psychologist
Thanks for the feedback. Yeah, I'd want to be in private practice doing this route. I am really drawn to the flexibility of private practice, but I don't want to be doing therapy all day. I like therapy, but I can't fathom 8 hours of it each day. A half day of therapy, half day of meds, some teaching, some research - that sounds far more ideal to me. I also love physical medicine.

What I'm less certain about is whether it would be financially worth it.
The only thing worse than doing therapy 8 hours a day which is what I do now would be to deal with the patients that the NP who writes the scripts down the hall has to deal with each day. I cringe whenever I get a referral from her because the vast majority of those patients do not really want to or believe that they can get better except through some miracle of medication combinations that is actually making them worse.
I have this fantasy of the old school psychoanalyst who occasionally prescribes something. Don't think it works like that unless you have an established private practice.
If I was ever to prescribe medications, this would be the only way that I could do it. My fear would be that market pressure, social pressure, and patient pressure would override this fantasy and I would end up being another mid level med manager.
 

psych.meout

2+ Year Member
Oct 5, 2015
1,533
882
81
Status
Pre-Psychology
The only thing worse than doing therapy 8 hours a day which is what I do now would be to deal with the patients that the NP who writes the scripts down the hall has to deal with each day. I cringe whenever I get a referral from her because the vast majority of those patients do not really want to or believe that they can get better except through some miracle of medication combinations that is actually making them worse.

If I was ever to prescribe medications, this would be the only way that I could do it. My fear would be that market pressure, social pressure, and patient pressure would override this fantasy and I would end up being another mid level med manager.
Hmm, so you're telling me my options are to work hard at making cognitive, behavioral, social, and emotional changes OR just take some pills and not have to change anything about my lifestyle?
 

medium rare

Psychologist & Psych NP
10+ Year Member
Jan 13, 2009
276
48
261
Status
Psychologist
So I've been considering going back to school and getting my PA degree, then joining a practice and doing 1/2 therapy 1/2 med management as a longer term career trajectory. I was wondering if anyone might have feedback on if this is a good path to consider? Would like to get away from the turf war, if possible. Obviously I'd be working, in the case of med stuff, under the supervision of a MD or DO.
I practice this way every day (as a clinical psychologist and PMHNP) and it works very well for me. I am in full-time private practice and it would be hard to practice in an integrated way working in a CMHC or VA - they would only want me to prescribe. But in private practice, I am able to integrate psychotherapy and medication management seamlessly and it works very well. I see most of my patients for 50 minutes combining therapy and meds and most of my patients seek me out specifically for this reason. I am able to run a very busy and thriving self-pay practice completely free of insurance (and I can't say enough about how enjoyable that part is).

I would encourage you to check into NP training vs PA training as you have considerably more ability to practice autonomously as a NP vs PA, but both models can work - you would just need to have a physician "supervisor" to practice as a PA.
 

Psycycle

Psychologist, ABPP
10+ Year Member
Jul 9, 2006
540
231
281
Status
Psychologist
I practice this way every day (as a clinical psychologist and PMHNP) and it works very well for me. I am in full-time private practice and it would be hard to practice in an integrated way working in a CMHC or VA - they would only want me to prescribe. But in private practice, I am able to integrate psychotherapy and medication management seamlessly and it works very well. I see most of my patients for 50 minutes combining therapy and meds and most of my patients seek me out specifically for this reason. I am able to run a very busy and thriving self-pay practice completely free of insurance (and I can't say enough about how enjoyable that part is).

I would encourage you to check into NP training vs PA training as you have considerably more ability to practice autonomously as a NP vs PA, but both models can work - you would just need to have a physician "supervisor" to practice as a PA.
Thank you for the input! It's hard to weigh out exactly how to do it. PA is 2 years, you're done, but you have to be supervised. In my state, I'd have to get the DPN, and the hardest year to navigate would be the RN training because I wouldn't be able to work.

What you're doing is what I'd like to do - pp with little or no insurance. Do you find that it has been financially worth it? I'd lose at least a year of income, plus the cost of school.
 

medium rare

Psychologist & Psych NP
10+ Year Member
Jan 13, 2009
276
48
261
Status
Psychologist
Thank you for the input! It's hard to weigh out exactly how to do it. PA is 2 years, you're done, but you have to be supervised. In my state, I'd have to get the DPN, and the hardest year to navigate would be the RN training because I wouldn't be able to work.

What you're doing is what I'd like to do - pp with little or no insurance. Do you find that it has been financially worth it? I'd lose at least a year of income, plus the cost of school.
It has been more than worth it financially. My practice is full and I have a waiting/cancellation list for new patients willing to wait to see me (even though I consistently try to refer them if I can't see them in a timely manner). Not taking insurance has not been a problem either. I cannot handle the volume the way it is; if I took insurance it would be entirely overwhelming.

