The Argument Against RxP (And How To Defuse It)

1. The Argument Against RxP(And How To Defuse It) Robert E. McGrath Fairleigh Dickinson University

2. The Arguments • Wording will change, but there are really only two arguments against psychologists’ prescribing • “If you want to practice medicine, go to medical school” • “Allowing psychologists to prescribe threatens public safety”

3. “If you want to practice medicine, go to medical school”The History • 1896: Two ophthalmologists charged an optician with “practicing medicine without a medical license” because he charged a $3 professional fee for his advice (Wallis & Wedding, 2004) • 1998: When nurse practitioners in New York established a primary care practice, the American Academy of Family Physicians stated what the nurses are doing “comes very close to practicing medicine, which, of course, requires a medical degree and a license” (Lardner, 1988) • This claim has been made every time another profession has attempted to adopt an activity that was traditionally part of medicine.

4. “If you want to practice medicine, go to medical school”The Facts • At this point, there are other professions prescribing medications for mental disorders in all 50 states • Advanced practice nurses • Physicians’ assistants • In many cases, this is done with little or no review by a physician

5. “If you want to practice medicine, go to medical school”The Questions You Might Ask Here's a list of texts from one training program for psychologists. Which subject that is essential to prescribing is not covered in one or more of these?

6. “If you want to practice medicine, go to medical school”The Questions You Might Ask • What information are prescribers regularly using that is not available on their Palm Pilot through programs such as Epocrates? Epocrates advertisement distributed via e-mail 11/25/04: “I use Epocrates multiple times a day. The formulary feature has saved me and my patients much time and many phone calls dealing with prescription coverage.” Michael Burry, MD Michigan

7. “If you want to practice medicine, go to medical school”The Questions You Might Ask • The most popular medications have changed completely in the last 10 years. Why is someone who attended medical school 15 years ago better prepared than someone who just completed two years of formal coursework in anatomy and physiology, neuroscience, and clinical pharmacy?

8. “If you want to practice medicine, go to medical school”The Questions You Might Ask • Whatever it is that medical school gives you, are you saying that professionals who have already met the standard of completing a doctoral degree, who study from the same books used in medical school, and have been supervised by a physician, cannot learn it?

9. “If you want to practice medicine, go to medical school”The Questions You Might Ask • If the response is that it’s something that can’t be quantified, then the most important question is: how do you know it exists? • The question is not whether psychologists need to go to medical school; the question is whether they can be taught to prescribe safely

10. “Allowing psychologists to prescribe threatens public safety”The History • Christopher W. Crenner, MD, PhD (1998): Though introduced in the U.S. in 1901, the blood pressure cuff was considered too complex to be entrusted to nurses until the 1960s • The same argument has been used against nurse practitioners, optometrists, and physician assistants. In all cases, the claim has proven untrue.

11. “Allowing psychologists to prescribe threatens public safety”The Facts • U.S. Congress Office of Technology Assessment (1986, pp. 5-6): The weight of the evidence indicates that, within their areas of competence, [nurse practitioners (NPs), physician assistants (PAs), and certified nurse-midwives (CNMs)] provide care whose quality is equivalent to that of care provided by physicians. Moreover, NPs and CNMs are more adept than physicians at providing services that depend on communication with patients and preventive actions. The evidence indicates that PAs also perform better than many physicians in supportive-care and health-promotion activities. Patients are generally satisfied with the quality of care provided by NPs, PAs, and CNMs, particularly with the interpersonal aspects of care.

