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'You're a doctor, aren't you?'

October 5, 2011
by Jerrold Pollak, PhD, ABN, ABPP
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Why “dramatic reforms” are needed in the training and education of behavioral health professionals

The issue of which professional groups may legitimately lay claim to the title “Doctor” remains controversial. 1 The conservative perspective would reserve this title for physicians holding the M.D. (medical doctor) or D.O. (doctor of osteopathic medicine) degree. 

A more liberal view would include persons with degrees in dentistry and podiatry but exclude persons holding doctoral degrees who offer healthcare services to the public, notably practitioners in clinical psychology, social work, marriage/family counseling, nursing and pharmacy.

The effort to restrict the title “doctor” to physicians and dentists included an unsuccessful bill considered by the United States House of Representatives in 2006.

This matter remains relevant, although the pendulum now appears to have swung in the opposite direction. Another house bill, promoted by the American Psychological Association, proposes that licensed psychologists be included within the definition of “Physician” for purposes of reimbursement by Medicare, free of physician oversight.

Presumably, this would allow patients easier access to behavioral health care from psychologists. Among the stated rationales for this inclusion is that other non-physician groups, currently reimbursed by Medicare, fall under this designation, specifically, dentists, podiatrists, optometrists and chiropractors.2

What's in a name?

All professions grapple with guild and identity problems as they evolve. Professional psychology is no exception; it continues to struggle to define itself as a health care profession and to establish the legitimacy of psychologists as “doctors.”

And while psychologists comprise the largest group of non-medically trained doctoral-level behavioral health providers, the issue of professional titles is also relevant to the aforementioned non-physician doctoral-level behavioral health clinicians.

Though I don't have any data on this issue, I suspect that there are differing opinions within the behavioral healthcare field about the use of the title “doctor.” Some practitioners, I am sure, would feel as comfortable with this title as do surgeons and critical-care physicians.

Others likely have some reservations and may even question whether the title is misleading to the public. However, most would probably support use of the title “Doctor” in their professional work. For those who see themselves as “doctors,” it can be difficult to appreciate the strength of their conviction in the face of so much invalidating evidence, such as:

  • The widening salary gap between psychologists (and other non-physician doctoral-level behavioral care providers) and the lowest-paid of the “physician” specialties-primary care physicians and psychiatrists. It is not uncommon to see starting salaries for young psychiatrists, just graduated from residencies and lacking board certification, of up to three times those of senior licensed psychologists with post-doctoral fellowship training, post-licensure board certification, decades of experience, and lengthy resumes.

  • The inability, even for experienced hospital trained psychologists, to formally admit or discharge patients for inpatient mental health or substance abuse care. Their privileges at hospitals are limited to appointment as “allied health professionals.”

  • The routine requirement that non-medically trained doctoral-level mental health clinicians who conduct urgent behavioral health and substance abuse assessments in hospital emergency departments clear their decisions about disposition with “back-up” psychiatrists and psychiatric nurses who were uninvolved in the case. This occurs despite the fact that the patient has been “medically cleared” by a physician, in the emergency setting, prior to the behavioral health assessment.

  • The fact that expert testimony of non-physician doctoral-level behavioral care providers, including board-certified neuropsychologists, is often called into question or discredited by opposing attorneys who ask, “Isn't it true that you never attended medical school and are not licensed to practice medicine?”

  • The ongoing opposition of the American Medical Association, the American Psychiatric Association, and many family physicians to the granting of prescription privileges to psychologists. The rationale is simple: Psychologists have not completed formal medical education and, therefore, should not treat patients with psychiatric medications.

  • The recurring comment from patients, who wonder why their doctoral level behavioral health providers are unable to prescribe, adjust, or offer an opinion about their psychiatric medications: “Well, I just don't understand, you're a doctor aren't you?”

Can we “level the playing field?”

Almost certainly, employment opportunities will continue to be much better for psychiatrists and psychiatric nurses (most of whom have a masters-level education) than for psychologists and other non-medically trained, doctoral-level clinicians because the former can prescribe psychiatric medications, while the latter cannot.

For some in professional psychology, the most sensible way to address this issue of being a “doctor” is to “level the playing field” by having psychologists obtain the right to independently prescribe psychiatric medications and become “medical psychologists.”