Personal Involvement: "My experience as a prescribing psychologist has been shaped largely by a solid education in psychopharmacology, serendipity and blissful ignorance. Upon receiving my conditional prescribing license in New Mexico, I left for Washington State and a position with the Department of the Army. I had a job offer in Farmington, New Mexico that would have ensured that I could use my new skill set as a prescriber, but my wife and I wanted to move to the West Coast. The federal position in Washington provided no guarantee that I would be permitted to prescribe. It was my ignorance of how many outstanding prescribing psychologists had NOT been able to prescribe in the Department of Defense that led me to optimistically pursue RxP in an Army hospital. The year was 2008 and the United States was deep into the conflict in the Middle East. The Department of Psychology, at what would later become Joint Base Lewis-McChord, was in a hiring frenzy and it was unceremoniously determined that I would be embedded as a clinical psychologist in a large family medicine department. Being placed in primary care is one of the serendipitous parts of this story. I had never worked in primary care and had no idea how this placement would be ideal for me personally and as a prescribing psychologist.
"I won't belabor the story, but after combatting the standard opposition from the usual sources I was credentialed by the hospital. This only happened with great leadership from the chief of my service, a neuropsychologist, LTC Gary Southwell, and support from my family medicine colleagues who saw great added value in my ability to prescribe psychotropic medications. I was to learn later that getting the approval of the hospital credentialing committee was the hurdle that many deserving prescribing psychologists working in military hospitals were not able to surmount.
"I was now free to develop my practice in this new setting. Over time I developed a model of combining clinical and prescribing psychology practice that my colleagues and I later described in The Journal of Clinical Psychology in Medical Settings in 2012. I regularly complained to my RxP colleagues that we didn't have enough data demonstrating that we are safe, effective providers. So, in the same article I published the results of a confidential, anonymous survey of almost 50 primary care providers with whom I had worked for several years. In this survey I wanted to ask the primary care providers, who shared every patient with me, direct questions about how they perceived and experienced working with a prescribing psychologist. I have argued, and continue to argue, that there is no medical professional better able to assess the safety and efficacy of RxP than primary care providers. They are responsible for the total health of their patients and, while I find my primary care colleagues to be courteous and welcoming, they have virtually no tolerance for unsafe or ineffective treatment by other providers. As an aside, if you are ever lacking in excessive amounts of anxiety I recommend you ask 50 of your closest colleagues to anonymously rate your performance and skills. The results, it turned out, were overwhelmingly positive and I have been gratified that the ensuing article has been used as supporting documentation in numerous RxP legislative initiatives.
"Working as a prescribing psychologist for the past 10 years has been a great opportunity to make a positive difference in patients' lives. Being embedded in primary care has further expanded my knowledge base and afforded my patients with true collaboration between their behavioral health provider and medical providers. Patients appreciate the ease of being able to obtain therapy and medication with one provider. While many patients can have a positive experience working with separate professionals providing therapy and medication management, most of us have seen that system break down from time to time. Referrals for psychopharmacological management by a different provider can result in a variety of problems such as poor communication or disagreement about diagnosis and/or treatment plans, failure of patients to follow up with referrals for psychiatric care, long wait times for psychiatric management, etc. When providing both medication management and therapy there is no lag time in responsiveness to patient needs or changes with regards to medication or therapy.
"Little did I realize when I was embedded in primary care that this was an optimal situation for a prescribing psychologist. All prescribing psychologists are expected to collaborate on some level with the primary care provider of their patients. In my case, those primary care providers are literally no more than a few doors away. This has provided coordinated care on a level I had never considered possible. I have developed reciprocal relationships with the primary care providers in our department such that I am always learning something new about medical diagnoses and treatments as they pertain to my behavioral health patients. In turn, my primary care colleagues avail themselves of curbside consults with me on a regular basis with questions about psychopharmacology and/or clinical psychology.
"As a core faculty member of the family medicine residency at Madigan Army Medical Center (MAMC) I teach medical residents, manage the behavioral health curriculum and engage in research and professional presentations. It turns out that teaching psychopharmacology to prescribers and non-prescribers alike is one of my favorite professional activities. I have found there are few incentives more powerful for continued learning in one's chosen field than having to teach the topic to smart, well-educated people who have high expectations for accuracy and relevance.
"As I became more settled in my position at MAMC, I began to turn my attention to my local environment. The State of Washington has not been immune to the shortage of psychiatric providers that most of the nation is experiencing. Wait time are excessive, access can be bleak, and frequently providers in the community are in such demand that they do not accept low paying Medicare reimbursements, or at least limit the number of Medicare patients on their panels. Some of our counties have few or no psychiatrists and our rural and low-income patients don't have adequate access to high quality psychiatric care. Primary care providers and psychiatric nurse practitioners have tried to make-up for the deficit, but the need continues to grow. In response, I decided to become involved with my State psychological association. As a prescribing psychologist I knew that expanding psychologists' scope of practice to include prescribing psychotropic medication could be a safe and effective way to be part of the solution to poor access to psychiatric care. As a result, I partnered with the Washington State Psychological Association (WSPA) to build an RxP Taskforce of almost two dozen enthusiastic psychologists. We are now pursuing legislation that would allow appropriately trained psychologists to prescribe. The way forward looks to be challenging, but I am encouraged and hopeful that we will get a bill passed. However, if we don't succeed in our first attempt, I believe we can plant seeds for the future that will benefit our patients. If that is the case then we can take refuge in Nelson Henderson's proclamation that 'The true meaning of life is to plant trees, under whose shade you do not expect to sit'" (David Shearer, Clinical and Prescribing Psychologist).
