Hi Judd,
I wasn't going to respond to this post since it appears to me to be an attempt at getting MD/DO to circle the wagons and bash other practitioners such as PhD/PsyD, NP, etc. but I changed my mind and decided to post just to support your excellent point: it's about OUTCOME MEASURES!!!
Currently, there are generally no psychologists prescribing in the US except for those who went through the Department of Defense (DOD) experimental project. PhD/PsyD in New Mexico are still working out the details of how to implement the RxP legislation (in conjunction with MD/DO by the way) and there is only one psychologist prescribing in Indiana (in a Native American reservation). So, the best outcome measures available are those of the DOD experiment. Following is the independent evaluation report:
FINAL REPORT (Part I)
MAY 1998
Prepared for: LTC Thomas J. Williams, USA, MS Program Director, External Monitoring of Graduates of DoD Psychopharmacology Demonstration Project Chief, Department of Psychology Walter Reed Army Medical Center Washington, D.C. 20307
Prepared by: American College of Neuropsychopharmacology 320 Centre Building 2014 Broadway Nashville, TN 37203
American College of Neuropsychopharmacology (ACNP)
Evaluation Panel Report May 1998
Executive Summary
The Psychopharmacology Demonstration Project (PDP) was undertaken by the Department of Defense (DoD) to determine the feasibility of training military clinical psychologists to prescribe psychotropic drugs safely and effectively. The first class entered the PDP in the Summer of 1991, and the last of four classes graduated in the Summer of 1997. The PDP produced a total of 10 prescribing psychologists who undertook post-graduate assignments at military posts scattered throughout the United States.
In January 1998, the DoD contracted with the ACNP to monitor and to provide an independent, external analysis and evaluation of the program and its participants. The ACNP Evaluation Panel was the chief mechanism for performing those functions throughout the program's lifetime. The ACNP Evaluation Panel did its work chiefly by means of frequent, periodic visits to training sites to observe, to interview significant participants, to collect data; providing external assessment of effectiveness and implementation of the PDP program.
In March and April 1998 the Evaluation Panel site visited all graduates of the program. Some had completed their formal PDP training almost four years earlier, and some were only nine months into the post-graduate period. This report includes much detail about the 10 graduates, the 10 sites of their assignments, and the 10 positions they filled. Our Findings and Conclusions, however, have reached beyond the individual. We examined the PDP as one particular training program and correlated its characteristics with its outcomes, as represented in the collective performances of the cohort of graduates.
After the Findings and Conclusions section below, an Introduction and a Brief History of the PDP provide short, detailed accounts of the PDP and the role, influence, and history of the ACNP and the ACNP Evaluation Panel. Next, is a Methodology of the 1998 ACNP Evaluation. Last, is a lengthy section that comprises the bulk of the report, 1998 Practice Profiles of the 10 Graduates. These Profiles report in detail the observations and findings of the 10 site visits. They are presented in sequence by service beginning with Air Force (three graduates), followed by Army (three graduates), then Navy (four graduates). Although there were three female graduates, only masculine pronouns are used to protect identity.
Findings and Conclusions
1. Effectiveness: All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed. It was striking to the Evaluation Panel how the graduates had filled different niches and brought unique perspectives to their various assignments. For example, a graduate at one site worked lull time on an inpatient unit with his supervising psychiatrist. The psychiatrist said he preferred working with the graduate rather than with another psychiatrist because the prescribing psychologist contributed a behavioral, nonphysician, psychological perspective he got from no one else. On posts where there was a shortage of psychiatrists, the graduates tended to work side-by-side with psychiatrists, performing many of the same functions a 'junior psychiatrist" might perform. In another location, a graduate was based in a psychology clinic but worked largely in a primary care clinic for dependents, thereby providing cost savings for care that otherwise would have been contracted out. Another graduate was the only prescriber for active duty sailors in a psychology clinic that was located near the ships at a naval base. Yet another graduate was to be transferred soon to an isolated base where he will be the only mental health provider. His medical backup will be primary care physicians.
2. Medical safety and adverse effects: While the graduates were for the most part highly esteemed, valued, and respected, there was essentially unanimous agreement that the graduates were weaker medically than psychiatrists. While their medical knowledge was variously judged as on a level between 3rd or 4th year medical students, their psychiatric knowledge was variously judged as, perhaps, on a level between 2nd or 3rd year psychiatry residents. Nevertheless, all graduates demonstrated to their clinical supervisors and administrators that they were sensitive and responsive to medical issues. Important evidence on this point is that there have been no adverse effects associated with the practices of these graduates! Thus, they have shown impressively that they knew their own weaknesses, and that they knew when, where, and how to consult. The Evaluation Panel agreed that all the graduates were medically safe by this standard. In a few quarters, the criterion for "medical safety" was equated with the knowledge and experience acquired from completing medical school and residency, and, of course, no graduate of the PDP could meet such a test.
3. Outstanding individuals: One indicator of the quality and the success of this group of graduates was that eight out of 10 were serving as chiefs or assistant chiefs of an outpatient psychology clinic or a mental health clinic. Two of these chiefs completed their PDP training less than a year earlier. Other indicators of quality and achievement that characterized this cohort were present when they entered the program. They all had not only a doctorate in clinical psychology but also clinical experience that ranged from a few to more than 10 years. All but two had military experience. The characteristics that led to these accomplishments showed again in that this cohort overcame their limited background in traditional scientific prerequisites for medical school. They certainly suggested that the selection standards should be high, indeed, for candidates for any future prescribing psychologist training, be it military or civilian. The opinion of the Evaluation Panel was that the history of the PDP has established that any program with comparable aims must be a post-doctoral program.
4. Should the PDP be emulated? There was discussion at many sites about political pressures in the civilian sector for prescription privileges for psychologists. Virtually all graduates of the PDP considered the "short-cut" programs proposed in various quarters to be ill-advised. Most, in fact, said they favored a 2-year program much like the PDP program conducted at Walter Reed Army Medical Center, but with somewhat more tailoring of the didactic training courses to the special needs, and skills of clinical psychologists. Most said an intensive full-time year of clinical experience, particularly with inpatients, was indispensable. The Evaluation Panel heard much skepticism from psychiatrists, physicians, and some of the graduates about whether prescribing psychologists could safely and effectively work as independent practitioners in the civilian sector. The usual argument was that the team practice that characterized military medicine was an essential ingredient in the success of the PDP that could not be duplicated in the civilian world. The Evaluation Panel urged the graduates collectively to produce their own consensus view on what would constitute an optimal program.
5. Relationships with psvchiatry: Six graduates worked in close, gratifying, and harmonious partnerships with psychiatrists, one in an inpatient setting and the others in outpatient units. A seventh graduate had a similar, but more business-like pattern. The psychiatrists in these partnerships were very competent pharmacotherapists. The remaining three graduates were somewhat isolated from psychiatrists with psychopharmacological expertise. One graduate was an independent provider who directed a military division clinic, and, while the clinic had a staff psychiatrist, he was less experienced in psychopharmacology than the graduate--and openly admitted this. Their relationship also was somewhat strained. The other two graduates worked in very busy settings with other psychologists in one case and with primary physicians in the other. Each treated many patients with medication. Each had an expert proctor who was available by phone, page, and e-mail, but not first hand. Although both were only nine months out of the PDP, and they were doing excellent work by all accounts, the Evaluation Panel believed as a matter of principle that they would benefit more from the experience of closer daily liaison with an expert practitioner.
Continued in next post.
