The Psychologist Prescribing Bill is Dead--Long Live Science in the Public Interest!

Oregon’s Governor Kulongoski has vetoed a bill that would have allowed psychologists to practice clinical medicine without adequate training-otherwise known by the euphemism of "prescribing." The Governor's rationale was precisely the one opponents of the bill, such as myself, had advocated. As the Oregonian newspaper put it:

“Medical groups and even some psychologists opposed the bill. [Governor] Kulongoski said such a change ‘requires more safeguards, further study and greater public input.’”

That is an understatement! And, contrary to an oft-repeated claim that the Oregon bill required  prescribing psychologists to obtain a medical assessment by the patient's “medical doctor", the bill required only "collaboration" with the patient's "health care professional". There was nothing in the bill that stipulated that this "professional" be a medical doctor.

Furthermore, the perverse notion that it is the job of physicians to demonstrate that psychologists have actually "caused harm" before opposing their unsupervised prescribing of medication turns science in the public interest on its head. It is the responsibility of those who claim the prerogatives of the physician to demonstrate to the general public, and to the scientific community, that their methods and practices have been proved safe and effective.

There is not a scintilla of credible, scientific evidence showing that "prescribing psychologists" in New Mexico or Louisiana have practiced safe and effective prescribing--though I suspect many have done so, and that most are careful and conscientious clinicians. There has been, to my knowledge, no systematic monitoring or objective analysis of these psychologists' practice patterns. The mere absence of reports (of adverse drug reactions) does not constitute "credible, scientific evidence." Nor are the data furnished by the Department of Defense project--which involved ten psychologist prescribers, closely supervised by psychiatrists--applicable to the psychologists prescribing in New Mexico and Louisiana.

Imagine if this sort of Orwellian logic were applied by a drug company to its newly-released medication: "Well, we don't have any adverse reports coming in, so our drug must be pretty darn safe!". Has it occurred to those who believe we have good "safety data" on psychologist prescribers that there is an inherent conflict of interest among psychologists and their collaborating physicians, with respect to reporting an adverse drug reaction? Does the term "malpractice suit" ring any bells?

All this said, psychiatrists and primary care practitioners need to get their own houses in order. We are far from unblemished in our own prescribing practices, as I have observed after 28 years in the profession. We need to ensure that prescribing on the part of PCPs and psychiatrists is undertaken only after thorough assessment of the patient; consideration of non-pharmacological options (e.g., "talk therapy"); a careful "risk-benefit" discussion with the patient--and after having mastered the relevant literature on psychopharmacology. To be sure, we have a long way to go--but the solution is better training and education for physicians, not the creation of new classes of "prescribers" who lack comprehensive medical training. We also need to find ways to address the crushing shortage of qualified physicians-both general and psychiatric-in underserved areas of the country. For example, we could consider national legislation that would subsidize medical education for those who agreed to practice either primary care or psychiatric medicine, in under-served regions. We could also offer incentives to primary care doctors for undertaking specialized training in psychopharmacology, under the tutelage of experts in the field.

Finally, we physicians need to educate the public and our legislative representatives on why "prescribing" cannot be separated from the art and science of medical care. To advocate such a separation is to dissect muscle from bone, using a paring knife: it can't be done without injuring the patient.

DR PIES WRITES IN RESPONSE TO DR QUILLIN'S QUESTION

James Quillin raises another good question: one that gives me the opportunity to explain how radically different the training and experience of the nurse practitioner (NP) is from that of doctoral level psychologists receiving post-doctoral training in psychopharmacology. I will try to answer Dr. Quillan’s research question in more detail shortly; the quick answer is that research on the safety and efficacy of nurse practitioners (of which, psychiatric nurse practitioners (PNPs) are a subset) goes back at least to 1989, with nearly 40 methodologically-sound studies of NPs in emergency settings recently reviewed by Carter & Chochinov (CJEM. 2007 Jul;9(4):286-95). Most of the research points to safe and effective practice on the part of NPs. However, controlled research seems to have followed by some years the initial granting of practice privileges for NPs, from what I can determine. I suspect that much of the initial skepticism on the part of physicians-with respect to the abilities of NPs-stemmed from this lack of systematic research.

Over the years, I believe the NPs have gradually gained more respect and trust from physicians (and I include myself in this category). Of course, I must begin this discussion with the premise that deficiencies in controlled research, prior to independent practice by NPs, would not excuse or justify a similar deficiency, with respect to granting “prescribing privileges” for psychologists. Furthermore, the mandatory, “hands-on” clinical training of NPs is far in excess of that required of current “prescribing psychologists”, who are mainly required to complete academic course work. (There is probably considerable variation, however, among available programs). The reader interested in more details may continue from here.

