New Jersey Bills - Assemblyman Patrick J. Diegan, Jr introduced bill A2170 that would grant psychologists the privilege to prescribe medications in New Jersey without earning this privilege by fulfilling rigorous requirements and meeting the high standards to become physicians.
The Access Argument -The group of psychologists,* who are pushing for prescription privileges, argue that access to mental health care will improve if they are allowed to prescribe. * Many psychologists oppose prescribing privileges for psychologists. Some psychologists have organized into Psychologists Opposed to Prescription Privileges for Psychologists.
There is a CASE for a better way to address access of care issues rather than granting "prescriptive authority" to psychologists, and thus, allow psychologists to practice medicine in the State of New Jersey based on inadequate standards and insufficient oversight. CASE looks at Culture, Access, Standards and Safety, and Education to arrive at a better way.
Culture - Becoming a physician is much more than training. A person becomes a physician through an acculturation process by “residing” in a biomedical culture and undergoing the trials and tribulations of that culture during four years of medical school, at least three to four years of residency and, in some cases, additional years as a fellow before being granted the privilege to practice without direct supervision. Psychologists do not undergo this acculturation into the biomedical culture.
Access - The psychologist organization, which is seeking prescribing privileges via A2170, claims that by allowing psychologists to prescribe there will be better access to mental health care. It claims that psychologists will practice in rural underserved areas and significantly increase the workforce in underserved populated inner cities, and thus, make mental health care more accessible. The data does not support this argument.
More importantly, there are many barriers to mental health care access, such as 1) economic a) lack of full parity for mental disorders including substance use disorders compared to health insurance coverage for general medical disorders and surgery, b) underfunding of public sector programs, c) overall high healthcare costs, d) low insurance, Medicare and Medicaid payment rates 2) stigma, and 3) social problems including unemployment, poverty, homelessness, and insufficient affordable housing. Granting prescribing privileges to psychologists is not a solution for these access to care problems.
Standards & Safety - Lowering standards decreases safety. A2170 will lower standards.
Education - How does the 400 hours of didactic distant classes in psychopharmacology and other subjects followed by "relevant clinical experience sufficient to obtain competency in the psychopharmacological treatment of diverse populations" required by A2170 compare to the 12,000-16,000 total patient care hours in the education of physicians? It doesn't.
Solutions---Better Way - An essential better way to improve access to care is collaboration, teamwork, the medical home model, and better integration of health care and mental health care. An example of better integration of care is the Essex County project Improving Access to Child and Adolescent Mental Health Care: Integrated Collaborative Care, in which child and adolescent psychiatrists collaborated with pediatricians. With physician-to-physician collaboration and teamwork, there is the benefit of people who understand biomedicine because they have been “raised” in and are part of the same culture – the biomedical culture. Psychologists should be part of health care teams and provide their special expertise. Psychologists should not have prescribing privileges and practice as if they were medical doctors.
Telepsychiatry is a tool that can improve access to care when it’s in the hands of experts and used properly.
Why? Since there is a better way, why are some psychologists pushing to prescribe medications? Articles and organizations supporting psychologist prescribing privileges give the reasons.
Becoming a Physician: Privileges and Sacred Trust Through Acculturation
Joseph C. Napoli, MD, DABPN, DLFAPA
Becoming a physician is much more than training. A person becomes a physician through an acculturation process by “residing” in a biomedical culture and undergoing the trials and tribulations of that process during four years of medical school and at least four years of residency before being granted the privilege to practice without direct supervision.
Through an experience of interacting with patients and active experiential learning under close supervision, future physicians learned how to think and reason as physicians, and internalize the language, ethics, values, different frames of reference of the specialties and subspecialties, caveats and limits of medical diagnostics and therapeutics, and the Hippocratic credo – “First, do no harm.” – in addition to acquiring the large amount of medical knowledge necessary to practice medicine. Some of the content of this medical knowledge becomes obsolete as medical research makes discoveries and increases our understanding; the intangibles that were internalized remain vital. Because of the change and increase of medical knowledge, physicians need to continuously engage in education throughout their careers. The acculturation process fosters the motivation for life-long learning that is necessary to grow as a doctor.
