Medical Psychologists on path to getting prescribing privileges, AMA/APA oppose

[purpledoc]

You have got to be ****ing kidding me. This is the same kind of idiotic logic that NPs and CRNAs use to justify their independent scope of practice thats not regulated by doctors...

Hey, MacG. Think about using your intellect to make your points, not your temper. You might convince a few more people that way.

Peace.

---

Members don't see this ad.

 

[PublicHealth]

Hey, MacG. Think about using your intellect to make your points, not your temper. You might convince a few more people that way.

Peace.

Great point, purpledoc.

 

[PublicHealth]

Regardless of the RxP arguments, PhDs are not innately more generous, humanistic, and all around nicer people than MDs.

Maybe not, but they sure know how to outlobby psychiatrists!

 

[purpledoc]

Maybe not, but they sure know how to outlobby psychiatrists!

Ooooooooo. *SWAT*

Not to mention, psychologists also have the better APA webpage, and got the web address www.apa.org before our APA (thus leaving us with the easy to remember, yet not nearly as nifty, www.psych.org.) What can I say?

 

[prominence]

when is SDN going to close this stupid thread? move it to the psychology forum or something.

 

[purpledoc]

when is SDN going to close this stupid thread? move it to the psychology forum or something.

Huh? Prominence, this is one of the biggest topics that psychiatrists are talking about these days. I can't think of anything going on right now that may change our field more, in terms of both our scope of practice and our ability to work together with psychologists in relative peace and harmony to promote policies that might actually help people with mental illness.

Feel free to skip this thread if you'd rather stay out of the discussion, but I think a forum in which psychiatrists and psychologists can discuss this issue without causing each other physical harm is a very good thing.

Peace,
Purpledoc

 

[PublicHealth]

when is SDN going to close this stupid thread? move it to the psychology forum or something.

This "stupid thread" is discussing one of the most important issues in psychiatry and psychology. If you're a psychiatrist, psychiatrist-in-training, medical student, pre-med considering psychiatry, psychologist, psychologist-in-training, or pre-grad, this issue will affect you for the rest of your career.

Give it about 10 years, more than half of the U.S. states (if not most) will have psychologists prescribing psychotropic medications. New Mexico, Louisiana, and several other states are leading the charge. The train has left the station. Soon it'll be coming through your state. When it does, make sure you wave hello to all the good-looking psychologists.

 

[purpledoc]

Give it about 10 years, more than half of the U.S. states (if not most) will have psychologists prescribing psychotropic medications. New Mexico, Louisiana, and several other states are leading the charge. The train has left the station. Soon it'll be coming through your state. When it does, make sure you wave hello to all the good-looking psychologists.

Did I really say, "without causing each other physical harm?" What was I thinking?

Public, you're probably right, though I hope it will take longer than 10 years. I do still think that PhDs will practice in the same urban settings as MDs, that they will prescribe just as much as MDs, that they will happily accept "drug money" from the pharmaceutical monsters, and that the only difference between RxPhDs and MDs will be the increased risk to patients. This risk is increasing every year as more and more medications for every condition under the sun (statins, for example) are being used by patients, and MDs have to keep up with more and more information.

It does bother me that most RxPs won't even admit that there is an increased risk. They don't say, "Well, yes, patients won't get the same level of care as they would with MDs, but you know, it's worth it because there aren't enough MDs in rural areas and RxPs will work there." (Which I still don't think will happen, but at least it's possible.) They say, "We could do it better than MDs do it." Does anyone believe that optometrists do better at correctly diagnosing and treating eye problems than ophthalmologists? Who would you choose if you were worried about losing your sight?

PhDs are very intelligent in areas other than medicine. It will be easy for them to overestimate their abilities to practice medicine (and I do think prescribing is "practicing medicine") simply because they are used to doing other things well. How long do you think it will take for RxPs to start treating patients with multiple medical problems, or geriatric patients, or pediatric patients?

So, I've probably now ruined this burgeoning friendship (or at least, mutual respect-ship), but I am curious to hear your response. I am trying to keep an open mind, but dang, that god complex just keeps messing with my ears...

Peace,
Purpledoc

 

[Sanman]

As much as I'm loving this verbal sparring session I figured I'd add my two cents. As far as who would be better at the diagnosis, I truly do believe that it would be a toss up and up to the individual. I know of psychologists who definitely should prescribe and others who should not. I can say the same for psychiatrists. Certainly, psychiatrists ideally are better at prescibing. However, psych is a specialty in which some programs, especially in the northeast, aren't looking for the strongest medical backgrounds and there are certainly psychiatrists coming out of strong psychodynamic programs that may not be as strong in catching these general medical conditions than others. Psychiatry certainly can be a haven for weak medical students. I'm not trying to knock psychiatry, I'm just saying that neither profession is perfect and being a better prescriber is the decision of an individual. In the end, I feel that there is no right answer to the question of whether psychologists should have the right to prescribe, however it will be decided by who has the best lobbyists and not who is the best for the patient. I do agree that psychologists will be practicing in the same places as psychiatrists and that there are some that will prescribe just as much. I however think that some will not prescribe as much simply due to the comfort factor. I should also mention that I am neither a psychologist or a psychiatrist, so everything I say should be taken with a grain of salt seeing as how I haven't completed the education. Maybe Public can tell if he completes both the PhD and the MD.

 

[Sanman]

Also on a seperate note, for all those who feel that psychology is just trying to horn in on psychiatry by trying to prescribe, it cuts both ways. Neuropsychiatrists are looking at learning and working to administer neuropsychological test batteries. Everyone wants to be the first to do everything, so I guess the race is on.

 

[PublicHealth]

the only difference between RxPhDs and MDs will be the increased risk to patients. This risk is increasing every year as more and more medications for every condition under the sun (statins, for example) are being used by patients, and MDs have to keep up with more and more information.

It does bother me that most RxPs won't even admit that there is an increased risk. They don't say, "Well, yes, patients won't get the same level of care as they would with MDs, but you know, it's worth it because there aren't enough MDs in rural areas and RxPs will work there." (Which I still don't think will happen, but at least it's possible.) They say, "We could do it better than MDs do it." Does anyone believe that optometrists do better at correctly diagnosing and treating eye problems than ophthalmologists? Who would you choose if you were worried about losing your sight?

You cannot just assume that prescribing psychologists will pose an increased risk to patients and that the level of care they will provide will be inferior to that of psychiatrists. On what grounds do you make that assumption? Have you attended graduate school in clinical psychology or one of the postdoctoral training programs in clinical psychopharmacology? Have you discussed psychopharmacology or patient care with an RxPhD? If you had read the above posts and respective legislation, you would have learned that psychologists are seeking to be able to prescribe a limited formulary of psychotropic medications upon consultation with each patient's primary care physician. They do not seek to prescribe all available drugs on the market and do not want to practice the full scope of medicine!

You're a psychiatrist, so obviously you're biased toward this issue. Perhaps if we were all a bit more open-minded, read all the relevant documents, and considered and discussed the facts as opposed to speculations, we could have a more healthy debate.

PH

 

[Anasazi23]

When psychologists want to prescribe medications to a population that is notorious for having comorbid medical conditions, it is a decreased standard of care compared to physicians. I just can't believe that this is considered a legitimate debate.

I've been absent from these forums for the last few weeks since starting my psychiatry residency. I've had precious few minutes to spend on the computer, and am on call overnight frequently, often not returning until the following night. The amount of patient complexities that I've seen this past month were enormous. I'm constantly in the ER evaluating emergency admissions, frequently on the medical floor with senior residents making recommendations on complex medical patients, and see a very sick population on the inpatient unit whilst dealing with their related comorbid medical conditions. Despite my graduating medical school, having two full years of clinical and basic science didactics, two years of clinical medical rotations, passing national medicine board exams, etc, I and my fellow residents find ourselves challenged by both basic medical management of psychiatric patients, and their (non separate) concomitant psychiatric illnesses. Inpatients eventually become (in most cases) outpatients. To ask a psychologist to perform these same duties without having gone to medical school is simply dangerous and asinine.

Handing these patients over to another allied health profession for management, despite the "limited formulary" (which it isn't....reread the LA law), having no formal medical training simply results in a lower standard of care...period. The glossing-over of medical conditions provided by psychopharm classes given by RxP hotel institutions (I make this assumption based on topic list divided by time courses) combined with the embarrasingly short "practicum" is a different level of care. It's been said by me and others on this board but seems to fall on deaf ears repeatedly - psychopharm does not exist in a vacuum. These people have medical problems. At psychiatry's most basic level, a handy concise guide to drug interaction principles for medical practice which speaks of cytochrome p450s, UGTs and P-glycoproteins (Cozza, Armstrong & Oesterheld) is complex reading for the well-versed medical scientist. I cannot imagine reading it having to look up every third word for its basic meaning or implication to the purpose of the paragraph.

I agree that some basic prescribing such as sertraline is in most cases benign. I get very worried, however, when I see things such as the prescribing outline program that's been proposed for prescribing psychologists - such as a CL rotation. The natural implication of this is that psychologists will think it within their scope to practice as psychiatrists on medical floors. This is no less akin to having a fraudulent practitioner practicing medicine without a license and under false pretenses. Were it my family member hospital-rideen in a delirious state with comorbid medical conditions, I certainly wouldn't want someone without medical training evaluating and worse, attempting to treat them.

I think someone above made an allusion to this, but I also feel that in today's turbulent health care cost-cutting reality, it is a veritable race to the bottom. Who can we get to act as physicians with the least amount of training and who will work the cheapest? As also said above, it's about the almighty dollar.....it is this same dollar that is driving the current push for these "rights."

 

[purpledoc]

You cannot just assume that prescribing psychologists will pose an increased risk to patients and that the level of care they will provide will be inferior to that of psychiatrists. On what grounds do you make that assumption? Have you attended graduate school in clinical psychology or one of the postdoctoral training programs in clinical psychopharmacology? Have you discussed psychopharmacology or patient care with an RxPhD? If you had read the above posts and respective legislation, you would have learned that psychologists are seeking to be able to prescribe a limited formulary of psychotropic medications upon consultation with each patient's primary care physician. They do not seek to prescribe all available drugs on the market and do not want to practice the full scope of medicine!

You're a psychiatrist, so obviously you're biased toward this issue. Perhaps if we were all a bit more open-minded, read all the relevant documents, and considered and discussed the facts as opposed to speculations, we could have a more healthy debate.

