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

August 4, 2011
by Jarrold Pollak PhD, ABN, ABPP
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Editorial: 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 view would reserve the title “Doctor” to physicians holding the M.D. or D.O. degree. A more liberal view would expand the title to dentists and podiatrists, but exclude other doctoral-level service providers, including clinical psychologists, social workers, marriage/family counselors, nurses, and pharmacists. 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.

A more recent House bill, promoted by the American Psychological Association, swung in the other direction. This bill proposed that licensed psychologists be included within the definition of “Physician” for purposes of reimbursement by Medicare, free of physician oversight. Presumably, this approach would allow patients easier access to behavioral health care from psychologists, while including them among a range of non-physician groups currently reimbursed by Medicare: dentists, podiatrists, optometrists and chiropractors.2

All professions grapple with guild and identity problems. Professional psychology is no exception; it continues to struggle to define itself as a healthcare profession and to establish the legitimacy of psychologists—the largest group of non-medically trained doctoral-level behavioral health providers—as “Doctors.”

However,psychologists (and other non-medically trained, doctoral level providers) who see themselves as “Doctors” must do so in the face of a lot of invalidating evidence:

  • A widening salary gap between psychologists and the lowest-paid of the “physician” specialties—primary care physicians and psychiatrists.
  • The lack of hospital discharge or admission privileges for inpatient mental health or substance abuse care. The privileges of even experienced, hospital-trained psychologists are limited to those of “allied health professionals.”
  • The need for doctoral-level mental health clinicians who conduct emergency behavioral health and substance abuse assessments to clear their decisions about patient 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 an ER physician prior to the assessment.
  • The fact that expert testimony of non-physician doctoral-level behavioral care providers, including board-certified neuropsychologist, can be called into question 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?”

What seems certain is this: Employment opportunities will continue to be 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.

Some would address this imbalance by having psychologists obtain the right to independently prescribe psychiatric medications and become "medical psychologists." However, this solution is replete with ethical, legal, clinical and logistical challenges. And, it’s been talked about, ad nauseam, since the late 1980s, with little progress to report. On the state level, a series of bills aimed at expanding psychologists’ scope of practice to include prescribing have failed.3

Meanwhile, behavioral health has seen a plethora of professions emerge---each with its own education/training and licensure requirements, ethical codes, and socio-political agendas. And, we have witnessed the emergence of the “new normal”: the "15 minute" psychiatric medication check, the proliferation of split- and multi-provider treatments, and the rise of physician's assistants, primary care nurses, and family physicians as "proxy" mental health clinicians despite limited education/training, time, and interest.

These trends have fragmented care delivery, reduced effectiveness, and frustrated consumers.4 And, because few medical school graduates are pursuing psychiatric residencies nationwide, a circumstance that has led to drastic shortages in child/adolescent and child/adolescent and geriatric psychiatry, the devolution of behavioral health care training and delivery is likely to continue.5

A new model—a “dramatic change in education and training”

Having watched the professional landscape for decades now, I don’t believe that professional psychology’s standing can be “fixed” by modest changes in curriculum and training and the “hope” that we’ll win prescribing privileges. What is really needed is a dramatic change in the education and training of all behavioral health professionals.