The price of peanuts in Iran

[sasevan]

Fortunately, psychotherapy training is on the rise in psychiatry programs now. In fact during most of my interviews everyone I spoke with was glad to hear my interest in psychotherapy as well as letting me know the minimum requirements for psychotherapy training in psychiatry residency has been elevated recently so now all psychiatry programs need to focus on psychotherapy more than in recent years.

And I kind of think that 4 years or more in psych residency can provide more than ample training in psychotherapy, so we don't have to take more than the psych boards after residency.

Hi,
BTW, best of luck to Poety, you, et al. on the upcoming match.
OK, back to topic: Couldn't the same be said about psychopharm training being on the rise in doctoral psychology programs not to mention in the post-doc psychopharm programs?
Doesn't a masters in psychopharm-which includes a practicum, the passing of a psychopharm national examination, and ongoing MD/DO supervision during provisional licensure preclude the need for any other step/board exam?

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[sasevan]

[/B]
It is not the role of a psychology licensing board to determine what is appropriate training for psychiatrists. Psychiatrists can work those issues out on their own. Similarly, it is not the role of psychiatry to determine what is appropriate training for psychologists.

I generally agree wholeheartedly with this.
At the same time, however, I believe that psychiatry is a legitimate stakeholder in mental healthcare, especially in the pharmacological tx of psych pts.
What role, if any, do you envision for psychiatry in this proposed development?
I'd like to see psychiatry work together with psychology to develope a training model (neither med school nor current psychopharm programs) wherein psych MD/DO would provide supervision to psych PhD/PsyD during pre-licensure practicum and during provisional licensure for 2-4 years.

 

[Harmony]

Hi,
BTW, best of luck to Poety, you, et al. on the upcoming match.
OK, back to topic: Couldn't the same be said about psychopharm training being on the rise in doctoral psychology programs not to mention in the post-doc psychopharm programs?
Doesn't a masters in psychopharm-which includes a practicum, the passing of a psychopharm national examination, and ongoing MD/DO supervision during provisional licensure preclude the need for any other step/board exam?

How can you train some one in understanding the biological functions of body with out any science (Bio/Chem) background? Degree in Phd/Psyd does not require any biologicial prequisites, if MS psychopharm is truely a post doc degree then why it is not a fellowship instead? How can psychologist legislate competence and control the increased number of desperate psychologist to prescribe? The requirements of LA are so lame, heck any one can prescribe leave alone psychologist. It seems that psychologist are making an assumption that mental illness is separate from the medical one. For an outsider, it is interesting to watch the desperate attempt by psychologist to salvage a profession from becoming a fifth wheel.

 

[Poety]

[/B]

According to COPP chair Norman A. Clemens, M.D., while many residency programs offer exposure to CBT, psychodynamic and supportive therapies, residents are not adequately prepared to competently use them to treat patients.

I'm glad to hear that Chelsea and Norman are wrong, and that things are getting better.

It is not the role of a psychology licensing board to determine what is appropriate training for psychiatrists. Psychiatrists can work those issues out on their own. Similarly, it is not the role of psychiatry to determine what is appropriate training for psychologists.

Viva California!

Hi Eval,

I agree, I won't be trained anywhere near that of a psychologist for either testing or talk therapy - thats why I'm gunna hire you to do that for me


ETA: Also, I think that psychologists have a very powerful tool as well as we all konw how dangerous therapy can be in the wrong hands (yeah I'm serious - you know what I mean) so I think thye should suffice with their tools and we'll suffice with ours - however, I also think psychiatrists are given enough training to do therapy -but I would argue its nowhere near as involved as the theory PhD's are trained in which would ofcourse make them more astute to applying it I'm sure.

Also, I respect psychologists and their place in psychiatry.

Ok, I'm done

 

[PublicHealth]

Wow...three pages...

 

[PublicHealth]

Let's not forget that psychologists "stole" psychotherapy from psychiatrists (thank William James). And now they're poised to steal pharmacotherapy as well.

 

[Solideliquid]

[/B]


It is not the role of a psychology licensing board to determine what is appropriate training for psychiatrists. Psychiatrists can work those issues out on their own. Similarly, it is not the role of psychiatry to determine what is appropriate training for psychologists.

Viva California!

I agree but only if your practice is limited to the scope of your training, and not the practice of medicine.

