David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
There is a movement within psychology for clinical psychologists to be able to prescribe medications just as psychiatrists do. On today's show we'll be talking about this issue with Dr. William Robiner, who is opposed to the idea. William Robiner, Ph.D. ABPP is professor in the Department of Medicine and director of Health Psychology and the Psychology Internship Program at the University of Minnesota Medical School. He's also the chair of the University of Minnesota's Medical Center Fairview Psychology Standards Committee. He received his Ph.D. in clinical psychology from Washington University of St. Louis, Missouri, and is board certified as a clinical health psychologist. He's been on the Minnesota Board of Psychology and is a fellow of the Association of State and Provincial Psychology Boards. He was on the committee that drafted the influential guidelines for prescriptive authority. He has numerous publications related to the education, training, supervision and workforce of psychologists, and has authored peer reviewed articles that address problems related to psychologists prescribing. Now, here's the interview:
Dr. William Robiner, welcome to Wise Counsel.
Dr. Robiner: Thank you, I'm welcome to be here.
David: I'm not sure how many of our listeners will be aware that for some time now the American Psychological Association has been struggling with the issue of whether or not clinical psychologists, with additional training, should seek prescription privileges. I've invited you here today as a member of a group named Psychologists Opposed to Prescription Privileges for Psychologists.
Dr. Robiner: Thank you, I'm happy to represent them and to share my personal views about this matter.
David: Excellent. Now I have to say I've not followed this debate closely myself, and have not personally staked out a position on either side of the issue. To kick things off, perhaps you can bring us all up to speed on the history of this issue within APA.
Dr. Robiner: Okay, well first of all, I think that many people are like you. They have not been following this issue as something of central importance to them. They've been remotely aware of it; at times they've heard things about it; and then there's a small number of people who have talked about it a great deal. But many psychologists have really been focused on other areas within psychology and have seen this as not being particular germane to what they do or what their interests are.
The issue of whether psychologists prescribe has been with us for awhile now, it's been over 20 years, and time goes fast. I remember when I first heard about it I thought it was a joke. I could not believe that people were serious about suggesting that. And my personal reaction to that was I felt I had made a decision, when I decided to become a psychology major and to go to graduate in school in psychology, not to pursue medicine, not to pursue the science classes that really were seen as the entry way to that type of profession. So I took one course in chemistry; I did well in it. I took a course in physics; I did well in that, too. But I decided that I was really more interested in the psychology kinds of classes I was taking, and so I stopped there.
And I'm not unlike most psychologists. Most psychologists really haven't had much exposure to the pre-medical or pre-nursing or pre-dentistry curriculum. They may have taken a few courses, but only about 7% have actually taken a few courses in chemistry and in biology. So when I first heard it, it seemed like a very peculiar thing to do because my training was so different from that. Nevertheless, other people had very different views about it and clearly were interested in exploring it and pursuing it.
In the early 1990s there was a study that got funded through the Department of Defense, that trained over a few years -- I think it was about three years -- a group of 10 psychologists who were in the military already. Most of them were already in leadership positions in the military, so this was a select group of psychologists; and they had them go through some of the basic training that was much like the first year of medical school, for example. They did take some of the biology and chemistry classes, for example, and they had a couple of years' worth of study that got whittled down in subsequent iterations to about one year study and one year of a more intensive practicum. But it was a full time endeavor for them. They were serving on call, at night, along with the psychiatry residents, for example. They were studying within medical hospitals; they were already entrenched there as professional trainees; and they were getting this additional training.
And what happened is that this was getting a lot of interest by various people, certainly by proponents of the psychopharmacology movement within psychology. They could point to the successes of these individuals saying, "Look, psychologists can learn how to do this."
David: Now this was in the military?
Dr. Robiner: This was in the military. I've heard from other people that there has been some de facto types of prescribing in the Indian health boards in some places and some other locations, but to my awareness this was the first time it was actually looked in. It was really, to my knowledge, the only study that's ever looked at this.
What's interesting about that study and what you don't hear from the proponents is there were a variety of concerns raised. Basically, although people were impressed that people could learn quite a bit, they really saw these psychologists as more at the student level than the physician level.
