physician questions & concerns
Not surprisingly, physicians raise the most skepticism and concern over any non-physician prescriber whose scope expands into what was once physician-only territory. While we believe that at least some of this concern is related to professional identity, we also acknowledge that many physicians have legitimate concerns for the health and safety of the patient population. So do we.
Many of us advocate for RxP-specific training due to our belief that the RxP model trains a safer and more knowledgeable prescriber than our alternative (a one-year bridge to RN + 1-2 years of PMHNP training). The following topics answer the most common legitimate concerns raised by caring, well-meaning physicians. If after reviewing these questions, you would like to speak with a physician who has worked side-by-side with a prescribing psychologist, please email us and we'd be glad to introduce you to several.
I. BASIC SCIENCES (permitted to be taken at the undergraduate pre-req level, or embedded into the program.
a. Human Anatomy
b. Human Physiology
c. Biochemistry
d. Genetics
II. FUNCTIONAL NEUROSCIENCE
a. Neuroanatomy
b. Neurophysiology
c. Neurochemistry
III. PHYSICAL EXAMINATION
a. Measurement and Interpretation of Vitals
b. Neurological Examination
c. Cardiovascular Examination
d. Respiratory Examination
e. Abdominal Examination
f. Eye, Ear, Nose, and Throat (EENT)
g. Gastrointestinal (GI)
h. Genitourinary (GU)
i. Integumentary
j. Allergic/Immunologic
k. Musculoskeletal
IV. INTERPRETATION OF LABS
a. Therapeutic Drug Monitoring
b. Other Blood/Urine Tests
c. Radiological
d. Electrocardiogram (EKG) and Brain Electrophysiology
e. Neuroimaging Techniques (to include MRI, fMRI, and CT)
f. Applied Genetics
V. PATHOLOGICAL BASES OF DISEASE
a. Pathophysiology of common clinical cardiovascular, respiratory,
gastrointestinal, hepatic, neurological, and endocrine conditions.
VI. CLINICAL MEDICINE
a. Clinical manifestations, differential diagnosis, and laboratory or radiological
evaluation of commonly encountered medical conditions
b. Special cases: children, women, and older adults, health-related conditions
(e.g., pregnancy hormone therapy), and people living with chronic health
conditions (e.g., hypertension, diabetes, HIV/AIDS, Hep C, breast and
hematological cancers and conditions)
c. Medical emergencies and their management.
VII. CLINICAL NEUROTHERAPEUTICS
a. Electrophysiology (e.g., quantitative electroencephalogram [EEG], neurofeedback).
b. Non-invasive interventions (e.g., transcranial magnetic stimulation, EEG
neurofeedback, biofeedback)
c. Electroconvulsive therapy (ECT)
VIII. SYSTEMS OF CARE
a. Coordination of care with other medical specialties
b. Consultation and referrals
c. Coordination and consultation in long-term care
IX. PHARMACOLOGY
a. Pharmacokinetics and drug delivery systems
b. Pharmacodynamic
c. Neuropharmacology
d. Toxicology
e. Mechanisms of medication interactions
X. CLINICAL PHARMACOLOGY
a. Major drug classes
b. Nutritional supplements
c. Special cases: children, women, and older adults, health-related conditions
(e.g., pregnancy hormone therapy), and people living with chronic health
conditions (e.g., hypertension, diabetes, HIV/AIDS, Hep C, breast and
hematological cancers and conditions)
XI. PSYCHOPHARMACOLOGY
a. Sedatives and Hypnotics
b. Antidepressants
c. Antipsychotics
d. Mood Stabilizers
e. Anxiolytics
f. Stimulants
g. Medications for drug dependence
h. Medication for drug adverse effects
i. Pediatric psychopharmacology
j. Geriatric psychopharmacology (including medications for cognitive impairment, polypharmacy, etc.)