For that you should go to medical school. Just my opinion, don't hate.

 

[Solideliquid]

Hi,
BTW, best of luck to Poety, you, et al. on the upcoming match.
OK, back to topic: Couldn't the same be said about psychopharm training being on the rise in doctoral psychology programs not to mention in the post-doc psychopharm programs?
Doesn't a masters in psychopharm-which includes a practicum, the passing of a psychopharm national examination, and ongoing MD/DO supervision during provisional licensure preclude the need for any other step/board exam?

I don't really know how else to say this. As medical doctors we are trained for 4 years in medical school in how all the drugs in use today affect the body, interact, etc etc. Just because some of us are going into psychiatry where we use a limited number of drugs on a daily basis compared to the other fields (such as Internal Medicine), that doesn't mean it's any easier to prescribe these psych meds.

If psychologists want to prescribe medications they should be required to undergo rigorous medical training and evaluation, and I'm not talking about a semester of psych med classes.

 

[sasevan]

Hi Harmony,
What field are you in/planning on going into; I'm a psychologist planning on becoming a psychiatrist.

How can you train some one in understanding the biological functions of body with out any science (Bio/Chem) background? Degree in Phd/Psyd does not require any biologicial prequisites, if MS psychopharm is truely a post doc degree then why it is not a fellowship instead?

You raise some interesting points; on the other side:
How to explain the ability of the DoD medical psychologists to prescribe safely and efficiently during the initial demonstration project and to this day? The demonstration topic was not med school.
What about other providers such as NP and PA who don't go thru med school?

For an outsider, it is interesting to watch the desperate attempt by psychologist to salvage a profession from becoming a fifth wheel.

Please elaborate.
Peace.

 

[Poety]

Let's not forget that psychologists "stole" psychotherapy from psychiatrists (thank William James). And now they're poised to steal pharmacotherapy as well.

no, the psychiatrists said, hell I don't want this anymore, now I got drugs to use and I don't have to listen to the whining - JUST KIDDING

you all know though that I don't do that nifty fifty psychotherapy stuff If you're not psychotic or developmentally challenged - you go to my psychologist its psycheval and he's down the hall, over there ---->

 

[PublicHealth]

If psychologists want to prescribe medications they should be required to undergo rigorous medical training and evaluation, and I'm not talking about a semester of psych med classes.

And neither are they. Current postdoctoral training programs in clinical psychopharmacology are two years in length. Following that, psychologists must complete a national examination in psychopharmacology (Psychopharmacology Examination for Psychologists [PEP]), complete a two-year conditional prescribing period under close supervision of a physician, and only then may they be able to prescribe psychotropic medications collaboratively with their patients' primary care physician.

This equals exactly a semester of psych med classes.

 

[Poety]

And neither are they. Current postdoctoral training programs in clinical psychopharmacology are two years in length. Following that, psychologists must complete a national examination in psychopharmacology (Psychopharmacology Examination for Psychologists [PEP]), complete a two-year conditional prescribing period under close supervision of a physician, and only then may they be able to prescribe psychotropic medications collaboratively with their patients' primary care physician.

This equals exactly a semester of psych med classes.

No but PH, come on really - what is the psychologist gunna do when the patient is having a medical condition thats exacerbating/blah blah the problem or the med they're already on - when they don't have the medical training? And yes this goes for NP's too - I'm so anti midlevel prescribing - grrrr

 

[PublicHealth]

No but PH, come on really - what is the psychologist gunna do when the patient is having a medical condition thats exacerbating/blah blah the problem or the med they're already on - when they don't have the medical training? And yes this goes for NP's too - I'm so anti midlevel prescribing - grrrr

Consult with the patient's PCP -- this is REQUIRED in both the NM and LA laws. This is the very reason why a 'collaborative practice agreement' exists.

By the way, some of the female Olympic figure skaters are HOT!

 

[Anasazi23]

And neither are they. Current postdoctoral training programs in clinical psychopharmacology are two years in length.

And take place every third weekend either online or at the local holiday inn. You will recive continental breakfast at the lectures though (which are largely taught by other psychologists who wouldn't know a Prozac pill if it slapped them in the face.

