The Next Generation of RxP in MN

While many psychologists may have linear career tracks and interests; some others may be driven by unique opportunities and, more importantly, the pressing needs of their community.  

During graduate school, I never thought my career would move through significant paradigm shifts.  The foundation of the scientist-practitioner still holds firm; however, my work in mobile crisis, primary care, and now that attainment of an advanced (MSCP) psychopharmacology degree has awoken a deeper perspective.  And it is this advanced degree, fraught with future obstacles and aspirations, that has been handled with much care, consultation, and, yes, consternation.  But then again, I also never thought I’d be called to duty (Operation Iraqi Freedom III) during graduate school.  So it is here, that my story has parallel processes, in so much that I seem to have been called to duty on another front.

But first, allow me to provide some context. 

My passion has always been to serve underserved, disenfranchised populations with significant health disparities; particularly Native American populations.  At my Alma Mater (the University of North Dakota; UND), the mission of the Indians into Psychology Doctoral Education (INPSYDE) program is to address the shortage of quality mental health services in Indian Country, promote/train more Native Psychologists, encourage that Native Psychologists serve Native Communities, and to address insufficient cross-cultural training in mainstream psychology. While both my UND and pre-doctoral internship at the University of New Mexico Health Sciences Center provided ample diversity and mentorship; it was my post-doctoral and inaugural year as a newly minted psychologist that brought me keenly aware of the healthcare gaps and shortages in rural America and vulnerable populations.

Later (2012), I happened to attend an Early Career Psychologist program at the APA Convention in D.C.  It was there that a chance encounter with former (2000) APA President Patrick DeLeon (Ph.D., MPH, JD) planted the seeds of RxP.    Dr. DeLeon (amongst others) argued that RxP in Indian Country was a valid venture for psychologists; as the quality and continuity of care was often in flux.  In many rural areas, Psychologists outnumber Psychiatrists 4 to 1; and most patients receive psychotropic medication from their Primary Care Provider, implemented during the course of (at most) a 15-minute encounter without non-pharmacological interventions.    

So from graduate neophyte to community mental health; I soon entered the world of Primary Care in 2010 (paradigm shift #1); transitioning from a Clinical to Clinical Health Psychologist.  It wasn’t long before I joined the National Register of Clinical Health Psychologists.  Then in 2012, I took home another change in identity as a psychologist; which you would imagine created much cognitive dissonance; this concept of the Medical and/or Prescribing Psychologist (paradigm shift #2). 

Thus, the decision to pursue RxP had not been considered lightly or haphazardly.  I moved through another stage of change only after considerable research, introspection, discussion with my superiors (both work related and spouse), and consultation with other respected Elders within the Society of Indian Psychologists and other Medical Psychologists.  Ambivalent colleagues or some opposition might well take note that a MSCP degree, at the least, expands one’s knowledge and scope of practice; allowing one to be a well suited consultant and champion of integrated care.  It was not long before I was able to review medical records, lab studies, and converse, with confidence, with other health professionals.  I also believe that my professional development served to influence my medical community; indirectly changing my Service Unit’s bylaws to promote Ph.D. Psychologists to active medical staff; with full voting privileges.

I would also highlight that my training has been both rigorous but rewarding.  NMSU offers a comprehensive program with more hands on training; however, Alliant International University California School of Professional Psychology (AIU CSPP) offers Indian Health Service employees a 50% tuition waiver APA (endowed by a Div 18 Benefactor) and the flexibility of distance learning.  As the Behavioral Health Director, and in clinical support of our local mission, I just could not travel abroad.  The AUI CSPP Clinical Psychopharmacology curriculum was intense; taught by subject matter experts with high expectations, who promote first line non-pharmacology interventions, ethics, and safety at all avenues.   By far, the most impressive instructor has been Dr. Randall Tackett.  Moreover, the knowledge and instruction of Louisiana’s first prescribing psychologist, Dr. John Bolter, cannot be discounted.  Dr. Bolter’s working knowledge of neuroanatomy and neurochemistry was intimidating.  There were also required courses on molecular nutrition and the ever prevalent concerns of dual diagnoses (Chemical Addictions/Dependency).  Finally, the didactic and case seminars alone are well worth the cost of tuition.

I have also begun practicums in pathophysiology, physical assessment, and supervised psychoeducation on basic psychotropic recommendations.  I think most of us can agree that graduate programs do not have the breadth and scope of training biological determinants of behavior; meaning there is likely a great deal of overdiagnosing common psychiatric conditions without fully reviewing medical records or consulting to ensure that “symptoms are not better accounted for the physiological effects of substances (i.e., clinical medicine; drug interactions) or another medical condition.”  Too long have we likely speculated and “referred out” due to a certified competence of the biopsychosocial model.