PH

Sorry, Public, but like Anasazi said, the LA law does not include a limited formulary, nor does it give any age restrictions, if I recall correctly. I know for sure that the New Mexico law does not have any age restrictions. I have read many of the relevant documents -- of course, I can't say whether more or fewer than you have -- from both sides of the fence. I knew about the issue from the very beginning of the DoD trial, followed the issue in Guam, and have kept up on the literature since then, with very good knowledge of the DoD experiment and its significant limitations. My partner is a psychologist and APA member, and I am an active member of my APA, so I read both of our newspapers, newsletters, and websites and follow-up articles of interest. If you know of anything else I should be reading, feel free to let me know, but from what I've read in this forum (including everything you posted) I believe that my *knowledge* on this topic is at least as good as your own, even if my opinions are different.

As far as graduate school in clinical psychology, no, I haven't attended it. As I said, my partner is a psychologist, I have many friends who are, and I work in close consultation with a number of psychologists. In fact, when I opened practice, I took out a notice in the local psychological association newsletter that began, "Looking for a psychiatrist who actually returns phone calls?" If you ask my PhD collegues, who regularly refer pts to me and to whom I refer pts, I think you'll find that none of them questions my respect for their level of knowledge, and my respect for the work they do. I explain my prescribing choices in depth and let them know when I make changes. Many of them support RxPhD, and I have had many discussions with them on the topic.

At any rate, the implication that I do not have enough knowledge yet or am not open-minded enough to discuss this issue is simply a smokescreen. You'll notice that I am not cutting and pasting points from my APA's website; I am familiar enough with the topic to make my own points. Also, if you don't wish to talk about speculation, don't argue that you know what psychologists will do when they get prescribing privileges. No one knows that.

Feel free to post your own qualifications to discuss this topic, if you'd like.

In response to the "assumption" that prescribing psychologists will pose an increased risk to patients, it is a simple fact. I have no doubt that you would agree that the vast majority of psychiatrists trained with 200 hrs of doing neuropsychiatric testing would make more mistakes on giving tests and analyzing the results than the vast majority of psychologists. There is no possible way to argue that someone who goes to graduate school and does not even learn how to do a basic physical exam or evaluate vital signs, will be able to prescribe as well as a physician with four years of medical school full-time, and four years of residency at more than full-time.

Anyway, the main points in response to your message, are (1) psychologists are not seeking a limited formulary or limitations on types of patients they can treat; (2) prescribing medications is the practice of medicine; and finally, (3) people who have not gone to medical school and done a 4-yr residency are not as knowledgable about practicing medicine as those who have done so, and 200 hrs will not give them that knowledge -- just as the DoD psychologists with 7+ times the number of hours in classes plus a year of full-time psychiatry only reached the level of a 3rd or 4th yr medical student. Those are the facts.

Sincerely,
Purpledoc

 

[PublicHealth]

Sorry, Public, but like Anasazi said, the LA law does not include a limited formulary, nor does it give any age restrictions, if I recall correctly. I know for sure that the New Mexico law does not have any age restrictions. I have read many of the relevant documents -- of course, I can't say whether more or fewer than you have -- from both sides of the fence. I knew about the issue from the very beginning of the DoD trial, followed the issue in Guam, and have kept up on the literature since then, with very good knowledge of the DoD experiment and its significant limitations. My partner is a psychologist and APA member, and I am an active member of my APA, so I read both of our newspapers, newsletters, and websites and follow-up articles of interest. If you know of anything else I should be reading, feel free to let me know, but from what I've read in this forum (including everything you posted) I believe that my *knowledge* on this topic is at least as good as your own, even if my opinions are different.

As far as graduate school in clinical psychology, no, I haven't attended it. As I said, my partner is a psychologist, I have many friends who are, and I work in close consultation with a number of psychologists. In fact, when I opened practice, I took out a notice in the local psychological association newsletter that began, "Looking for a psychiatrist who actually returns phone calls?" If you ask my PhD collegues, who regularly refer pts to me and to whom I refer pts, I think you'll find that none of them questions my respect for their level of knowledge, and my respect for the work they do. I explain my prescribing choices in depth and let them know when I make changes. Many of them support RxPhD, and I have had many discussions with them on the topic.

At any rate, the implication that I do not have enough knowledge yet or am not open-minded enough to discuss this issue is simply a smokescreen. You'll notice that I am not cutting and pasting points from my APA's website; I am familiar enough with the topic to make my own points. Also, if you don't wish to talk about speculation, don't argue that you know what psychologists will do when they get prescribing privileges. No one knows that.

Feel free to post your own qualifications to discuss this topic, if you'd like.

In response to the "assumption" that prescribing psychologists will pose an increased risk to patients, it is a simple fact. I have no doubt that you would agree that the vast majority of psychiatrists trained with 200 hrs of doing neuropsychiatric testing would make more mistakes on giving tests and analyzing the results than the vast majority of psychologists. There is no possible way to argue that someone who goes to graduate school and does not even learn how to do a basic physical exam or evaluate vital signs, will be able to prescribe as well as a physician with four years of medical school full-time, and four years of residency at more than full-time.

Anyway, the main points in response to your message, are (1) psychologists are not seeking a limited formulary or limitations on types of patients they can treat; (2) prescribing medications is the practice of medicine; and finally, (3) people who have not gone to medical school and done a 4-yr residency are not as knowledgable about practicing medicine as those who have done so, and 200 hrs will not give them that knowledge -- just as the DoD psychologists with 7+ times the number of hours in classes plus a year of full-time psychiatry only reached the level of a 3rd or 4th yr medical student. Those are the facts.

Sincerely,
Purpledoc

I'm impressed.

Unfortunately, we still need data, and your and my posts in this internet chatroom are not going to affect psychologist RxP legislation in any way.

By the way, psychologists don't do neuropsychiatric testing...whatever the hell that is.

 

[Svas]

It's hard for me to say this, MacGyver, but anything insightful you have to say is probably going to be overlooked because of the venom that surrounds your style. I know that I tend to read your posts in a skimming fashion & don't give them much time because of what comes off as mostly "so much adolescent foot stomping."

When I was early in practice, a wise old psychoanalyst told me that I would become a good psychiatrist because I was smart, articulate, and good at pissing people off. He then told me that I could become a great psychiatrist is I could also master why I pissed people off.

He was right. It took me far longer to understand what was happening in me and why I used it the way I did.

Can I suggest the same thing to you without sounding condescending? I really don't mean to come off that way, but don't know how to say this any more politely.

S

You have got to be ****ing kidding me. This is the same kind of idiotic logic that NPs and CRNAs use to justify their independent scope of practice thats not regulated by doctors.

When you give someone an SSRI, the method of action WORKS THE SAME, regardless of if you are a psychologist or psychiatrist. Dont feed us this bull**** that medications given by a psychologists are somehow different than when a psychiatrist gives them.

This is the same kind of bull**** logic that nurses use all the time. For example, when an NP does a lumbar puncture, its supposedly under a "nursing" model, whereas when an internist does it, its under a "medical" model and therefore there is some kind of magical distinction to be made. Of course this distinction is bull****, and it serves as an attempt to set up an artificial platform for nurses to do the same procedures as doctors, WITHOUT the doctors having any say over the scope of practice.

 

[Svas]

Public -

Do I need to tell you that this sort of thing is EXACTLY what no one needs. If we want to use this as a forum for an intellectual debate, then there's much mileage to be gained.

Please reconsider this style so that we can reap better results. You have much to learn and much to teach. It won't help you if your current style results in no one wanting to be involved with you to do either.

Thank you.

S

I'm impressed.

<Snipped>

By the way, psychologists don't do neuropsychiatric testing...whatever the hell that is.

 

[Svas]

Anyway, the main points in response to your message, are (1) psychologists are not seeking a limited formulary or limitations on types of patients they can treat; (2) prescribing medications is the practice of medicine; and finally, (3) people who have not gone to medical school and done a 4-yr residency are not as knowledgable about practicing medicine as those who have done so, and 200 hrs will not give them that knowledge -- just as the DoD psychologists with 7+ times the number of hours in classes plus a year of full-time psychiatry only reached the level of a 3rd or 4th yr medical student. Those are the facts.

In terms of the DoD document, the comment that the DoD grads generally were seens as having the knowledge of 3rd or 4th years students was an interesting perspective. I commented in an earlier post that I saw the psychologists with RxP training very differently. In terms of "psychiatry," I believe that they were easily as well trained, but were weaker in general medical knowledge. For instance, I'd never let one perform an appendectomy on me. For that matter, I'd hesitate to let a psychiatrist do it . . . but I think that the psychiatrist would probably have a better chance of doing it correctly and without killing me.

Now, because the latter is true, does that make the psychiatrist better at practicing mental health medicine? I think this is the essence of the contention.

Does the current platform of training of psychologists make for a better foundation for being a doctor of mental health (adding medical training to prescribe), or is the current medical training the better foundation (adding psychological training to allow for psychological interpretation and therapy).

I'm just one person with an opinion, but I am of the growing position that there is room for both (and that there was some evidence of bias in the DoD report). Otherwise, why would the military be continuing to accept new prescribing psychologists and be funding the training of several as we speak?

Svas

 

[purpledoc]

I'm impressed.

Unfortunately, we still need data, and your and my posts in this internet chatroom are not going to affect psychologist RxP legislation in any way.

By the way, psychologists don't do neuropsychiatric testing...whatever the hell that is.

Well, I guess the intellectual part of this debate is over. As for the "not going to affect psychologist RxP legislation," well, that's not always the main point of a public intellectual debate. Political discussions are often 1-on-1, and they may not have enormous effects on the election, but if they get people to think, that's worthwhile. I'm guessing that a number of MDs/PhDs are at least noticing the discussion and forming opinions, even if they don't add to the thread.

Oh, and "by the way," UCLA has a neuropsychiatric institute. There is also a Journal of Neuropsychiatry and Clinical Neuroscience, one of several well-respected journals that include the term -- just FYI.

 

[PublicHealth]

Well, I guess the intellectual part of this debate is over. As for the "not going to affect psychologist RxP legislation," well, that's not always the main point of a public intellectual debate. Political discussions are often 1-on-1, and they may not have enormous effects on the election, but if they get people to think, that's worthwhile. I'm guessing that a number of MDs/PhDs are at least noticing the discussion and forming opinions, even if they don't add to the thread.

Oh, and "by the way," UCLA has a neuropsychiatric institute. There is also a Journal of Neuropsychiatry and Clinical Neuroscience, one of several well-respected journals that include the term -- just FYI.