Following that, psychologists must complete a national examination in psychopharmacology (Psychopharmacology Examination for Psychologists [PEP]),

Written and scored by other psychologists. A lack of an independent licensing board is unheard of in medicine. They refuse to release passing scores. Their intent is to pass everyone eventually, not weed out incompetency.

complete a two-year conditional prescribing period under close supervision of a physician,

A non-psychiatrist. To quote myself earlier in the thread: This is akin to going to a skiing instructor for tennis lessons. It's completely ass-backwards.

and only then may they be able to prescribe psychotropic medications collaboratively with their patients' primary care physician.

So if a psychologist is caught prescribing a medication without permission from a PCP, can their prescribing license be revoked? I wait for the American Psychiatric Association's attack on this. All that work to be disciplined by the board and have your rights taken away. Almost sad. But not really.


I'm heading over to the Poety earring thread. It's much more fun.
Your doom and gloom scenarios for psychiatry are pretty much ridiculous and obtuse.

 

[sasevan]

Consult with the patient's PCP -- this is REQUIRED in both the NM and LA laws. This is the very reason why a 'collaborative practice agreement' exists.

Good Point.

Plus, if psychiatry were more open to this development there might even be more medical safeguards; such as psychiatrists, instead of PCPs, providing the teaching and supervision.
I don't understand the absolute opposition of some psych MD/DOs to med psychologists as there are already psych NPs out there prescribing safely and in some states with full formularies and autonomous practices.
In any case, there may be a market out there for psych MD/DOs willing to train psych PhD/PsyDs...perhaps that, more than other considerations, will ultimately shape the outcome of this debate.

 

[john182]

Hi Harmony,
How to explain the ability of the DoD medical psychologists to prescribe safely and efficiently during the initial demonstration project and to this day? The demonstration topic was not med school.
What about other providers such as NP and PA who don't go thru med school?

Peace.

The final result of the PDP project by the DoD, which I posted above, revealed that it would have been quicker and cheaper to send the psychologists each to medical school.

 

[sasevan]

The final result of the PDP project by the DoD, which I posted above, revealed that it would have been quicker and cheaper to send the psychologists each to medical school.

No doubt that is one avenue-which btw is the one I'm personally pursuing.
But med school is not the only avenue.
Some psychologists have gone the way of nursing school in order to become psych NPs.
Others have gone the route of post-doc MS psychopharm, i.e., NM and LA.
IMO the question is not whether psychologists and other non-physicians can be trained to be safe psychopharmacologists, at least for less complicated outpatient cases, but whether med school is the only viable model.
How can we insist on that when evidence from the DoD et al. suggest otherwise?

 

[Harmony]

No doubt that is one avenue-which btw is the one I'm personally pursuing.
But med school is not the only avenue.
Some psychologists have gone the way of nursing school in order to become psych NPs.
Others have gone the route of post-doc MS psychopharm, i.e., NM and LA.
IMO the question is not whether psychologists and other non-physicians can be trained to be safe psychopharmacologists, at least for less complicated outpatient cases, but whether med school is the only viable model.
How can we insist on that when evidence from the DoD et al. suggest otherwise?

The DoD model was a very small pilot can not be replicated in the real world. Here were some of the cornerstones:
-High selection criteria (all the psychologist were very experienced and successful practitioners holding prestigious positions- Source NAMI)
-Biological foundations courses were required that are ignored in the current MS pharm model
- Residency type rigorous training, much more comprehensive
- Limited to only outpatients with readily available insights from psychiatrists
- Type of patients were mainly young, healthy individual without other complications

None of the above factors are applicable in LA and NM. It seems that the psychologists think that they can cherry-pick the less severe patients and take over some of the roles of the PCP. But a little knowledge is a dangerous thing!! I am a firm believer that free market forces and the legal system will take care of this automatically.

BTW, I am a management consultant, working in health and life science industry and am involved in projects to improve health care, reduce costs and improve efficiencies. Since healthcare cost is around 15% of the GDP it is important to achieve efficiencies and reduce costs.

 

[nortomaso]

No doubt that is one avenue-which btw is the one I'm
IMO the question is not whether psychologists and other non-physicians can be trained to be safe psychopharmacologists, at least for less complicated outpatient cases, but whether med school is the only viable model.
QUOTE]


I think this is an excellent point. Let's face it, after spending over $200,000 and years of personal sacrifice its threatening to think that someone can take an "easier" path to the same destination. But 90% of what we learn in med school is useless, in-one-ear-out-the-other, crap that is more hazing than learning. This can't be the only, or even the best way, to become a psychopharmacologist. Whatever controversy surrounds the studies cited in this thread, there is undoubtably a crisis in mental health care delivery in this country. And we as a society need to face it head on by bucking tradition and experimenting with new ways to serve our population more equitably.

