Oregon House Bill 2702 coming out of State Senate Committee for a full vote

[Therapist4Chnge]

Just let it be, sooner or later someone will die and the state will come down on them. Someone will think someone is psychotic and keep increasing meds when the patient is actually impacted and decompensating.

That is the straw man everyone (in opposition) keeps propping up.......and yet, nothing.

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Members don't see this ad.

 

[appelsoranjes]

Just let it be, sooner or later someone will die and the state will come down on them. Someone will think someone is psychotic and keep increasing meds when the patient is actually impacted and decompensating.

You really have little respect the critical-thinking abilities of PhDs if you think we won't rule out medical-based causes and just follow a flow-chart cookbook approach to RxP. Just because you have anectodal stories of Joe Psychologist being a horrible prescriber doesn't mean much. There are outliers in every field.

 

[appelsoranjes]

one of the premises that medical psychologists claim was to increase access in the underserved area, but they tend to be in big cities. they now pushing for hospital admission right, and be on the same level as attending psychiatrists in LA.

I agree this isn't the primary motivation for obtaining RxP, and while it may help some rural areas, it likely wont make a significant difference. However, there are arguments from the other side that it would "endanger patients" that are similarly unpure. The primary motivation on both sides is money & ego - and unfortunately the insurance companies are the ones that are ultimately pulling the strings.

As a scientist, I will trust the data.

 

[whopper]

they now pushing for hospital admission right, and be on the same level as attending psychiatrists in LA.

If a psychologist prescriber had just as much rights as a physician in a hospital, I'd wonder how that psychologist would react when they suffered the usual turfing/dump job that often occurs in a hospital. How would they handle themselves when in suspicion if the pregnancy test is accurate or not--> would they know to do a serial quantitative (not qualitative) B-HCG test? What they would do with a patient in need of Clozaril, Lithium, Depakote etc, noticing their patient was on pegylated interferon and is now severely depressed, and see their puzzlement on interpreting labs, keeping the patient on the interferon or not, etc.

I remember about once a week having diplomatically go to the ER or IM doctor, mentioning why the patient was not truly medically cleared. On a few occasions, the other doctor would get mad, and I had to pull out the data which they could not contest. E.g. I'd mention that the patient had asterexis, and no serum ammonia test was ordered, and that it would be a violation of the mental health law of NJ to admit a patient to psychiatry if that was the cause of their behavioral presentation.

Seriously, I'd be waiting in the wings for a possible malpractice suit. I'd imagine a bunch of lawyers looking on the situation, and a bunch of non-psychiatric doctors actually looking to dump knowing that doing so will be much easier. You think the psychiatrists had it bad with scientologists--they'll have a field day if any psychologist prescriber missed a medical problem that a physician would have otherwise caught.

Anyways, since there are some new posters on this debate, I am reiterating that I have a B.S. in psychology, am a member of Psi Chi, my wife is a counselor and I have the utmost respect for psychologists, and would love to work with one (or several) in private practice. I truly respect what psychologists do that we psychiatrists sometimes don't. I however don't agree with the Oregon law.

That is the straw man everyone (in opposition) keeps propping up.......and yet, nothing.

And this move is still experimental in several ways, with very limited numbers, with several psychologist prescribers possibly not using several of the powers given to them by law. E.g., how many of them are prescribing lithium, depakote or Clozaril? However experimental as it may be is completely the point---their patients are the guinea pigs on to this bold area with not much data supporting it, the defenders often citing the GAO report which truly is not compatible.

 

[CAPBonanza]

You really have little respect the critical-thinking abilities of PhDs if you think we won't rule out medical-based causes and just follow a flow-chart cookbook approach to RxP. Just because you have anectodal stories of Joe Psychologist being a horrible prescriber doesn't mean much. There are outliers in every field.

But this begs the fundamental question...how will you be able to rule out medical-based causes without medical training?

 

[whopper]

I'm an academic psychologist who does clinical work on the side; personally I wouldn't feel comfortable dealing with children/geriatrics or polypharmacy without med-school training, and even if I had RxP, I would be very conservative with it.

Which is one of my major points--the Oregon law gives psychologist prescribers powers on the order of a physician when they are not physicians.

The laws do not give directives to refer to psychiatrists for harder cases. It gives psychologists prescribers the full gamut of psychotropics--including meds which require lab interpretation such as lithium, Clozaril & depakote as if they were practicing psychiatrists who had the skill to deal with the above.

And as for patients even without physical medical problems--have a patient for several months to years--they can develop one, and that medical problem can screw with even the SSRIs which are generally considered benign. SSRIs can cause complications with bleeding disorders, sexual side effects, weight gain, sedation, anticholinergic side effects etc.

IMHO--the best way to allow psychologists to get psychotropics out would be for them to work in conjunction with an M.D. (psychiatrist or not). That would put the medical liability on the M.D. while allowing the psychologist to work in conjunction with the physician on choosing a psychotropic. It already happens that way in several primary practice offices with the psychologist in that office given as much respect as their physician counterparts.

Or both APAs could've worked together on addressing this issue--in a manner that was not so antagonistic. For example, both APAs or the psychological APA could've teamed up with the AMA on facilitating psychologist-MD/DO partnerships & practices.

Like I said, I'm not against psychologists at all, I'm against the extreme few being able to practice medicine without medical training. We physicians should be inviting any insight a psychologist (or counselor) can provide. Unfortunately this psychologist prescription approach IMHO is driving a wedge between our 2 professions.