Great points. I concur completely. Let's put aside our slanderous comments and resume intellectual debate. Emotions all too often have a way of fueling debates such as this one, so I think it's good that we took a couple days to cool off a bit.

By the way, I am aware of UCLA's Neuropsychiatric Institute and JNCN. Rest assured that it's OK to admit to a typo. We all know that you meant to say "neuropsychologic testing," as no psychologists, to my limited knowledge, do neuropsychiatric testing.

That being said, I'd be curious to know what purpledoc, Svas, and others involved in this discussion think about current curricula in postdoctoral Master's Degree programs in Clinical Psychopharmacology.
Here's an example: http://www.alliant.edu/download/2003/pubs/RxPMD.pdf

How, if at all, can these programs be improved? Which other courses or practica do you recommend? Should postdoctoral clinical psychology programs be restructured?

Do you recommend restructuring existing curricula in PhD/PsyD programs in clinical psychology? How about entrance requirements to PhD/PsyD programs in clinical psychology?

 

[purpledoc]

I just have to ask a question. Public, I read on another thread in the psychology forum that you are planning (or at least were at the time your post was written) to go to medical school. Would you mind explaining why? Does it have to do with the PxPhD issue, or something else entirely?

I am honestly just asking out of curiousity, not as some sort of underhanded attack on psychologist prescribing. Feel free not to answer if the reason is personal.

 

[PublicHealth]

I just have to ask a question. Public, I read on another thread in the psychology forum that you are planning (or at least were at the time your post was written) to go to medical school. Would you mind explaining why? Does it have to do with the PxPhD issue, or something else entirely?

I am honestly just asking out of curiousity, not as some sort of underhanded attack on psychologist prescribing. Feel free not to answer if the reason is personal.

My goal is to become a comprehensive behavioral healthcare provider. I'd like to train in both psychotherapy and psychopharmacotherapy. I also have an interest in clinical research in psychiatry and psychotherapy process and outcome. For these reasons, I have decided to pursue somewhat of a non-traditional educational program -- PhD in clinical psychology and neuropsychology and MD/DO with residency training in psychiatry.

Now that I've been "exposed," you can go ahead and suggest to the readers of this forum that I am not qualified to have an opinion regarding psychology RxP.

How would you reply to the questions about postdoctoral psychopharmacology training posed above?

 

[sasevan]

My goal is to become a comprehensive behavioral healthcare provider. I'd like to train in both psychotherapy and psychopharmacotherapy. I also have an interest in clinical research in psychiatry and psychotherapy process and outcome. For these reasons, I have decided to pursue somewhat of a non-traditional educational program -- PhD in clinical psychology and neuropsychology and MD/DO with residency training in psychiatry.

Now that I've been "exposed," you can go ahead and suggest to the readers of this forum that I am not qualified to have an opinion regarding psychology RxP.

How would you reply to the questions about postdoctoral psychopharmacology training posed above?

Hey PH, Svas, Sanman, Purpledoc, Anasazi23, et al.,

Thanks for continuing to promote a discussion of this critical issue in mental healthcare.

Special thanks to you PH for really putting yourself on the line in this forum.

I have been super busy completing my psychology residency, passing the nat'l and state psych lic exams, obtaining professional employment, and commiting myself to completion of my pre-med reqs by this time next year.

PH,
I'm glad that you're going to pursue both psychology and psychiatry; its going to be a long haul but its doable.
Maybe one day we can develop a psych MD/DO-PhD/PsyD program; BTW there's already an MD/PsyD at the Medical University of the Americas, Nevis, West Indies.

Sanman,
What are you up to these days? Are you considering the combined route as well?

Svas and Purpledoc,
I'd really like to hear from both of you a reply to PH's questions as to whether (and why) current post-doctoral MS psychopharm are (or, are not) adequate training for PhD/PsyDs to become safe and competent psychopharmacotherapist.

Purpledoc,
You mentioned that your partner is a psychologist; I was wondering if the two of you share similar views on RxP. I know a psychologist who is involved in the RxP movement whose partner is a psychiatrist.

Anasazi23,
Congratulations on starting your psychiatry residency!!!

Random Rumblings:

The idea that one MUST go to med school in order to become a pharmacotherapist is no longer a tenable position as there are plenty of safe and competent non-physician prescribers (e.g., DDS/DMD, OD, DPM, PA, NP).

IMHO, the real issue is what training should PhD/PsyD receive in order to gain RxP.

psych.org opposed and continues to oppose the expansion of the DoD program.
I believe this results in the indefensible claim on the part of psychiatrists that psychologists cannot be prescribers because they are just not trained to be prescribers.
How can psychologists gain emergency, inpatient, detox, C-L, etc experience if they are not allowed to do so in psychiatry programs and psychiatrists are trying to block psychology programs from doing so? Isn't this a circular argument? Psychologists can't be allowed to prescribe because they lack proper training and psychologists can't be properly trained because they are not physicians.

IMHO, it would serve psychiatry well to partner with psychology in developing and implementing a fair and adequate training program. As a future psychiatrist I don't want to see my discipline exclusively relegated to hospital settings, which is what I believe will happen to psychiatry if it continues to attempt to obstruct psychology from RxP. Psychologists will just partner with non-psychiatric physicians in primary care clinics and non-mental health specialty clinics, resulting in psychologists becoming in effect the principal mental healthcare providers. This is not just conjecture; it was the successful strategy employed in LA.
IMHO, the biggest threat to psychiatrists are not medical psychologists but family medicine, internal medicine, and other primary care physicians. If psychologists successfully partner with PCPs to whom they have been driven because of the obstinancy of psychiatrists it will probably result in the very thing that psychiatrists have been fearful of happening if psychologists gained RxP, i.e., the demise of psychiatry.
IMHO, psychiatrists should not be threatened by the few medical psychologists who will be the product of current psychopharm programs but rather should be concerned about the partnering of clinical and health psychologists with PCPs.

I say that few med psychs will result from curent psychopharm programs because according to the apa.org the psychology prescribing model is and will remain very different from the psychiatry one.
Even after psychology gains RxP it will only employ a few practitioners as prescribers since med psych will be a sub-specialty akin to neuropsych.
The overwhelming number of cl psychs are not neuro nor forensic, etc. The majority of cl psychs are general practitioners. Psychology envisions a future wherein most cl psychs are the ones who do psychological assessments and psychotherapy while neuropsychs, forensic psychs, med psychs do in addition to the aforementioned the specialized evaluations/treatments pertinent to their sub-specialty field. Thus, med psychs, who will be the only ones exercising RxP, will remain a small minority among psychologists unlike psychiatrists who are all trained and expected to function as psychopharmacotherapists whether or not they function as psychotherapists.

OK, enough for now. I have a Bio final test in a few hours.
Peace.

 

[purpledoc]

My goal is to become a comprehensive behavioral healthcare provider. I'd like to train in both psychotherapy and psychopharmacotherapy. I also have an interest in clinical research in psychiatry and psychotherapy process and outcome. For these reasons, I have decided to pursue somewhat of a non-traditional educational program -- PhD in clinical psychology and neuropsychology and MD/DO with residency training in psychiatry.

Now that I've been "exposed," you can go ahead and suggest to the readers of this forum that I am not qualified to have an opinion regarding psychology RxP.

How would you reply to the questions about postdoctoral psychopharmacology training posed above?

I have no intention to suggest to anyone that you are not qualified to have an opinion regarding RxP, anymore than I am unqualified. I mean, who really is fully "qualified" except people who have completed both medical school and graduate school in psychology? I look forward to hearing your opinions after you complete your psychiatry training. I really was just curioius.

As far as the Alliant program that you suggested we read, I can only say that it actually supports my fears:

(1) It continues the double-speak doctor-bashing of RxPhD proponents; that PCPs have "neither specialized training in mental health nor sufficient time to evaluate mental health needs," yet that PhDs will be safe to prescribe because they will be working with PCPs. Huh? If the PCP doesn't know enough about the medications the PhD would be prescribing, how exactly is that "safe"?
By the way, I diagnosed hyperammonia in a patient this week who has both a very nice PCP and a liver specialist -- feel free to use the "snoring person" smiley again, if you wish.

(2) "Pharmacotherapeutics," a course designed to teach you when to use psychotherapy and when to prescribe medications, is 12 hours. Twelve hours for something that is the most critical decision in daily clinical practice with both existing and new patients? It's as absurd as 12 hrs to teach PhDs which neuropsychological test to use, or which therapeutic modality to use.

I would love to go on, but unfortunately I don't have time right now -- I will try to write more shortly about this and sasevan's comments, as well.

Peace,
Purpledoc

 

[Sanman]

Hey sasevan,
Right now I'm getting ready to start applying to grad school. As far as the combined route, I'll leave that decision to when I am at your juncture. There are too many personal and financial considerations for me to decide that quite yet, however I am looking for programs with a strong biological/physiological orientation in the mean time. It certainly allows for much more complete and well rounded education, if not a painstakingly long one.

It continues the double-speak doctor-bashing of RxPhD proponents; that PCPs have "neither specialized training in mental health nor sufficient time to evaluate mental health needs," yet that PhDs will be safe to prescribe because they will be working with PCPs. Huh? If the PCP doesn't know enough about the medications the PhD would be prescribing, how exactly is that "safe"?

Purpledoc,
In my opinion, the point of view being expressed by those that believe that a psychologist/ PCP combo is better because the PCP may not know the medication to be used in combination with which therapy would provide the best results, that would be where the psychologist's knowledge works best. However, a PCP is stil quite competent in catching drug interactions, possible medical complications of the meds, etc. And yes psychiatrists are certainly capable of doing this in a perfect world, but this world is far from perfect. How many doctors are there, PCP or psychiatrist that don't inform the therapist of the medical treatment of the patient and vice versa with the therapist not communicating with the doctor. The idea being that if the prescription priveleges were given to the therapist in coordination with the PCP it would facilitate a better continuity of care. There are many people to blame for this situation. Among them PCP's, who are prescribing the meds. instead of referring to psychiatrists. The many psychiatrists who chose to remove continuity of care in favor of making more money by dropping therapy and sending patients to others for it, thereby giving PCP's the ability to do the same and completely cut out the psychiatrist. And yes, there are overzealous psychologists who are perhaps making the same mistakes because they are afraid to be squeezed out of practice by insurance companies. This is not a simple psychology vs. psychiatry issue. Purple, you continue to mention the all of the general medical conditions you are catching thatothers did not. Well ask youself this, if you are just doing med checks and catching comorbid conditions, what unique treatments are you as a psychiatrist offering your patients? Or are you simply a GP, and it sounds like a good one, with more extensive knowledge of psychiatric medications. Mind you this if you are in private practice and doesn't apply nearly as much to hospital based psychiatrists.