David: Who did? You say, "They saw." Who saw them?
Dr. Robiner: There was a report that was put out that reviewed the DOD study, and this report -- which anybody can look at, I think parts of it are actually on the web -- explained that there was a range of outcomes; and whereas there was some good news, there was also some bad news, which of course the proponents never talk about.
I don't know about you, but I'm very reluctant to get my health care from a student; I want to get my health care from a professional. And they were seen as being both weaker psychiatrically and weaker medically; and there were a few other things that were interesting that you don't hear much from the proponents. For example, the people who graduated from the program said that they would advise against "short-cut programs." They also considered that a year of intensive full-time clinical experience, including in-patient care, was essential. And so the first iteration, I think, had about 700 hours and it whittled down some, but most of the types of legislation that has been proposed and the model that the APA went on to devise for this kind of training after psychologists have already gotten their Ph.D.s in psychology, they've been much less and much looser. The APA suggested it be 300 hours and some of the states that have tried to pursue this it's been somewhere between 400 or 450 hours, but none of them have, then, had the kind of supervised experience, for example, in military hospitals; they don't require things like it be an intensive full year practical experience. They don't require any in-patient experience.
And so what's happened is that proponents, nevertheless, said they were able to do these positive things and therefore psychologists should prescribe, and the APA then went on to develop this model and various state psychological associations have presented initiatives in their state legislatures to allow psychologists to prescribe. The first place that passed prescription privileges for psychologists was Guam.
David: Was that because of the military connections somehow?
Dr. Robiner: You know, I don't know the history of that; that's a really good question. My guess is that it's just a smaller area, a relatively smaller population. It's a territory, it's not a state, and so it was a place that was seen as being able to do it for some reason, but I don't really know. It probably had to do with the politics, with the geography and so forth, people whose relationships with legislators were in what kind of shape, but I really don't know the answer to that.
David: I gather there's several states at this point that have…
Dr. Robiner: There are two states that have it now. The first one to pass this was New Mexico and that was in the early 2000s, and then a few years later Louisiana passed it. Those are the only two states that have ever passed it. And so it has been perceived by some people that it's a little bit like the tale wagging the dog for Guam to sort of try to promote what some people believe the future of psychology should look like, rather than coming from a more populous state with more of the types of health care system that's seen in other parts of the country. Nevertheless, that's kind of where we are.
Each year since then several states have had initiatives that have been advanced, typically by the state psychological associations I believe, and they've come before legislatures. There are some currently being considered, I think, in Missouri and Tennessee, Oregon, Hawaii and I think there had been one in Illinois; a few others, Montana, I think, may have had one earlier this year. There are only two states that have it.
David: It's interesting that it's state by state and not somehow mandated federally. You would think that it's an important enough issue that somehow it would be more of a federal issue than a state issue.
Dr. Robiner: Well, in terms of psychology I think it's been pushed by the American Psychological Association; they spent millions of dollars in lobbying and so forth to try to advance this cause. But because licensure is a states issue rather than a national issue and people have a license to practice, as any health professional, it is considered a state issue. So the way this gets dealt with legislatively is as expanding the scope of practice of psychologists from what they already have; this would be added on to that.
David: Let me just cut in here and back you up just a little bit to have you summarize it, because I could have set this up as a debate, inviting a psychologist from the other side of the fence but I didn't want to put you in that awkward position. So perhaps you can take us through both sides of the argument as fairly as you can, and let me have you start with the pro, as best as you can represent that position. What is their argument of why psychologists should be able to prescribe?
Dr. Robiner: A number of arguments have been advanced, some of which make more sense to me than others, but one of the issues is that psychologists are already very well trained health professionals dealing with mental health issues, and as we've had a greater range of options that are pharmacologic it would make sense to expand what psychologists are already doing to allow them to bring this set of options into the care that they provide. That would be seen as potentially being more efficient in some ways, because somebody seeing a psychologist while they're there they can also address the psychopharmacology needs. And that's, I think, what some of the thinking has been.