It would more than make up for losing a year of income, IMO. I took a year off as well when I decided to go back to train as a NP. Keep in mind, if you go the PA route, you will have to pay your physician for supervision per your state's requirements and that could easily amount to $1000/month for as little as 2 hours/month of contact.
 

tartar

Postdoctoral Fellow
2+ Year Member
Nov 19, 2015
49
29
61
Status
Post Doc
Hi all! Anyone here know of any decent post-doctoral clinical psychopharmacology M.S. programs?
 

Therapist4Chnge

Neuropsych Ninja Faculty
Moderator Emeritus
10+ Year Member
Oct 7, 2006
21,454
2,415
281
The Beach
Status
Psychologist
New Mexico St is probably the only active program I'd recommend. I know some of their faculty (who are solid) and I think their clinical training is some of the best integrated training available for this type of training. /didn't go there
 
  • Like
Reactions: tartar

tartar

Postdoctoral Fellow
2+ Year Member
Nov 19, 2015
49
29
61
Status
Post Doc
New Mexico St is probably the only active program I'd recommend. I know some of their faculty (who are solid) and I think their clinical training is some of the best integrated training available for this type of training. /didn't go there
Oh great, thank you! I'm still torn between NP, PA and psychopharm MS.
 

Therapist4Chnge

Neuropsych Ninja Faculty
Moderator Emeritus
10+ Year Member
Oct 7, 2006
21,454
2,415
281
The Beach
Status
Psychologist
It depends what you want to *do* in your day to day practice. If you want to solely prescribe, I wouldn't recommend Psych RxP for a number of reasons I've previously written about on here. I'd rec MD/DO >> NP > PA...based on training + autonomy + earning. NP is probably the best bang for your buck, but I think there are weaknesses in the training when it comes to Psych NPs.
 

briarcliff

7+ Year Member
Aug 26, 2011
739
353
181
USA
Status
Psychology Student
anyone know how supervision for RxP works in LA? I was reading the state's law the other day, and I noticed that they used the word "consultation" instead of supervision, which I thought was interesting


Sent from my iPhone using SDN mobile
 

AnnoyedByFreud

10+ Year Member
Mar 26, 2009
566
107
281
Status
Non-Student
It depends what you want to *do* in your day to day practice. If you want to solely prescribe, I wouldn't recommend Psych RxP for a number of reasons I've previously written about on here. I'd rec MD/DO >> NP > PA...based on training + autonomy + earning. NP is probably the best bang for your buck, but I think there are weaknesses in the training when it comes to Psych NPs.
this is perhaps the most vaguely positive thing I've seen you post about NPs... I'll take it.
 

msc545

Clinical Psychologist & Neuropsychologist
Jun 11, 2017
18
9
11
San Francisco
Status
Psychologist
Thanks! I plan on maintaining a connection with medicine even while practicing law, but most likely, I'll go back to internal med. One of my best friends owns a small, urgent care clinic in a pretty swanky neighbourhood not too far from my condo, so once I get established in law, and as long as there are no conflicts of interest, I would most likely augment my income by pulling weekend duties at the clinic. You know, a few ear infections, some allergic conjunctivitis, exacerbations of asthma/COPD, basic wound care, etc. Anything "severe" is referred to a local ER. I miss IM. To be honest, I'm getting burned out with psych.

If I could do it over again, I would have gone to law school after undergrad. I would have gotten my JD, passed the Bar, and then worked for several years. Then I would have gone back for a PhD/PsyD. Psychiatry is mostly...script writing with minimal actual patient counseling/therapy. Even though I'm a physician, I don't believe that every pathology has a biogenic or genetic etiology. Most of my peers, however, are quick to Rx an SSRI or TCA for reactive depression! And patients now expect it. I had a patient today beg me for Paxil/Prozac due to bereavement. Her husband died a week ago and she wants meds. I tried to tell her that her depression is natural, not endogenous...and that with time, her condition will improve. Psychotherapy is the best course of action, if any, in her case, not pharmacological intervention. She was pissed I suggested such a thing and stormed out of my office.

That's what psychiatry has become...at least based on my personal experiences.

Sorry to vent!
Zack

Sorry to hear this, but not surprised. This may very well be a cultural issue. In my travels, I have noted that some patients from some cultures *expect* medicine or an injection and if they don't get it they feel that they have received inadequate treatment. They cannot be talked out of this, so vitamin pills or an injection of saline may actually go a long way toward helping them and maintaining patient rapport.