 

[mdblue]

Sanaman and PH,
Good luck w/ your endeavors. I do feel you will revise your opinions after you have gone thru 4 yrs of med-school, when you will appreciate the intricate pathophysiology of human body. Hopefully you will then understand that you can't possibly pick up human brain as an isolated organ system and treat it's dysfunction. Right now it is "ignorance is confidence".

 

[purpledoc]

Purpledoc,
In my opinion, the point of view being expressed by those that believe that a psychologist/ PCP combo is better because the PCP may not know the medication to be used in combination with which therapy would provide the best results, that would be where the psychologist's knowledge works best. However, a PCP is stil quite competent in catching drug interactions, possible medical complications of the meds, etc.

OK. So doesn't it make sense that psychologists, with the expertise in psychiatric diagnosis, should give the PCP their clinical impression like any other consultant, and let the physician prescribe the medications?

Honestly, it would be a lot easier for me to go ahead and prescribe lactulose (the treatment of choice) when I diagnose hyperammonemia, rather than fax the labs to the PCP and call her so that she can prescribe the medication. However, I know enough not to prescribe outside of my expertise except in dire emergencies, because there are probably lots of ways I could mess up. So, I know that it is an inconvenience for psychologists to call someone else to prescribe a medication, but it is no different than when I refer a patient to an endocrinologist to prescribe thyroid medication, even when I'm the one who made the diagnosis.

And yes psychiatrists are certainly capable of doing this in a perfect world, but this world is far from perfect. How many doctors are there, PCP or psychiatrist that don't inform the therapist of the medical treatment of the patient and vice versa with the therapist not communicating with the doctor. The idea being that if the prescription priveleges were given to the therapist in coordination with the PCP it would facilitate a better continuity of care.

But why would it facilitate better continuity of care? How many therapists now call their patient's PCP to discuss the person's psychiatric diagnosis, except when they want the PCP to prescribe something? Why would therapists who win the right to prescribe independently call PCPs more, since they won't need to call at all?

There are many people to blame for this situation. Among them PCP's, who are prescribing the meds. instead of referring to psychiatrists.

I agree, at least for patients with complex psychiatric issues; they should be able to do basic psychiatric treatment just as well as they can do basic cardiology.

The many psychiatrists who chose to remove continuity of care in favor of making more money by dropping therapy and sending patients to others for it, thereby giving PCP's the ability to do the same and completely cut out the psychiatrist.

...Some of whom are only paid by managed care companies for psychopharm visits and not for psychotherapy visits.

And yes, there are overzealous psychologists who are perhaps making the same mistakes because they are afraid to be squeezed out of practice by insurance companies. This is not a simple psychology vs. psychiatry issue.

Agreed.

Purple, you continue to mention the all of the general medical conditions you are catching that others did not. Well ask youself this, if you are just doing med checks and catching comorbid conditions, what unique treatments are you as a psychiatrist offering your patients? Or are you simply a GP, and it sounds like a good one, with more extensive knowledge of psychiatric medications. Mind you this if you are in private practice and doesn't apply nearly as much to hospital based psychiatrists.

I think that's the point, though. (And thanks for the compliment!) A psychiatrist is trained as a GP along the way. We learn how to treat heart conditions, infections, liver problems...etc etc etc. Even the worst psychiatrist has had to finish medical school, pass board exams x3 in general medicine (including ob/gyn, cardiology, hematology, oncology...etc) to get a medical license, and do a medical internship. Do we forget some of our knowledge? Sure. But basically, we are general practitioners who specialize in psychiatry.

I don't think I'm offering any unique treatment other than taking a really good history, which is 95% of diagnosis, as any GP will affirm. The rest is just observation. Calling an appointment with a psychiatrist a "med check," is an unfortunate term that subtly denigrates what psychiatrists do when they practice medicine. How many people describe visits with cardiologists to follow their heart condition as "med checks"?

Thank you for the thought-provoking questions. It really is an interesting discussion.

Peace,
Purpledoc

 

[Anasazi23]

How can psychologists gain emergency, inpatient, detox, C-L, etc experience if they are not allowed to do so in psychiatry programs and psychiatrists are trying to block psychology programs from doing so? Isn't this a circular argument? Psychologists can't be allowed to prescribe because they lack proper training and psychologists can't be properly trained because they are not physicians.

Hi....

I understand what you're saying. However, the sub-disciplines of psychiatry that you mention above in particular, especially C-L, emergency and inpatient...well detox too have very heavy medical components to them. I think more than most psychologists may realize. In fact, people do entire year-long separate fellowships in CL and addiction in order to feel confident doing this routinely. I think psychiatrists get nervous when you can say that a psychologist, after a training course, can do not only all this, but prescribe to children and geriatric patients (many psychiatrists wouldn't touch children pharmacotherapeutically with a 10-foot pole).

When I read thing like Public posted about Alliant's course curriculum, I just raise my eyebrows when they say that they can teach you to learn how to read CTs, MRIs, eegs, ekg's etc in one course. I, like all residents, have had at least some formal training in radiology, cardiology, and the like. I've been reading ekgs for a few years now, and still feel somewhat unconfident about interpreting them for fear of missing something vital, despite all I know about cardiac physiology, cardiopathology, and cardiopulmonary medicine. It takes more than just looking at the top of the page and see a QtC value of 489 and say it's ok to start ziprasidone.

I wish you good luck on your Bio test!!!

 

[Svas]

I think psychiatrists get nervous when you can say that a psychologist, after a training course, :

I think that in order to be fair, we have to stop calling this "a training course" and call it what it is: a graduate degree in psychopharmacology.

If we don't think it adequately prepares folks, fine. But there's no way what these psychologists are doing could be equated with "a training course."

Personally, I think that they'll probably do as well or better than psychiatric nurses with the addition of the training at places like Nova.

S

 

[PublicHealth]

I think that in order to be fair, we have to stop calling this "a training course" and call it what it is: a graduate degree in psychopharmacology.

If we don't think it adequately prepares folks, fine. But there's no way what these psychologists are doing could be equated with "a training course."

Personally, I think that they'll probably do as well or better than psychiatric nurses with the addition of the training at places like Nova.

S

Great point, Svas.

You mentioned that psychologists will probably do as well or better than psychiatric nurses once they obtain an M.S. in Clinical Psychopharmacology. Are you suggesting that these programs train psychologists in the nursing model? Also, how would the training of a Ph.D./Psy.D. clinical psychologist with an M.S. in Clinical Psychopharmacology differ from a Ph.D./Psy.D. clinical psychologist with an M.S.N./A.P.R.N. + specialization in psychiatry?

 

[PublicHealth]

THE PRESCRIPTION JIHAD:

http://www.psychiatrictimes.com/p010720.html

Commentary: The Prescription Jihad
by Ali Hashmi, M.D.
Psychiatric Times July 2001 Vol. XVIII Issue 7

I was compelled to pen this piece after reading yet another opinion on the fierce psychologist-prescribing debate in the Feb. 3 issue of Psychiatric News.
Before I go any further, some disclosures are in order. I am a psychiatrist, employed by a community mental health center in Arkansas, in a 100% outpatient practice. I am one of four psychiatrists (three specializing in the treatment of adults and one in child psychiatry) employed by our center, and we serve a catchment area of seven counties with a combined population of approximately 200,000. Despite having trained in a traditionally psychoanalytic program at Baylor College of Medicine, I was always more comfortable with medication evaluations and with what today would be called the biological aspect of psychiatry. I do very little therapy per se, apart from supportive therapy, some crisis intervention and education. I do, therefore, have a vested interest in keeping prescribing privileges out of the hands of non-physicians.

Having said that, I find it more than a little amusing when I hear all kinds of high-minded arguments being bandied about over what is obviously an economic issue. To quote from the above-mentioned article by Jan Leard-Hansson, M.D., "To prescribe medication properly the physician must know the patient from head to toe?We, as psychiatric physicians, must maintain a steadfast commitment to protecting and providing high-quality patient care."

Admirable sentiments indeed, but when was the last time Leard-Hansson, or any of us, did a rectal examination on a patient? Or auscultated their chest? Or palpated their lymph nodes or liver? Even my colleagues who work in hospital settings routinely defer physical examination to their internal medicine or family practice consultants. The simple truth of the matter is that sub-specialization, by definition, means that most of us lose some of the skills that we learned in medical school, primarily those that we do not use on a regular basis. I know that I would have a tough time picking up a murmur on a chest exam or appreciating a subtle physical finding. It is, therefore, more than a little disingenuous to claim that we, as psychiatrists, know our patients from head to toe. The day-to-day practice of our art demands, in fact, that we concentrate on certain areas and de-emphasize others, referring patients to others with more expertise when necessary. Surely, I find it easier to examine a routine blood report and pick up obvious abnormalities or interpret the results of a computed tomography or magnetic resonance imaging scan, but those are skills that can be learned with time.

Coming back to the main topic of non-physician prescribing, the arguments being put forward by both camps (i.e., physicians and non-physicians--mainly psychologists but soon to be joined, I am sure, by social workers and other clinical personnel) are similar. Each side accuses the other of being petty and money-grubbing, while claiming the moral high ground for themselves.

 

[PublicHealth]

CONTINUED...

The Psychiatrists

Psychiatrists claim that the whole psychologist-prescribing effort was born of the drive toward managed care. Managed care organizations are increasingly driving down the rates of reimbursement for both therapy and psychological testing, while farming out therapy to ancillary (read "cheaper") clinical staff such as licensed certified and master's level social workers and associate counselors, or even counselors with only a bachelor's degree.

The managed care trend has also put psychologists in the uncomfortable position of feeling like a fifth wheel relegated to doing psychological and neuropsychological testing, which may also one day be delegated to even less costly technicians. Prescribing ability would ensure a more reliable income stream for psychologists. In addition, prescribing is much less labor intensive than therapy or testing.

The psychiatric community claims, with some justification, that this is uncomfortably similar to the top of a slippery slope. What is next? Prescribing privileges for social workers, marriage, family and child counselors, case managers, and mental health technicians? Where does it stop?