The biomedical culture inculcates a healthy skepticism in the student of medicine to challenge research methodology and data instead of easily accepting study conclusions. Likewise, this culture develops a capacity to critically analyze clinical data and an attitude of thinking of the worse possible pathology and when indicated search for it while providing a patient with hope and striving for the best outcome.
The culture of medicine encompasses both sickness and health. Although there is an emphasis on pathology and treatment, the biomedical culture embraces health and prevention. Students of medicine concentrate on the study and healing of disease. Future physicians learn epidemiology, pathology, diagnosis, and therapeutics of illness. Medical research pursues the etiologies, mechanisms, and cures for illnesses. Some critics accuse the medical field of having a negative frame-of-reference that only embraces what is wrong with people. They claim medicine neither sufficiently attends to health nor takes into account the individual who suffers with a particular ailment. Although the art and science of healing and relieving suffering by treating pathology is a noble endeavor, medicine also focuses on the positive – prevention, public health, wellness, and healthy behaviors. Medical students also learn about normal human biology and function. Like other future physicians, my classmates and I delivered babies and experienced the exhilaration of helping to bring healthy life into the world. Medical research also addresses the question – Why do some people remain healthy while others become sick? This perspective is not new. The wisdom of attending to health and the healthy is embodied in the ancient words of Hippocrates – “ . . . it is well to superintendent the sick to make them well, to care for the healthy to keep them well, also to care for one’s self, . . .”
The biomedical culture fosters an understanding of the human dimension within a biopsychosociological model. Through example, instruction, and guidance, medical students learn and appreciate the importance of the interpersonal dimension of working with and caring for patients and their families. Through identifying with humanistic faculty role models who demonstrate compassion, and competent interpersonal and communications skills, medical students hone their interpersonal and communication skills to effectively collaborate with patients as partners in healing and maintaining their health. My colleagues and I recall learning the limits of medical science as medical students sitting by the bedside of dying patients, grieving for them, and being powerless to save them despite all efforts and available therapeutic tools. There is no human interaction that is more intense and profound.
Only after this long and arduous initiation of trials and tribulations in which individuals are tested and molded, does society grant them certain privileges – The privilege to attend the sick. And in order to heal them: The privilege to pry into people’s lives, ask embarrassing questions, and learn their secrets. – The privilege to cut into people’s bodies. – The privilege to give people poisons. Yes, poisons! In my first lecture introducing me to pharmacology, my professor came into the amphitheatre and wrote on the blackboard, “All medicines are poison.” He went on to say, “You, as doctors, will be given a sacred trust to use these poisons. How you use them will be the difference between healing and doing harm.”
In addition to “First, do no harm,” other responsibilities accompany these privileges. Physicians shall observe confidentiality, make medical decisions and use their skills in the best interest of their patients, acknowledge the limits of their abilities, seek assistance and advice from other physicians and in return offer other physicians good counsel, and teach others “who are worthy” the art and science of medicine.
When I talk with my physician colleagues and we relate our experiences in becoming doctors, we appreciate that in depth experiential learning, the process of internalization, confronting life, death and suffering within a medical culture forges a person into a doctor. Training can teach the science of medicine. Only acculturation teaches the art of medicine and the application of that science. Only by undergoing this acculturation process should individuals be granted certain privileges, assume the attendant responsibilities, take an oath as physicians, and reside in the House of Medicine.
Copyright © 2013 Joseph C Napoli, MD All Rights Reserved
Speaking as a Physician
Paul Summergrad, MD
President, American Psychiatric Association
In my response to the presidential address at APA’s annual meeting in New York in May, I highlighted four key tasks facing psychiatry. The first task is that we need to speak as the physician experts on mental health.
By this I meant that we must always remember, first and foremost, that we are physicians. It is thus incumbent upon us to be aware of the best scientific evidence available when we make clinical decisions, doing so in the context of the total needs—medical and otherwise—of our patients. It means to speak on their behalf even when it may bring us into conflict with others whose primary focus may be financial, legal, or ideological. It requires us to be deeply knowledgeable not only about the scientific literature and best practices, but also to have more than a passing familiarity with the limitations of that literature and to be prepared to speak when we must despite those limitations. And to do so on our patients’ behalf, not our own.