There are a number of other issues that get brought in by proponents. One is that they point to a mental health need. For example there's a shortage of providers -- of psychiatrists for example -- in rural areas; and they say, "Well, see, if the psychologists in those rural areas could prescribe, then we would compensate for the shortage of psychiatrists in those areas." I personally have trouble with both of those issues. There are other issues as well.
David: Let's not leave the pro side yet, because I can think of one or two others that I've heard. One is that, from the point of view of the profession, I think there is some sense that psychology wants or needs to differentiate itself from people who have master's level licenses, and so this would help to make sure that the Ph.D. had special privileges attached to it. Is that one of the arguments?
Dr. Robiner: What you're describing is a very complex issue; it's about the workforce and what we do with people within the field at various levels of training, and also about the health care system. How can psychology stake out a firm footing as other fields -- both within psychology like masters level folks, or social workers, or marriage and family therapists -- as they increasingly provide psychotherapy, which is a skill that psychologists are probably the best trained in? What are psychologists going to be able to do to distinguish themselves? What niches can they occupy?
And I think that, one, that's a guild issue rather than a more public policy issue; that's internally, I think, with the base. Part of it is, many psychologists are frustrated that over time they feel like they've kind of lost ground in terms of the prestige of the field relative to other fields. For example, other fields like nursing have gone from not being able to prescribe but as nurse practitioners then gaining the right to prescribe. Then they can and psychologists can't.
There's also concern about, I think, reimbursement issues. You know the reimbursement over the course of my career has really been damped down quite a bit by the caps that HMOs and other third party payers have placed on reimbursement. And so people are thinking, well, how can psychologists earn a better living? And if they have more of the skills, for example, that psychiatrists have -- who get typically paid considerably more than psychologists -- then this might be a really good opportunity for psychologists, for people in the field.
So I think actually those economic issues have been driving issues for this, but the public face of this when it's brought in front of legislators has been more about not what's good for people in the field, but they've tried to cast it as an issue that what's good for the public, what makes sense in terms of efficient care, how do we get patients who need psychoactive medications greater access to people who understand them?
And one of the things that they will say is that -- which is true -- is that about 70% of psychoactive medications are already prescribed by non-mental health professionals; they're prescribed by GPs, by internists, by family medicine doctors, by pediatricians, by Ob/Gyns who have very much less experience with mental health issues, so why are these people then prescribing psychoactive medications? And whereas we know all this, we know a great deal about mental health concerns, why can't we prescribe better? So that's kind of how they view that.
David: Yes, I was actually speaking with a colleague, telling him that this interview was coming up and asking for his perspective, and he definitely brought up the point that you just made about GPs prescribing and so on. Another point that he made was that -- and I don't know if this is accurate or not -- but it's his perception that the workforce of psychiatrists is shrinking, that because psychiatry has become so much less the practice of psychotherapy and so much more the practice of psychopharmacology that not as many young people are drawn to psychiatry as they were in the past, and so that, in fact, there is some kind of a workforce issue.
Dr. Robiner: Well, you know we can talk about the workforce issues within psychiatry for a minute. I was the sole representative of the American Psychological Association to a project about 20 years ago that was trying to forecast how many psychiatrists do we need in the year 2010. You can imagine back in 1990, when I was the person that the APA requested to represent them as they were looking at this issue, I could never imagine that we'd be close to 2010 and it's around the corner. But I'm in a unique perspective based on that, so I've sort of tracked these issues about the psychiatric workforce for a long time.
David: Oh, good.
Dr. Robiner: And back then we knew there was a shortage of psychiatrists. There've been multiple times that we have said, you know, there's a shortage of psychiatrists, we should be training more psychiatrists. Although what's interesting is, if that really is the issue that was driving psychologists, wouldn't you think that it would make more sense to have the APA, the American Psychological Association, work with psychiatry to advocate for greater funding to expand psychiatry training programs; or to do things to encourage physicians to go into psychiatry, which to my knowledge has never happened, which would be a more straightforward in my mind of addressing the workforce issues?