I don't know enough to be for or against the recent legislation in NM and LA, but it seems to me that most of the outcry by my future colleagues arises from fear rather than genuine concern for patient safety.

 

[Anasazi23]

No doubt that is one avenue-which btw is the one I'm personally pursuing.
But med school is not the only avenue.
Some psychologists have gone the way of nursing school in order to become psych NPs.
Others have gone the route of post-doc MS psychopharm, i.e., NM and LA.
IMO the question is not whether psychologists and other non-physicians can be trained to be safe psychopharmacologists, at least for less complicated outpatient cases, but whether med school is the only viable model.
How can we insist on that when evidence from the DoD et al. suggest otherwise?

This'll be my last post on this thread. The topic is just simply beaten to death and tired. The Dod psychologists prescribed almost exclusively ssri's to healthy, non-pediatric, non-geriatric patients and had much more oversight by medical doctors.

The natural course of events will be for psychologists to demand complete autonomy, as they already are hinting at with further legislative revisions insisting that they be able to prescribe to these delicate populations (without further training!).

Again, it's not about "NP's prescribe safely, etc." 1/4 of my time on my geriatric rotation was fixing the local 2 local NP's mistakes in an inpatient setting. They were not atypical. While no harm per se (save about 2 cases) was done to patients, her choices often simply sucked, or were very suboptimal or put the patient at a future risk. These types of things cannot be quantified in studies.

Reducing medicine to "safe prescribing" and "what's the least common denominator for prescribing medicine" ignores so many factors and concepts learned in medical school and residency. This isn't auto mechanics.

 

[sasevan]

I think this is an excellent point. Let's face it, after spending over $200,000 and years of personal sacrifice its threatening to think that someone can take an "easier" path to the same destination. But 90% of what we learn in med school is useless, in-one-ear-out-the-other, crap that is more hazing than learning. This can't be the only, or even the best way, to become a psychopharmacologist. Whatever controversy surrounds the studies cited in this thread, there is undoubtably a crisis in mental health care delivery in this country. And we as a society need to face it head on by bucking tradition and experimenting with new ways to serve our population more equitably.

Good to know that there are other future psychiatrist colleagues out there willing to consider alternative models to the current paradigm...models that are safe and efficient and increase access.
However, I don't think that the "easier" route will lead to the same destination.
I believe that if there's a future for medical psychology it will be one more geared towards providing primary mental healthcare.
Psychiatry will still be the specialty discipline best equiped to manage medically complicated cases and the severely and persistently mentally ill.

I don't know enough to be for or against the recent legislation in NM and LA, but it seems to me that most of the outcry by my future colleagues arises from fear rather than genuine concern for patient safety.

I'm not too concerned about the NM or LA situations since, I believe, that in both states collaboration with the pt's PCP is required.
I do, however, have some concern about the current post-doc psychopharm programs.
I'm starting to believe that as currently implemented they may not meet the DoD standard which IMO is the one most suitable and valid alternative to med school.

 

[Poety]

I just can't take it anymore - let me tell you all about NP's prescribing ok?

One ordered Mellaril on top of thorazine and sent my patient into a malignant hypertension and a neuroleptic fit - they're CONTRAINDICATED. Another ran an IV wide open on someone with CHF, another ordered WELLBUTRIN for someone with SEIZURE DISORDER because she FAILED TO ASK THE PATIENT IF THEY HAD A MEDICAL HISTORY - I could go on and ON - but I'll stop there.

NP's SHOULD NOT PRESCRIBE, nor should psychologists or PA's without a PHYSICIAN right there to approve the order. This is silly - if half of these people saw the mistakes I've seen (Yes life threatening with psych meds too).

 

[Solideliquid]

You know, why don't we just get pharmacists to prescribe all the meds and close all the medical schools altogether?

 

[Poety]

You know, why don't we just get pharmacists to prescribe all the meds and close all the medical schools altogether?

