This past week both Daniel Carlat and John Grohol posted about prescribing privileges for psychologists. And I think this debate is a lot about the turf war that has gone on between psychiatrists and psychologists for at least a couple of decades now.
Carlat favors psychologists gaining prescribing privileges but as a part of what he would propose as a rather sweeping change to the training of both psychiatrists and psychologists.nHe would have them train together with psychiatry leaving behind those aspects of medical education that he sees as not relevant to psychiatry -
I suggest that the process begin with a work group created jointly by the American Psychiatric Association and the American Psychological Association. Yes, let’s get psychiatrists and psychologists in the same room, and reverse engineer an ideal curriculum for integrative psychiatric practitioners. Let’s face it, going to 5 to 7 years of psychology graduate school, then capping is with 2 years of psychopharmacology is not an efficient use of training resources. It’s almost as ridiculous as going to four years of medical school, one year of medical internship, then three years of psych residency.
There must be a middle path—perhaps a five year program that would interweave coursework in physiology, pharmacology, and psychology from day one. The specifics would require much thought and discussion, and would best be done by reverse engineering. Start with the ideal psychiatric practitioner, list the core competencies such a person requires, and then figure out the very best way to teach those competencies.
And certainly that is an intriguing possibility. But how would not the market forces continue to work in this new blended profession in the same way that it has in psychiatry? I recall a study in which it was shown that a psychiatrist doing a medication only practice, seeing 3 or 4 patients per hour could easily earn 57% more than one who spends a significant amount of hours seeing therapy patients. Why believe that members of this blended profession would be immune to this kind of economic incentive? And, given that third party payers are already biased away from therapy to medication, why would they change their position?
I think what we see here is the confluence of a couple of issues underlying the old turf battle. For psychologists to gain prescribing privileges, they become more like "real" doctors, which as everyone knows can and do prescribe medicines. So it addresses an old inferiority contained within the profession.
Psychiatrists have pretty much abandoned psychotherapy -- many residency programs provide very weak training in therapy these days -- in favor of a model rooted more firmly in the medical model. As non-medical professionals gained the right to practice psychotherapy, doing so began to carry less prestige for physicians already in a specialty often derided by their more "medical" colleagues. Abandoning psychotherapy for psychopharmacology and a brain illness model has allowed psychiatrists to be "real" doctors.
But now the psychopharmacological enterprise has fallen under a cloud with the problems of compromised researchers and the emergence of data suggesting that the medications perform much more poorly than thought. Which begins to make psychotherapy more attractive again.
But the siren song of money will trump any of this. And so long as volume of patients yields the most income, psychotherapy will be honored more in the breach than in practice.
