Patient Safety

Complexity

• Human Beings – The mind is not separate from the brain and the body.  Only physicians have been educated in the totality of the human being in regard to health /mental health, normal function and physiology, pathology and pathogenic agents, risk and protective factors, prevention, public health, and epidemiology.
• Human Behavior – Physicians are educated about human behavior and how attitude, motivation, personality traits, and other aspects of human psychology are integral to engaging in and maintaining healthy habits, forming and maintaining a doctor-patient relationship, a patient's persisting at a course of treatment, and healing. Psychology is the study of the mind and human behavior but psychologists do not have the extensive experience of being immersed in a culture in which the student witnesses human behavior in the face of illness and death.  
• Medical Knowledge and Understanding – The complexity of scientific medical knowledge is ever increasing. For example: medication-medication interactions and the effects of medications on different organ systems are more numerous not less. Cormidity – having two or more disorders either mental and/or general medical - complicate treatment and require the perspective of physicians who have been educated in general pathology. The role of psychogenomics is progressively increasing in clinical practice. The role of infection as an etiology or, at least, a factor in a multi-variant model of mental disorders is becoming more apparent.
• Association of Mind/Brain/Behavior and Body – For example: individuals who have mental illnesses have greater rates of diabetes, hypertension, and obesity
• Psychotropic Medications and the Whole Person – For example: Second generation antipsychotics have a metabolic syndrome adverse effect in which a person gains weight, develops diabetes, and has an increase of cholesterol and fatty acids.
• Vulnerable Populations – A2170 grant broad prescription privileges with no restriction for vulnerable populations such as children and adolescents, and seniors.
• The pharmacodynamics and pharmacokinetics of medications can be different in these populations compared to the 18-59 year old cohort.
• Doses of medication that are not toxic to those who are 18-59 years old might be toxic for children, adolescents, and/or seniors
• The DOD PDP restricted prescribing psychologists to prescribe only for patients from18 to 65 years of age.

A2170 grant psychologists the authority to practice independently
 

• The group of psychologists seeking prescribing privileges argues that Nurse Practitioners and Physician Assistants have been granted prescribing privileges. Nurse Practitioners and Physician Assistants do not practice independently in New Jersey.
• The New Mexico law requires an ongoing collaborating relationship with a medical doctor or nurse practitioner.
• The Louisiana law requires strict oversight by the attending physician.

A2170 require only 400 didactic hours
 

• Physicians are required to successively complete pre-medical basic science courses to qualify for medical school. In four years of medical school and in 4 to 7 years of postgraduate education didactic education is integrated with learning by clinical experience under supervision.
• 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” [Underlining is added for emphasis.]
• Physicians engage in 12,000-16,000 patient care hours under supervision during four years of medical school and four to seven years of residency and fellowship in addition to didactic hours. 

What does “relevant clinical experience” mean?
 

• A2170 require the “prescribing psychologist to pass a [one time] examination developed by a nationally recognized body, such as the American Psychological Association Practice Organization’s College of Professional Psychology, and approved by the Board.”
• Physicians who received their education in the United States are required to pass the United States Medical Licensing Examination (USMLE), a three part national examination sponsored by the Federation of State Medical Boards and the National Board of Medical Examiners, in order to be granted a state license to practice medicine. Foreign medical graduates need to take an equally demanding examination. There are cases in which states have denied medical licenses to immigrate physicians because their education is not judged to meet the standards in the United States although they are licensed to practice medicine in their country of origin.
• “such as the American Psychological Association Practice Organization’s College of Professional Psychology [APAPO]”

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” [Underlining is mine.]

• This is vague. What is “relevant clinical experience?”
• “Direction” is ambiguous. On the one hand, it can mean “guidance or supervision of an action" or on the other hand it can mean “instructing” or “managing, overseeing.” The latter is not supervision. 
• The New Mexico law requires a probationary period in which a conditional prescriptive certificate is granted and the psychologist has to “successfully complete 2 years of supervised prescribing” and passes a review by both the New Mexico Board of Psychologist Examiners and the New Mexico Board of Medical Examiners.
• The Louisiana requires a 3 year probationary period in which the “medical psychologist” shall treat “a minimum of one hundred patients including twenty-five or more involving the use of major psychotropics and twenty-four or more involving the use of major antidepressants which demonstrate the competence of the medical psychologist.” Two collaborating psychiatrists familiar with the psychologist’s competence need to recommend the psychologist, the Medical Psychology Advisory Committee needs to recommend the psychologist, and the psychologist needs to “complete a minimum of one hundred hours of continuing medical education relating to the use of medications in the management of patients with psychiatric illness” [Note: This is in addition to completing a postdoctoral masters degree in psychopharmacology.

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.”
 

• This averages to 9 hours per year.
• This is much less than the 20 hours per year that is required both in the New Mexico and Louisiana laws.
• Physicians in New Jersey need to participate in 150 hours of Continuing Medical Education (CME) every three years or an average of 50 hours per year to maintain their license to practice medicine.
• 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 narcotics.
 

No State Medical Regulatory Oversight

In A2170 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. 
 

• 13 psychologists in military service were selected for the pilot program.
• 10 completed the training.
• Of the 10 who completed the training, three left the military as of 2003 and two of these enrolled in medical school.
• Two years of training – one year of classroom and one year of clinical
• Clinical training was on inpatient wards and outpatient clinics.
• After graduating from training, they completed one year of supervised or proctored practice.
• Limited scope of practice: only treat patients 18 to 65 years of age with mental conditions without medical complications
• Restrictions on what psychiatric medications that they could prescribe
• After its study, the Government Accounting Office (GAO) concluded that the “Need for More Prescribing Psychologists is Not Justified.” [Underlining is mine.]
• The GAO concluded that the “PDP was costly and its benefits uncertain.” [Underlining is mine.]
• Cost: $6.1 million or about $610,000 per prescribing psychologist

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.

Carve Out

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 A2170 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. [Underlining is added for emphasis.]

A2170 has 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 A2170 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.” [Underlining is added for emphasis.]

Lower Standards - Decreased Safety