Psychiatrists argue that they oppose this effort purely for the sake of their patients and with the purest motives at heart. (I am exaggerating, of course, but you get the gist.) Psychiatrists are resistant to psychologist prescribing because non-physicians would have a greater risk of missing crucial side effects, drug interactions and co-existing medical conditions, thereby leading to increased morbidity and mortality. There is something to be said for this concern, but it requires a greater leap of faith. Have none of us psychiatrists ever had any patients with bad outcomes? Of course we have, but one learns and moves on and, presumably, non-physician prescribers could do the same.

The Psychologists

Psychologists, on the other hand, claim that managed care organizations are increasingly restricting access to psychiatrists, preferring that psychopharmacological management is done by primary care physicians.

Also, thanks to managed care, Medicare and the Health Care Financing Administration, recent graduates from psychiatric residency training programs are well-versed in medication evaluation and management but are increasingly unaware of, and uninterested in, therapy skills. This makes psychiatrists little more than "dispensers," diagnosing people through DSM-IV checklists and prescribing the recommended medications according to various algorithms--something that can be done by a simple computer program, and for much less cost than using human dispensers. The move away from trying to understand the inner lives of people and learning how their relationships, families and feelings impact their illness makes today's psychiatrists increasingly expendable and replaceable by family physicians who can do the necessary prescribing while also caring for day-to-day illnesses. Psychologists argue, with some justification, that psychiatrists are already obsolete or will be in short order.

Also, unlike oncological chemotherapy, invasive cardiology or neurosurgery, for example, psychopharmacology is hardly rocket science. There are a limited number of agents, with most belonging to two or three major classes with similar efficacy and side-effect profiles. The safety margins--especially for the newer agents--are wide, with even large overdoses rarely proving fatal. In addition, the proponents of the psychologist-prescribing effort point out that the recently discontinued U.S. Department of Defense program has demonstrated that non-physicians with appropriate training can be just as effective and safe as physicians.

However, psychologists argue that they want prescribing privileges not for the crass purpose of making more money, but because the result would be an increase in the availability of qualified psychopharmacologists in rural areas where the need is still great. This argument flies in the face of several recent papers that have pointed out that, traditionally, doctorate level psychologists tend to cluster in big cities usually in and around universities.

It is the psychologists and their supporters, some say, who are the noble warriors in this crusade, battling against those dastardly psychiatrists (again, I exaggerate, but you get the gist).

Conclusions

As can be seen, there are valid arguments from both sides, and both sides have a vested economic interest in the outcome, which is usually unacknowledged. From personal experience, I have spoken to a number of psychologists on this issue, none of whom were enthusiastic about prescribing. These are qualified, competent people who do therapy, psychological testing, disability evaluations and some administrative work and are well-satisfied with what is on their plate. Most of them were of the opinion that the added monetary benefits of prescribing were not worth the additional risks of making decisions about people's suicidality, proneness to violence and other issues of potential medicolegal consequence, such as the use of psychotropics in pregnancy. They were more than happy to defer such decisions to the physician.

An added disincentive is the attendant deluge of drug-seeking patients, such as those with ill-defined physical conditions (i.e., chronic back pain, fibromyalgia, chronic fatigue) or others with intractable personality disorders who demand benzodiazepines, pain medications and the like. I see a large proportion of such patients in my day-to-day practice, and they are usually the ones I dread.

There are others who are either on, or in the process of applying for, disability. There is, of course, no hope that any of them will ever improve, since substantial improvement would mean loss of benefits. It's like walking on a treadmill. No matter how long you walk, you stay in exactly the same place.

Of course, I practice in a rural area where there are generally more patients than qualified practitioners. The situation is likely different in larger cities where there may be a large number of practitioners and where competition for patients may be fierce.

On the other hand, I have at times wished that there were more of us, simply because the need appears so great. The number of people needing care, from nursing home patients to adults to schoolchildren, means that most of us are booked up to six weeks or more in advance, and at times some extra help would be welcome. Just as family practice doctors often have nurse practitioners or physician assistants who can prescribe under supervision, perhaps a similar system could be devised for non-psychiatric prescribers. The quality and knowledge base would likely vary widely, but in the long term, self-selection would eliminate those with obvious deficiencies.

I think prescribing privileges for non-physician personnel are inevitable at some point. If such practitioners would cost less than psychiatrists, you can be sure managed care will be the first to jump on the bandwagon. As psychiatrists, our choice is not between having or not having non-physicians prescribe psychotropics. Our challenge is to engage in this process in a way that is productive and non-confrontational. In the long term, as with managed care, we will gain more by being active and shaping the debate rather than being isolated behind the ramparts of our self-righteousness, firing off shots in the dark.


Dr. Hashmi is a board-certified psychiatrist practicing at Mid-South Health Systems, a community mental health center in Jonesboro, Ark.

 

[Tenesma]

hmmmm... i used to teach psychopharm to clinical psych. PhDs (for their grad degree)... it was 10 lectures, of which 4 were spent just explaining pharmacokinetics.... but there is more to it than that.... do they get taught how to recognize the symptoms of SIADH? or do they learn the interactions with other drugs and the suggested management of that? (ie: SSRIs and beta-blockers)? no....

this is akin to naturopaths prescribing drugs in arizona... dangerous

 

[PublicHealth]

hmmmm... i used to teach psychopharm to clinical psych. PhDs (for their grad degree)... it was 10 lectures, of which 4 were spent just explaining pharmacokinetics.... but there is more to it than that.... do they get taught how to recognize the symptoms of SIADH? or do they learn the interactions with other drugs and the suggested management of that? (ie: SSRIs and beta-blockers)? no....

this is akin to naturopaths prescribing drugs in arizona... dangerous

Newsflash: Clinical psychologists seeking prescription privileges have to complete a postdoctoral Master's degree in Clinical Psychopharmacology, which consists of coursework and clinical practica, and pass a licensing exam before being able to prescribe. The psychopharmacology "curriculum" that you described is a far cry from the actual postdoctoral training that clinical psychologists have to complete prior to gaining prescription privileges. Even at that, only two states have passed such legislation to date.

A link to the curriculum for an M.S. in Clinical Psychopharmacology is posted above. I'd welcome your critique of the curriculum and recommendations for improving it.

 

[sasevan]

Hi....

I understand what you're saying. However, the sub-disciplines of psychiatry that you mention above in particular, especially C-L, emergency and inpatient...well detox too have very heavy medical components to them. I think more than most psychologists may realize. In fact, people do entire year-long separate fellowships in CL and addiction in order to feel confident doing this routinely. I think psychiatrists get nervous when you can say that a psychologist, after a training course, can do not only all this, but prescribe to children and geriatric patients (many psychiatrists wouldn't touch children pharmacotherapeutically with a 10-foot pole).

When I read thing like Public posted about Alliant's course curriculum, I just raise my eyebrows when they say that they can teach you to learn how to read CTs, MRIs, eegs, ekg's etc in one course. I, like all residents, have had at least some formal training in radiology, cardiology, and the like. I've been reading ekgs for a few years now, and still feel somewhat unconfident about interpreting them for fear of missing something vital, despite all I know about cardiac physiology, cardiopathology, and cardiopulmonary medicine. It takes more than just looking at the top of the page and see a QtC value of 489 and say it's ok to start ziprasidone.

I wish you good luck on your Bio test!!!

Hey Anasazi23,
Thanks for the wishes; I did well on the test and the class.
Planning on finishing my pre-med reqs, taking MCAT, and applying to med school by this time next year and hopefully entering med school a year after that.
Currently, I'm taking a break from ed/training but will soon be working part-time at a clinical psychology site and also at a forensic one.
My psychology residency officially concluded on 7/30/04; I hope to be a licensed psychologist by 9/04.
How's your psychiatry residency going?

I know that C-L, addiction, pediatric, and geriatric psychiatry are sub-specialties (didn't know that emergency and inpatient were, though) but from what I understand a fellowship in a sub-specialty is NOT a requirement for a licensed psychiatrist to legally work with that sub-specialty population. Please correct me if I'm wrong.
I also know that medical school and psychiatric residency are intended to teach physicians-in-traning how to rule-out med conds presenting as psych disorders and that physicals and lab tests are critical in this process. No one will EVER argue against the idea that psych MD/DO are/will be the best med-mental health practitioners (in fact, that's part of the reason why I want to become a psychiatrist myself). The argument is against the idea that psych PhD/PsyD need to go through the extensive medical school/psychiatric residency model to become safe and competent prescribers. Not that the Alliant model is necessarily the answer either.

I believe that what apa.org is asking is this: what is REQUIRED for psychologists to become safe, effective, and efficient precribers?
If psych.org responds: med school/psych residency; the discussion will be over because there's evidence that other practitioners are safe and competent prescribers without going through med school/spec residency.
So, in your opinion, what is required?

P.S. I have worked for the past several years with psychiatrists and psychiatry residents; I have never witnessed any doing a physical and almost all read lab results according to what the computer monitor says is the correct interpretation. I also have two friends that have been treated-including prescription-by outpatient psychiatrists and neither ever got a physical nor had lab tests ordered-despite one of them complaining of chest pain prior to getting the prescription for Lexapro. I know all of this is anecdotal but I present it in a spirit of honest inquiry as to the issue of how critical these procedures are and how truly commonplace they are in psychiatric practice.
I understand that it takes a professional (as opposed to a technician) to integrate test results (same principle is operant in psychology with its assessment instruments) but do doctoral-level professionals, with years of critical thinking skill development and practice, need to undergo a further 8 years of training to achieve proficiency in doing physicals/interpreting labs?

Peace.

 

[PublicHealth]

I understand that it takes a professional (as opposed to a technician) to integrate test results (same principle is operant in psychology with its assessment instruments) but do doctoral-level professionals, with years of critical thinking skill development and practice, need to undergo a further 8 years of training to achieve proficiency in doing physicals/interpreting labs?

Now THAT'S the $200,000 question!

sasevan, if the state in which you practice (Florida?) passed psychology RxP legislation, will you reconsider medical school/psychiatry?

 

[sasevan]

hmmmm... i used to teach psychopharm to clinical psych. PhDs (for their grad degree)... it was 10 lectures, of which 4 were spent just explaining pharmacokinetics.... but there is more to it than that.... do they get taught how to recognize the symptoms of SIADH? or do they learn the interactions with other drugs and the suggested management of that? (ie: SSRIs and beta-blockers)? no....

this is akin to naturopaths prescribing drugs in arizona... dangerous

OMG!
No one is suggesting, least of all apa.org, that current (pre-doctoral) psychopharm courses in clinical PhD/PsyD programs are anywhere close to what is required for psych PhD/PsyD to become safe, effective, and efficient prescribers.
What apa.org is promoting is a POST-DOCTORAL, Masters Degree in Psychopharmacology; a program that will be at least 2 years of academic/practicum training in addition to the 5 years of the clinical psychology program. Furthermore, once the clinical psychologist has received the appropriate sub-specialty ed/training, has passed the required examinatons, and is licensed to prescribe psychotropic meds that medical psychologist will still be required to practice under a physician supervisor for at least 5 years (in LA the supervision is in perpetuity).
Peace.