 

[nortomaso]

I just can't take it anymore - let me tell you all about NP's prescribing ok?

One ordered Mellaril on top of thorazine and sent my patient into a malignant hypertension and a neuroleptic fit - they're CONTRAINDICATED. Another ran an IV wide open on someone with CHF, another ordered WELLBUTRIN for someone with SEIZURE DISORDER because she FAILED TO ASK THE PATIENT IF THEY HAD A MEDICAL HISTORY - I could go on and ON - but I'll stop there.

NP's SHOULD NOT PRESCRIBE, nor should psychologists or PA's without a PHYSICIAN right there to approve the order. This is silly - if half of these people saw the mistakes I've seen (Yes life threatening with psych meds too).

I don't see what the problem is with a psychologist diagnosing a patient and suggesting a psychotropic med to be subsequently approved or vetoed by a family doctor. This seems like a sensible way to fill in the current gaps in care.

 

[Poety]

I don't see what the problem is with a psychologist diagnosing a patient and suggesting a psychotropic med to be subsequently approved or vetoed by a family doctor. This seems like a sensible way to fill in the current gaps in care.

Hi Norto, I just disagree, I've said my reasons, now I can't take this thread anymore

I understand your point - and you ofcourse have a right to that opinion

 

[sasevan]

I just can't take it anymore - let me tell you all about NP's prescribing ok?

One ordered Mellaril on top of thorazine and sent my patient into a malignant hypertension and a neuroleptic fit - they're CONTRAINDICATED. Another ran an IV wide open on someone with CHF, another ordered WELLBUTRIN for someone with SEIZURE DISORDER because she FAILED TO ASK THE PATIENT IF THEY HAD A MEDICAL HISTORY - I could go on and ON - but I'll stop there.

NP's SHOULD NOT PRESCRIBE, nor should psychologists or PA's without a PHYSICIAN right there to approve the order. This is silly - if half of these people saw the mistakes I've seen (Yes life threatening with psych meds too).

I'm sure you didn't mean to suggest that prescription errors are exclusively committed by non-physicians.
I don't mean to minimize the errors committed by those NPs but I believe that pharmacists and others have horror stories about both MD/DOs and
non-MD/DOs prescribing contraindicated medications, etc.
Isn't then the question more about empirical as opposed to anecdotal evidence, i.e., do non-physicians commit statistically significantly more prescription errors than physicians?
Dentists, podiatrists, optometrists, NPs, PAs, and even medical psychologists in the DoD (and now NM and LA) all have a track record that can be compared to physicians.
Do you, or anyone for that matter, know of any study that has found in either direction?

 

[Poety]

I'm sure you didn't mean to suggest that prescription errors are exclusively committed by non-physicians.
I don't mean to minimize the errors committed by those NPs but I believe that pharmacists and others have horror stories about both MD/DOs and
non-MD/DOs prescribing contraindicated medications, etc.
Isn't then the question more about empirical as opposed to anecdotal evidence, i.e., do non-physicians commit statistically significantly more prescription errors than physicians?
Dentists, podiatrists, optometrists, NPs, PAs, and even medical psychologists in the DoD (and now NM and LA) all have a track record that can be compared to physicians.
Do you, or anyone for that matter, know of any study that has found in either direction?

Ofcourse not, but fortunately, most MD/DO;s have 4 years of residency with senior docs watching them so mistakes like these don't get made in the first place - they get caught in time for the most part. Thats the problem with the whole non-supervised midlevel prescribing.

Ok, I'm outta this thread

You know I love ya sas

 

[Doc Samson]

I'm sure you didn't mean to suggest that prescription errors are exclusively committed by non-physicians.
I don't mean to minimize the errors committed by those NPs but I believe that pharmacists and others have horror stories about both MD/DOs and
non-MD/DOs prescribing contraindicated medications, etc.
Isn't then the question more about empirical as opposed to anecdotal evidence, i.e., do non-physicians commit statistically significantly more prescription errors than physicians?
Dentists, podiatrists, optometrists, NPs, PAs, and even medical psychologists in the DoD (and now NM and LA) all have a track record that can be compared to physicians.
Do you, or anyone for that matter, know of any study that has found in either direction?