k. Issues of diversity and cultural competence in pharmacological practices (including both classical categories of diversity as well as traditional practices and lifespan factors related to drug metabolism, access, acceptance, and adherence)
l. Clinical decision-making and standard practice guidelines
m. Guidelines for prescribing controlled substances
XII. PSYCHOPHARMACOLOGY RESEARCH
a. Phases of drug development
b. Clinical trials in psychiatry
c. Critical evaluation of evidence
XIII. PROFESSIONAL, ETHICAL, & LEGAL ISSUES
a. Documental (e.g., nomenclature, abbreviations, prescription writing, etc.)
b. Conflicts of interest and relationships with the pharmaceutical industry
c. Scope of practice issues
d. Diversity and equity issues related to treatment access and adherence
As stated above, in states where psychologists cannot prescribe, the alternative is to complete a one-year RN "bridge" degree, followed by an MSN in Psychiatric Mental Health Nursing. The total process is anywhere from 2-3 years and includes a minimal amount of patient contact hours. The total process for an RxP training program is also anywhere from 2-3 years, however, the third year is dedicated entirely to obtaining physician-overseen clinical treatment.
Muse and McGrath (2010) compared the fields of general medicine (not psychiatric specialties), psychiatric nursing practice, and prescribing psychology. They compiled a chart demonstrating the overal hours of training between the three, as follows:
In addition, Cooper et al. (2019) presented relevant coursework side-by-side, absent any labels that might bias raters, and discovered that when reviewing viewing training programs side by side, physicians rated the training of prescribing psychologists as more qualified to prescribe psychiatric medication than family nurse practitioners or pschiatric nurse practitioners.
The Cooper et al. study used only programs from Texas Tech (plus Chicago School of Psychology for the additional RxP degree, on top of the Texas Tech Ph.D. in Clinical Psychology). The program, shown side-by-side, are as follows:
PHYSICIAN ASSISTANT (PA)
FAMILY NURSE PRACTITIONER (FNP)
PSYCHIATRIC NURSE PRACTITIONER (PMHNP)
PRESCRIBING PSYCHOLOGIST (RxP)
Here are the results of this study:
Members of the public rated PhD+RxP as the best training (8) to prescribe psychiatric medication, with psychiatric nurse training coming in second (7), and physician assistant and family nurse practitioner training rated as generally inadequate (4).
Non-Psychiatric NPs and PAs also rated PhD+RxP training as the more rigorous of the programs (9), with psychiatric nurse training coming in second (8), and they themselves (FNPs and PAs) as generally not well-trained to prescribe psychiatric medications (4).
Physicians (Family, Hospitalists, OBGYN, etc.) also rated PhD+RxP training as the most rigorous (8), with psychiatric nurses coming in even lower (6), and FNP/PA training as generally inadquate (4).
Finally, Psychiatric Precribers (Either MD or PMHNP) rated PhD+RxP training as equal to Psychiatric Nurse Training (both rated as a 7), and FNP/PA training as generally inadequate (4).
We should point out that research consistently demonstrates that anywhere from 80-90% of psychiatric prescriptions are written by family physicians and family NPs.
As Cooper and Aguirre (2020) pointed out, comparing the "didactic" knowledge between physicians, nurse practitioners, and prescribing psychologists is challenging due to the fact that each prescriber takes a different examination testing their basic psychopharmacological knowledge.
In an effort to assess differences, they tested psychopharmacological knowledge of 66 providers: psychiatrists, general physicians, psychiatric nurses, family nurses, prescribing psychologists, and non-prescribing psychologists. The examination covered children, adolescents, adults, and the geriatric population.
Psychiatrists performed slighty better than prescribing psychologists; prescribing psychologists performed slightly better than psychiatric nurses. There was no statistical difference between the performance of these three groups.
Non-psychiatric physicians and non-psychiatirc nurses--who ironically write 80-90% of psychiatric prescriptions--performed worse than the first three groups, and non-psychiatric nurse practitioners performed significantly worse. General psychologists were included as a measure of validy, and scored no better than chance, indicating the higher performance on prescribing psychologists' examinations was likely due to the additional RxP training on top of the PhD or PsyD.
The results are presented visually below:
Note (in the box and whisker visual) that the performance of family physicians, family nurse practitioners, and even psychiatric nurses was highly variable. However, prescribing psychologists performed not only well, but consistently well.