 

[Sanman]

Hey,
Great article Public!! It pretty much somes up the my views on the whole debate. From the reactions that my last post has gotten, I should probably clarify a difference in our arguments. I have never felt that PhD/PsyD prescribing was the ideal. Frankly I am not really worried about which outcome prevails because I am going to grad school with the intention of specializing in psychological/neuropsychological testing and don't really want to deal with prescribing. My suggestions of the PhD/PsyD prescribing in collusion with PCP's is just a possible way things might happen in this marketplace. I feel it would foster better communication between providers because the PhD's/PsyD's would want/need physician approval, if not by law then at least to cover themselves against lawsuits and that will force better communication. However, I may be wrong about that. Frankly, with this managed care marketplace quality of care is not nearly as important. While I think it should be, being an MD or PhD/PsyD is also a job and I don't want my idealism to transfer into a tougher reality for me. One of the reasons that I picked grad school instead of med. school is that if this trend of managed care continues, I have more options to change my career as a PhD than and MD. Also, whichever side you take on this debate, it must be admitted that at least psychologists are trying to extend the limits of their field while psychiatrists are, for the most part, staying stagnant. Psychiatry is a wonderful field, but at this moment is fighting a losing battle. They may be able to stave of PhD/PsyD's, but what about PCP's, Psychiatric nurses, etc. This has become a business, just like any other and psychiatrists are losing ground and it will continue to be felt until something is done about it. Frankly, it could all be solved by dissolving managed care, but that is a seperate issue.

 

[sasevan]

Now THAT'S the $200,000 question!

sasevan, if the state in which you practice (Florida?) passed psychology RxP legislation, will you reconsider medical school/psychiatry?

Hi PH,

BTW, are you entering NYCOM this year?

If Florida passes psychology RxP within the next two years I would reconsider med school/psychiatry but only because I would like to avoid having to complete 8 (!!!) more years of ed/training. Ultimately, however, my decision will be based on what the legislation authorizes.
For example, in FL psych NP don't have independent practice nor full formulary; they have to be supervised by psychiatrists and cannot prescribe controlled substances. That's an arrangement that would not work for me; if it did I would've chosen to be doing pre-nursing instead of pre-medicine right now.
If I have to do 8 more years to gain independent/full scope RxP then I will do it but I believe that it is an excessive demand; that's why whether as a psychiatrist-psychologist or as a medical psychologist I will continue to advocate for a model wherein clinical psychologists can gain RxP without having to undergo an additional 8 years of med school/psychiatry ed/training.
Peace.

 

[sasevan]

Hey sasevan,
Right now I'm getting ready to start applying to grad school. As far as the combined route, I'll leave that decision to when I am at your juncture. There are too many personal and financial considerations for me to decide that quite yet, however I am looking for programs with a strong biological/physiological orientation in the mean time. It certainly allows for much more complete and well rounded education, if not a painstakingly long one.

Hi Sanman,
Congratulations on your decision to enter grad school/neuropsych.
I believe that becoming a clinical psychologist with a sub-specialization in neuropsychology will serve you very well, especially if you are really passionate about assessment and research. Additionally, I believe that the trend in mental health/neurology is for an increasing integration between the brain and behavioral sciences. Neuropsychologists along with psychiatrists and neurologists are at the forefront of this integration. Again, congratulations.
Peace.

 

[Anasazi23]

I know that C-L, addiction, pediatric, and geriatric psychiatry are sub-specialties (didn't know that emergency and inpatient were, though) but from what I understand a fellowship in a sub-specialty is NOT a requirement for a licensed psychiatrist to legally work with that sub-specialty population. Please correct me if I'm wrong.

Congrats on aceing your bio class!
To answer the above question, when you receive your medical license, you are licensed to practice medicine and surgery. That means that as a psychiatrist, if I felt so inclined to remove someone's gallbladder, I am legally entitled to do so. However, I would undoubtedly be sued and lose in court if something went wrong because I was practicing outside my area of expertise. While a general psychiatrist can work in the geriatric settin or in C-L, you are not considered the most qualified practitioner in that respect, and would not have the backing of the boarded specialty in the event of malpractice or adverse outcome. When it comes to child psychiatry in particular, you would be hard pressed to find a general psychiatrist prescribing sertraline to an 8 year-old if they were not boarded in child psychiatry. To think that a psychologist, who not only lacks general psychiatry residency training, but child psychiatry fellowship training in particular will prescribe to this already delicate population raises serious questions.

.....The argument is against the idea that psych PhD/PsyD need to go through the extensive medical school/psychiatric residency model to become safe and competent prescribers. Not that the Alliant model is necessarily the answer either.......
I believe that what apa.org is asking is this: what is REQUIRED for psychologists to become safe, effective, and efficient precribers?
If psych.org responds: med school/psych residency; the discussion will be over because there's evidence that other practitioners are safe and competent prescribers without going through med school/spec residency.
So, in your opinion, what is required?

I guess the answer is simply one of "how competent do you want to be?" Yes, you can prescribe medications and let the computer tell you when things are high and low. As you mentioned, this is akin to a technician. As I'm sure you'd agree, a neuropsychological technician can administer a Halstead with as much validity as a board-certified neuropsychologist. However, we both know that the interpretation of that test and meaning of the test comes from that data garnered. I'm not saying that RxPs will be technicians, but they will neither be as competent as physicans in treating psychiatric patients.

P.S. I have worked for the past several years with psychiatrists and psychiatry residents; I have never witnessed any doing a physical and almost all read lab results according to what the computer monitor says is the correct interpretation. I also have two friends that have been treated-including prescription-by outpatient psychiatrists and neither ever got a physical nor had lab tests ordered-despite one of them complaining of chest pain prior to getting the prescription for Lexapro. I know all of this is anecdotal but I present it in a spirit of honest inquiry as to the issue of how critical these procedures are and how truly commonplace they are in psychiatric practice.

That to me is just strange. I perform at least 2-3 physicals a day, and am obligated to address most (legitimate) physical complaints, especially chest pain. The computer monitor can tell you what the value ranges are for labs, but it is again what you do with the information that is important. While there are many subtle pearls of information in reading laboratory values, the majority of it is straight-forward, and is often done by physicians, including psychiatrists, as part of standard routing healthcare. I had a lot of problems with one particular patient these past two weeks who had extremely high blood sugar levels, yet remained (mostly) asymptomatic. He was on 2 mood stabilizers, 2 antipsychotics, an anxiolytic, Inderal for tremor, and over 100 units of NPH QD alone, not including his sliding scale coverage and regular. The massive amounts of insulin kept causing him to become hypokalemic, which needed to be replaced. This interacted delicately with his beta blocker, and it was a tricky case. He was subsequently discharged and will follow-up in the outpatient clinic in the coming weeks. If you were an RxP psychologist, would you feel comfortable having this patient sit across from you at your office? The interplay of his endocrine, cardiovascular, psychiatric and other pathophysiologies are complex. I'm not sure this can be garnered from the training program without at least a few years of formal medical training and experience.

I understand that it takes a professional (as opposed to a technician) to integrate test results (same principle is operant in psychology with its assessment instruments) but do doctoral-level professionals, with years of critical thinking skill development and practice, need to undergo a further 8 years of training to achieve proficiency in doing physicals/interpreting labs?

Peace.

I understand that psychologists are critical thinkers, and that is good. However, if you don't know the information, you just don't know it. I don't think you need 8 additional years to do a physical or interpret a lab. But like information gathered from psychological tests, its the myriad information obtained (or not) that makes the difference. Then once you have said information, what will you do with it? Medical information is like taking a language class in high school or college. You can get a few introductory lectures in vocabulary and putting sentences together. But if you then try to skip to advanced classes in that same language without learning all the "in-between" information, you'd have a very broken lexicon, but could yet, perhaps, still function.

For example, would you agree that physicians, who are doctoral level professionals that have 8 years of training should obtain their PhD in clinical psychology if they underwent a year of learning psych tests and did a research project? As you'd agree, there is so much more "in-between" learning that goes on, the physicians would undoubtedly miss important and vital information necessary to becoming a good psychologist.

The medical side says you must complete 4 years of medical undergrad, then at least 3 years of medical residency to be competent in practicing at least family medicine, general medicine or pediatrics. Psychologists assert that they should only be required to learn the relevant information that pertains to psychopharmacology. While I agree that many psychiatrists have lost their skills in physical exam and general medicine, I'd have to say that the vast majority (that I have worked with) have not. Medical problems come up every day on the floors, and they are dealt-with in a competent medical manner. Of course, we refer to medicine/surgery and other disciplines as necessary when we feel that they cannot be handled in the above manner. Any resident or attending physican knows that the more they know, the more they realize they don't know about this field. I guess they as a medical specialty just feel insulted that another discipline can undergo what they consider a glossed-over medical training and then treat psychiatric patients as effectively as physicians. Do I need a CBC and chem-7 to prescribe Lexapro? Probably not in most cases. However, I would order these tests and others if I felt that the clinical presentation suggested a thyroid panel or other study.

Just as a neuropsychologist who defers all his testing to a technician WILL miss some of the most vital information to be garnered from the patient (i.e. observation of how he completes the tasks) yet still function, the psychologist who has not undergone medical training will be missing some of the most important aspects of the patient also.

 

[Tenesma]

okay... the post-doctoral masters degree looks up to snuff... now what are the prescription limitations?

 

[PublicHealth]

http://www.louisianapsychologist.org/LPAspecialNews.pdf

 

[Svas]

Great point, Svas.

You mentioned that psychologists will probably do as well or better than psychiatric nurses once they obtain an M.S. in Clinical Psychopharmacology. Are you suggesting that these programs train psychologists in the nursing model? Also, how would the training of a Ph.D./Psy.D. clinical psychologist with an M.S. in Clinical Psychopharmacology differ from a Ph.D./Psy.D. clinical psychologist with an M.S.N./A.P.R.N. + specialization in psychiatry?