Implicit in these capacities is not just a comprehensive knowledge of psychiatry, but of clinical medicine as well. Whether on a consult service or in an emergency room, a state hospital, or a community mental health center, no one else can duplicate what we do, or do it with the years and depth of clinical experience that under the best of circumstances leave us seasoned practitioners.
It is critically important that policymakers and the general public understand that as physicians, the scope of our attention is to the totality of our patients’ historical, personal, and medical conditions. Our patients don’t come disconnected from the neck up, and neither does the way we practice. Regardless of the setting where we work, our ability to diagnose and treat patients from this broad perspective is an essential capability.
The unmatched breadth and intensity of our training in the full range of psychiatric illness make us the essential partners to both primary care and specialist physicians at, as our family practice colleague Dr. Frank DeGruy has so eloquently said, “the deep end of the pool.”
Our scientific and research training makes it possible for us to not only create new knowledge but to speak authoritatively about psychiatric illness as well. While scientific training is not unique to us, the breadth of our training in neuroscience, medicine, and genetics, in addition to cognitive neuroscience and epidemiology, mean that our practice guidelines represent the most authoritative available guides to clinical care.
We must always be mindful that as physicians we have a special responsibility to speak from our rich clinical experience, and most importantly, from the best science available, wherever that may take us and regardless of opposition. These values and clinical and scientific expertise must be the primary touchstones of our policies and public statements about psychiatry.
Excerpts from the "From the President" column in Psychiatric News, July 4, 2014, Vol 49, Number 13
The psychologists, who are seeking prescribing privileges via A2170, claim that by allowing psychologists to prescribe there will be better access to mental health care. They claim that psychologists will practice in rural underserved areas, and thus, make mental health care accessible to people in rural areas.
The data does not support this argument.
No Difference in Geographical Distribution
Maps that depict the geographical locations in New Jersey of primary care physicians and psychiatrists vs. psychologists demonstrate an overall identical distribution. There are not more psychologists than psychiatrists in rural areas.
Click on each image to download PDF of each map.
Click on title to download PDF of each map.
Psychiatrists and Primary Care Physicians
Distribution Comparison - Physicians (Psychiatrists and Primary Care) vs. Psychologists
Insufficient Increase and No Redistribution of Prescribing Workforce
What has been the effect on the size of the workforce and geographical distribution of prescribing psychologists in the two states that have graned psychologists prescribing privileges? The following data demonstrates that there is not a sufficient increase in the psychopharmacology workforce or a distribution of prescribing psychologists that would yield a significant improvement in access to mental health care.
The New Mexico law that was enacted in 2002 requires a two phase process in which a psychologist first fulfills the requirements to be granted a conditional prescription certificate. After fulfilling further requirements, a psychologist can advance to a prescription certificate and the conditional prescription certificate for that psychologist is nullified. Over twelve years, 28 psychologists have been granted prescribing privileges. This is 1.3 prescribing psychologists per 100,000. What is the cost of adding only an average of 2.8 prescribers per year? This small increment in prescribers does not improve access. ["Total" refers to the total number of psychologists licensed in New Mexico.]
Addresses of licensees are not available on the New Mexico Board of Psychologist Examiners Website. A sample of Conditional Prescription Certificate or Prescription Certificate psychologists can be retrieved from the New Mexico Psychological Association Website directory where 5 members are listed as having one of these certificates.
The Louisiana State Board of Medical Examiners licenses psychologists who fulfill the medical psychologist requirements. The data for Louisiana does not demonstrate a sufficient increase in the psychopharmacology workforce or a distribution of prescribing psychologists that would yield an improvement in access to mental health care. Since 2004 when the the law was enacted, 72 psychologists have been licensed as medical psychologists. This is 9.6% of all psychologists that are licensed in Louisiana. And provides only 1.6 prescribers per 100,000 population. There are 16,742 licensed physicians in Louisiana or 369.3 physicians per 100,000 population.
Addresses of licensees are not available on the Louisiana State Board of Medical Examiners Website. A sample of medical psychologists is available on the Louisiana Psychological Association Website membership directory where 9 members are listed in this category.
