|
Dear
Colleagues:
In light
of the ongoing debate about psychologist prescribing privileges,
I thought you would be interested in the following insightful
letter to the editor titled "I'm a Psychologist, Not
a Prescriber" by Teresa Bailey, Ph.D. printed a recent
issue of Behavioral Healthcare Tomorrow.
Paul S.
Appelbaum, M.D.
President, American Psychiatric Association
NOTE:
For a .PDF version of the letter to the editor, please contact
jabadie@psych.org
I'm
a Psychologist, Not a Prescriber
By Teresa Bailey, Ph.D.
(EDITOR'S
NOTE: We received dozens of comments on our October 2002 cover
story on New Mexico's psychologist prescribing law. We decided
to print this response in its entirety because of the writer's
perspective and the eloquence of her words. The writer is
a licensed psychologist in
California.)
Long before
I ever thought of becoming a Ph.D.-level psychologist, I served
two summers as a chaplaincy intern at a Midwestern tertiary-care
teaching hospital, where patients, as well as the medical
and nursing staff who cared for them, were my "flock."
The theory behind training chaplains to work in this setting
was that if we were to be truly useful to the entire treatment
team, we should have some realistic idea of everyone's role
and responsibility.
As a result
of this philosophy, we were given access to all areas of the
hospital. I was present with medical and nursing students
for surgeries and autopsies. I went with students, doctors
and nurses to morbidity and mortality conferences. I worked
in oncology, gynecology, cardiology and neurosurgery, and
made occasional trips up to psychiatry.
I sat
with patients at the bedside, and walked the halls with their
families. I baptized dying babies when the parents asked,
and helped families with the impossible decision of starting
an experimental treatment with no predictable outcome. Sometimes
my job was to work with the staff to help a family accept
that there was nothing more to be done medically. In quite
a few cases I was the only professional staff member patients
saw on the ward who didn't potentially wield a needle.
During
those six months I saw first-hand and up close how medicine,
nursing and other healthcare professions were practiced and
taught. I learned some medicine and nursing in that time -
enough to know what the stakes are. All these years later,
I see that time as central to understanding my role as a psychologist
in the total care of a person who suffers. The most important
lessons I learned from the medical world were to be honest
about what I know and do not know, and how to form collaborative
alliances with other professionals, because the implications
for the patient are enormous.
Am I smart
enough to become an M.D.? Yes I am. I decided not to pursue
a medical degree for reasons that have nothing to do with
my academic abilities. Do I believe that the programs for
prescribing psychologists are enough for us to prescribe safely
for the variety of patients to be seen over the course of
a career? No, I do not.
If we
prescribe safely as psychologists, it will be because we are
lucky, not because we know enough medicine to do the job right.
Doing the job right is more than memorizing the book and the
probabilities of outcomes, and listening for patient reports
of effects and side effects. When it goes wrong, and it does
(more than one would want to admit), it can either go very
wrong very quickly or it can creep up over weeks and months,
and masquerade as or exacerbate other medical conditions.
None of
the prescribing programs call for the kind of intensive training
of being totally responsible for a patient's care over the
course of a hospitalization; tweaking meds left and right
till something works or works well enough, or doesn't; finding
out there's a whole new set of medical problems that weren't
known before; dealing with the patient and family when things
don't go as planned - and doing this day in and day out, year
after year, all the while seeing outpatients in clinic. This
kind of clinical decision-making cannot be duplicated in the
research and observation atmosphere with some practica and
another two years of general clinical training. That training
doesn't necessarily include contact with the severely mentally
ill, or even the physically ill, so that one may learn to
spot the differences, or to see how physical and mental conditions
mutually influence each another.
The argument
that other health professionals prescribe medications is a
straw man. Dentists perform anesthesia for brief intervals
and prescribe pain medicine and antibiotics for circumscribed
periods of a patient's life - usually six weeks or less. Nurse
practitioners have more training and
experience in how the body works than psychologists receive
in the normal course of their training.
Nurse
practitioners have seen enough during their training and experience
to know when to call in an M.D. Few are confused about the
scope of their training and practice.