This fall or next spring I will persevere through the Psychopharmacology Examination for Psychologists; followed by my winter/spring intentions for LP reciprocity and applying for a Conditional RxP license in New Mexico. The rudders through this journey continue to be the support of my colleagues, guidance of my supervisors, the networking I have made in MPA and APA Div 55.  I would also be remiss if I did not mention the sage advice of Dr. Dan Foster and Dr. Michael Tilus.  Perhaps the world would be a better place if we could only all consider ourselves Public Servants.  If MN were to pass RxP legislation, I suspect that we would not see psychologists clamoring to pursue RxP; as it certainly is not for the weak of heart.  

Casey L. McDougall, Ph.D., L.P., is a Clinical Psychologist from the White Earth Nation (Minnesota; Mississippi Band of Chippewa).  In Nov. 2010, he accepted a psychologist position with the Red Lake Comprehensive Health Services (Red Lake Nation, Red Lake, MN); shortly thereafter accepting the Supervisory Clinical Psychologist position within Indian Health Service (Red Lake Service Unit).  He served on APA Division 45 (Cultural Diversity) Governance as the Program Chair (2011-2013) and currently serves as the Native American Member at Large.  He is also a member of APA Division 18 (Public Service) & 38 (Health Psychology).  

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Comments on "The Next Generation of RxP in MN"

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Harlan Gilbertson - Monday, August 15, 2016
1000676216

Dr. Sethre: I appreciate your desire to be objective and accurately represent concerns of critics regarding RxP privileges for psychologist. Unfortunately, and perhaps well-intentioned, your arguments are archaic and a disservice to RxP prescribers as well as more advanced board-certified medical psychologists. I have attempted to address the four items previously highlighted in your column. 1. Does a "distance learning" program provide adequate, and safe, training for RxP? I don't think so. Obviously, you have not reviewed the content of the educational programs for RxP as well as required proctored examinations. You failed to share that despite being a distance learning program, these degree programs now incorporate hands-on training to ensure basic medical competencies to monitor patients. For individuals such as myself, this included 10 additional postdoctoral (and post-MSCP) courses across nine months at New Mexico State University-Las Cruces in advanced pathophysiology and hands-on medical assessment. In essence, one day in the classroom and another at the local medical clinic assessing blood pressure, respiration rate, cardiac functioning, chest percussion, reflexes, cranial nerves etc. We were then required to successfully perform a complete medical and neurological examination. The clinician must then pass the American Psychological Association Psychopharmacology Exam for Psychologists (PEP). This is no easy task. For New Mexico licensure, the clinician must participate in a 400-hour supervised practicum for a minimum of six months with documentation of all services provided whether prescribing and/or ‘unprescribing’. Clinicians are also required to participate in two years of supervised prescribing prior to receiving full prescribing privileges. It is also mandatory for the RxP psychologist to have a written consent for release of information form for the patient’s primary medical provider. If the patient is unwilling, the psychologist does not prescribe. 2. Advocates for RxP typically claim RxP practitioners would be able to provide mental health prescriptions to underserved communities, particularly rural areas and impoverished communities. Is there any evidence that RxP advocate can provide that actually indicates RxP has improved access in underserved areas, such as rural areas? Once again, you have obviously chosen not to thoroughly investigate the parameters of services provided by RxP clinicians, but rather review the documented practice location of such clinicians. Had you taken the time to contact New Mexico prescribers you would have discovered there are currently approximately 40 prescribing clinicians and 18 conditional prescribing psychologists (as well as several military and IHS prescribers). Thirty of these clinicians work with underserved populations such as homeless, CMHC, SBD or in rural areas. Just because one does not practice in a rural area does not mean they are not providing services to underserved areas. All but one prescribing clinician in New Mexico takes Medicaid. While Medicare does not currently recognize RxP psychologists as prescribers, this is potentially going to change in the near future. If you truly want to appreciate the complex population served by these psychologists I would suggest you take the three-course series mandated for both clinical as well as prescribing psychologists in New Mexico (e.g. New Mexico Culture Part I & II, and New Mexico Health, Injury & Violence Mortality: Racial & Ethnic Health Disparities Report Card 2011). Perhaps then, you will have a greater appreciation of the clientele they serve on a daily basis. 3. As a health care psychologist who has worked in hospital systems for almost 30 years, I have never felt the need for RxP training in order to understand medical records. Why would RxP be needed for this? Given the fact RxP clinicians are expected to work in concert with medical clinicians it is imperative they are competent with understanding not only the medical chart but also various laboratory values and any needed tests necessary for competent prescribing and/or ‘unprescribing’ (especially given the frequency of concurrent medications for pathophysiological issues). As you are aware, many psychotropics are processed through the CYP450 hepatic system, and hence, knowledge of liver enzymes would be essential. Given the renal processing of lithium, a clinician would want to know the GFR & creatinine clearance, thyroid functioning, and lab work to assure therapeutic dosage and reduce toxicity risk. The protein albumin is essential to medication binding, and if not evaluated, could contribute to ineffective or toxic drug reactions. And the list goes on…. 4. Finally, how about some consideration of other ways that psychologist can help with the shortage of psychiatrists? Once again, while I appreciate your concerns, I was somewhat dismayed you would use the RxP platform as a means to direct others to your business website. Similarly, while you recurrently reference Psychologists Opposed to Psychologist Prescribing Privileges (POPPP), you failed to share with members-at-large that Iowa passed legislation for psychologists to prescribe on May 27, 2016. It is my understanding the aforementioned POPPP attempted to quash this legislation. However, legislators identified this as mere scare tactics and passed this bill. Finally, as a licensed psychologist in Minnesota and New Mexico, in addition to conditional prescribing in New Mexico, I am well aware of the pitfalls regarding psychologists wanting to pursue RxP privileges. This is obviously a delicate topic and could serve to fraction members of the MN Psychological Association. Given the current hurdles for psychology and the potential divisiveness created by this very sensitive topic, it would obviously be detrimental to ‘impose’ this enhanced privilege on a psychologist. Rather, it would be beneficial for other senior psychologists such as yourself to take the time to fully investigate this complex issue and use this knowledge to bring this privilege to the forefront for those of us willing to delve into, and manage the complexities of the biopsychosocial model. Harlan. Harlan J. Gilbertson, MS, PsyD, MSCP, LP has been a Licensed Psychologist in Minnesota since September of 1997; Licensed Psychologist in New Mexico since June of 2014; and New Mexico Conditional Prescribing Psychologist since December of 2015. Since 2000, he has provided statewide clinical and forensic psychological services through his RURAL private practice in Mora, MN.

