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Across the country state legislatures are debating a variety of bills that would grant independent prescribing privileges to psychologists. Proponents and opponents agree that the success or failure of these bills has huge economic implications for psychiatrists and mental health practitioners. The disagreement lies in whether patients will benefit overall from increased access to care or will be harmed by poor medical decision making. Although many psychiatrists have strong opinions on this subject, few have had the opportunity to work or train with psychologists who are being trained to prescribe medications independently.
In this month's Residents' Forum, John Kennedy, M.D., describes his experiences in training and collaborating with psychologists who were a part of the Department of Defense Psychopharmacology Demonstration Project. Dr. Kennedy is a lieutenant in the Medical Corps of the U.S. Navy and a fourth-year resident in the National Capitol Area Military Psychiatry Residency. Following completion of his training, he will be assigned to the U.S. naval air station in Sigonella, Italy. This column contains the personal opinions of Dr. Kennedy and does not necessarily reflect the views of the Uniformed Services University of the Health Sciences, National Naval Medical Center, or the U.S. Navy.
If you would like to submit an essay for the Residents' Forum or contact me about other issues, I may be reached by e-mail at abbusch@erols.com; phone, 410) 522-4516; or fax, (410) 614-5904. All submissions will be considered.
-Alisa Busch, M.D.
Member-in-Training Trustee
By Lieutenant John Kennedy, MC
I first heard of psychologists seeking prescribing privileges when I was a third-year medical student at the Uniformed Services University of the Health Sciences, an institution dedicated to the training of military and public health physicians. One year later I learned that my school was required to prepare selected military psychologists to prescribe psychotropic medications. The program was called the Psychopharmacology Demonstration Project (PDP).
I began the inpatient rotations of my psychiatry residency in summer 1995, just as the first group of PDP fellows was beginning clinical rotations. My fellow residents and I spent the following academic year working side by side with them, and there was in fact some overlap in our respective didactic curricula.
On a personal level, I had a positive impression of the PDP fellows. They were intelligent, motivated, caring practitioners who, by force of will and the pursuit of a highly focused curriculum, had mastered the scientific fundamentals and clinical practicalities of prescribing psychotropic medications. My respect for their diligence was soon overshadowed, however, by my concern that they were inadequately prepared. The PDP has now been discontinued, but news of analogous programs being proposed in the civilian sector prompted me to report my observations and to express my concerns.
The rationale (as I understood it) was that psychologists, by virtue of their knowledge of the psychosocial aspects of mental illnesses, were well positioned to prescribe medication for such conditions, once they had received training in psychotropic-specific neuroanatomy, neurophysiology, and pharmacology.
In my opinion, the PDP fellows received excellent training in these areas. They gathered careful histories, did excellent mental status exams, performed competent physical exams, and chose psychotropic medications well-suited to the DSM diagnoses of their patients. But armed with something short of a third-year medical student's knowledge, they were suddenly called upon to function as semi-independent practitioners. Lacking the additional training of a psychiatry intern, they were unprepared to address their patients' total clinical picture.
The PDP fellows were unable effectively to take into account concurrent general medical illnesses and the medications being used to treat them, to interpret abnormalities in the physical exam, or understand the laboratory evaluation. They were unable to order radiological procedures appropriately or interpret the resulting reports. They had difficulty consulting medical specialists appropriately or appreciating the implications of the subsequent recommendations.
To their credit, the PDP fellows sought guidance and assistance in these matters, but clinical care and treatment via PDP fellow-psychiatry resident collaboration was burdensome and inefficient.
Take, for example, a patient who had bipolar disorder comorbid with alcoholism and a history of seizures. An effective medical workup would involve a physical; a laboratory evaluation including electrolytes, BUN, creatinine, LFT's, and CBC; and a neurology consult with an EEG. A PDP fellow would likely do a physical exam by rote and order a standard battery of lab tests, but as soon as the abnormalities appeared (an elevated PT and creatinine, say) and it was time to address the seizure history, the fellow would require guidance.
Assistance might involve a second physical, additional lab tests, and a time-consuming discussion of the need to rule out alcohol withdrawal as a possible seizure etiology. Two more years of clinical training might fill in these knowledge gaps, but at that cost, the PDP fellow could have earned an M.D. One of the PDP fellows did exactly that.
My experience led me to question the value of training psychologists to provide medical care to the mentally ill. Furthermore, the success or failure of the PDP graduates is a poor guide to how such an endeavor would fare in a civilian setting. The military patient population is literate, employed, and employable. Disabilities have been largely screened out, there is close collaboration between the occupational and health care settings, and military patients are duty-bound to cooperate in the treatment of their illnesses. My experience led me to believe that only carefully chosen, medically stable, mildly mentally ill patients could be safely treated by prescribing psychologists, and then only under the supervision of an M.D. The structural guidance of the military health care mission offers the potential for such restraint, but the economic forces of the civilian health care market would be likely to challenge such restrictions from day one.
I would like to point out that I made my point by describing the care of a medically complicated patient. Psychiatrists' opposition to the psychologist-prescription movement is more likely to be effective when we commit ourselves to being full practitioners of psychiatric medicine. The public will be served only to the extent that the participants in this debate focus on what is best for patient care.
Without such a focus, this debate will devolve into a turf battle that can only detract from the larger goal of providing effective treatment to the mentally ill.