Fortunantly, we do have some research to help answer this question, but we'll be the first to say: we'd love to see more.
Shearer and colleagues (2012) surveyed 47 physicians who had direct experience working side-by-side with a prescribing psychologist. Here were the results of their study:
1) Physicians opined that the role of the prescribing psychologist was helpful, overall, within the hospital.
2) Physicians found no negative impact or concern regarding patient safety.
3) Physicians found the presence of the prescribing psychologist to add convenience and efficiency for not only physicians, but also patients as well.
4) Physicians found that overall patient care was improved by the added services of the prescribing psychologist.
In addition, Linda and McGrath (2017) surveyed thirty prescribing psychologists along with twenty-four of their medical colleagues. The participants provided opinions regarding the safety and clinical capabilities of prescribing psycholoigsts. Results indicated that they were "overwhelmingly perceived positively by their medical colleages." None of the physicians indicated any concern that prescribing psychologists woudl inappropriately prescribe, prescribe an incorrect dosage, or fail to consult or know when to refer to a colleague. Their medical colleagues overwhelmingly agreed that prescribing psychologists were adequately trained to prescribe medication, and that prescribing psychologists possessed appropriate knowledge of medical tests relevant to prescribing.
Most importantly: if you, as a physician, have doubts about the capabilities of a prescribing psychologist, please let us share your contact information with physicians who know us, and work with us day by day.
Every bill proposed and/or enacted, at a minimum, requires psychologists to keep each patient's primary care provider (PCP) informed about any and all medication changes. Not only does this permit the PCP to be a second set of eyes for each patient's medication treatment, but it also fosters interprofessional collaboration. This is a goal that has long been researched and advocated for - for decades. This new interprofessional dynamic could be a key to realizing such a hightened aspirational approach to healthcare.
We believe that the more psychologists are integrated with primary care, the more we can expect mental health to be viewed with the same level "prevention and wellness" as physical care. We believe that this collaborative relationship can literally change how Americans think about mental healthcare.
Absolutely.
Texas actually already has prescribing psychologists, and has for three decades... but only on military bases. Non-military citizens do not have access to these services. Here is how long psychologists have been permitted (with the advanced post-doctoral master's degree training) to prescribe:
United States Military: Over 30 years.
United States Public Health Service: Over 30 years.
United States Indian Health Service: Over 30 years.
U.S. Territory of Guam: Over 20 years.
U.S. State of New Mexico: Over 20 years.
U.S. State of Louisianna: Over 18 years
U.S. State of Illinois: Since 2014
U.S. State of Iowa: Since 2016
U.S. State of Idaho: Since 2017
U.S. State of Colorado: Since 2023
U.S. State of Utah: Since 2024
If you would like to speak with a prescribing psychologist (either military or civilian) please let us know.
First, thank you. And we truly mean that.
We've had many physicians (especially family, GP, and OBGYN) tell us that they would rather refer patients to us since we know the diagnoses, can differentiate diagnostic complexities, and monitor patients more regularly... but are afraid to voice this opinion.
Right now, you can do two things to help:
First, Legislation: In Texas, organized psychiatry visits with legislators and offers a very one-sided view of the RxP situation. Of course, we can try to combat this with data and research, but nothing is more powerful than a physician calling/emailing and responding with "no, that isn't true; I've reviewed their training and it's incredibly robust." Or, "no, that isn't true, in fact my patients wait weeks, sometimes months to get in to psychiatry, leaving me in a situation where I'm forced to write a prescription when I'm not entirely sure what's going on with the patient psychologically." Legislators need to hear from physicians that the struggle is real, and the few psychiatrists they are hearing from every legislative season do not in fact represent the overall medical voice of Texas. You can find your legislator here.
Second, national support: If you truly believe that specially trained psychologists can partner with physicians to help solve the current mental health crisis, you can make your support known publicly by visiting standwithrxp.org. This shows law makers all across the country that physicians have reviewed our trianing, and do in-fact support our pledge to make a difference.