The issue is really quite complex. The issues that your friend talked about, I think, are true. There are other things that contribute to it: one is some people find it not very rewarding to see a new patient every 15 or 20 minutes for medication checks. Although, when you speak to psychiatrists as we've had now a greater range of psychoactive medications, it's also becoming more complex to try to understand it, so there are a lot of challenges inherent in that. What I would say is interesting is that part of what's created the disincentives for people to go into psychiatry has been that the reimbursements for a psychiatrist has been lower than other more lucrative areas within medicine. So if you have the choice to become a neurosurgeon or a GI doctor who may earn a half a million dollars a year, I'd say, or a psychiatrist where you're earning maybe $150,000 or $175,000 to $200,000 a year, what are going to look at more seriously?
David: Hasn't that always been the case, though?
Dr. Robiner: Well, it has been the case, which is part of why there was a shortage 20 years ago in psychiatry. People weren't really paying any attention to this issue, and it affects a lot of fields: it affects primary care, where you have trouble getting people into primary care, internal medicine, family medicine, pediatrics. So there are shortages in various fields, and just how you even decide what is a shortage and how many psychiatrists are needed -- I've written about how many psychologists are needed as well -- these are very complex issues.
First of all, for example, in Minnesota where I live, the psychiatry programs fill regularly so it's not as if nobody's going into psychiatry. Part of the issue is that the population has expanded but the number of psychiatry slots has not been expanding. And part of the issue is that as the greater number of psychoactive medications becomes available, or as we become better at diagnosing mental illnesses, as there are more diagnostic categories that are added, the need for more psychiatrists has grown at some level.
But one of the things that could be interesting to look at is what historically have been the calls for the numbers of psychiatrists per 100,000. And I was reading one thing the other day that suggested that it would be anywhere between 15.9 in one person's model; one set of researchers are 7.2 per 100,000, 3.9 per 100,000, or 5.73; and that's in a report that I found on the Web the other day by MHA Merritt Hawkins and Associates. And so the physician to population ratio will be calculated based on whatever you put into the algorithms.
The question that I think is more important to look at when you're considering how many psychiatrists do we need, what's the shortage, is what is the role of psychiatrists? First of all, if 70% of prescriptions are being rendered by non-psychiatrists, is that good or bad? I think a lot of people would say that's good. Most primary care doctors are comfortable with several anti-depressants and anti-anxiety medications and so forth, and have been getting training in that and developing a lot of experience. It may not be what draws them into internal medicine, for example, but they are very used to dealing with those medications.
David: My friend who I spoke with about this, thought that that was bad; actually that came up and he thought that it's bad that GPs and others are doing 70% of the prescribing and that he had the impression -- and I don't know if he read this somewhere, if there's statistics behind it or not -- but he had the impression that when psychologists start prescribing, they actually have more of a tendency to reduce the amount of medication that people have been taking, rather than upping.
Dr. Robiner: Well, I work in a primary care setting with internists, from pediatricians and [?] medicine doctors, so I see this first hand every day. And what typically happens is that they have a comfort zone working with certain types of diagnoses, certain types of medications, they're sort of the front line. If somebody's not responding or if somebody's more complex or if somebody's having a first psychotic episode, they would much prefer a psychiatrist provide the care. But because patients already know their primary care doctors and feel comfortable with them, they generally feel comfortable talking about these issues; they know them better, they may have known them for many years before they ever talk about depression. So it's not as all bad as proponents of prescription privileges for psychologists might think.
The question really is when does the psychiatrist need to be involved directly in somebody's care versus when might they be able to provide care indirectly, be it through education? So, for example, there's been a lot of training of family doctors in the last several years to help and prescribe better or to detect depression better. What about telemedicine? So in the hospital where I work at, in the last few months they've seen at least 80 patients through telemedicine in remote rural areas; psychiatrists here at the University of Minnesota have done that. And so there are other models and in England, for example, it's not the case if somebody sees a psychiatrist the expectation is that they will keep seeing that psychiatrist indefinitely, but it's on a more consultative basis. When they need to make adjustments or when there are questions about what's going on, then they're sent to the psychiatrist.