 

[Therapist4Chnge]

IMHO--the best way to allow psychologists to get psychotropics out would be for them to work in conjunction with an M.D. (psychiatrist or not). That would put the medical liability on the M.D. while allowing the psychologist to work in conjunction with the physician on choosing a psychotropic. It already happens that way in several primary practice offices with the psychologist in that office given as much respect as their physician counterparts.

Or both APAs could've worked together on addressing this issue--in a manner that was not so antagonistic. For example, both APAs or the psychological APA could've teamed up with the AMA on facilitating psychologist-MD/DO partnerships & practices.

That is my hope too.

The Oregon bill is far too thin for independent practice. While I object to the straw man arguments of Patient Deaths!.....I think it is foolish to push for independence when a multidisciplinary approach has shown success and (obviously) helps in the continuation of care, which is a big issue in mental health.

 

[CAPBonanza]

The Oregon bill is far too thin for independent practice. While I object to the straw man arguments of Patient Deaths!.....I think it is foolish to push for independence when a multidisciplinary approach has shown success and (obviously) helps in the continuation of care, which is a big issue in mental health.

1. It's not a straw man argument. We haven't misrepresented your position, nor have taken your words out of context or anything of the sort.

2. The idea that you think of "Patient Deaths!" as a "straw man argument" or even laughable (as I assume your use of italics is meant to portray), highlights your cavalier attitude towards a set of medications with potent side-effect profiles. I find this extremely disturbing.

 

[appelsoranjes]

1. It's not a straw man argument. We haven't misrepresented your position, nor have taken your words out of context or anything of the sort.

2. The idea that you think of "Patient Deaths!" as a "straw man argument" or even laughable (as I assume your use of italics is meant to portray), highlights your cavalier attitude towards a set of medications with potent side-effect profiles. I find this extremely disturbing.

Maybe not a straw man, but i'd classify it as an "appeal to fear" - patient death is a real (and unwanted) outcome in any area of medicine. To suggest, in the absence of any data, that RxP psychologists would produce a greater frequency of deaths is what I have a problem with.

Anyways, kudos to whopper- you seem to be one of the few level-headed ones here (maybe because you were a psych major and didn't go into psychiatry for the hours/pay or match-rate, but for a true interest in the science and practice).

 

[appelsoranjes]

But this begs the fundamental question...how will you be able to rule out medical-based causes without medical training?

Well the idea is that they would get this sort of training in the post-doc RxP classes/fellowships. Whether they actually do or not is another question - fortunately I'm not responsible for making up the requirements...

 

[Therapist4Chnge]

1. It's not a straw man argument. We haven't misrepresented your position, nor have taken your words out of context or anything of the sort.

2. The idea that you think of "Patient Deaths!" as a "straw man argument" or even laughable (as I assume your use of italics is meant to portray), highlights your cavalier attitude towards a set of medications with potent side-effect profiles. I find this extremely disturbing.

Arguments for "patient safety" have been made by stating the training can't possibly be sufficient (lacks supporting data), and thus unsafe (also lacks data), and that psychologists don't care about these "facts" because they continue to prescribe. The actual argument is not for patient safety, but for turf. There isn't data showing harm by prescribing psychologists, but there is data that shows an increase in prescribers and that they have been effective. It is harder to argue against patients receiving much needed services, so instead the focus is on the psychologists not caring that they are "harming" patients by prescribing because they "obviously" haven't received enough training, which leads to....*wait for it*....."Patient Deaths!! / "Patients will die!!" There hasn't been any data to support this, but who is going to argue against patient safety?! Not psychologists. When we mention "turf" the response is "Patients will die!" When we mention wanting to help pts in need, the response is, "Patients will die!". When we mention the 6+ week waiting periods in many undeserved communities the response is, "we will train more people"...but that isn't happening. The states have statistics to support the need, and the lack of professionals to meet their needs.

While I'm not on board with independent practice, I do think the "safety" issue around all RxP is meant to incite unfounded fear. I don't have a cavalier attitude towards the medications, as I recognize the potential side effect profiles, but any opposition to your position seems to put the person in the "doesn't care about patients" and/or "doesn't know enough" categories...which are false placements.

 

[CAPBonanza]

I feel that the burden of proof should be upon those who want more prescribing authority. Absence of proof is not the proof of absence. Yet, what few studies that have been performed have been lacking, as has been pointed out in previous posts.

The need is undeniable as you point out, yet this is not the answer. The psychiatric patient population deserves the best of care. I feel that there may be psychologists out there could prescribe safely, however the majority probably couldn't. On the same token there are WAY TOO MANY FP's that throw SSRIs at anything that moves and probably shouldn't be allowed to do so. But, the reason the rural population is underserved is the same reason why the majority of Americans live in cities, because only a minority of individuals want to live in the boonies (including Psychologists, prescribing or not). Furthermore, The lack of providers is hardly the fault of the psychiatry community as the number of available training positions is controlled by medicare funding, among many other factors that are not controlled at the local or state level. Don't like it? Write your US Senators and Reps.

The team model does work. Psychologists are experts in psychotherapy (among other things), and Psychiatrists are experts in the pharmacological treatment of psychiatric disease (among other things). We can all work together to achieve great things, but this is not the way to do it.

 

[psychforme]

How much can you earn as an expert witness when the scum psychologist get sued? Sounds like a possible new subspecialty!

 

[whopper]

Anyways, kudos to whopper- you seem to be one of the few level-headed ones here (maybe because you were a psych major and didn't go into psychiatry for the hours/pay or match-rate, but for a true interest in the science and practice).