12. “Allowing psychologists to prescribe threatens public safety”The Facts U.S. News & World Report (1/31/05): What research has established most notably is that an assortment of nurses with advanced training, including nurse practitioners and certified nurse midwives and other registered nurses with master's- or Ph.D.-level education, are safe. … More than 100 studies have examined, for example, the care delivered by nurse practitioners. "To my knowledge, there is not a single study showing negative impact of [nurse practitioner] practice on health," says Linda Aiken, director of the University of Pennsylvania's Center for Health Outcomes and Policy Research and a nursing professor. She adds that numerous studies of advanced practice nurses show the care they deliver is equal to or better than that delivered by physicians

13. “Allowing psychologists to prescribe threatens public safety”The Facts • The irony: 2/3 of advanced psychiatric nurses eligible for prescriptive authority choose not to apply for it, with a primary reason being they feel that their psychopharmacology training is inadequate (Nolan et al., 2001)

14. “Allowing psychologists to prescribe threatens public safety”The Facts • Prescribing nurse practitioners pay approximately the same for malpractice insurance as psychologists • Psychiatry’s malpractice rates are the lowest of any medical specialty • Medications for mental disorders are among the least likely to result in a malpractice suit

15. “Allowing psychologists to prescribe threatens public safety”The Facts • The large majority of medications for mental disorders are prescribed by non-psychiatrist physicians (Schulberg & Burns, 1988), with limited training in diagnosis or alternatives to medication.

16. “Allowing psychologists to prescribe threatens public safety”The Questions You Might Ask • Can physicians identify one instance in the last century where they claimed increasing the scope of practice of another profession would compromise public safety where that ever proved to be the case? • Has any other health profession lost a component of its scope of practice for incompetence?

17. “Allowing psychologists to prescribe threatens public safety”The Questions You Might Ask • If medications are so dangerous, why are they leaving prescribing to physicians with little training in any other modality of treatment?

18. One Last Question • Is that all?

19. “The training is insufficient” • How do people learn to be practitioners? • Basic knowledge, skills, and abilities • How to incorporate new concepts • Where to get the information you need

20. Distance Learning • Allen et al. (2004): A review of the literature, involving 71,000 participants, concluded “distance education course students slightly outperformed traditional students on exams and course grades.” • International Virtual Medical School: Will offer the first two years of medical school on-line. 30 partners around the world, including Brown, Florida, and Wake Forest • Florida offers doctorates in pharmacy and audiology completely on-line. • One of medicine’s answers to the shortage of psychiatrists: distance supervision. • Over 50 medical schools offer distance and web-based CE to physicians, including _____.

21. Additional Materials • The following is an email sent to Eric Schindler by the president of the ApA (Thursday, August 19, 2004), suggesting lack of respect for the role legislators play as gatekeepers in ensuring public safety. It’s a little below the belt, so you may not want to use it: Hi Dr. Schindler: I appreciate your thoughts and desire to try to reduce the animosity but we will continue to oppose prescribing privileges for psychologists because we believe it is a quality of care issue, and something that legislators should [sic] cannot, and should not, be proscribing. Michelle Riba, M.D. President, American Psychiatric Association • The truth is that decisions about public safety are precisely the task of the legislature, not the profession of medicine. We hope you will both improve access and ensure public safety, by awarding psychologists prescriptive authority.

22. Additional Materials • In one state, psychiatrists noted that none of the training programs are housed in top-tier universities. • The facts: When University of Florida, clearly a top-tier institution, attempted to create a training program, the Department of Psychiatry threatened to stop making any referrals to psychologists. • Given that almost all top-tier institutions have a medical school, and therefore a Department of Psychiatry, such institutions will not be able to develop programs until licensure is in effect. • So, if you want the training to take place in such institutions, you should support licensing for RxP.

23. Additional Materials • Psychiatry has been passing around an indictment of the DoD program using quotes from some of their evaluations (see notes)

24. Additional Materials • Why not compromise? • CAPP v. Rank: In 1990, the California Supreme Court ruled that psychologists are permitted to have primary responsibility for patient care and do not require psychiatric supervision in hospitals. Thanks to opposition from medicine, the decision has not yet been implemented • New Mexico: Despite passing a prescriptive authority law agreed to in compromise with the state Medical Board, regulations took more than 2 years, and physicians are still fighting the bill • New Hampshire: Psychology replaced RxP bill with study bill in compromise with medicine, then medicine lobbied against it