No Provision for Improving Access
Standards & Safety
A2170 grant psychologists the authority to practice independently
A2170 require only 400 didactic hours
A2170 require during training to “obtain relevant clinical experience sufficient to obtain competency in the psychopharmacological treatment of diverse populations under the direction of qualified practitioners, including but not limited to, licensed physicians or prescribing psychologists, as determined by the board”.
What does “relevant clinical experience” mean?
The APAPO is an organization to promote “the professional interests of practicing psychologists in all settings through a wide range of activities. APAPO’s mission is to advance and protect the practice of psychology.” This is a guild and advocacy organization. It is not an independent certifying organization like the National Board of Medical Examiners, the American Board of Medical Specialties or it subsidiary boards including the American Board of Psychiatry and Neurology. On its Website it has a section advocating for “Prescriptive Authority.” This presents a conflict of interest, and thus, this entity should not be part of a certification process for psychologists seeking prescribing privileges.
No Supervision under A2170
A2170 require “obtain[ing] relevant clinical experience sufficient to obtain competency in the psychopharmacological treatment of diverse populations under the direction of qualified practitioners, including but not limited to, licensed physicians or prescribing psychologists, as determined by the board”
A2170 require “Each applicant for renewal of prescriptive authority shall present evidence satisfactory to the board, demonstrating the completion of 18 contact hours of continuing education instruction relevant to prescriptive authority during the previous two year license period of the licensee.”
No Limit on What Can be Prescribed
A2170 allow the prescribing of any drugs as defined in the New Jersey statute.
The statute defines drugs as “(a) substances recognized in the official United States Pharmacopoeia, official Homeopathic Pharmacopoeia of the United States, or official National Formulary, or any supplement to any of them; and (b) substances intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals; and (c) substances (other than food) intended to affect the structure or any function of the body of man or other animals; and (d) substances intended for use as a component of any article specified in subsections (a), (b), and (c) of this section; but does not include devices or their components, parts or accessories.” [P.L. 1970, c.226 (C.24.21-2)]
Controlled Dangerous Substance
A2170 will allow the prescribing of controlled dangerous substances including narcot-1864 the “board” is defined as the State Board of Psychological Examiners” The approvals by “the board” required in A2170 are not by the New Jersey Board of Medical Examiners, which is responsible for “the protection of the public’s health, safety, and welfare. The Board meets its responsibility by licensing medical professionals, adopting regulations, determining standards of practice, investigating allegations of physician misconduct, and disciplining those who do not adhere to requirements - thereby assuring the public that the physicians are qualified, competent, and honest.” The BME licenses acupuncturists, athletic trainers, electrologists, hearing aid dispensers, midwives, perfusionists, physician assistants, podiatrists, and physicians (MD and DO).
Progressively Lowering Standards
RxP training then and now: This is progress? (Click to download PDF)
A2170 requirements are far below the requirements of the Department of Defense Psychopharmacology Defense Project that trained psychologists to prescribe in the closed system of the military from 1991 until the program was terminated in June 1997.
Standards and Requirements for the Practice of Medicine are Increasing
The bar to practice medicine is continuously being raised not lowered. In addition to board certification, there is now maintenance of certification and state medical licensing boards are working on implementing maintenance of licensure. These maintenance programs require lifelong self-learning, periodic examinations, and continuously working on practice improvement. A2170 allow psychologists to practice medicine without satisfying any of the present rigorous requirements and standards. It has no provision to anticipate the development of new requirements and standards that are being implemented in medicine.
Carving out one aspect of a person from the whole person can cause problems, be counter-therapeutic and increase risk. With the ever-growing scientific medical knowledge, there is no choice that specialization and sub-specialization is necessary in the field of medicine. But each physician attending to only one aspect of a person can be problematic. Where there is a choice, deliberate carve outs should be and must be avoided. Examples of carve outs are: lack of insurance benefit parity, managed care for people with mental disorders separate from people with other medical disorders, state institutions without integrated general hospital resources for patients with serious mental illnesses, and establishing treatment programs for substance use disorders separate from other mental disorders.