I would like to think I fit that model, though money has become more important given the amount of debt one accumulates, and that I have spent the last year working in a facility where I've been doing 2-3x the amount of work as my colleagues and they get the same amount of pay. Kinda hard not to demand more when your feet are literally hurting from all the working & running (trust me, my unit is pretty rough), you spend about 7 hrs on your unit a day, and you see a guy on another unit only there about 1 hr a day, taking up the patients you've already stabilized (more stable patients get transferred to his unit), making the same amount. I'm actually looking forward to fellowship even though my pay will be cut in half because as the new psychiatrist on the block, the place hazed me & put me on the toughest unit there (which is the toughest psychiatric hospital in the state--so literally I may have had the toughest unit in a 5 state region--not joking)

scum psychologist

Don't agree with that. That's just name calling. However I do think this will create a market for malpractice lawyers & forensic psychologists & psychiatrists putting new psychologist prescribers to the legal test. I also anticipate that several new psychologist prescribers will probably only do SSRIs in a defensive attempt to prevent from being sued. Since SSRIs are much safer vs the antipsychotics & mood stabilizers, I can imagine the APA (psychological) citing such a psychologist prescriber as an example that the new law is a good one because their lesser bad outcomes. I'm suspecting that's happening now.

And if that speculation is correct that really would defeat much of the purpose of the Oregon law. Primary practice doctors already prescribe SSRIs in large (perhaps too large) amounts. Primary practice doctors are readily available in several areas psychiatrists are not available. Further, the law allows psychologists the full gamut of prescriptions over the psychotropics, and to only prescribe one class of med, then use that to justify all the psychotropics is not valid. Again this is speculation, but speculation I'd be willing to bet is happening & would happen with new psychologist prescribers.

I feel that the burden of proof should be upon those who want more prescribing authority. Absence of proof is not the proof of absence. Yet, what few studies that have been performed have been lacking, as has been pointed out in previous posts.

Agree, and this is pretty much basic common sense. If someone produces a new med, the burden of proof is on them to prove that the med is effective & safe, not the other way around where the pharm company can market it as such, and consumer groups have to prove it to not be safe & effective.

The entire way this law has been pushed smacks of special interest pandering by pharm companies & the APA (psychological one), and government appearing to legislate something it really doesn't understand. The way this is being handled--it appears the pharm lobbyists will push this issue--state to state creating more & more people in both professions to jump at arms against the other.

The team model does work. Psychologists are experts in psychotherapy (among other things), and Psychiatrists are experts in the pharmacological treatment of psychiatric disease (among other things). We can all work together to achieve great things, but this is not the way to do it.

I still don't know if I will do private practice or not, but as I mentioned, I plan on working with psychologists & counselors if possible. I would love to have someone do an MMPI, a Halstead Reitan, or other tests when need be. Its also good to have another voice double check on my work. I am greatly enjoying working with psychologists now at my current job. I am also considering working with an already established outpatient agency where a buddy of mine who is a Ph.D. psychologist has a good likelihood of becoming its CEO in the future--and would actually be my boss if I worked there.

 

[whopper]

Here's a psychologist prescriber curriculum I could agree with.

Get a degree in psychology. The degree would have to have the pre-PA courses so one could apply to PA school.

Then graduate from a 2 year program as a physician's assistant.

This liscence is accepted in all states, and in 48 states, PAs do have limited prescription ability.

It would nullify or reduce several of the arguments against the psychologist prescribers--e.g. there is a national standardized exam PAs would have to pass to practice with tons of data to support it. It would allow one practice in pretty much all the states, so the fear of being limited to specific area would be nullified. Most MDs/DOs I know fully accept a PA with no qualms. The stigma against psychologist prescribers under the Oregon law need not apply in this situation.

PAs in general do report to an MD or DO, but in rural areas can be the primary provider.

For more info..
http://www.bls.gov/oco/ocos081.htm

Then it would be up to the psychologist on whether or not they would want to pursue a Psy.D, Ph.D. or simply a masters in psychology.

However, and this is a reason why I suspect some ulterior agenda with the Oregon (and other state's laws), this curriculum would be much more intense, and while not as difficult as medical school, far more difficult than the current Oregon law curriculum. It also would not be under the control of the APA (psychological) and that APA in addition to the pharm companies appears to be the entities pulling the strings with this psychologist prescriber movement.

 

[ronin12]

I agree. It is a very simple solution.psychologists will be welcomed with this qualification.there would not be any bickering back and forth .PA's are involved in full range of practice and supervised by physicians.This whole notion of independent,unsupervised practice with laughable qualification and training Irks most of us.

 

[whopper]

It is a very simple solution.

Which makes me wonder why the APA (psychological one) has pushed for the Oregon law. I'm either missing something, or this smacks of an agenda, as was brought up by a psychologist in the previous Oregon law thread. A PA/psychologist prescription movement would not be controlled by the APsychologicalA. The med aspects would be covered by the PA aspects, and therefore give the AAPA (American Academy of Physician Assistants) the extra power.

As finger pointing as that sounds, both APAs have pushed an agenda, and it has gotten political, and with lots of lobbying money being pumped into it. To many in both APAs-this has become a political battle.

Anyways, as I've said several times, we should be working with psychologists, and this PA path I mentioned I think would be accepted both by the layperson and several physicians. I doubt though that it will gain momentum.