So how grave a problem this is or isn't, is really in the eyes of the beholder. And as someone who works in primary care, I see it work for most patients, and then when it's not working they're very interested in getting the person to see a psychiatrist. So I think it's probably been overstated, at least in my opinion. I'm sure that there's some not so great prescribing that is done by psychiatrists, by general practitioners, and by everybody, but I don't think that it's logical to assume, well, psychologists could do it better given that they've got less training in it, and that's how I would kind of counter that perspective.
If we had the same training that they did plus the training that we as psychologists have -- I meet psychologists who have become nurse practitioners and so forth -- that, I think, works really kind of well. Or I have a friend, an old supervisor actually, who had a great affection for education so he became a psychiatrist; then he got his Ph.D. in psychology, and then he went to law school. He thinks it's not a good idea of psychologists to prescribe based on his experience as a psychiatrist and as a psychologist.
And there was a psychologist at, I think, the University of Illinois many years ago, who after being on the faculty for a few years decided he wanted to become a psychiatrist. And so he wrote some articles in The American Psychologist and in Professional Psychologist Research and Practice about the different mindsets and training of psychiatrists and psychologists. And I'm going to sort of butcher his comment, but one of the things that he said was, that he was struck when he started to learn psychiatry, about how much about prescribing had to do with the functioning of the kidneys and the heart and the liver, and how little of it actually had to do with psychology; which I thought was a very profound perspective to have and which really, I think, helped me to formulate my position on this issue.
And that is that we are very good at what we do, but when psychologists seek to pursue prescription privileges, we're going quite a distance from where we have been. And the question is how do we make up that distance if we're going to do it well or as well as different other groups, be it nurse practitioners or general practitioners or psychiatrists. And to me that's really the heart of the matter. And the reason it's important to answer that question -- and the proponents think it's already been answered, the opponents don't -- is that it then becomes a public health issue if people with lesser training are prescribing, because there is a truism, you don't know what you don't know. And if you haven't gotten trained in some things you may not know what you're missing by lack of having gotten that training.
David: Okay, I asked you to tick off the pro reasons and you've gone through them; and I certainly want to give you equal time for the cons, the reasons why you're against extending…
Dr. Robiner: I've been kind of bringing those in as we speak, but I've been trying to be as open-minded as I can.
David: Yeah, I think you have been bringing them in and it sounds like the main one is insufficient training, and I'm wondering are there others?
Dr. Robiner: Well, for me that is the main issue. Very early in my career I used to go meet with -- I'm a health psychologist so I'm an ABCHP or board certified in health psychology -- and early in my career I used to go to rounds by a group of psychiatrists at our medical school called consultation-liaison psychiatrists. And consultation-liaison psychiatry is the subfield within psychiatry that deals with medically ill patients. And as a health psychologist working at a tertiary care like I do, we deal with very complex medical patients, so it's not uncommon for the patients that I see -- which include liver transplants, heart transplants, diabetics, people with cancers, bone marrow transplants, neurological problems and so forth -- to be on many, many medications. They're not just taking one, they're on many medications; and so I get very concerned about, not just what are the potential psychoactive medications that they need, but what are all these other things that they're taking and how do those things then interact with the psychoactive medications? Maybe they will diminish the body's metabolism of the psychiatric medications, maybe they will augment them and vice versa.
And that's the concern that I have, is that when people are really sick, then it gets beyond the kind of limited, sort of focused training that the APA has proposed, where you really don't have any scientific background in terms of the hard sciences like biology and chemistry, physiology; but you then after your Ph.D. in whatever branch of psychology you study -- be it counseling or clinical or school psychology -- and then you go into this very accelerated type of training program.
To get into a psychology graduate school, there are very few programs around the country that even require a course in biology or chemistry. Only about 7% again of psychologists have taken several courses in biology and chemistry; it's a very small percentage versus physicians and nurses and dentists and all those others who have, they've all taken that. And what I think about this is as setting the foundation for understanding what's to come; and without that, how well can you then understand all the chemical… if you don't learn to think like a chemist to some degree, then when you start seeing chemical compounds, how much are you actually understanding about how they work and why they're doing what they're doing?
David: Yes, as I went through your website -- there is a website; tell us the name of it again. I don't think we've mentioned it.
