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 I,¹ had advocated. As The Oregonian newspaper put it²:

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 (the only 2 states in which this practice is currently legal) have practiced safe and effective prescribing-although 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 10 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 primary physicians and psychiatrists is undertaken only after thorough assessment of the patient; consideration of nonpharmacological options (eg, “talk therapy”); and 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 underserved 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 do so is to try to dissect bone from muscle, using a paring knife: it can’t be done without injuring the patient.

References:

References

1. Pies R. “Prescribing psychologists”: practice medicine without a license? http://www.psychiatrictimes.com/display/article/10168/1545667. Accessed April 9, 2010.
2. Esteve H. Kulongoski vetoes bills on prescriptions, educators and bottles. April 8, 2010. http://www.oregonlive.com/politics/index.ssf/2010/04/kulongoski_vetoes_bills_on_pre.html. Accessed April 9, 2010.