Slowing Down

Yesterday, April 11, 2010, the Governor of Oregon, Ted Kulongoski, vetoed a bill that would have allowed psychologists to prescribe medication after completing two years of additional education. To date only, two states, New Mexico and Louisiana, have granted prescribing authority to psychologists despite significant lobbying by psychologists over the past few years.

Proponents of prescribing authority for psychologists point to the shortage of psychiatrists, claiming that granting prescribing power to psychologists would alleviate that shortage and allow greater access to mental health care for patients in need. They also cite studies that (so far) have not found negative consequences from the granting of such prescribing authority.

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I have written a number of times about the problems with the field of psychiatry. For example, I believe that psychiatrists make a mistake when they leave the mind behind, thinking that the symptoms of depression, anxiety, and other disorders can be understood using only the “hard sciences” of physiology, chemistry, and anatomy. But hard science is where the field is going; those without a firm grip on neuroscience blindly follow the leaders on a professional snipe hunt, taking it on faith that there will be answers at the end of their journey. While much of the training for my PhD in Neuroscience is out of date, I have enough background to know that there is no “there” there. Understanding the metabolic pathway for paroxetine for specific individuals is going to have profound effects on mental health care.

Many of the patients who I see tell me horror stories about their prior encounters with psychiatrists. They talk about appointments lasting several minutes. They talk about being prescribed medications without any explanation of why they are to take them, what side effects to expect, or what other options are available besides the medications. Many times, they do not even remember their psychiatrist’s name! All of these issues come down to one thing: time. People want more time to explain themselves, more time to hear the options that are available, and more time to learn whether they are “normal.”

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In a way, I am saying that psychiatrists need to emulate… psychologists. I find it a bit odd that psychologists are striving to get the very power that is pulling psychiatrists from patients! It will be interesting to see if the psychologists who gain prescribing authority move toward the psychiatry model of the “med check” appointment.

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Psychiatrists do not fret over the issue of prescribing authority for psychologists. Many of them work for health systems on a salary, and if anything they would prefer a lighter load. So what if a few patients disappear?! Besides, most psychiatric medications are already prescribed by non-psychiatrists (ie, family care docs or nurse practitioners). But, I think that such nonchalance is a mistake. I assume that third-party payers are looking forward to the day when the initials MD no longer command a higher fee schedule than NP or even PhD. And I doubt that any leveling of fees will do as much to elevate the fees of non-MD practitioners as it will to lower those of MD psychiatrists. There have clearly been efforts to make everyone the same in the eyes of healthcare consumers. Those efforts are fine and dandy for the person who spend eight years accumulating debt!

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If physicians are ever forced into a position of having to justify their higher fees, they have placed themselves in a bad position in the battle for PR. If everything else is even close to equal, patients will choose the practitioner who provides over the 7-minute appointment with someone “more educated.” Already, I hear patients talk about “Dr. Steve” or “Dr. Betty” in reference to their AP/NPs, any difference in training compared to “Dr. Thompson” totally lost on them.

For the sake of the profession, I hope that psychiatrists learn one thing: slow down.