Silber JH, Kennedy SK, Even-Shoshan O, et al: Anesthesiology direction and patient outcomes. Anesthesiology 93:152–163, 2000

"The study revealed a rate of 25 excess deaths per 10,000 Medicare surgical cases when a physician anesthesiologist was not directly involved in the case"

Pine M, Holt KD, Lou YB: Surgical mortality and type of anesthesia provider. AANA Journal 71(2):109–116, 2003

"45 deaths per 10,000 cases in hospitals in which all anesthetics were administered by anesthesia nurses supervised by a non-anesthesiologist physician—an 18 percent increase over when anesthetics were administered by an anesthesiologist"

 

[sasevan]

You know I love ya sas

Thanks Poety and best of luck with the match.

 

[sasevan]

Silber JH, Kennedy SK, Even-Shoshan O, et al: Anesthesiology direction and patient outcomes. Anesthesiology 93:152–163, 2000

"The study revealed a rate of 25 excess deaths per 10,000 Medicare surgical cases when a physician anesthesiologist was not directly involved in the case"

Pine M, Holt KD, Lou YB: Surgical mortality and type of anesthesia provider. AANA Journal 71(2):109–116, 2003

"45 deaths per 10,000 cases in hospitals in which all anesthetics were administered by anesthesia nurses supervised by a non-anesthesiologist physician—an 18 percent increase over when anesthetics were administered by an anesthesiologist"

Thanks DS,
This is very cool; I believe that studies such as this are what really needs to inform our opinions.
Peace.

 

[PublicHealth]

I don't see what the problem is with a psychologist diagnosing a patient and suggesting a psychotropic med to be subsequently approved or vetoed by a family doctor. This seems like a sensible way to fill in the current gaps in care.

This is exactly the model of psychologist prescribing in NM and LA. It's called a "collaborative practice agreement."

 

[nortomaso]

This is exactly the model of psychologist prescribing in NM and LA. It's called a "collaborative practice agreement."

So could someone tell me why this is more dangerous than a psychiatrist (who has less medical experience and training than a family doc/internist) alone prescribing meds?

 

[f_w]

So could someone tell me why this is more dangerous than a psychiatrist (who has less medical experience and training than a family doc/internist) alone prescribing meds?

Because the psychiatrist has spent 3 years of his training prescribing psychotropic meds.
The collaborative model with FP or IM however seems reasonable if no psychiatrist is available to supervise prescribing.

 

[PublicHealth]

Because the psychiatrist has spent 3 years of his training prescribing psychotropic meds.
The collaborative model with FP or IM however seems reasonable if no psychiatrist is available to supervise prescribing.

Anyone know how this works with respect to reimbursement? I would imagine that the PCP who collaborates with the medical psychologist will want some pay for his or her services.

That said, I heard from Dr. Joseph Comaty, a medical psychologist in Louisiana, that the "MPs" there are using the same CPT codes for pharmacotherapy services as psychiatrists. Not sure if this equates to the same pay.

 

[f_w]

I would imagine that the PCP who collaborates with the medical psychologist will want some pay for his or her services.

I don't think that there is a particular reimbursement code for writing a script. In all likelihood a PCP would bill a regular E+M code for this service. The reimbursement depends on the level of services provided (new vs established patient, level of service).

 

[eddieberetta]

Excuse my ignormace -- what would the difference be (in terms of provided services) between a psychiatrist and a prescribing psychologist? If they are functionally identical, they in my opinion should pass the same board exams.

 

[PublicHealth]

Excuse my ignormace -- what would the difference be (in terms of provided services) between a psychiatrist and a prescribing psychologist? If they are functionally identical, they in my opinion should pass the same board exams.

Psychiatrist - Unlimited scope of medical/psychiatric practice including hospital admitting privileges and full formulary medical and psychiatric medication prescribing privileges.

Medical/Prescribing Psychologist - Limited formulary psychopharmacotherapy practice that must be conducted collaboratively with a primary care physician. No hospital prescribing privileges (yet). Sort of like a psychiatric PA/NP.

 

[sasevan]

Excuse my ignormace -- what would the difference be (in terms of provided services) between a psychiatrist and a prescribing psychologist? If they are functionally identical, they in my opinion should pass the same board exams.

