1) What do you think about the trend toward non-MD/midlevel practitioners (i.e. Psychologists, LCSWs, etc.) having the ability to prescribe medications?
So I'm going to have to answer your questions piecemeal. They're really good questions but they do require some background to adequately answer. Here's the first one:
Though the term mid-level provider is sometimes applied to masters level therapists, it's often most referring to nurse practitioners and physician assistants. I'll definitely answer your intended question but I'll address mid-level providers generally first. The original idea behind a nurse practitioner was to take people who already had extensive experience within a particular field and then have them be trained as nurse practitioners. This is most certainly not the standard currently, as many (I don't have the actual numbers but I'd probably go almost as far as saying most) nurse practitioners never worked as an RN (if they did, it was on the side as they were going through training). What really differentiates a physician is residency training. While medical school is an essential part, it's really in residency where you learn a specialty and have extensive training and experience in the entire spectrum of your field. This doesn’t exist in the mid-level world and there really isn't a substitute for that. Unfortunately, what can often be seen is that, despite the level of training and experience required to be a physician in any particular specialty, there are many, many examples of that training pathway falling short. So, simply training is not necessarily "sufficient" for being a competent physician. This leads to the implied argument that since it's not
sufficient it is therefore not
necessary. As there have been physician shortages across the board in most specialties, these started to be filled by mid-level practitioners and particularly over the past 15-20 years, the number of programs that have opened up has exploded exponentially. Whereas it takes a minimum of 7 years to produce a physician, here you can produce a mid-level provider in two years, and the nursing lobbies have really stepped it up, whereas all physician groups (in particular the AMA) are absolutely impotent and many physicians have become afraid of the super-imposed social dynamic at play with the old stereotype of a physician being a paternalistic entity that is antiquated. So the answer to healthcare coverage issues has been to throw more mid-level providers into the system to “meet” the demand. In most states, supervision for mid-level providers falls under a physician who can’t really supervise every thing they do, but ultimately the physician carries 100% of the liability.
There is certainly a role for mid-levels, but currently mid-levels are being filled in to health systems in roles that are too broad and often too little supervision. For instance, I struggle with the idea of mid-levels taking over primary care.
Anyhow, with how this relates to psychiatry is that the largest “mid-level providers” by population will be nurse practitioners, as they have created a specific training pathway (psychiatric mental health nurse practitioner or PMHNP). I’d guess that the majority of these programs are online. About ten years ago while I was in residency, I was admitting a patient from the emergency department and I was giving report to the charge nurse. They had another person with them shadowing them and, when I inquired, they had told me that they were completing their clinical requirements for their PMHNP. Somehow they were able to get their “hours” by shadowing a charge nurse, which was absolutely mind-blowing.
But by far the nurse practitioners have been the largest group that’s moved into this territory. As a result of that, it sets a standard of comparison (“if they can do it, why can’t we?”).
Where your question is concerned is with regard to prescribing psychologists, you mentioned LCSWs and others but there is no legislation anywhere regarding any of them being able to prescribe, nor do I ever believe there will be. The number of psychologists who prescribe is insignificant. I've never met one or heard of one in any professional capacity (in real life) in my entire career, with the exception of just hearing about it online. That said, every couple years there's proposed legislation in some new state regarding prescribing psychologists. But it's not as simple as just handing them a prescription pad. This started in the 90s when the Department of Defense had a pilot program where they took a total of 13 doctoral level psychologists that were well experienced in their field and put them through a rigorous two-year training program that honestly resembles what you would envision a psychiatry physician assistant program to look like (those don't exist). Only 10 completed that program. They had them take numerous basic science courses (that’s a term, it’s not saying the classes are basic) alongside the first and second year medical students at the Uniformed Health Services University of Health Sciences in Bethesda, Maryland, during their first year. Their second year they were embedded within the psychiatry residency training program at Walter Reed Army Medical Center, where they participated in at least 6 months of inpatient psychiatry, and then did a combination of emergency psychiatry, consultation services, or outpatient care for the next 6 months. They also participated in on-call. If you ever look into any legislation regarding prescribing psychologists, you will invariably hear people refer to the "Department of Defense study." It isn't a study at all. Nobody has actually read through it. It was simply the report handed over to congress after the program concluded in 1997. There were no metrics used, it was simply an extensive review of what the program was and their experiences of when they asked supervisors and clinic staff how things were going with the prescribing psychologists. In any case, I can't really complain about that program because it legitimately was a program that you can make an argument gives prescriptive authority to psychologists, because they're essentially completing the same type of curriculum and rigor that physician assistants are completing, just that this was a little more specific to psychiatry. But that accounts for only 10 psychologists who were trained in the 90s and were only practicing within the military.
Of any state that has legislation in place for prescribing psychologists, each state requires that you be a doctoral level psychologist and additionally do a two year masters degree in psychopharmacology. These programs do not at all resemble what the DoD modeled. All of these masters programs are done online and are part time (advertising only a couple hours per week). There is no formal clinical training, just that you go out there and shadow some physician to get "experience" and they require something like 80 hours. To put that in perspective, psychiatry residency is typically working about 60 hours per week over the course of four years. A third year medical student will graduate with more formal psychiatric clinical training than any of these programs would put out. Every single physician in the US will have completed, at minimum, a 4 week psychiatry rotation in their third year, yet nobody is clamoring for PCPs to be doing more psychiatry (even though they're tasked with a lot of it), and no PCPs are out there arguing that expertise.
But the more important part of your question that isn’t being asked. We’re jumping to the “solution” of having more people prescribe medication but we’re not asking what the actual question is that has that for a solution. This is too large of a discussion to have but there are numerous different ideas that are being thrown out and conflated with each other where we talk about a ‘shortage’ of psychiatric providers. One is that you have people who don’t have good access to a psychiatrist. Many times, if you do have access to a psychiatrist, it’s going to take you months or upwards a year to be able to get in. But what are people needing to see a psychiatrist for? Current cultural views and insurance reimbursement favors medication intervention. There are plenty of reasons for that, some good, some bad, some neutral, but we have to acknowledge each piece of that pie. Because there’s a comparative oversupply of therapists and comparatively few people prescribing, the push to expand scope is more about financial issues and securing the future of any given field, than it is about asking what’s really best for patients.
A big part of this discussion is the idea that this will open up access for patients. However, this isn’t really the case. The people that need care are in underserved areas and have experienced a downward drift socioeconomically. They are often people with more complex diagnoses than garden-variety depression and anxiety. People wishing to add prescriptive ability to their practice aren’t doing so to treat people with schizophrenia with antipsychotics. That won’t happen. What’s most likely is that 95+% of prescriptions are going to be for SSRIs and then likely some brand-name medications like Latuda that’s going to be thrown at anything labeled bipolar disorder. But the more important question to ask is if there’s really a shortage of SSRIs being prescribed in the US.
But that said, there is still a legitimate need not being met due to the shortage of folks with an 'MD' behind their name, and that simply cannot be argued. A high percentage of military vets experiencing PTSD living in rural areas, and therefore lacking the services needed to treat the host of diagnoses related to their complex trauma, has few solutions right now. And that's just one example in an absolute ocean of underserved individuals who are impacted by trauma and need help. So many people pass from early childhood into the next phases of life with what may as well be a predetermined path of hardship; I feel like nothing short of a cultural revolution, not to mention a massive restructuring of the role insurance companies get to play in how and when services are offered, is going to change any of that with any kind of permanency. I can only imagine how often your inclinations as a provider get cut off at the pass by government regulation that looks like it's producing an awfully convenient outcome for private entities-- namely big pharma and the insurance companies.