Also, prescribing mild exercise (like 15 minutes of walking per day at normal pace or slower), which actually does help, will also make them feel like something has been done. It helps to actually write these things out on an official prescription pad as it lends weight to the whole intervention. So - therapy, medication, and exercise is the usual protocol for depression, but we know SSRI's are pretty ineffective, and psychotherapy is not useful in many cases, so we substitute placebos for real meds, and forgo the psychotherapy. The exercise is really mandatory. If your patient has a sleep disorder, as do most people who have depression, you also may want to medicate for that in the short term. I have seen pretty good results with fairly refractory depression using these methods or permutations of them.

I think that the problem with psychiatry is that it is far too medication-focused, and I see psychiatrists shotgunning patients with medications, sometimes as many as six or seven simultaneously, none of which work, but produce plenty of side effects. To be fair, meds for Bipolar I and Schizophrenia do seem to work when other things don't, although they too usually have some pretty unpleasant side effects (Tardive Dyskinesia and diabetes in anti-psychotics, and chronic diaphoresis in meds used for Bipolar I)...but still they work!
 

psych.meout

2+ Year Member
Oct 5, 2015
1,533
882
81
Status
Pre-Psychology
Sorry to hear this, but not surprised. This may very well be a cultural issue. In my travels, I have noted that some patients from some cultures *expect* medicine or an injection and if they don't get it they feel that they have received inadequate treatment. They cannot be talked out of this, so vitamin pills or an injection of saline may actually go a long way toward helping them and maintaining patient rapport.

Also, prescribing mild exercise (like 15 minutes of walking per day at normal pace or slower), which actually does help, will also make them feel like something has been done. It helps to actually write these things out on an official prescription pad as it lends weight to the whole intervention. So - therapy, medication, and exercise is the usual protocol for depression, but we know SSRI's are pretty ineffective, and psychotherapy is not useful in many cases, so we substitute placebos for real meds, and forgo the psychotherapy. The exercise is really mandatory. If your patient has a sleep disorder, as do most people who have depression, you also may want to medicate for that in the short term. I have seen pretty good results with fairly refractory depression using these methods or permutations of them.

I think that the problem with psychiatry is that it is far too medication-focused, and I see psychiatrists shotgunning patients with medications, sometimes as many as six or seven simultaneously, none of which work, but produce plenty of side effects. To be fair, meds for Bipolar I and Schizophrenia do seem to work when other things don't, although they too usually have some pretty unpleasant side effects (Tardive Dyskinesia and diabetes in anti-psychotics, and chronic diaphoresis in meds used for Bipolar I)...but still they work!
Uh, Wut?
 

nitemagi

Senior Member
15+ Year Member
Oct 15, 2001
2,851
935
381
Los Angeles, CA
Visit site
Status
Attending Physician
:laugh::laugh::laugh:
Right?

SSRIs are very effective in certain cases, but sure if you're pooling the data with those who they don't work at all with (potentially explainable through genetic mechanisms like those with serotonin transporter SLC6A4 with S/S genotypes), then sure, they look less effective. This is the problem of using such reductionistic thinking. Either they work or they don't work.
 

DynamicDidactic

Ass of Prof
7+ Year Member
Jul 27, 2010
986
346
181
Status
Psychologist
:laugh::laugh::laugh:
SSRIs are very effective in certain cases, but sure if you're pooling the data...
To be clear, what "certain cases" are we talking about? The studies, which are often heavily sided toward medication efficacy (e.g., placebo washout groups, favorable outcome measures), often represent typical prescribing habits. More precisely, SSRIs are often prescribed to anyone with depressive affect so, pooled data is a fairly accurate manner of assessing efficacy.

This is the problem of using such reductionistic thinking. Either they work or they don't work.
I view the literature very differently, yes SSRIs work but why do they work. The placebo effect seems to play a strong role but not exclusively. However, the serotonin-hypothesis has very little supporting evidence at this point.
 

DynamicDidactic

Ass of Prof
7+ Year Member
Jul 27, 2010
986
346
181
Status
Psychologist
Also, prescribing mild exercise (like 15 minutes of walking per day at normal pace or slower), which actually does help, will also make them feel like something has been done.
I am not aware of any controlled studies indicating that such a low dosage of physical activity treats depressive disorders.

To be fair, meds for Bipolar I and Schizophrenia do seem to work when other things don't, although they too usually have some pretty unpleasant side effects (Tardive Dyskinesia and diabetes in anti-psychotics, and chronic diaphoresis in meds used for Bipolar I)...but still they work!
Work in the short-term but may potentially increase the chronicity of psychotic disorders.
 

nitemagi

Senior Member
15+ Year Member
Oct 15, 2001
2,851
935
381
Los Angeles, CA
Visit site
Status
Attending Physician
I view the literature very differently, yes SSRIs work but why do they work. The placebo effect seems to play a strong role but not exclusively. However, the serotonin-hypothesis has very little supporting evidence at this point.
Look up BDNF.
 