1) No, I don't think they're being trained in a nursing model. I think that psychologist's "psychological" skills far outstrip nurses and they've simply added psychopharmacology to their tool bag.

2) I don't know the answer to the latter question. I would presume that both would be able to safely prescribe within a limit forumulary. After reviewing related programs, however, I would have to say that the psychopharm master's programs provide much more training in pharmacology than any of the MSN programs I reviewed.

S

 

[Svas]

hmmmm... i used to teach psychopharm to clinical psych. PhDs (for their grad degree)... it was 10 lectures, of which 4 were spent just explaining pharmacokinetics.... but there is more to it than that.... do they get taught how to recognize the symptoms of SIADH? or do they learn the interactions with other drugs and the suggested management of that? (ie: SSRIs and beta-blockers)? no....

this is akin to naturopaths prescribing drugs in arizona... dangerous

Yes, but not in their doctoral programs. If you will take the time to review the threads, you'll understand that we're talking about these psychologists getting two years of additional training.

 

[Svas]

I guess the answer is simply one of "how competent do you want to be?" Yes, you can prescribe medications and let the computer tell you when things are high and low.

<SNIPPED DISCUSSION ABOUT PSYCHIATRISTS NOT DOING PHYSICALS>

That to me is just strange. I perform at least 2-3 physicals a day, and am obligated to address most (legitimate) physical complaints, especially chest pain.

Anasazi,

1) Of course, everyone WANTS to be competent at what they do. The question will be "who gets to set the bar." How competent do psychiatrist want to be a psychological assessment and psychotherapy? Using the argument you've presented, psychiatrists should get considerably more training in both. The same should also be said about neurology as psychiatrists are really practicing a form of neurology and generally do NOT have adequate training in this field (at all).

2) As far as the physicals issue goes, I have to believe that you are aware that you are in a WILD minority of psychiatrist who do physicals. I would be willing to be the better part of a year's salary that the percentage of psychiatrists performing physicals is absolutley in the singe digits. *However,* frankly I applaud you for maintaining this skill.

3) Have you met with and talked to any graduates of the 2 year master's degree programs? I think that you will be surprised at what they know.

S

 

[sasevan]

Congrats on aceing your bio class!
To answer the above question, when you receive your medical license, you are licensed to practice medicine and surgery. That means that as a psychiatrist, if I felt so inclined to remove someone's gallbladder, I am legally entitled to do so. However, I would undoubtedly be sued and lose in court if something went wrong because I was practicing outside my area of expertise. While a general psychiatrist can work in the geriatric settin or in C-L, you are not considered the most qualified practitioner in that respect, and would not have the backing of the boarded specialty in the event of malpractice or adverse outcome. When it comes to child psychiatry in particular, you would be hard pressed to find a general psychiatrist prescribing sertraline to an 8 year-old if they were not boarded in child psychiatry. To think that a psychologist, who not only lacks general psychiatry residency training, but child psychiatry fellowship training in particular will prescribe to this already delicate population raises serious questions.

Hey Anasazi23,
Thanks.
You make some very good points which I want to address from another angle.
Let me start with the above. I believe that the same practical considerations that keep licensed psychiatrists from practicing outside their area of expertise, even when they are legally able to do so, will at the very least equally impact licensed psychologists. In fact, according to our code of ethics we are not to practice outside our area of expertise unless we have appropriate supervision, etc. (e.g., a licensed clinical psychologist is legally able to assess and treat adults, adolescents, and children HOWEVER, it would be unethical to do so unless that PhD/PsyD was in fact fully ed/trained in working with each of these populations; if he/she isn't then he/she must obtained supervision from another lic cl psych). I can't imagine medical psychologists intervening with geriatric or pediatric patients unless they have received very specialized ed/training well beyond the post-doc MS in psychopharm. The same practical/ethical considerations that already apply to psychiatrists and psychologists will prevent that, i.e., if a psych MD/DO would lose a court case for treating outside of training then certainly a psych PhD/PsyD would also.

I guess the answer is simply one of "how competent do you want to be?" Yes, you can prescribe medications and let the computer tell you when things are high and low. As you mentioned, this is akin to a technician. As I'm sure you'd agree, a neuropsychological technician can administer a Halstead with as much validity as a board-certified neuropsychologist. However, we both know that the interpretation of that test and meaning of the test comes from that data garnered. I'm not saying that RxPs will be technicians, but they will neither be as competent as physicans in treating psychiatric patients.

Agreed. Medical psychologists are not envisioned by the apa.org to be as competent medical-mental health providers as psychiatrists. Any more than primary care physicians could be envisioned to be as competent med-mh providers as psychiatrists. As I said before, part of the reason why I want to be a psych MD/DO is because I do want to be able to be the most competent practitioner that I can be BUT I don't believe that every (most?) mh patients require the most advance level of care; those that do will of course be referred by the psych PhD/PsyD (as they are now by the PCP) to the ultimate med-mh specialist, the psychiatrists.

That to me is just strange. I perform at least 2-3 physicals a day, and am obligated to address most (legitimate) physical complaints, especially chest pain. The computer monitor can tell you what the value ranges are for labs, but it is again what you do with the information that is important. While there are many subtle pearls of information in reading laboratory values, the majority of it is straight-forward, and is often done by physicians, including psychiatrists, as part of standard routing healthcare. I had a lot of problems with one particular patient these past two weeks who had extremely high blood sugar levels, yet remained (mostly) asymptomatic. He was on 2 mood stabilizers, 2 antipsychotics, an anxiolytic, Inderal for tremor, and over 100 units of NPH QD alone, not including his sliding scale coverage and regular. The massive amounts of insulin kept causing him to become hypokalemic, which needed to be replaced. This interacted delicately with his beta blocker, and it was a tricky case. He was subsequently discharged and will follow-up in the outpatient clinic in the coming weeks. If you were an RxP psychologist, would you feel comfortable having this patient sit across from you at your office? The interplay of his endocrine, cardiovascular, psychiatric and other pathophysiologies are complex. I'm not sure this can be garnered from the training program without at least a few years of formal medical training and experience.

Like Svas said, I believe that psych MD/DOs doing physicals is very, very uncommon. But like Svas also said, I'm glad that some (you included) are committed to doing them and to really providing medical treatment to your patients and not just prescribing meds to them.
I can't personally answer this question because I have not received RxP ed/training. However, the medical psychologist that went through the DoD project were evaluated to be at the level of a 3rd/4th year psychiatric resident. I presume that an RxP psychologist would probably feel as comfortable treating the case you presented as a 3rd/4th yr psych resident would.

I understand that psychologists are critical thinkers, and that is good. However, if you don't know the information, you just don't know it. I don't think you need 8 additional years to do a physical or interpret a lab. But like information gathered from psychological tests, its the myriad information obtained (or not) that makes the difference. Then once you have said information, what will you do with it? Medical information is like taking a language class in high school or college. You can get a few introductory lectures in vocabulary and putting sentences together. But if you then try to skip to advanced classes in that same language without learning all the "in-between" information, you'd have a very broken lexicon, but could yet, perhaps, still function.

Agreed. The question is, then if not 8 more years (or 2 either) then how many more additional years?

For example, would you agree that physicians, who are doctoral level professionals that have 8 years of training should obtain their PhD in clinical psychology if they underwent a year of learning psych tests and did a research project? As you'd agree, there is so much more "in-between" learning that goes on, the physicians would undoubtedly miss important and vital information necessary to becoming a good psychologist.

Actually, I believe that 2 years of ed/training in psychological assessment would be sufficient for most physicians to be able to administer/interpret these tests. Those cases that are very complex would of course be referred to the appropriate specialist in cl psych, neuropsych, forensic psych, etc.

 

[sasevan]

The medical side says you must complete 4 years of medical undergrad, then at least 3 years of medical residency to be competent in practicing at least family medicine, general medicine or pediatrics. Psychologists assert that they should only be required to learn the relevant information that pertains to psychopharmacology. While I agree that many psychiatrists have lost their skills in physical exam and general medicine, I'd have to say that the vast majority (that I have worked with) have not. Medical problems come up every day on the floors, and they are dealt-with in a competent medical manner. Of course, we refer to medicine/surgery and other disciplines as necessary when we feel that they cannot be handled in the above manner. Any resident or attending physican knows that the more they know, the more they realize they don't know about this field. I guess they as a medical specialty just feel insulted that another discipline can undergo what they consider a glossed-over medical training and then treat psychiatric patients as effectively as physicians. Do I need a CBC and chem-7 to prescribe Lexapro? Probably not in most cases. However, I would order these tests and others if I felt that the clinical presentation suggested a thyroid panel or other study.

Disagreed. In my experience, albeit limited that it is, PCPs, cardiologists, nephrologists, and even gerontologists appear to prefer working with psych PhD/PsyDs more than with psych MD/DOs. I don't know "why" but from what they have said I believe that many physicians want a mh provider who will do more than just prescribe meds and they feel frustrated when they refer a pt to a psychiatrist and all that the pt receives is a prescription; often times these physicians will refer to a psychologist knowing that the pt will receive therapy (supportive, CBT, behavioral, etc) and will informally consult with the psychologist about which psych med is appropriate for the presenting psych condition and then prescribe as such if there are no med contra-indications.

Just as a neuropsychologist who defers all his testing to a technician WILL miss some of the most vital information to be garnered from the patient (i.e. observation of how he completes the tasks) yet still function, the psychologist who has not undergone medical training will be missing some of the most important aspects of the patient also.

Disagreed. I believe that med psychologists cannot be considered med techs. In fact, I believe that RxP psychs will be on a par, or even higher, than psych NPs. Many physicians employ NPs and PAs to assess/treat routine cases and the MD/DO only sees the more complex ones. NPs and PAs cannot possibly be ed/trained to pick up everything that an MD/DO would but they can be ed/trained to pick up most routine problems and to differentiate between these and those that require further evaluation by the expert, to whom they will then defer and/or refer. I believe that psych PhD/PsyDs will function in a similar manner in reference to a psych MD/DO; or at least that's what I hope for. Due to the animosity that has developed over RxP between the guilds psych PhD/PsyDs may well ultimately associate with PCPs and non-psychiatric specialists, possibly resulting in the marginalization of psychiatrists.

 

[PublicHealth]

As far as the physicals issue goes, I have to believe that you are aware that you are in a WILD minority of psychiatrist who do physicals. I would be willing to be the better part of a year's salary that the percentage of psychiatrists performing physicals is absolutley in the singe digits. *However,* frankly I applaud you for maintaining this skill.