 

[ronin12]

Which makes me wonder why the APA (psychological one) has pushed for the Oregon law. I'm either missing something, or this smacks of an agenda, as was brought up by a psychologist in the previous Oregon law thread. A PA/psychologist prescription movement would not be controlled by the APsychologicalA. The med aspects would be covered by the PA aspects, and therefore give the AAPA (American Academy of Physician Assistants) the extra power.

As finger pointing as that sounds, both APAs have pushed an agenda, and it has gotten political, and with lots of lobbying money being pumped into it. To many in both APAs-this has become a political battle.

Anyways, as I've said several times, we should be working with psychologists, and this PA path I mentioned I think would be accepted both by the layperson and several physicians. I doubt though that it will gain momentum.

Actually it seems proponents of this moment are infatuated with the notion of premium providers of mental health and now they want it all, In their own self centered thinking it seems this is the ultimate prize,i.e getting the prescription rights on top of being "lords of psychotherapy".I found it quite unfortunate that by doing so it will make psychology look even more irrelevant and bring down the standards of care in mental health.
I always wonder how would they manage their anxiety while prescribing medicines, as even after 2 years of psychiatry residency in 3rd yr outpt clinic, it was fairly anxiety provoking experience seeing patients independently and prescribing meds.Supervision of our attendings was very crucial, as you often need them to make approprite prescriptive or other decisions. I am very doubtful by doing this quick crash course will bring any confidence or essential knowledge of prescribing correct meds and looking for their effects.we still discuss patients with our collegues i.e curb side consult or 2nd opion to ensure proper decisons.
I found it very strange proponents of this bill defend it with blind fervour and bizzare authority ,which shows they are quite oblivious to the realities of medicine.

 

[Therapist4Chnge]

Actually it seems proponents of this moment are infatuated with the notion of premium providers of mental health and now they want it all, In their own self centered thinking it seems this is the ultimate prize,i.e getting the prescription rights on top of being "lords of psychotherapy".I found it quite unfortunate that by doing so it will make psychology look even more irrelevant and bring down the standards of care in mental health.

Thank you for speaking for every psychologist out there, as I am sure you accurately captured our thinking and position on the matter. Oh wait.....

 

[ronin12]

Thank you for speaking for every psychologist out there, as I am sure you accurately captured our thinking and position on the matter. Oh wait.....

The level of desperation is astounding , speaks volume about professional integrity of people behind this quackery.

 

[appelsoranjes]

As finger pointing as that sounds, both APAs have pushed an agenda, and it has gotten political, and with lots of lobbying money being pumped into it. To many in both APAs-this has become a political battle.

Agreed. I feel any curriculum that advances a PhD to RxP should be formulated and provided by an accredited school of medicine (instead of a professional argosy-esque school). It shouldn't be a short-cut to psychiatry, and there should be limits to the scope of psychopharm practice. I do feel there is a role for PhD subscribers...at the very least, we can prescribe SSRIs more effectively knowing the side-effect profiles to pick a drug that matches with a patient's presentation and history, something PCPs don't have the time (and in some cases, the awareness) to do.

Unfortunately, the APA is mishandling this movement - which is why the spinoff (APS) has been attracting psychologists in droves.

 

[Anasazi23]

I've often wondered this. Is there a way to see what prescriptions psychologists have written "just this one time" for patients that are out of their scope, and report them to the state medical society or DEA?

I'm more than certain that a number have already grossly overstepped their bounds and practiced medicine without a license.

 

[Faebinder]

I've often wondered this. Is there a way to see what prescriptions psychologists have written "just this one time" for patients that are out of their scope, and report them to the state medical society or DEA?

I'm more than certain that a number have already grossly overstepped their bounds and practiced medicine without a license.

If it's a prescription, you are better off reporting to the DEA. Especially for class IV or higher. They have no business prescribing opiates for example.

 

[Therapist4Chnge]

I'm more than certain that a number have already grossly overstepped their bounds and practiced medicine without a license.

Does "more than certain" = "know for a fact" or is it just conjecture? If you there are practitioners who are doing something illegal, then definitely report it. If it is just conjecture....it is a generalization meant to smear/discredit hard working individuals.

 

[Harmony]

Louisiana is about to pass the following legislation pertaining to medical (prescribing) psychologist in the state:

SB 294 - Status sent to Governor for final signature, approved in both houses.

Transfers the regulation of medical psychologists from the State Board of Examiners of Psychologists to the Louisiana State Board of Medical Examiners and provides for requirements for and rights acquired by licensure, prescribing drugs, and other regulations for such profession.

http://www.legis.state.la.us/

 

[scottresident]

interested, they have more freedom under the State Psychology. why? would this increase their bargaining status for inpatient work? or to limit additional medical psychologists? why?why?????

 

[Doc Samson]

Here's some more turf that psychology has carved out for itself (and is welcome to). Makes an interesting point re: the difference between a physician (who has patients) and a psychologist (who has clients).

http://pn.psychiatryonline.org/cgi/content/full/44/11/4

Source material:

http://www.bmj.com/cgi/content/full/338/apr30_2/b1653?view=long&pmid=19406892

and

http://www.sciencedirect.com/scienc...=3661629&md5=736f21c38f93b96705e90d311718a7b2

 

[whopper]

Actually it seems proponents of this moment are infatuated with the notion of premium providers of mental health and now they want it all, In their own self centered thinking it seems this is the ultimate prize,i.e getting the prescription rights on top of being "lords of psychotherapy".

Despite my previous posts defending psychologists as a whole, I agree with this statement.