Dr. Robiner: The organization is Psychologists Opposed to Prescription Privileges for Psychologists and the website is www.poppp.org.
David: Okay, and as I was going through that, I realized that maybe you're not totally against psychologists having those privileges, but what you want is for them -- if they're going to go down that road -- you want them to have far more training than the APA has currently proposed.
Dr. Robiner: Well I would want them to have as good a training at least as a nurse practitioner or a physician assistant.
David: And let's say that if a person went to school to that, remedially, how much time are we talking about?
Dr. Robiner: Well, you know, you have to take the prerequisites first of all; and so those prerequisites to get into those programs would be probably a year, a year and a half if you haven't taken them before. And then a physician assistant program is about two years. A nurse practitioner program typically you become a nurse first, an RN, and then you go on to take what has been a two year additional training program to get the master's and become a nurse practitioner. But interestingly, for nurse practitioners that is a migrating standard. By the year 2015 nurse practitioners will have to have doctoral degrees because they're finding that they need to have more education about more things than they thought we were on.
David: It sounds like you're envisioning that they would need to have another, maybe, three full time years or four more years.
Dr. Robiner: Something, I haven't really thought it through. Any psychologist could already go those routes if they wanted to, like that psychologist I told you at the University of Illinois, or could go on to become a nurse practitioner. I know a nurse practitioner went the other way and then became a psychologist. But, yes, it's about the inadequacy of the training model and it's about the lack of a foundation. So a couple of analogies, if I can: one is, let's say you wanted to learn how to study French literature. Do you think it would be a good idea to study French first?
Dr. Robiner: If you wanted to learn how do design airplanes, before taking advanced aeronautics, do you think it would made sense to learn geometry and calculus and physics first?
Dr. Robiner: Yeah, but we don't have any prerequisites to even get into these programs that are now training psychologists allegedly to prescribe. And so, again, I was starting to talk about what it takes to get into a psychology graduate program. Very few require any prerequisites to get into a Ph.D. program, in terms of hard sciences. So after getting your doctoral degree to go into one of these clinical psychopharmacology programs, you still don't need to get any of the prerequisites for going in as you would for medicine or nursing, for example.
Now I knew people when I was in college who were like English majors or history majors who, after getting out of college, they thought, what am I going to do with this degree? Maybe I should go to medical school. And they would then go back and get those prerequisites and apply to medical school and they would become physicians. But for psychology, for this clinical psychopharmacology, there's a what I consider a very arrogant attitude, which is to say, "Well, we're psychologists, we don't need that. We should be able to prescribe even though we would be the only prescribers, in fact, who don't have that foundation."
David: You know there's another contingent that I would think would be against this, and I had assumed that you would be of that contingent but clearly you're not; and those would be the psychologists who really would have grave concerns about psychology embracing what's called the medical model, and who feel that an educational model is far more appropriate for psychology.
Dr. Robiner: Yes, I agree with you. When I was in graduate school, it seems to me that there was absolutely some training that addressed that, that was saying, "Well, our model is not the medical model; we have problems with the medical model." But I think the economic issues that we were talking about earlier have really sort of filtered into the discussion, made people rethink their positions. I was never particularly opposed to the medical model earlier on, and I also don't fully embrace it either. I probably would embrace the bio-psychosocial model, but if we're going to do the bio part of that, I want it to be really bio.
And, you know, I come from at this from an interesting perspective for lots of reasons. We didn't really talk much about my background. I was on the group within the Association of State and Provincial Psychology Boards that was trying to create a model for addressing prescriptive authority when this was first being looked at several years ago. I tended to take the more con position, but we were trying to help the psychology boards around North America figure out if the state legislature decides to do this, what do we do? Ultimately that group did not take a position about whether psychology should or shouldn't, but wanted to sort of address what are some of the issues involved with this.
So I have an interest from a regulatory perspective having worked on some task forces for ASPPB and having been on a board of psychology. That's one set. I've also worked on the workforce issues, so this sort of intersects with some of those issues as well.
David: You sent me a copy of your résumé and you mentioned that you're a health psychologist, and one of the things that stands out, in addition to a huge number of publications, is that so much of your work has been in medical settings.