“One Stop Shopping” - The group of psychologists that are seeking prescribing privileges argue if granted prescriptive authority they would be able to provide “one stop shopping.” By having the tools of both psychotherapy and pharmacotherapy, they claim they could offer their clients both modalities so that the treatment does not have to be split between two mental health professionals.
Psychiatrists are trained both in psychotherapy and pharmacotherapy. Even medical students are taught about various psychotherapies. Cognitive Therapy that many psychologists claim as their form of psychotherapy was developed by Aaron Beck, MD, a psychiatrist. Many psychiatrists practice both psychotherapy and pharmacotherapy.
Granting prescribing privileges to psychologists will further carve out mental health care from the rest of health care. Psychologists are trained in psychosocial aspects of mental health not biomedical science.
As physicians, psychiatrists have the knowledge and skills to provide primary care and some do so. In addition, there are psychiatrists that have dual board certification in psychiatry and internal medicine or other medical specialties.
Carving out mental health care via A2892/S1864 guarantees that at least two professionals must care for the patient – a physician and a psychologist.
Will prescribing psychologists have the competency to use non-psychotropic medications to treat the adverse effects of psychotropic medication? As physicians, psychiatrists have this competency.
Role of Physician of Record
In the last legislative session, A2170 stated, “A prescribing psychologist shall not issue a prescription unless the psychologist: (2) has first contacted the physician of record of a patient to discuss the prescription”
This was vague. Several questions were raised: What is the purpose of this contact? What should be discussed? Is this “for your information” or a request for approval? What happens if the “physician of record” does not concur with the psychologist? What if there is no physician of record?
The Louisiana law requires that a “medical psychologist” shall prescribe “only in consultation and collaboration with the patient’s primary or attending physician, and with concurrence of that physician.” and in the event the patient does not have a primary or attending physician, the medical psychologist shall not prescribe for the patient.” The “medical psychologist” also has to consult with the patient’s physician prior to making any changes of the medication.
A2170 have revised the role of the physician of record so that it is similar to the Louisiana law.
While A2170 require a better interaction with a patient’s physician of record than A-2419 and S-137, they fall short of the collaboration or supervision required of other physician extenders like physician assistants and APN’s, whose practice acts guarantee direct access to the highest trained provider.
The New Mexico law requires the psychologist to have an ongoing collaborative relationship with a physician or nurse practitioner to “ensure the psychotropic medication is appropriate.”
Lower Standards - Decreased Safety
400 hours of didactic distance training (Bill A2170) for psychologists vs. 12,000 - 16,000 hours total patient care hours for physicians
How does the 400 hours of didactic distance training in psychopharmacology with relevant clinical experience sufficient to obtain competency in the psychopharma-cological treatment of diverse populations required by A2170 compare to the 12,000-16,000 hours total patient care hours in the education of physicians?
A2170 require training in “basic life sciences, neurosciences, clinical and research pharmacology and psycopharmacology, clinical medicine and pathophysiology, physical assessment and laboratory exams, clinical pharmacotherapies and research, professional, ethical and legal issues.
In only 400 hours, these would be survey courses compared to the in depth study, laboratory experience, and other experiential learning for the education of physicians.
Yet, Patrick Deleon, PhD, Past President, American Psychological Association said, "It's always going to be a public-health argument: that we should not have prescription privileges because we did not go to medical school. But prescription privileges is no big deal. It's like learning how to use a desk-top computer." [Underlining is added for emphasis.] Roan, Shari “Tug-of-War Over Prescription Powers Health: Pharmacists, nurses, other non-doctors want the authority to prescribe drugs. Others insist only physicians have the training to do so safely." Los Angeles Times Sept 7, 1993 [When he was an administrative assistant to Senator Daniel Inouye, Dr Deleon was the driving force for the US Congress authorizing the Department of Defense Psycho-pharmacology Defense Project].
Continuous reduction of training requirements starting with the Department of Defense Psychopharmacology Defense Project and ending with the New Jersey bills (A2170)
Click here or on the image to view larger Graph. Physician Biomedical Eduction Compared to the Department of Defense Psychopharmacology Defense Project Training and A2170 proposed Training for Psychologists to Prescribe
Psychologists that are pushing for prescribing authority state that primary care physicians are not sufficiently trained to diagnose mental disorders and to prescribe for these disorders.