Though I will also add that I've been involved in lobbying efforts in the past from my experiences with working with an environmental lobbying group and the NJ branch of the APA. People involved in such can develop a very egocentric--"get this bill passed, damn everything else" attitude. People with an open minded attitude & willing to be flexible usually get their requests lost in the sea of arguments that arise in the miasma of politicians, special interests, etc. all wanting their angle satisfied.

And as cynical as that sounds, that's how the game is played, and people playing that game get results. Kinda like hiring the best hot shot lawyer. Will that lawyer care about the truth? I don't know, but that lawyer will probably get you a better result.

I'm suspecting some of this "attitude" may be the result of this type of mindset that develops with lobbying. We will see this egocentric attitude even with lobbying groups that are the ones we support such as the AMA & the APsychiatricA.

On a similar note, my wife who is working on a degree in counseling mentioned several areas where the APsychologicalA is working in several states to keep Ed.D level counselors from doing several of the tests that psychologists do, even though those counselors are just as qualified in terms of education such as an MMPI or a Hamilton Depression Scale.

All this lobbying that I am having a strong disagreement with from the APsychologicalA has me thinking that Appelsoranjes is on to something when he mentioned psychologists leaving the APsychologicalA for the APS.

 

[Ollie123]

Totally agree Whopper, I made a similar point over on the psychology board awhile back. I think the biggest problem is that for the folks on both sides involved in the issue, it has become about "winning". What is right or wrong is completely irrelevant. Its been played out to a lesser degree in this thread, but I think it gets 100x worse when you look at it on a national level. I think its true of most political movements...the biggest idiots are usually those yelling the loudest

 

[Therapist4Chnge]

And as cynical as that sounds, that's how the game is played, and people playing that game get results. Kinda like hiring the best hot shot lawyer. Will that lawyer care about the truth? I don't know, but that lawyer will probably get you a better result.

Welcome to politics. Most lobbyists lean hard towards their issue, or more likely they are "paid enough to care". Lobbying is a dirty, backroom, sell a bit of yourself job. I've done enough work on the Hill to see some of the best lobbyist out there work their magic, and it isn't always pretty. I'm not saying all of it is like this, but no bill gets passed through without being traded upon multiple times.

On a similar note, my wife who is working on a degree in counseling mentioned several areas where the APsychologicalA is working in several states to keep Ed.D level counselors from doing several of the tests that psychologists do, even though those counselors are just as qualified in terms of education such as an MMPI.

I have no love lost on the APA, but the vast majority of Ed.D. programs I've seen have no business doing certain types of assessments. Ed.D. programs tend to have a good grasp on IQ testing, but less in regard to personality, and next to no experience with neuro and related areas. Not all assessments are created equal, and that is what they want.

 

[whopper]

I have no love lost on the APA, but the vast majority of Ed.D. programs I've seen have no business doing certain types of assessments. Ed.D. programs tend to have a good grasp on IQ testing, but less in regard to personality, and next to no experience with neuro and related areas. Not all assessments are created equal, and that is what they want.

I'm sure we could debate the validity of counselors administering an MMPI, and in fact you'd probably have the edge there because your training on that test probably far exceeds my own.

However, IMHO its pretty much obvious that they should be able to administer a HAM-D.

 

[scottresident]

sorry for the hit and run this morning. is there any speculation to the reason why the medical psychologists want to be under the LA medical board?

 

[Ollie123]

sorry for the hit and run this morning. is there any speculation to the reason why the medical psychologists want to be under the LA medical board?

The cynic in me thinks it was a PR decision to try and increase perceived legitimacy, and perhaps to limit entry.

The optimist in me thinks this is being done in the hopes of a compromise and increased medical input into the training programs, standards, etc.. Personally, I think it should have been under the medical board to start with for those reasons, but per recent discussion, perhaps that's just because I'm not playing to win

 

[ronin12]

sorry for the hit and run this morning. is
there any speculation to the reason why the medical psychologists want to be under the LA medical board?

probably a more altruistic assessment is that these guys realized how limited their knowledge is and the risk it posed( getting sued) .now they want some help from medical board to lessen the risk. trust me it is terrible feeling if you are a "quack" practicing in law suit country i.e USA.
on the other hand it could be they want legitimacy to be part of medical board(through backdoor entry), to fulfill their childhood desire of being "doctor".
Blocking entry for "future quacks"(most likely, again they want it all), getting privileges for inpatient (may be, they have no limits for ethical and professional lows, because they are desperate).

 

[Anasazi23]

Does "more than certain" = "know for a fact" or is it just conjecture? If you there are practitioners who are doing something illegal, then definitely report it.

Well, it's the psychologists that continually claim that they've written tens of millions of prescriptions without ever having a side effect.

I'm just saying that someone should pour through the prescribing records and pull out the 'inevitable' nifedipine, levothyroxine, OCP, imitrex, celebrex, or any other script that they are unqualified to prescribe. Because like I said, this is practicing medicine without a license, and I don't trust the pharmacists to catch it.

If it is just conjecture....it is a generalization meant to smear/discredit hard working individuals

This itself is just conjecture. You have no idea how hard these people work. They could be the laziest POSs this side of the river for all you know. Again, I'm only interested in the notion that someone should police these prescribers. I'll be interested in obtaining these prescription records. I think I'll look into it.