A systematic review by Carter & Chochinov 2007) concluded that, “Although some questions remain, a review of the literature suggests that NPs can reduce wait times for the ED, lead to high patient satisfaction and provide a quality of care equal to that of a mid-grade [medical] resident.” I do not believe we have any research, at present, remotely comparable to this for “prescribing psychologists” now practicing in New Mexico and Louisiana. From my brief review of the NP literature, it appears to me that while the research goes back over 20 years, most of it was done after NP practice was permitted or already established in some states.

First, however, it’s important to note that “…"The most common path to a career as a nurse practitioner begins with completion of an undergraduate nursing program and the acquisition of a registered nursing certification. Most will then work in a clinical setting for at least a year or two before entering a master's degree program. The master's degree program includes an advanced study of anatomy, physiology, epidemiology, virology, pharmacology and other medical topics. Students are taught how to perform a variety of medical and diagnostic procedures.”  Thus, most NPs are already RNs and have had extensive clinical experience caring for very sick patients, as well as in detecting signs and symptoms of underlying medical illness, drug side effects, etc.

Psychiatric Mental Health Clinical Nurse Specialists (PMHCNS) were the first advanced practice nurses in the U.S. Differences between a Psychiatric/Mental Health Clinical Nurse Specialist (PMH-CNS) and a Psychiatric/Mental Health Nurse Practitioner (PMH-NP) are explained on this same website. In California, PMH-NPs are eligible for prescriptive authority and PMH-CNSs are not. A representative curriculum for advanced practice nurses may be found at http://cmhda.org/go/Portals/0/CMHDA%20Files/MHSA/WET%20Docs/Careers%20as%20a%20Psychiatric%20MHNP.pdf. It includes Assessment/Management of Common Psychiatric Symptoms; Advanced Health Assessment; Health Protection and Promotion; Clinical Pharmacology; Symptom Assessment and Management; Management of Psychotropic Regimens; Complex Health Problems & Management; and, for PMH-NPs, clinical residency (12-20 hrs/week) for two half-semesters. The amount of hands-on clinical training in the UCSF PMH-NP program is clearly far in excess of anything now mandated by masters programs in psychopharmacology for psychologists. For example, the program at Fairleigh Dickinson University states that, “The length of the supervised clinical experience, which is elective and post-degree, will vary depending on your personal circumstances.” In short, the mandated (vs. elective) clinical training for a PMH-NP is not in any way comparable to that of a graduate of a “prescribing psychologist” program.

Interestingly, the nursing profession has been very receptive to skepticism on the part of many physicians, with respect to the abilities of NPs. Writing from the nursing perspective in Australia, Elsom and colleagues state, “It is entirely appropriate that medical practitioners question the capacity and ability of NPs to provide an optimal standard of medical care for the consumers of medical services. With this in mind, doctors have a responsibility to challenge the educational preparation of NPs to ensure it meets the standards necessary to provide this level of care. The nursing profession shares this concern and strives for quality educational programs for NPs.” [Perspectives in Psychiatric Care Vol. 45, No. 1, January 2009].

I must say, I have not yet seen this degree of openness to questioning, among advocates of the “prescribing psychologist” programs. In any case, after reviewing the available evidence, Elsom et al conclude that, “Available evidence suggests that care and treatment from nurse practitioners in primary health care is equal to that provided by medical practitioners.”

Specifically, Elsom et al found that “There is strong evidence from systematic reviews concluding that NPs can provide levels of primary health care that are at least equivalent to that provided by physicians (Horrocks, Anderson, & Salisbury, 2002; Kinnersley et al., 2000; Parliament of Victoria, 2006; Rosenthal et al., 2005; Shum et al., 2000; Venning, Durie, Roland, Roberts, & Leese, 2000). Large-scale studies (n = 1,815, Shum et al.; n = 1,368, Kinnersley et al.; n = 1,316, Mundinger et al., 2000) did not find any significant differences in treatment outcomes between NPs and medical practitioners.” The authors added the important caveat that “…this research has predominantly been conducted in primary care settings and, therefore, whether specialist mental health NPs can provide care and treatment that are equivalent to those provided by either general practitioners or psychiatrists is, as yet, unclear and should be the subject of further research.” The American College of Nurse Practitioners cites data tending to confirm the overall safety and efficacy of NPs.

In summary: although controlled research on Nurse Practitioners seems to have lagged behind actual granting of practice privileges-which is certainly regrettable-we now have considerable evidence showing that NPs provide safe and effective care. It is not yet clear if this is comparable to that delivered by psychiatrists. Finally, I do not believe that the apparent failure to do preliminary research-i.e., prior to granting prescriptive authority to NPs-justifies a similar dereliction of duty now, with respect to “prescribing psychologists.”