The rigorous requirements for primary care physician graduate education do not support this statement.
The educational pharmacology requirements for all physicians:
AMA Advocacy Issue Brief: Pharmacology education of physicians, 2011
Family Medicine residency curriculum requires human behavior and mental health competencies, attitudes, knowledge, and skills. The American Academy of Family Physicians (AAFP), the American Psychiatric Association (APA), the American Psychological Association (APA), the Association of Departments of Family Medicine (ADFM), the Association of Family Medicine Residency Directors (AFMRD), and the Society of Teachers of Family Medicine (STFM) endorsed these curriculum guidelines.
Internal Medicine residency curriculum includes psychiatry.
ACGME Program Requirements for Graduate Medical Education in Internal Medicine
Obstetrics and Gynecology residency curriculum includes behavioral medicine and psychosocial problems, including domestic violence, sexual assault, and substance abuse, the emotional and psychosocial impact of pregnancy or pregnancy loss on an individual and her family, and psycho-somatic and psychosexual counseling;
ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology
Pediatric residency curriculum requires a concentration in developmental and behavioral pediatrics.
ACGME Program Requirements for Graduate Medical Education in Pediatrics
Solutions - Better Way
Integrated Care, Collaboration, and Teamwork
Improving Access to Child and Adolescent Mental Health Care: Integrated Collaborative Care
This is a child psychiatry access project in New Jersey.
Massachusetts Child Psychiatry Access Project
Ron Steingard, MD, a child psychiatrist at UMass Medical School, developed a pilot program in Central Massachusetts (TCPS- Targeted Child Psychiatric Services) providing consultation to pediatricians around child psychiatry problems, including the prescribing of psychotropic medications. This program is now well-established system of regional children's mental health consultation teams designed to help primary care providers (PCPs) meet the needs of children with psychiatric problems. Link to MCPAP by clicking here.
A new APA report - Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry - details the significant cost savings of integrating primary care and behavioral care.
Executive Summary - Full Report - Press Release
Click here for PDF of "The Need for Integrated Care" Infographic.
Telepsychiatry is a tool that can improve access to care when its in the hands of experts and used properly. The New Jersey Psychiatric Association (NJPA) supports the proper use of Telepsychiatry. Click here for PDF of NJPA Position Statement on Telepsychiatry.
Speaking to the psychiatric physicians of the American Psychiatric Association Assembly Meeting November 9, 2013
Click on arrow below to listen to former Congressman Kennedy.
“Only someone with a medical degree and training, like all of you, can make those diagnoses and prescribe the necessary medications for people with a brain-related illness.”
Phone: 973-699-3115 (cell)
Don’t let psychologists prescribe drugs
Dr. Consuelo Cagande: Don’t let psychologists prescribe drugs
During the last state legislative session, New Jersey psychologists aggressively lobbied for a bill that would grant them the authority to write prescriptions for any drug in the Physician Desk Reference. Under the proposed legislation, non-physician psychologists with a master’s degree and 400 hours of training would be able to write prescriptions for some of the most powerful psychotropic medications available on the market today.
Read the full article from Asbury Park Press on April 13, 2016 by clicking here.
N.J. bills allowing psychologists to prescribe medications would harm patients
As a licensed medical doctor and practicing psychiatrist in New Jersey, I am very concerned that the state Legislature is considering bills A2892 and S1864. This legislation would allow psychologists to prescribe medications; it would, in effect, confer a license to practice medicine without a medical education.
Read the full article on nj.com by clicking here.
Only medical doctors should be allowed to prescribe medication
Newly appointed executive director of NJ Psychiatric Association says proposed legislation will endanger patients
Read the full article on myCentralJersey.com by clicking here.
News on A2892/S1864
TRENTON — Psychiatrists in New Jersey have launched an online campaign they hope will torpedo “risky” legislation that gives psychologists the authority to write prescriptions.
The New Jersey Psychiatric Association unveiled a new website, ProtectNJpatients.com, that explains why the state legislature, the governor and the public should oppose the bill that passed the Assembly in June. To view the full article on nj.com click here.