The National Psychologist reported in its Sept/Oct 2007 issue that prescription privileges bills to give psychologists prescription privileges in nine different U.S. states failed in each and every case. Most never left committee, reflecting the leadership’s unease of granting prescription rights to non-medical professionals.
The bills …
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medical doctors don’t receive much medicinal training either. i think it’s unfair.
I don’t think so. As a medical student, I had more pharmacology than you could imagine. The entire three-year training program is full of medication management. If anything, some physicians prescribe incautiously, and since when did the performance of the worst rpedict the behavior of the group?
Enough people dump on me as it is. If it’s your adverse event, don’t refer the patient back to me. On the other hand, if you think your patient really needs a medication, I’ll take your recommendation, if you ask me first.
For a full and more irreverent response see http://executivephysician.blogspot.com/2007/09/psychologists-prescribing.html
I don’t think so. As a medical student, I had more pharmacology than you could imagine. The entire three-year post-graduate training program is full of medication management. If anything, some physicians prescribe incautiously, and since when did the performance of the worst rpedict the behavior of the group?
Enough people dump on me as it is. If it’s your adverse event, don’t refer the patient back to me. On the other hand, if you think your patient really needs a medication, I’ll take your recommendation, if you ask me first.
For a full and more irreverent response see http://executivephysician.blogspot.com/2007/09/psychologists-prescribing.html
Psychotropic medication effects a lot more than mood…ANY drug that penetrates the brain may have wide ranging effects, including neurologic side effects. Also, all psych meds can effect organs such as the liver, kidneys, heart & cardiovascular system, bone marrow. MDs have had approximately 23,000 hours of training including medical school and residency. Psychologists are requesting “prescription writing privileges” with less than 500 hours of additional education, and minimal initial supervision (only) – depending on the state/legislation, supervision may be provided by primary care physicians. Even though, prescribing psychologists would then perform a medical function, their licensure would only be evaluated by fellow psychologists (and not necessarily those who are also precribers). Not medical practitioners. The truth is, it is easy to prescribe meds. It is much, much harder, to prescribe medication effectively, safely, and to know how to monitor meds – when to recognize a physical side effects (liver toxicity for example) and when to order a lab (liver tests, for example), much less to know how to recognize and act on a critical lab value or patient report of a side effect. Prescriber-want-to-bes often cite the Defense Department
s program to have psychologists prescribe. What they don’t relate is how many Ph.Ds flunked medical classes or other medical exams – and the DoD cancelled the program (cost, time, training necessary). Bottom line, in my view: this effort to prescribe meds began at a time when insurance companies made it harder for psychologists to bill for and gain compensation for their work. This is not about access to meds (psychologists have roughly the same distribution as psychiatrists in terms of where they live and practice). I work with a number of Ph.Ds and cannot function without their capabilities. None that I currently work with, or any I have previously worked with, feel it is safe or appropriate for psychologists, with no substantial medical training, to prescribe any medications.
I’m grateful that psychologists haven’t been given prescribing rights too. I agree with the above poster that there are significant issues around monitoring medications safely. I also think that there is a further issue that I haven’t seen many people raise (so maybe there is an easy answer to this that I’m simply missing). The presence of somatic disorder acts as an exclusionary criteria for the diagnosis of a fair number of psychiatric disorders. This is partly due to the fact that the psychiatric symptoms (mood etc) clear up when the underlying somatic disorder is attended to.
I’d expect medical doctors (with medical training) to be much better placed to differentiate mental disorders due to an underlying somatic / organic disorder (and hence refrain from prescribing psych meds and instead attending to the somatic disorder and / or referring the client on). Psychologists don’t have the relevant medical training to differentiate endocrine (for example) from psychiatric disorders, however. There would thus be a tendency for them to overprescribe and put patients in danger as their underlying somatic condition would not be adequately attended to.
One could say that a psychiatrist can make the differential but that a psychologist could do the follow-up. It might be the case that the relevant symptom picture doesn’t emerge on one initial interview, however.
I also think that there is a danger in psychologists having ‘prescribing envy’ and (in some instances) an undue faith in medications. I think that doctors tend to know enough about medications to be more circumspect as to its utility. I’d be sad if people went with the ‘cheapest option’ (of allowing psychologists with less relevant training) to prescribe medications over the more competent option.