 

[appelsoranjes]

probably a more altruistic assessment is that these guys realized how limited their knowledge is and the risk it posed( getting sued) .now they want some help from medical board to lessen the risk. trust me it is terrible feeling if you are a "quack" practicing in law suit country i.e USA.
on the other hand it could be they want legitimacy to be part of medical board(through backdoor entry), to fulfill their childhood desire of being "doctor".
Blocking entry for "future quacks"(most likely, again they want it all), getting privileges for inpatient (may be, they have no limits for ethical and professional lows, because they are desperate).

If we are to trust you, I'm assuming it's becuse you've had some exeprience in filling this role? Let's hear more - I'm sure it makes for an interesting story.

As for being called "doctor" - my only childhood dream was to be a Dr. J, but I learned quickly in high school that it wasn't gonna happen- I was too short (at 6'), too sloow, and couldn't hit the outside shot with reliability. While I'm not a physician, and don't prented to be, I am a doctor - though I never parade that title etiher. My students and clients both call me Dr., but i'd be fine if they called me by my first name or just "hey you";

DOCTAH JONES, DOCTAH JONES - U NO REAL DOCTAH?

 

[CGOPsych]

I'm sure we could debate the validity of counselors administering an MMPI, and in fact you'd probably have the edge there because your training on that test probably far exceeds my own.

However, IMHO its pretty much obvious that they should be able to administer a HAM-D.

Just about any medical personnel can administer an injection, write a drug name on an Rx pad or give advice about that nagging cough. We all know that nurses write or call in a lot of prescriptions without legal Rx authority. It's the greater issue of when to use a test, how to interpret it, what to do with the results, and how it fits into a larger picture.

That being said, the issue of who can do psychological testing is indistinct and complicated, just like psychology! Any knucklehead can "administer" an MMPI and cut-and-paste the results into a "report". The question is how we try to enforce some kind of quality in psychological services, and limiting some of the testing to those with a sufficient training is one way, but that system has more holes in it than your average sieve.

Many people who don't understand the psychology business, including some psychiatrists, think all you have to do is get the printout and it tells you if the person is depressed or a borderline. And some of the test manufacturers make good money catering to the people who just want to be told what it means without having to know too much.

I've never heard of Ed.D.'s being limited in their practice scope, or an attempt to do so by APA, although their training is very thin on psychometrics. (APA's current political model is to have as many people under their tent as possible regardless of the quality of their training or practice.) The same goes for the counseling psychology degrees. They were originally designed to counsel in vocational and educational settings, and not perform clinical assessments or deal with severely ill populations. But the law usually says they and Ed.D.'s are the same as those trained in clinical psychology.

And many of the professional schools which purport to give a clinical psychology degree also give short shrift to this kind of training. They teach the what but not the how or why, saying that's "science stuff" and they aren't training "researchers". I had one professional school student, a star in her program, who could not tell me what a t-score is. She had memorized what the cutoff was on the MMPI scales, but she had no idea what the score was, or why it was the cutoff. This is like saying "I know that an A1C of 10 is bad, but I have no idea what an A1C really is."

And to be fair, I've met psychologists from good Ph.D. programs I wouldn't send my dog to. You've met plenty of M.D.'s who are the same.

So can a counselor administer a Ham-D? Sure. And that person might use it very well, or misuse it. Does the counselor understand the cutoffs and what they really mean? Does she understand depression and how to distinguish the cognitive, affective and physiological symptoms and the various factors that may influence them? Or does she just say "this patient is depressed because his score is an XX." Does she choose the HAM-D over the Zung or the Beck or the DEP scale of the PAI or Scale 2 of the MMPI for a reason? They each have their advantages. And so forth ...

The answer is that the odds of properly using psychological testing increase with the training, experience and skills of the examiner. You can't get around it.

 

[silas2642]

Well, it's the psychologists that continually claim that they've written tens of millions of prescriptions without ever having a side effect.

I'm just saying that someone should pour through the prescribing records and pull out the 'inevitable' nifedipine, levothyroxine, OCP, imitrex, celebrex, or any other script that they are unqualified to prescribe. Because like I said, this is practicing medicine without a license, and I don't trust the pharmacists to catch it.



This itself is just conjecture. You have no idea how hard these people work. They could be the laziest POSs this side of the river for all you know. Again, I'm only interested in the notion that someone should police these prescribers. I'll be interested in obtaining these prescription records. I think I'll look into it.

I was wondering if the psychologists malpractice premiums have been going up with Rx privileges (I'm going to assume that most of them carry some sort of malpractice insurance). I'm wondering that if/when a lawsuit does occur, what is going to happen to their insurance rates and if this would dissuade others from writing prescriptions and staying within their scope of practice.

 

[whopper]

Just about any medical personnel can administer an injection, write a drug name on an Rx pad or give advice about that nagging cough. We all know that nurses write or call in a lot of prescriptions without legal Rx authority.

Agree that interpreting tests does require the proper training, though the HAM-D is something IMHO a counselor can interpret, and at least where my wife is training, they are getting training in statistics & psychometrics.
The MMPI on the other hand is a much more sophisticated test.

But the more important bottom line is the special interest battling going on. Lobbying to say who can do what or not do it, based on self preservation & promotion not on higher ideals.

However I do fully acknowledge what you mean, and if other programs aren't giving the backing for pyschometrics, then what you say is extremely valid. In fact is the same reason why I have a problem with the Oregon law--not enough training--shouldn't be given the power.

I was wondering if the psychologists malpractice premiums have been going up with Rx privileges

I mentioned this in the previous Oregon thread, and CGOPsych answered it. The APsychologicalA is providing the insurance. CGOPsych mentioned that it is doing so, pooling money into it on the interest that more psychologists can prescribe.