PSYDR

Psychologist
10+ Year Member
Dec 18, 2005
2,605
2,070
281
Status
@nitemagi : While I'm sure you are aware, I believe dynamic is referring to the works of Dr. Kirsch at MGH when he/she is referring to the placebo effect of SSRIs. There is consistent debate between the likes of Kirsch and Krystal which seem to be predicated upon the statistics used. There was also that debate about tianeptine. An explanation of Kirsch's finding and the STAR*D stuff using genetic polymorphisms would be very interesting. In all seriousness, you should at least submit a letter to the relevant journal about this.

@DynamicDidactic : There is a consistent and robust evidence base that aerobic exercise has an incredible effect on depression with effect sizes that approximate CBT and SSRI treatment. Behavioral activatoin, which incorporates exercise, has a superior effect size to CBT on meta analysis. There is also very robust data regarding the efficacy of SSRIs, which is also discussed in the Kirsch papers and the STAR*D study.
 
Mar 24, 2014
4,393
3,838
81
Rural Area Medical Facilty
Status
Psychologist
@nitemagi : While I'm sure you are aware, I believe dynamic is referring to the works of Dr. Kirsch at MGH when he/she is referring to the placebo effect of SSRIs. There is consistent debate between the likes of Kirsch and Krystal which seem to be predicated upon the statistics used. There was also that debate about tianeptine. An explanation of Kirsch's finding and the STAR*D stuff using genetic polymorphisms would be very interesting. In all seriousness, you should at least submit a letter to the relevant journal about this.

@DynamicDidactic : There is a consistent and robust evidence base that aerobic exercise has an incredible effect on depression with effect sizes that approximate CBT and SSRI treatment. Behavioral activatoin, which incorporates exercise, has a superior effect size to CBT on meta analysis. There is also very robust data regarding the efficacy of SSRIs, which is also discussed in the Kirsch papers and the STAR*D study.
I thought behavioral activation was a part of CBT. :confused: In any case, I always recommend physical activity and also sunshine and fresh air and fun. If the patient and I can find one thing that combines all of the above, then all the better.
 
  • Like
Reactions: PSYDNEUROGUY

DynamicDidactic

Ass of Prof
7+ Year Member
Jul 27, 2010
986
346
181
Status
Psychologist
Look up BDNF.
I forgot about this till being bored today. Sorry to retread an old post.

If you are saying people should be prescribed SSRIs to increase BDNF production, I would say that you are not learning from past mistakes. While the prospect that the therapeutic effect of SSRIs may be due to an increase in BDNF production is interesting and worthwhile to pursue with research, one still falls prey to the same logical fallacies that led to the erroneous serotonin-theory of depression (and the general poorly-supported chemical imbalance theory of depression) - correlation does not mean causation.
 

DynamicDidactic

Ass of Prof
7+ Year Member
Jul 27, 2010
986
346
181
Status
Psychologist


[USER=342724]@DynamicDidactic
: There is a consistent and robust evidence base that aerobic exercise has an incredible effect on depression with effect sizes that approximate CBT and SSRI treatment. Behavioral activatoin, which incorporates exercise, has a superior effect size to CBT on meta analysis. There is also very robust data regarding the efficacy of SSRIs, which is also discussed in the Kirsch papers and the STAR*D study.[/USER]
@PSYDR
I was commenting earlier (again, sorry to rehash an old post, its been a busy semester) that "15 minutes" is not considered a therapeutic dose, it would have to be longer (i.e., 25-30).

I disagree with the term "robust data" to support SSRI efficacy. I believe the exact numbers from Kirsch were that 83% of the therapeutic effect came from placebo or 2.5 points lower score on the HAM-D for the SSRI groups. These numbers indicates a statistically significant difference but not what most people would consider a clinically significant difference. The STAR*D study is similarly lacking in clinical significance. While its true that 67% of participants got well after their 4th round of medication, only 3% of the sample remained in the study, got well, and stayed well for a year.

I'll climb back into my hole now.
 
  • Like
Reactions: Magick91683

briarcliff

7+ Year Member
Aug 26, 2011
739
353
181
USA
Status
Psychology Student
I started casually looking into direct-entry MSN programs recently (i.e., psychiatric and mental health nurse practitioner [PMHNP] programs), and was wondering if anyone had any suggestions or experience with pursuing this route for prescription privileges? any specific program recommendations? or other feedback on the viability of this route?
 

medium rare

Psychologist & Psych NP
10+ Year Member
Jan 13, 2009
276
48
261
Status
Psychologist
I started casually looking into direct-entry MSN programs recently (i.e., psychiatric and mental health nurse practitioner [PMHNP] programs), and was wondering if anyone had any suggestions or experience with pursuing this route for prescription privileges? any specific program recommendations? or other feedback on the viability of this route?
I did this and it has worked out extremely well. Clinical Psychologist & Psych NP dual training is a great combination. PM me if you’d like more specific information.