I remember
reading something written years ago by a nurse who chose to
retrain and go to medical school. She said that she was completely
unprepared for the differences in knowledge and responsibility,
and that while she had many advantages in the training for
having been a nurse, the
jobs were both very necessary and very different.
General
practitioners may not have specialized psychiatric training,
but they have years of experience in understanding medications
and how they behave in the body. Many of them probably should
refer to psychiatrists, but in the absence of a psychiatrist,
they are in a position to monitor
medications and make adjustments better than someone without
medical training is. A collaborative relationship with a licensed
psychotherapist who can more closely track the emotional functioning
of an individual would be even more to the point.
Psychotropic
medications are usually taken for more than a few weeks at
a time. Many people take them for years, even decades. Some
of these (Xanax, for one) are highly addictive. Many of the
newer medications are metabolized slowly in the body (Prozac,
for instance), and some have serious side effects. What level
of training do we as a society want to require for persons
who evaluate the medical appropriateness of, and write prescriptions
for, these medications? Maybe the probability of something
going wrong is low, but when it's happening to you, it's happening
100 percent.
I have
too much respect for what those who undergo medical training
know and can do, ever to put a patient of mine at risk by
taking on such potentially dangerous work for which no series
of weekend courses and part-time supervision could prepare
me.
If there
aren't enough prescribing psychiatrists, then we need to look
at the way we recruit, train, reimburse and support them.
If psychologists want to respecialize in psychopharmacology,
then medical school is only three years, and with appropriate
planning and changes in current policy, a
dedicated respecialization track to psychiatric residency
might become available.
States
with a shortage of prescribing psychiatrists might want to
considers subsidizing this respecialization, and/or forgiving
loans for those who practice in underserved areas. Medical
schools might also want to rethink their ageism about who
can be trained to know and practice what they teach.
As a society,
we also need to consider the role insurance companies play
in deciding who is treated with psychotherapy, who is medicated,
and who requires both approaches. Do we want those decisions
to be made primarily in light of profit considerations for
the benefit of stockholders, or with an eye to individual
patient quality-of-life outcomes?
Clearly
the problem of who prescribes is not about "us"
and "them." The issue is, who knows enough to prescribe
safely to the wide range of persons who will present themselves
to persons who prescribe? Will that person know enough to
know his or her own limits? For all its faults, medical training
is the best way to come to this knowledge.
When push
comes to shove, who would you want prescribing for you or
your family? Someone with years of full-time experience and
supervision, or someone who learns it on the side or as a
sub-routine to another training focus? Handing over the responsibility
for medical treatment to someone who is sincere and motivated
is not the same thing as having someone who trained for what
the job really is.
I realize
I am probably in the minority among my colleagues in the profession.
I also am in the even smaller minority of having been so close
to the training of medical interns and residents, and the
day-to-day working realities their teachers face. I would
wish such an experience for everyone
who seeks to write prescriptions, not so that they would necessarily
come to share my opinion, but so that they would better know
the privileges and responsibilities of caring for a person's
body in this way.
Reprinted
with permission: Behavioral Healthcare Tomorrow. February
2003
Legislation
Update
Dear IPS
member,
I have
sent this message to all IPS members for whom we have e-mail
addresses. On behalf of the IPS Council, I am trying to organize
a grass roots network that can be used to communicate our
concerns to state and national legislators from time to time.
The national APA is eager to have a psychiatrist from every
congressional district willing to communicate with their representative
from time to time. This is particularly true if the legislator
is on a committee considering and important peace of legislation.
At the
state level, there are generally a few issues we follow. For
instance, this year there is legislation for committing sex
offenders to state hospitals after the completion of their
sentence, a bill to eliminate formulary control for psychotropics
in the DOC, a bill for parity for substance abuse treatment,
and a bill calling for psychiatric advance directives, that
would allow patients to agree or refuse treatment in advance
should they become psychotic. As these work their way through
committees, it could be helpful to have a doctor from the
home district of a key legislator.
If
you think this would interest you, please respond me at sdunlop395@aol.com.
Steve
Dunlop, Legislative Representative, IPS
|