Anasazi,

Please correct me if I'm wrong, but aren't you currently in the second month of your internship? Theoretically, your primary clinical responsibilities should be internal medicine, not psychiatry. In fact, according to your PGY-1 schedule, you're currently on your four-month rotation in internal medicine...of course you're doing physicals!

The First Postgraduate Year

1. Clinical Rotations

Internal Medicine - 4 months

Each resident spends four months in Internal Medicine at Cabrini Medical Center where their duties and responsibilities are identical to those of an internal medicine first year resident. (emphasis added) The resident is responsible for the total care of a wide variety of medical inpatients. Direct supervision is provided by senior medical residents and attending physicians.


Neurology - 2 months

The neurology rotation consists of primary responsibility for an active inpatient neurological consultation service and participation in the Neurology Outpatient Clinic where a wide variety of neurological illnesses are seen. Direct supervision is provided by Neurology attendings. The clinical experience is complemented by a yearlong didactic program covering the neurological examination, diagnosis, and treatment.


Inpatient Psychiatry - 6 months

During the first year, the resident learns the fundamentals of psychiatric clinical practice including the diagnostic interview, mental status examination, differential diagnosis and treatment planning. Residents are assigned to Cabrini Medical Center's 30 bed inpatient unit, where they assume primary responsibility for the diagnosis and treatment of adult patients with a wide range of psychopathology, including psychotic disorders, affective disorders, cognitive disorders, severe personality disorders and comorbid substance abuse problems. The average length of stay is 10-15 days and the caseload ranges between 6 and 8 patients. During this year, residents develop extensive practical experience in the evaluation and management of inpatients and become well versed in pharmacotherapeutic strategies, electroconvulsive therapy, and brief psychotherapeutic techniques relevant to inpatient work. Residents are closely supervised on a daily basis by the attending staff, but at the same time are encouraged to take increasing levels of responsibility in decision making as the year progresses. Working on a multidisciplinary team, the resident participates in community meetings, group therapy, and family meetings, and works closely with social workers, psychologists and activities therapists. Residents receive daily supervision from the Chief of Inpatient Services and regularly attend teaching rounds and clinical case conferences conducted by senior faculty.

Source: http://www.cabrininy.org/gme_psychbrochure.html#firstpostgrad

 

[purpledoc]

Anasazi,

Please correct me if I'm wrong, but aren't you currently in the second month of your internship? Theoretically, your primary clinical responsibilities should be internal medicine, not psychiatry. In fact, according to your PGY-1 schedule, you're currently on your four-month rotation in internal medicine...of course you're doing physicals!

Regardless of what Anasazi says, Public, this is why you shouldn't comment on areas you're not familiar with, and shouldn't use webpages to get your information. Those clinical rotations -- very similar to other psychiatry programs -- can occur in any order. Some residents start with psychiatry, some with internal medicine, etc., and the clinical rotations themselves may even be broken down into smaller blocks, say, spending two months of internal medicine at one hospital, and another two at a different hospital.

How about sticking to responses related to the content of the postings, and not related to the people posting?

 

[purpledoc]

THE PRESCRIPTION JIHAD:

Commentary: The Prescription Jihad
by Ali Hashmi, M.D.
Psychiatric Times July 2001 Vol. XVIII Issue 7

<<SNIP>>

Nothing new. Of course there are psychiatrists who disagree on this issue. Let me point out that psychologists disagree as well. Case in point, a letter by the president of the American Association of Applied and Preventive Psychology in 2001, a suggested model letter for opposing RxP bills:

ADDRESSEE

DATE

Re:* BILL NO. AND TITLE
* ******* ******* ******* ******* ******* ******* *******
Dear Honorable Senator OR Representative NAME

*** We are psychologists writing against the [BILL OR RESOLUTION TITLE AND NUMBER] being considered by the 2001 [NAME OF STATE] State Legislature. We are the American Association of Applied and Preventive Psychology, which is an affiliate of the American Psychological Society.* In 1995, we passed a Resolution Opposing Prescription Privileges for Psychologists.* This AAAPP Resolution has been endorsed by Section III of the Clinical Division (12) of the American Psychological Association (Society for a Science of Clinical Psychology).* Other professional psychological associations have opposed prescription privileges.* The National Council of University Directors of Clinical Psychology programs voted against the pursuit of prescription privileges in 1995.* In 1996, the Council of Graduate Departments of Psychology voted that a decision to pursue prescription privileges should not be made until those involved in providing university training support this major change to the profession.***

*** While the American Psychological Association supports prescription privileges, the [BILL OR RESOLUTION NUMBER] may be incorrectly predicated on the assumption that privileges are universally supported by the discipline of psychology and that there is an urgent need for society to train more prescribers. In fact, some surveys of psychologists have found that only about one-half support prescription privileges and only a small percentage of the supporters would be willing to undergo the necessary training.* We will list five reasons why we are against prescription privileges and why we conclude there is not a societal need to spend taxpayer money on making clinical psychology a new medical profession.

*** 1) Prescription authority for psychologists may result in greater risk to the consumer of medical mental health services.* Therefore, consideration of appropriate medical training and regulation must be a conservative process.* Psychoactive substances are poorly understood.* Many of these drugs have serious medical side effects and are drugs of abuse.** Prescribing them requires knowledge not just about their behavioral effects (which fits within the traditional domain of psychology) but also about how they impact organ systems, how changes in one organ system interacts with other organ systems, and how these powerful chemicals interact with other drugs.

** No state in the country has licensed nonmedical mental health professionals, such as psychologists or social workers, to prescribe.* Prescription authority has been extended in some states to paramedical providers, such as nurses and optometrists, but training for these professions is already based upon the medical sciences.** Psychologists are trained in the social and behavioral sciences and cannot be compared to nurses or optometrists.* Licensed psychologists are trained to provide services that do not physically invade the body cavity, such as psychological assessment and psychotherapy.*

*** The APA curriculum for the training of psychologists in the practice of medicine has not been evaluated.* There is a short-term evaluation of the U.S. Department of Defense (DoD) psychopharmacology training program conducted by the U.S. Congress General Accounting Office, but the DoD program included about twice the medical training than what is proposed in the APA model curriculum.** In addition, programs purporting to offer the APA curriculum in fact offer only part of the recommended training.* The APA model of training includes 30 semester hours of undergraduate courses in biology, chemistry, and related life sciences. Programs in the country offering APA model training do not require the 30 semester hour pre-requisites. Therefore, the risk to the consumer of licensing nonmedical professionals such as psychologists or social workers, to prescribe is unknown.

*** 2) Societal needs for medical mental health services can be provided by those who are already trained in nursing and medicine.* For example, there is no shortage of physicians.* The 1995 report of the Pew Health Professions Commission states there is a surplus of about 150,000 physicians and 20% of medical schools should be closed.* When needed, medication can readily and inexpensively be provided by already trained medical professionals in collaboration with psychologists.*

*** The U.S. Public Health Service's 1995 statistics on health professional shortage areas did indicate a geographic maldistribution of most health professionals.* There is a resulting need to provide services to underserved populations, such as those living in rural areas.* These needs can be met with existing health professionals if incentives are provided, such as the policy of many managed care companies to reimburse multidisciplinary care.

*** 3) Because psychologists are not currently trained in medicine, to do so would be extremely costly to the taxpayers and consumers of mental health services.* Expenses of include more faculty at universities, greater liability insurance, more state regulatory agents, and several additional years of training (currently 7 - 11 years of graduate school).* The General Accounting Office reported to the U.S. congress in 1997 that the training of psychologists to prescribe in the military costs $610,000 per psychologist and was an unnecessary expense.* Estimates of the cost of providing the APA model training at state universities is $800,000 to $1, 000,000 per year in additional faculty alone. These expenses are likely to be passed on to the consumer and taxpayer and thereby increase health care costs.**

*** 4) The costs of training and regulating prescription privileges for psychologists unnecessarily duplicates health care services already provided by medical professions.* Prescription privileges would ultimately change psychology training at the undergraduate, graduate, post-doctoral, and continuing education levels.*

*** When nurses and optometrists have pursued prescription privileges, doing so was not divisive within their professions.* This may be because their training was already medical in nature.

*** Psychologists who wish to prescribe may currently do so by completing nursing or medical school and utilizing the training and regulatory resources already provided by the taxpayer.* Some psychologists have already earned prescription authority by becoming advanced practice nurses. Training in nursing is already an option for psychologists.

*** Over 600 psychologists already have both a doctorate and an advanced nursing degree, and thereby may prescribe in most states.* The University of Hawaii's School of Nursing has plans to provide training for psychologists. The Hawaii Campus of the American Schools of Professional Psychology plans to provide nursing training for psychologists so they can prescribe as advance nurse practitioners. There are 11 psychologists enrolled in Felician College in Lodi, N.J. in a masters of science degree in nursing program, which will permit them to prescribe. Similar nursing programs designed for psychologists are being developed. Therefore, legislation is not necessary for psychologists to prescribe.

*** and

*** 5) Psychology is an identified health profession that allows the consumer choices of treatment modalities.* Psychological treatments have been shown to improve the human condition, often more effectively than drugs.* The science of psychology has contributed to the understanding and amelioration of human suffering by the development of dozens of empirically-supported psychosocial interventions and prevention strategies. Psychology is not outmoded and continues to make important contributions to society.*

*** Prescription privileges could impair the public's access to psychological services.** Since the development of psychoactive medications, psychiatrists have abandoned psychosocial treatments in order to specialize in the provision of these chemical compounds that are often ineffective, particularly in the long-term.* Consumers of mental health services who prefer not to use drugs have come to rely upon the availability of the psychosocial approach of psychologists.*

** In conclusion, high quality and cost-effective treatment for mental health consumers can be provided by collaboration between psychologists and medical professionals.* Such collaboration has worked well for many years and continues to be effective.* It is commonly practiced, consistent with established disciplines, and in the best interest of the consumer.* Psychologists who have not learned how to collaborate can easily do so through continuing education on how to work with psychiatrists and other physicians who write the majority of prescriptions for psychoactive medications. Psychologists who wish to prescribe can pursue training in nursing or medicine.** This solution would not be divisive within psychology and would not rely on major additional taxpayer resources.

Thank you for your kind consideration of this opinion.
* ******* ******* ******* ******* ******* *******
Respectfully,

Lee Sechrest, Ph.D.
President
American Association of Applied and Preventive Psychology ***** *******

link: http://w3fp.arizona.edu/aaapp/