The point I was trying to make was an insurer cannot really gauge a psychologist precriber's acturarial risk because there isn't a ton of data showing the risk/cost ratios. However supposedly the APsychologicalA is willing to provide insurance anyways (putting in resources insurance companies are normallly not willing to provide) because it backs their agenda. Its a typical "evil corporation" business tactic. Wal-Mart has done the same in the past (e.g. try to drive Toys R Us out of business by selling toys at a loss, but they'll make up for it on their other products, then when the local toy store is out of business, they ramp up prices).

I must to state that while I believe CGOPsyche (because it makes complete sense, and has been done in the past by several corporations--how can you provide insurance without acturarial data?), I have not seen any actual black & white evidence of this.

 

[CGOPsych]

The point I was trying to make was an insurer cannot really gauge a psychologist precriber's acturarial risk because there isn't a ton of data showing the risk/cost ratios. However supposedly the APsychologicalA is willing to provide insurance anyways (putting in resources insurance companies are normallly not willing to provide) because it backs their agenda. Its a typical "evil corporation" business tactic. Wal-Mart has done the same in the past (e.g. try to drive Toys R Us out of business by selling toys at a loss, but they'll make up for it on their other products, then when the local toy store is out of business, they ramp up prices).

I must to state that while I believe CGOPsyche (because it makes complete sense, and has been done in the past by several corporations--how can you provide insurance without acturarial data?), I have not seen any actual black & white evidence of this.

I don't know how they pool the risk, or even estimate it. I am told that APA's insurance arm, APAIT, is providing the extra rider for the prescribers. APA's political insiders who are driving this campaign have demonstrated total willingness to do anything it takes, no matter how smarmy, to move RxP forward.

We can draw our own conclusions. You can be sure they will never willingly disclose the details of this arrangement.

 

[Thorazine]

the psychologists get pretty defensive when people try to encroach on their turf of psychological testing.....

of course you are better trained to administer these tests. just like psychiatrists are better trained to prescribe medicine. you cant have it both ways...

 

[Therapist4Chnge]

of course you are better trained to administer these tests. just like psychiatrists are better trained to prescribe medicine. you cant have it both ways...

Agreed, which is why a collaborative model should be sought. Only a small % of psychologists are pushing for independent prescribing rights (which most of the field is again), which seems to be kicking up most of the vitriol.

 

[ronin12]

Agreed, which is why a collaborative model should be sought. Only a small % of psychologists are pushing for independent prescribing rights (which most of the field is again), which seems to be kicking up most of the vitriol.

there are already available routes for prescription rights, i.e pa and Np's. It is both collaborative, to some extent tried and tested. I do not see any need for cooking up new legislation without medical board's oversight and guidance. most disappointing fact is kangaroo jumps by these proponents, as now they are asking for medical board's oversight in Louisiana. It is frankly pathetic and these guys are giving bad name to the field of psychology and making mockery of medicine as well.

 

[whopper]

We can draw our own conclusions. You can be sure they will never willingly disclose the details of this arrangement.

Just to let you know, I didn't mention the lack of hard evidence because I question you, its because in my effort to be transparent, (actually on several of our parts since several are acting IMHO in good faith) I feel that if I make a statement without solid reference I have to state so.

However given that an insurer pretty much can't do any risk/cost ratio without lots of acturarial data--the burden of proof to prove that that the insurance provider is NOT providing coverage simply for conventional purposes is pretty much proven. In such a situation, anyone willing to provide coverage in an unproven area has to be doing it for a reason other than for the conventional reasons because they're basically gambling.

So it makes complete sense what you mentioned.

One could reasonably argue that since you or I don't have the smoking gun evidence, perhaps we should not conjecture the APsychologicalA's motives with the insurance, but that would likewise BEG the question as to why they would be willing to offer insurance in an area that could cost them bigtime moolah.

 

[CGOPsych]

the psychologists get pretty defensive when people try to encroach on their turf of psychological testing.....

of course you are better trained to administer these tests. just like psychiatrists are better trained to prescribe medicine. you cant have it both ways...

I fully agree. Many psychologists get their panties in a twist when others encroach on the area of doing psychological assessments (not the occasional HAM-D, etc) but then shrug when the power players at APA push for ripping into the Rx market with third-rate training. (Oh gosh, those psychiatrists are just protecting their turf ... terrible!)

Don't forget that RxP as we know it is a political campaign initiated at the very top without the prior knowledge or consent of the governed, maintaining this controversial 14-year turf war by propaganda, media control, hiding the budget, suppressing dissent and debate, etc. These process issues are very similar to the ones involving the international storm of controversy over APA's bizarre and shameful policies on torture and whether psychologists should be allowed to participate in interrogations of prisoners.

Many of those political hacks have moved on (e.g. Practice Directorate Exec Dir. Russ Newman, after unofficially working for years for the private, for-profit professional schools, finally quit and started drawing a paycheck from one of those schools, where he gets to sell RxP programs at $10,000 a pop), so there are questions about whether their replacements will continue this repressive, authoritarian, oligarchic style of government.

Those hacks are why a new psychology organizaiton based on respect for science over cheap hustling (APS) was started and has a sizable membership, and why a new organization has begun taking steps to accredit psychology traing programs, because APA's accrediation standards were nothing more than a sellout to the vested interests.

 

[CGOPsych]

Just to let you know, I didn't mention the lack of hard evidence because I question you, its because in my effort to be transparent, (actually on several of our parts since several are acting IMHO in good faith) I feel that if I make a statement without solid reference I have to state so.