Hi,
Medical psychologists won't be functionally identical to psychiatrists anymore than PCPs, currently the primary mental healthcare provider (from the perspective of the group that most prescribes psychotropic meds) are so to psychiatrists.
Med psychologists will likely take over the role of PCPs as the primary mental health pharmacologists while psychiatrists will remain the specialists treating, as now, the medically complicated cases, severely and persistentally mentally ill, refractory cases, inpatients.
Psych MD/DOs may also find a role in training/supervising psych PhD/PsyDs in the latter's new role as pharmacologists.
Med psychs may also use a different prescribing model, i.e., med mgm in the context of therapy.
Ultimately, I believe, patients will benefit from psychiatry cooperating with psychology in defining med psych scope of practice.

 

[PublicHealth]

Hi,
Medical psychologists won't be functionally identical to psychiatrists anymore than PCPs, currently the primary mental healthcare provider (from the perspective of the group that most prescribes psychotropic meds) are so to psychiatrists.
Med psychologists will likely take over the role of PCPs as the primary mental health pharmacologists while psychiatrists will remain the specialists treating, as now, the medically complicated cases, severely and persistentally mentally ill, refractory cases, inpatients.
Psych MD/DOs may also find a role in training/supervising psych PhD/PsyDs in the latter's new role as pharmacologists.
Med psychs may also use a different prescribing model, i.e., med mgm in the context of therapy.
Ultimately, I believe, patients will benefit from psychiatry cooperating with psychology in defining med psych scope of practice.

Sure, but what's the likelihood of this actually happening? The turf wars in states without psychologist RxP will likely go on for at least the next decade.

 

[sasevan]

Sure, but what's the likelihood of this actually happening? The turf wars in states without psychologist RxP will likely go on for at least the next decade.

Agreed; that's why I chose to undertake 10 more years of formal ed in order to guarantee that in a decade I will be able to provide pharmacotherapy.
RxP is going to take decades and med psychologists will never have the same training/scope as psychiatrists.

 

[PublicHealth]

Agreed; that's why I chose to undertake 10 more years of formal ed in order to guarantee that in a decade I will be able to provide pharmacotherapy.
RxP is going to take decades and med psychologists will never have the same training/scope as psychiatrists.

Do you really think it'll take decades? If California goes, it may expedite the process in other states. When optometry first obtained RxP in NY, it took ten years for all the other states to pass such legislation.

 

[Anasazi23]

Agreed; that's why I chose to undertake 10 more years of formal ed in order to guarantee that in a decade I will be able to provide pharmacotherapy.
RxP is going to take decades and med psychologists will never have the same training/scope as psychiatrists.

Hi Sasevan.
This is basically what it boils down to. That's why I eventually gave up some years and chose to do the same. I didn't feel like being a revolutionary for the rest of my life begging and hoping for still lower-level privilages when there was already an established method with superior training to do this.

I told myself that I was determined to never play second fiddle again to a more respected, higher paid, and more comprehensive health care leader if I could help it. This way, I'm ensured that I can write for whatever I want, conduct TMS therapy (on the way soon...lot of cool new data), perform ECT without legal battles, never worry about inferior training lawsuit threats, receive substantially higher pay, be much more marketable, have full access to established physician-only continuing education programs, have equal and full respect amongst my physician colleagues, write for non-psychiatric drugs as I saw fit to further help my patients, not worry about insurance coverage providing payment to non-physicians, have a comprehensive medical background so that I am fully versed with my patients' many, varied and often complex medical questions, work in psych C/L settings if I so chose without impunity, have full access to drug company samples to help patients who cannot immediately pay or have access to medications, have the peace of mind knowing that I can relocate to anywhere in the country knowing that great jobs are available, teach psychiatry at a university at physician level pay if I so chose, have full gamut of psychiatry APA approved fellowships should I want to pursue them (I do), and simply know that I went through the most extensive training available to 'do what I do.'

How's that for a run-on sentence?

 

[Doc Samson]

I don't see what the problem is with a psychologist diagnosing a patient and suggesting a psychotropic med to be subsequently approved or vetoed by a family doctor. This seems like a sensible way to fill in the current gaps in care.

Hey Norto... What happened to the rigorous evidence-based only approach to practice. This seems like an awfully cavalier statement when the only large studies of physician vs. non-physician prescribers (see anesthesia references above) indicate that there is, in fact, "a problem."

 

[PublicHealth]

Hey Norto... What happened to the rigorous evidence-based only approach to practice. This seems like an awfully cavalier statement when the only large studies of physician vs. non-physician prescribers (see anesthesia references above) indicate that there is, in fact, "a problem."