I mean really, we worry enough about the competency of psychiatrists to diagnose medications appropriately. At least… I do.
I’m neither for or against this yet. I DO understand MDs are probably the most capable to write Rx, but in today’s world MDs are not the only ones who write. Actually MANY other degrees write Rx now. DO (osteo med), OD (eyes), DPM (podiatrists), NP (nurse pract), PA (physician asst), DVM, anything else…CRNA maybe and now pharmacists in some states! Many are master’s levels, not doctorate. The whole point of allowing PA/NP to do this was to increase the access to heath care. There are a shortage of doctors, especially psychiatrists in many parts of the country. I’m not sure… but why not let them… as long as they are trained to the same pharmacology standards as NP/PA/DPM/OD etc… What do you guys think? It’s almost 2008, MDs aren’t the God of health care anymore. DOs, NPs, PAs, etc are playing an incredible role in serving humanity and we need all the help we can get.
And the one things all those professions have in common that is noticeably lacking in psychologists is the extensive background and residency in medicine, meds management and human physiology. Psychologists get virtually none of that (depending upon the specific doctoral program) in their existing formal training.
I’m not saying a psychologist shouldn’t be allowed to prescribe, but as you point out, why not have them do so under one of the many pre-existing medical degrees that already offer them that option?
My main concern is the suggestion that somehow psychologists’ existing professional background somehow prepares them for the world of medicine. It doesn’t. If someone wants to pursue a sideline of medicine (prescribing meds), they should go and get a medical degree.
Robert Karp wrote: >> “The truth is, it is easy to prescribe meds. It is much, much harder, to prescribe medication effectively, safely, and to know how to monitor meds – when to recognize a physical side effects (liver toxicity for example) and when to order a lab (liver tests, for example), much less to know how to recognize and act on a critical lab value or patient report of a side effect.”
(Apologies – the rest of my message didn’t post.)
Robert, thank you, this is (imo) the single, most dangerous aspect of the issue.
My concern extends to medicating patients with chronic physical illnesses (and co-morbid mental disorders as well).
Choosing the correct med is a critical consideration here as well. The risk inherent in medicating patients in the mental health area is far greater than in mainstream medicine.
(Have these folks weighed the malpractice/liability/insurance issues in all this? )
I’m still not clear about the central argument among the pro group in the psychologist community nor have I heard a compelling reason from them that would make me waver. I’ve heard a constellation of ” … and another thing!” items, but not a clear, core argument. Have I missed something?
Using the weary and dog-eared “what about rural areas and people who can’t access a psychiatrist” is one of the poorest arguments – grant an entire profession privileges to medicate everyone because a few patients have limited access to doctors per se. Not limited access to medical attention, limited access to doctor, and the para-professionals work under the supervision of a medical doctor.
“Less expensive” is equally weak. In many, many areas of the country, the fee for a session with a psychologist is about the same as a medication check with a psychiatrist. A psychologist who medicates a patient would be bound to see that patient on a regular basis and take away the patient privilege of scheduling sessions according to need (and finances),
Dr. Grohol, I do – and have always – embraced your take on this. Thank you to you, too. Great article and discussion.
Patricia
As a psychologist that has gone through the masters in psychopharmacology program I can tell you with authority that psychologists are prepared well to prescribe. But let the proof be in the ability for psychologists that have received such training to then pass the national exam. Psychiatrists and psychologists played a role in crating the national exam, and only one who has rec’d sufficient training should be able to pass such an exam!
It’s interesting how I have NUMEROUS professors of psychology who seem to know more than than the average psychiatrist/medical doctor about anti depressants and so on…
With extra medical training, I see psychologists as being FAR more effective than psychiatrists. Psychologists spend much more time with their clients and seem to know more about them then a primary care physician (who has little to NO training in psycho-tropic, antidepressants, etc) yet they are still allowed to prescribe.
It’s interesting how I have NUMEROUS professors of psychology who seem to know more than than the average psychiatrist/medical doctor about anti depressants and so on…
With extra medical training, I see psychologists as being FAR more effective than psychiatrists. Psychologists spend much more time with their clients and seem to know more about them then a primary care physician (who has little to NO training in psycho-tropic, antidepressants, etc) yet they are still allowed to prescribe.