Richard Sethre - Saturday, July 30, 2016
1000676435

Thanks to Dr. McDougal for his detailed and thoughtful article. He certainly has pursued an intense and challenging personal journey, including service to our country in the armed forces and serving a community with considerable medical, mental health, chemical health and social needs. I commend him for his service! Dr. McDougal advocates that Minnesota should join the very small group of states with RxP. Much of his argument is based on personal experience, personal passion, and consultation with RxP advocates. I would like to raise questions that I hope are objective and accurately represent the concerns of RxP critics: 1. Does a "distance learning" program provide adequate, and safe, training for RxP? I don't think so. 2. Advocates for RxP typically claim that RxP practioners would be able to provide mental health prescriptions to underserved communities, particularly rural areas and improvrished communities. According to reviews of licensing records in RxP states (there are currently only two with functioning RxP programs, Louisiana and New Mexico) done by members of Psychologists Opposed to Psychologist Prescribing Privileges (POPPP), most RxP providers practice in metro areas; in other words, adapting RxP has not led to a significant increase in access to mental health medications in underserved areas of those states. Is there any evidence that RxP advocate can provide that actually indicates that RxP has improved access in underserved areas, such as rural areas? 3. As a health care psychologist who has worked in hospital systems for almost 30 years, I have never felt the need for RxP training in order to understand medical records. Why would RxP be needed for this? If a psychologist wants to understand medical records and be an valued member of the health care system, wouldn't learning more about health care psychology work? 4. Finally, how about some consideration of other ways that psychologist can help with the shortage of psychiatrists? For example, see my recent blog posting: http://mhconcierge.com/three-progressive-suggestions-for-helping-with-the-shortage-of-psychiatrists/ If MPA is to consider, again, whether to support RxP in MN, it is imperative that we have an objective and informed discussion, with all viewpoints represented. Also, I suggest that it would be crucial for our members of the Governing Council to have a dialog with their own constituents about whether to support RxP. Ideally, if someone wants to support RxP they should run for Council, or even Pres of MPA, on that platform - which, a far as I know, has never occurred. Richard Sethre, Psy.D., L.P.

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