Apples and oranges. Show me more data that mid-levels achieve poorer outcomes than physician providers.

How are you going to have an "evidence base" for or even test the null hypothesis of purported inefficacy and ill-safety of psychologist prescribing when you're outright against the idea altogether? It is likely that medical/prescribing psychologists may achieve superior outcomes in treating psychiatric disorder given that they are more likely than psychiatrists to utlize combined pharmacotherapeutic and psychotherapeutic modalities of care. Combined pharmaco- and psychotherapy in mental health, we all know, has a rich evidence base.

 

[nortomaso]

Hey Norto... What happened to the rigorous evidence-based only approach to practice. This seems like an awfully cavalier statement when the only large studies of physician vs. non-physician prescribers (see anesthesia references above) indicate that there is, in fact, "a problem."

You feel that you can reasonably extrapolate a study on nurse anesthetists (as a replacement of MD anesthesiologist) to a collaborative practice between psychologist and MD family doc/internist? Family docs are no doubt worse than specialist at almost everything they do, but they serve a needed function in the absence of specialist in the regions in which they practice. I am making an assumption here that gyn care provided by a PCP is better than no gyn care, and that psych care provided by a PCP and psychologist is better than no psych care. I think this is a safe assumption, but you are right--why not study it empirically? If you can show that waiting 2 months to see a psychiatrist is more beneficial to the patient than receiving collaborative care, then I will change my tune.

 

[Doc Samson]

You feel that you can reasonably extrapolate a study on nurse anesthetists (as a replacement of MD anesthesiologist) to a collaborative practice between psychologist and MD family doc/internist? Family docs are no doubt worse than specialist at almost everything they do, but they serve a needed function in the absence of specialist in the regions in which they practice. I am making an assumption here that gyn care provided by a PCP is better than no gyn care, and that psych care provided by a PCP and psychologist is better than no psych care. I think this is a safe assumption, but you are right--why not study it empirically? If you can show that waiting 2 months to see a psychiatrist is more beneficial to the patient than receiving collaborative care, then I will change my tune.

I would estimate the current wait time for an appt with a psychiatrist (when you include teaching hospitals, which the psychology data never do) in the city of Boston at less than 1 week. And yes, I see very little difference between a psychologist under non-psychiatrist MD supervision, and a nurse anesthetist under non-anesthesiologist MD supervision.

 

[PublicHealth]

And yes, I see very little difference between a psychologist under non-psychiatrist MD supervision, and a nurse anesthetist under non-anesthesiologist MD supervision.

So then why are you in opposition of psychologist RxP?

 

[Solideliquid]

One thing I don't get: What's the point of a RxP psychologist working under a IM/FM PCP MD physician? That PCP/IM doc doesn't really know how to treat serious mental health problems anyway so what qualifies him/her to supervise a psychologist attempting to treat possibly complicated mental health issues?

 

[nortomaso]

I would estimate the current wait time for an appt with a psychiatrist (when you include teaching hospitals, which the psychology data never do) in the city of Boston at less than 1 week. And yes, I see very little difference between a psychologist under non-psychiatrist MD supervision, and a nurse anesthetist under non-anesthesiologist MD supervision.

DS:

1) you know quite well that Boston is one of the few cities in the US in which the market is oversaturated with psychiatrists.

2) "yes, I see very little difference between a psychologist under non-psychiatrist MD supervision, and a nurse anesthetist under non-anesthesiologist MD supervision." This is an interesting statement you make. I'm assuming the problem of a surgeon being the green light for the nurse anesthesthist is one of safety-- the surgeon doesn't have the pharm knowledge of an anesthesiologist. Is the problem with a non-MD psychiatrist also one of safety? Can an IM doc not be trusted to safely prescribe a psychotropic med? Or is it a problem of efficacy, i.e. knowing whether the psychologist is choosing the best drug for that patient? If the problem is merely the latter, then it seems to me that the whole issue comes back to the availability of psychiatric care and whether collaborative care is better or worse than none.

On a sidenote, anyone here from Stanford? When I visited there, I was interviewed by a psychologist who specialized in psychopharm. He was running one of the inpatient units at the Palo Alto VA. I'm wondering how that model works.