Dr. Robiner: Yes, I've worked most of my career -- really all of my career -- in medical settings.
David: Yeah, so there are two questions that come out of that. The first one is, how has your experience working so intimately with physicians affected your thinking on this issue?
Dr. Robiner: That's a great question. Before I answer that, let me just finish one last thing I was going to say about the personal side of it as well, which we were getting to. My brother is currently the head of the neurobiology department at Harvard Medical School and so -- we were stepbrothers actually -- but we were the same age and we were often taking the same classes. So he has a Ph.D., not an M.D. But I have a great deal of respect for what I don't know based on my knowledge of neuroscience and my recognition of the courses I did not take that he was taking at the same time he was in graduate school. He obviously doesn't prescribe either, nor does he want to, but we talk a lot about what's going on within the brain in ways I don't hear most psychologists talking about.
But getting back to the issue about where I've come from professionally, how does it affect me? Well, first of all, none of the physicians that I know or work with really care about this issue. Some people think I must be interested in this because I'm wanting to kind of make my boss happy in some way. My boss is an internist; he doesn't really know much about the training of psychologists; he wonders why I even pay attention to this issue; it's not on his radar screen. I'm not in a department of psychiatry, so I don't have a head of a psychiatry department saying to me this is a problem, that psychologists would do this. And so I've come to this conclusion entirely on my own based on what I see I don't know when I deal with medically complex patients, and how much I enjoy the collegial collaborations that I have with all kinds of physicians.
You know, physicians really appreciate what psychologists bring to the table currently: the ability to talk to patients and spend time and calm them down, and assess what's going on with them. We work hand in hand all the time, but I think a lot of psychologists feel like physicians are trying to have psychologists under their thumb or something like this, and I just don't experience that. I've always had good working relationships with physicians and surgeons, various types of specialties within medicine, as well as within psychiatry. But I've never been in a psychiatry department. And I've also never received a dime for talking or writing about this issue.
David: Okay, well good, you addressed my second question which was going to look for some polite way to ask you if you were somehow a shill for the medical establishment.
Dr. Robiner: You know in the same way that there's so much news these days about people who have become shills for the pharmaceutical companies, I can see the temptation, but I've given various talks; they've always been unreimbursed. I really have not gained a dime by any of the positions I've taken. However, I would say that I don't think that's true for people who really are the advocates for prescription privileges.
Dr. Robiner: I think they actually are focused on the financial implications. You know some of the schools that wish to offer this are for profit professional schools, as an example. It's not the Harvard and Yale and Stanford medical schools that are trying to provide the kind of prescription privilege training. It tends to be professional schools that wish to have more students, but have not been at that level and have not been providing the kinds of training that involves lab space, for example, like a nursing school or a dental school or a medical school might typically provide.
I don't know all the reasons why the APA wants to promote this. One person said that -- and I thought it was kind of jaded when I first heard it, but I think there may be some truth to it -- the American Psychological Association is the largest publisher of mental health journals; and wouldn't it be nice as the largest publisher of mental health journals, to be able to have a lot more advertising revenues from pharmaceutical companies?
David: Wow, now there's a real conspiracy theory.
Dr. Robiner: Isn't that interesting?
David: Yes, Bill, it's probably time for us to wind down here. I wonder if there are any final thoughts that maybe you haven't had a chance to articulate.
Dr. Robiner: Well, there are a few. My own experience with this is that when I hear advocates talking about the reasons for doing this, I always want to listen to them and see if it makes sense to me. So when people say, "Well, we need to help people in rural America get good psychiatric care," I think, well, that sounds good, but the reality is psychiatrists and psychologists have very similar demographics. They tend to work mainly in cities and in suburbs and relatively few of both groups are in rural areas. And so because there's never been any effort to get psychologists who go through this kind of training then redistributed throughout rural areas, it seems to me that there's something disingenuous about that argument.
Some of the concerns I have about the quality of the training, you're right; for me this is all about quality of training and how that relates to quality of care for patients. And if you look at my vitae, you'll see that I've written about quality training in various ways and supervision and so forth; that's been a very strong focus of mine, I'm the director of a psychology internship. And I have concerns about the quality of the training.
