Point

October 1, 1997

Prior to training in psychiatry, my practice was in a rural primary care setting where I routinely collaborated closely with physician assistants and nurse practitioners. I see prescriptive privileges of one form or another for psychologists to be an inevitability. I watched a similar struggle for nurse practitioner prescriptive privileges in Oklahoma during my stint in primary care. My recommendations to physicians in California would be to endorse prescriptive privileges for other mental health professionals in the format of the "physician extender" model similar to the traditional physician assistant.

As a psychiatry resident, I have watched with interest the ongoing struggle by psychologists to obtain prescriptive privileges in California and elsewhere. I routinely receive requests to write my congressman and to make cash donations to support "the cause" on behalf of both camps (pro and con).

Aside from the obvious potential impact that psychologist prescriptive privileges might have on my budding career in mental health, I also follow the struggle from a different perspective. Prior to training in psychiatry, my practice was in a rural primary care setting where I routinely collaborated closely with physician assistants and nurse practitioners.

I see prescriptive privileges of one form or another for psychologists to be an inevitability. I watched a similar struggle for nurse practitioner prescriptive privileges in Oklahoma during my stint in primary care. Both sides voiced basically the same arguments, pleas and promises that I have been hearing about California psychologists and their need to prescribe.

My recommendations to physicians in California would be to endorse prescriptive privileges for other mental health professionals in the format of the "physician extender" model similar to the traditional physician assistant. The physician extender model provides for physician supervision and collaboration on the overall treatment plan and implementation for the patient; frequently relies on written protocols for common ailments; often requires development of a formulary between the extender and physician; provides for ongoing routine audit and quality supervision of the physician extender by an identified physician supervisor; encourages close collaboration between the two disciplines; and lends itself to rural health and telemedicine models for increasing access to care. I believe a "physician extender" model for expanding prescriptive privileges in mental health allows psychiatrists and physicians in general to retain long-term control over the practice of medicine.

Physician assistants (PAs) and nurse practitioners (NPs) are the two most common physician extender professions. In most states, PA licensing is through the state's medical board. On the other hand, NPs are almost universally licensed through state nursing boards with limited or minimal input from medicine with respect to scope of practice, qualifications, professional training or standards of care. I am very hesitant to make the same mistake with psychologists.

If prescriptive privileges are to come to other mental health professions, I see significant advantages to a PA model where psychologists, MFCCs, LCSWs and Advanced Practice Nurses can apply to the equivalent of a physician assistant training program with a clinical specialty in mental health.

Classwork would be provided by accredited physician assistant training programs (usually affiliated with a medical school) with clinical work split between ambulatory primary care and psychiatry settings. Most PA programs run three to four years in duration and offer a strong foundation in basic medicine with the option for some subspecialization in the form of electives. Mental health professionals completing such a scheme should be well prepared to function as physician extenders for psychiatrists or primary care physicians with limited prescribing privileges. Such a scheme provides for physician involvement both on the direct patient care level as well as on the policy and health systems levels, while retaining control over the practice of medicine by nonphysicians.