To the idiot who cant count: Physicians do not get 23 thousand hours of training. I have not the foggiest idea of where you came up with that number. At the rate for which credit is given ( about 12- 15 hours per semster hour) medical school is about 600 hours of class time, first year internship 2000 hours, and three years of residency 6000 hours. This makes the five hundred hours of Psychology required training roughly comparable to completing medical school. Pharmacology training in medical school, roughly 45 hours total. ( I know, I help teach it.) I have not the foggiest idea where you came up with your numbers.
Several very key issues are often missed in the discussion.
#1) Path-of-least-fear rather than the most effective path. Suppose drug A is the best drug for the patient but causes blood disorders (this happens). Suppose drug B is much less effective but doesn’t require the blood test monitoring. What do you think a psychologist is going to prescribe.
#2) Full patient evaluation and assumption of the patient-doctor relationship rather than piecemeal care. Psychologists often argue that they will be supervised during their care by an MD. However, psychologists are not trained to adequately communicate a patient’s history relevant to medication. Taking a patient with muscle spasms off a tranquilizer like xanax can have an aggrevating effect. It actually requires you to go to medical school to know that the back pain is actually relevant in this “psychological” encounter. Good luck on a psychologist picking up on this, asking the patient the right questions about back pain and communicating it their supervisior. My point is, presribing medications is hard and takes training beyond a narrow field.
Prescribing psychologists are a tempting concept unless you have to go to one and wonder if they know what a prolonged QT is.
I don’t know where Dr. Roxanne Lewis gets her numbers but I think she is the on that can’t count. She says that medical school amounts to 600 hours. That would average to less than 1/2 an hour a day of training in medical school. It is more like 6-8 hours of didactics plus 4-5 hours self learning daily x 2 years or around 7,500 hours during the first two years. The last two years is mostly hands on experience working on average 10 hours daily and 2 hours didactics for a total of 8000 hours training. Residency is about 70 hour work week x 4 years or 13,000 hours for a total of 28,500 hours of training. Of course not all of this is in pharmacology but all of it is part of the knowledge that is drawn from everytime one prescribes. And learning pharmacology was not just the hours of lecture in 2nd year of medical school.
To MP PHD OK smarty pants. If you want to count hours studying as “hours of training time” I got you beat. Lets see, 5 years to get a PHD while working full time in medical clinics 10 hours a day plus 30 years of practice = 80,000 hours plus of training in mental health, psychopharmacology and medical school. ( yeah, I went there too.)
Now top that. But Medical school class hours are about 600 with roughly 15 credit hours per semester over four years. Of that usually less than five hours are in Psychopharmacology in medical school. But I think that the ten hours of scut work a day collecting stool samples and writing in charts that medical students do as well as watching other people work does not really count as Psychopharmacology training, now does it. So get real.
Most of these arguments that psychologists )*couldn’t possibly* learn psychopharmacology and prescription management are absolutely specious. I’d suggest these arguments are more likely founded in academic elitism, salary level preservation and political turf protection.
I find it mythical to suggest that these elements of overall medical school curriculum are so precisely designed, rigorous and selective that non-medical students *couldn’t possibly* acquire these competencies. If this is true, it’s a sad indictment of the inefficient nature of today’s medical education curricular design.
The “massive hours” arguments are specious unless you can identify how each hour targets the prescription competency from a skills development perspective.
Psychologist privileges target a very specific subset of the overall medical curriculum and this should not ignore the prudent recognition of the holistic and systemic aspects of the training.
Nurse practitioners receive limited *general prescription* rights with 2-3 year post Bachelors Degree but we can’t do this for psychopharmacology?
If public risk is so great, why haven’t psychiatrists targeted toward non-psychiatrist/neurologists physicians who are likely misdiagnosing and misprescribing based on a lack of psychiatric training? What about the risk/ethics regarding underserved populations experiencing 4-6 month waitlists for psychiatrists due to shortages.
Psychologist privileges are certainly not to be oversimplified and many complex issues would need to be carefully considered. However, to base objections on the *impossible nature* of designing a psychopharmocologic prescription curriculum brings one to question the validity and efficiency of current medical school curricula.
Should we propose that non-PhD physicians be excluded from interpreting or contributing to scientific journals due to absence of research design and statistics in their curriculum? I’d bet there would be strong reaction to that suggestion.