Some of the training is being given online currently, as an example; although the American Psychological Association accredits doctoral programs and internships and now post-doctoral residencies, the kinds of programs that seek to train psychologists to prescribe don't fall under the American Psychological Association's own organization, the Commission on Accreditation, for accrediting them.
So here we're providing training that's not accredited by a psychological group, so unlike medical residencies, for example, where -- just like psychology programs have to get accredited -- medical residencies and medical schools are accredited by their respective organizations, there isn't accreditation. So I have concerns about the quality control within the training; things like who's doing the supervision; how much supervision is being provided; how extensive is the patient load that these people can be trained on.
Most of the programs adopt the American Psychological Association's requirement of seeing 100 patients. Well, what does seeing 100 patients mean? If you see them once, tell them they should take a medicine, then you never see them again? Is that seeing a patient once? And will you do that in five weekends and if you're working in a busy emergency room, for example; I'm using some hyperbole there; I don't think that's what's actually happening, but I see that there are a lot of gaps in terms of the quality issues that I think would need to be addressed to train psychologists well.
The other thing that I would add is in terms of the testing. There is one quality mechanism for people who seek to do this; they have to pass a national exam. The name of that exam is the Psychopharmacology Examination for Psychologists or the PEP. Ironically, I was the person who came up with that name, even though I don't actually support this, while I was on the ASPPB subcommittee, or the committee that was looking into this. We were kicking things around and I came up with that name, and it got communicated to the people who have the exam, and so part of my legacy is I have created the name of that exam. And that's the only exam people have to take that has anything that's vaguely medical about it. The licensing exam for psychology really has relatively little along these lines.
Now compare that with what someone has to do to become a physician. First they have to pass and get good grades in those basic prerequisites. Then they have to do well on the med board, the MCATs; then, within medical school, there's increasingly been a sort of nationalization of the exams that are called shelf exams. So these are national exams that people take when they take basic science courses in some cases -- some schools have them -- and when they take the clinical courses, like the clinical rotations. And so to become a physician people have to be tested and tested and tested and tested. There are numerous types of tests that are directly related to practicing and to understanding the basic concepts like biochemistry, as an example.
That is, again, different than the way things are within psychology, where it's based on a single exam -- I can't remember how many hours it is. And so we've got just very different training models and paradigms, and I personally think they're not even close. And I think that, in fact, they're further than we know; no one really knows how close they are.
Well, the only data that we have is based on that Department of Defense study that was done in the early 1990s. We don't really have any good ongoing studies that I'm aware of that are looking at how safely are psychologists prescribing and how much have they actually learned. I'm concerned that they may be learning more by rote in a very abbreviated program rather than having the fluency in dealing with the subject matter that comes from really getting in and rolling up your sleeves and wrestling with the material more than happens.
David: Okay, well, that's a good place for us to wrap it up, I think.
Dr. Robiner: Well, I just appreciate immensely this opportunity to discuss this with you and I hope that you don't lose any friends that you're being willing to talk with me. I know that some people think I am talking about very important things kind of like talking about the emperor's new clothes; and other people think that I'm torpedoing my colleagues in psychology. I don't view it that way; I view it more a little bit like there's a public service announcement, friends don't allow friends to drive drunk. I just see the potential problems here and I'd like to steer clear of them; and if psychologists want to prescribe I want them to do it as well as every other prescriber out there, based on their scientific background. And that's what I would like to see happen.
David: I hear you looking out for both the public good and for the good of the profession. And so you've alerted us to important concerns here and it's been educational for me and I'm sure to my listeners. So Dr. William Robiner, you've been very generous with your time and information and thanks so much for being our guest today on Wise Counsel.
Dr. Robiner: Thank you very much, it's been a pleasure. Thank you for the invitation.
David: I hope you found this interview with Dr. Robiner as interesting as I did. Clearly there are a lot of thorny issues here requiring careful deliberation. If you have strong feelings one way or the other, I hope you'll let us know by posting your comments on our site.
You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC.
If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkraprado.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.