Anticipating Challenges to Prescription Rights

By John T. Tennison, M.D.          Copyright 2002


          During the effort on the part of psychiatrists and others to fight the recently passed psychologist prescribing law in New Mexico, I wondered how efficacious some of the public-relations efforts on the part of organized psychiatry had been.

For example, before New Mexico’s Governor Johnson signed the psychologist-prescribing bill into law, the Patient Defense Fund of the American Psychiatric Association took out a full-page advertisement in the Santa Fe New Mexican on February 7, 2002.  Among other things, the ad stated, “Only medical doctors have the medical knowledge to understand how complex medicines for the brain affect the entire body.”  Although I agreed that a 400-hour course should not be a substitute for 4 years of medical school and 4 years of residency, I didn’t feel that this sentence made the point strongly.  I thought, “Is it really true that only medical doctors can understand how medication affects the body?”  For me, the answer was “No.”  Don’t get me wrong:  I am fully in support of continuing to fight the granting of prescription rights by those who are unqualified, but for us to ultimately succeed, our claims must be defensible.

For example, many psychologists are every bit as capable as any physician at understanding human physiology.  Consequently, we when say that only medical doctors have the knowledge to prescribe safely, this statement begs the questions:  “What exactly are the necessary and sufficient components of medical school and residency that have given us this knowledge?  Has every single thing we have been required to do in order to become a psychiatrist been necessary to safely prescribe?  Was taking gross anatomy necessary?  Was holding a retractor for several hours during a surgery rotation necessary?  Was staying up all night during numerous calls necessary?”

          Rather than making a blanket statement to the effect that psychologists couldn’t possibly understand what we have learned in medical school and residency, our position would be more defensible if we focused on quantifying the differences in the magnitude of current psychiatric training and that which will be required for psychologists in New Mexico.  Yet, doing this would not prevent the possibility that psychologists will rise to the challenge and eventually develop a parallel curriculum that contains the necessary and sufficient elements of medical school.  For example, I can’t help but think of the beginnings of the D.O. degree in the 19th century.  Andrew Taylor Still, who was a medical doctor and surgeon by profession, created the first school of osteopathic medicine in Kirksville, Missouri and the first charter of the American School of Osteopathy was registered May 10th, 1892.  Now, osteopathic medical schools exist in parallel with allopathic medical schools, and from every indication, there is plenty of work to go around for both D.O.s and M.D.s.  The difference, however, is that the osteopathic curricula more closely resemble the allopathic curricula, as compared to the limited resemblance of a 400-hour course to 4 years of medical school and 4 years of residency. 

          Yet, creating comparable curricula might not be enough.  How are we going to respond if the frequency of medication complications from prescribing psychologists in New Mexico turns out to be no greater than the rate of medication complications from prescribing psychiatrists?  Psychologists are well trained in statistics and will no doubt be gathering and processing data from the New Mexico experience in trying to make the case to gain prescription rights in other states.  We, too, must be statistically sophisticated and gather every bit of data that might reveal differences in patient safety when under the care of prescribing psychologists as compared to psychiatrists.  However, if the evidence reveals no differences, we would be less stressed by knowing now where we would go from there.

Even though it might appear so over the finite span of a human lifetime, no profession is static.  Like other professions, the identity of psychiatry is in flux and always will be.  What we do will change over time.  A barber is still called a “barber,” even though barbers no longer use leeches to bleed their customers.  If barbers had placed all of their self-worth and esteem in being able to perform the procedure of leeching, barbers would have found their self-worth and esteem on a decline when leeching fell out of fashion.  However, barbers who placed their identity in the simple fact of helping the customer found that their identity was impervious to attack from other professions.  It is no different for psychiatrists:  If we identify with the simple fact of improving mental health for as many as possible, our identity will be impervious.  Even if another group, such as psychologists, begin to do exactly what we do, our identity will still be unassailable, because we will have chosen to identify with the process of helping in general, not with the process of being the only ones who help in a certain way, (i.e. prescribing medication).

          Ultimately, clinical psychiatrists and clinical psychologists are interested in exactly the same thing:  maximizing mental health for as many people as possible.  Perhaps mental health parity would more likely be advanced if the American Psychiatric Association and the American Psychological Association combined financial resources to fight for mental health parity, rather than using their financial resources to fight turf battles with each other.  I have no doubt that there are more than enough patients to keep us all employed.



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