A Data-Based Approach: One of the most intriguing thoughts that comes to mind when involved in the public policy process is the extent to which those colleagues in academia and clinical practice and those on the Hill (including at the State level) seem to live in two distinct worlds, with their own unique languages and sense of timing. In 2014 the Institute of Medicine (IOM) (now the National Academy of Medicine) convened a workshop entitled "Considerations in Applying Benefit-Cost Analysis to Preventive Interventions for Children, Youth, and Families." Kimber Bogard (Senior Vice President for Strategy and Programs at the New York Academy of Medicine and previously Director of the Board on Children, Youth, and Families at the IOM) served as one of the rapporteurs.
All would agree that benefit-cost analysis holds great promise for influencing policies related to these populations. By comparing the costs with the long-term benefits, this approach could provide an important tool for determining what kinds of investments have the greatest potential to reduce the physical, mental, and behavioral health problems of young people. However, its utility has been limited by a lack of uniformity in the methods and assumptions underlying various studies. For example, researchers use a variety of techniques to calculate the costs of a program and the benefits it produces. For years, those who perform and those who use benefit-cost analyses have argued that the development and use of theoretical, technical, and reporting standards would enhance the validity of results, increase comparability across studies, and accelerate the progress of the field. Perhaps the establishment of national clearinghouses for the dissemination of the results of findings would be appropriate.
In my view, one of the most impressive presentations was by the Washington State Institute for Public Policy which was created in 1983 by the State's legislature to carry out practical, nonpartisan research at the direction of the legislature or the Institute's Board of Directors. Over the years, the Institute has explored a range of topics including crime, education and early education, child abuse and neglect, substance abuse, mental health, health care, and housing among others. It employs a three-step process to determine benefits and costs. First, it examines what works to improve outcomes and what does not work – not limiting itself to the State of Washington. Second, what is the return on investment by computing the benefits, costs, and risks to the people of Washington? And third, it uses this information to help form budgets by exploring how a combination of options would affect statewide outcomes. It tries to present these in a Consumer Reports style, so the results look the same for a legislator working on K-12 education and for a legislator working on the juvenile justice system.
Their Lessons Learned include: * the results of benefits-analyses need to compare apples to apples, not apples to oranges. Legislators are routinely provided with various options to consider. * Results have to be understandable by all 147 members of the legislature – or at least by the Committee Chairs, the Majority Leader, and the Ranking Members. * Results are calculated on an annual cash flow basis from three perspectives: that of taxpayers, that of participants in the program; and that of others who are affected by the program, such as victims of crimes. * The effect size of a program is important, but so is the risk associated with that estimate and its uncertainty. * Local conditions vary and thus the results of benefit-cost analysis will also. * Greater use of longitudinal research is sought. * And, one should borrow the best current thinking on the valuation of outcomes. Work needs to be adapted to local circumstances, rather than necessarily redone. When, for example, the Institute demonstrated that by investing in a portfolio of evidence-based crime prevention programs the State legislature could reduce crime rates, avoid the need to construct a new prison, and save taxpayers $2 billion, this resulted in the enactment of relevant legislation. As former APA President Alan Kazdin has consistently argued, relying excessively upon randomized controlled experiments and reporting only statistically significant findings can prevent real benefits from occurring. Further, serendipitous secondary findings can lead to new research avenues that in the long-run significantly advance the field.
Honoring Those Who Serve: Jennifer Kelly served on the APA Board of Directors for nine years, including two terms as Recording Secretary. "I had the opportunity to attend the VA Psychology Leadership Conference, held in San Antonio, Texas on May 28-31. The theme of the conference was: 'Promoting Quality, Integrated Healthcare for All Veterans.' The meeting began with a dinner to celebrate the retirement of Russell Lemle. Dr. Lemle, a pioneer and principle organizer of the conference, was the Chief Psychologist at the San Francisco VA Medical Center and Clinical Professor in the Department of Psychiatry, UCSF. In addition to honoring the life and legacy of Dr. Lemle, the dinner was a history lesson about the conference. During the evening I learned how the VA is the largest employer of psychologists. As the conference progressed, I also learned how the VA is managing difficult issues such as the suicide rate among our nation's Veterans, the opioid crisis, Integrated Care or Whole Health Transformation, and Women in Leadership. I left the conference with the feeling that the VA is working hard to ensure that the care of our Veterans is in good hands. This is yet another aspect of our profession that is making a difference in people's lives." "You have to spend it to make a difference." [Kamala Harris]. Aloha,
Pat DeLeon, former APA President – Division 42 – August, 2019
Sent from my iPhone