However given that an insurer pretty much can't do any risk/cost ratio without lots of acturarial data--the burden of proof to prove that that the insurance provider is NOT providing coverage simply for conventional purposes is pretty much proven. In such a situation, anyone willing to provide coverage in an unproven area has to be doing it for a reason other than for the conventional reasons because they're basically gambling.

So it makes complete sense what you mentioned.

One could reasonably argue that since you or I don't have the smoking gun evidence, perhaps we should not conjecture the APsychologicalA's motives with the insurance, but that would likewise BEG the question as to why they would be willing to offer insurance in an area that could cost them bigtime moolah.

No problem. The bottom line is that liability insurance does not seem to be an issue at this time. It's been neatly taken care of by APA and we really don't have any details as to how.

Now if a couple of psychologsists get sued then things could heat up. You'd have a long line of malpractice lawyers salivating over the case ... imagine cross-examining a prescriber whose "medical school" was an online course. Whoa! They don't make enough Xanax to stand that.

With only 65 people prescribing in civilian life the odds remain low. One of them said he's in a clinic doing mostly refills, for example.

Wait until a prescribing psychologist changes the Rx of an MD and the patient has an adverse reaction, and his brother-in-law is a lawyer.

 

[DrFraud]

No problem. The bottom line is that liability insurance does not seem to be an issue at this time. It's been neatly taken care of by APA and we really don't have any details as to how.

Now if a couple of psychologsists get sued then things could heat up. You'd have a long line of malpractice lawyers salivating over the case ... imagine cross-examining a prescriber whose "medical school" was an online course. Whoa! They don't make enough Xanax to stand that.

With only 65 people prescribing in civilian life the odds remain low. One of them said he's in a clinic doing mostly refills, for example.

Wait until a prescribing psychologist changes the Rx of an MD and the patient has an adverse reaction, and his brother-in-law is a lawyer.

The current arrangement with the APA might work on a small scale but it is very doubtful that it will work widespread without private underwriters taking some risk. With that being said, that is exactly what is involved - Risk.

The ability to qualify and quantify the Risk will be based on who is doing the numbers and how much risk a given underwriter and clinitian is willing to take, but if what is past is prolog reguarding malpractice, you'll find that the cost of providing risk to psychologists who are not trained with meds and not formally trained in other areas of medicine like high blood pressure management and dyslipidemia management will be greater than the cost of providing malpractice to those with formal training (psychiatrists), which will in turn reduce the profitability and the financial incentive to prescribe by psychologists. Underwriters & psychologists can reduce risk by severly limiting the scope of prescribing by psychologists. The nature of the limitations will be entirely based on cost assessments by underwriters.

As a result, the scope of prescribing amonst psychologists will be severly limited to the point of being almost useless............or the psycholgist and/or their underwriter will be taking on excessive risk.

 

[DrFraud]

Here are some ways an underwriter might work with Psychologists to lower malpractice rates and make malpractice affordable:

-limit the types of psych meds that can be Rx. to those with minimal side effect profiles and that are not addictive
-limit doses
-limit refills
-limit tx of patients with comorbid conditions
-limit ability to d/c drugs prescribed by MDs
-require an MD to sign off on an Rx.


etc.......

 

[whopper]

You'd have a long line of malpractice lawyers salivating over the case ... imagine cross-examining a prescriber whose "medical school" was an online course. Whoa! They don't make enough Xanax to stand that.

Mentioned this in the previous Oregon law thread, but if a psychologist prescriber was sued, I could think of plenty of questions a plaintiff attorney could ask that I doubt the psychologist could answer--that would be completely within the bounds of what an average practicing medical doctor should be able to know.

E.g. pull out all the abnormal EKG readings in a typical ACLS course. Have the psychologist answer each one of them on the stand.
Ask what the requirements are to diagnose someone with diabetes, (the psychologist must state the exact lab values) among several others.

These would completely be fair game. The standard of care dictates that metabolic labs & EKGs need to be ordered before starting an antipsychotic. How could one in good faith claim to understand & interpret those labs if they couldn't do the above?

EKGs are a very good example because one truly needs repetitive & supervised instruction to be able to interpret them. You just can't take a course and that's it-you're an expert. Most medical doctors I know had to restudy it several times--which is what happens in the M.D. curriculum. You get it in physiology, then again in the clinical years, then again in USMLE 2 & 3, residency (where on a daily basis you are pimped on it), etc.

I doubt the Oregon law would provide this level of instruction.

 

[hereandnow]

I think that these concerns about malpractice are critically important. Thank you for raising them.

If any prescribing group is party to an inordinately high number of prescription-based malpractice claims, this would definitely call into question the legitimacy of that group's prescription rights.

Does anyone know ...
... what percentage of prescription-trained psychologists have had prescription-based malpractice claims issued against them?
... what percentage of psychiatrists have had prescription-based malpractice claims issued against them?

If the percentage of prescription-based malpractice claims against RxP psychologists is significantly in excess of the percentage of prescription-based malpractice claims against psychiatrists, then it would point to inadequacy in the training for prescription rights for psychologists.

If the percentages are relatively equal, then it may suggest that the training for prescription rights for psychologists may be adequate.

On the other hand, if the percentage of prescription-based malpractice claims against psychiatrists is significantly in excess of the percentage of prescription-based malpractice claims against RxP psychologists, it may be interesting to ask why this may be so and what might be done to bring these percentages more in line.