Abstract
Robiner, et al's thesis is a "Cassandra argument," one that has been used by physician advocacy groups for decades in trying to push back the ever-increasing number of non-physician health care providers (NPHCPs). In contrast we put forth the view that no one really knows what kind of training produces a safe and effective prescriber of psychotropics. Medical education does not, as demonstrated by physician outcomes in general and in the prescription of psychotropics. Non- medical training appears to do no worse than medical training, and may in fact do better, as indicated by data bearing on outcomes with NPHCPs and with the Department of Defense Psychopharmacology Demonstration Project.

KEY WORDS:

Non-Physician Health Care Providers
Patient Safety
Physician Training
Prescribing psychologists
Psychopharmacology demonstration Project

Of Cassandras and Canards
     The fundamental thesis advanced by Dr. Robiner and his 6 colleagues is that psychologists cannot be appropriately trained to safely incorporate psychotropic drugs into therapeutic regimens. Their argument is founded on three basic assumptions: a) Psychologists' training does not adequately prepare them to take a curriculum leading to prescriptive authority; b) Only highly skilled medical professionals can safely use psychotropic drugs, and therefore: c) If psychologists are to prescribe safely and effectively, they must succumb to the blandishments of the medical model in order to do so, and if they do not they will affirmatively bring harm to their patients.

     We respectfully submit that, while all of these assumptions have previously been employed in arguments against psychologists prescribing, they remain without significant merit and contribute little to the ultimate question of how to appropriately train psychologists in this area. It is a facile but pointless exercise to argue worst-case scenarios in the absence of compelling data that such scenarios are likely to come to pass (for this reason, we have labeled this line of thinking the "Cassandra" argument). Regrettably, this is the tack that Robiner et al. have elected to pursue. Readers must understand clearly that Robiner et al. have adopted the same argument that physician advocacy groups have used for decades in their heretofore vain attempts to stanch the ever-increasing numbers of non-physician health care providers (NPHCPs): i.e., absent a medical education, the expansion of scope of practice of non-physicians poses a direct hazard to patient well being. Yet the ranks of NPHCPs continue to expand, with no apparent detriment to the health care seeking public. We suggest that the Cassandra argument, although not without some seductive qualities, basically misses the point.

     We believe that the following statement is true: No one really knows what kind of training produces a safe and effective prescriber of psychotropics. We know, by virtue of the Institute of Medicine (1999) study cited by Robiner et al, that a medical education likely does not. We also are reasonably confident (see below) that non-medical training at the very least appears to do no worse than physicians' training. But as to what exactly does, we don't know. We suspect, however, that (at least in the case of prescribing psychologists) it involves the following:

• Abandoning the notion that mental disorders are purely disorders of the brain, but rather are multifactorial, with environmental, personal, and biological antecedents.
• Abandoning the belief that psychotropics are the mainstay of treatment for the vast majority of mental disorders, a belief apparent in both psychiatrists' practices (West, Zarin, & Pincus, 1997) and pharmacoepidemiological studies (Zuvekas, 2001) documenting an astonishing increase in the rate of prescription of psychotropics.
• Refuting standards of care for mental disorders that are based on the medical model (e.g., for depression, 3 visits in 3 months; Simon, von Korff, Rutter, & Peterson, 2001)
• Embracing the notion that in order to safely prescribe psychotropic drugs, one must be informed of other physical processes, but that one need not have the ability to treat them.

     We believe that all models proposed to date for postdoctoral training in clinical psychopharmacology incorporate the above into their guiding schemae. On the basis of those curriculae that we are familiar with, it is clear that psychologists will be trained to a high degree of knowledge regarding psychotropic agents. These programs will also impart pertinent fundamentals of biological science and clinical health care, and emphasize appropriate standards for the use of medication in the management of mental distress. Space does not permit a detailed dissection of these programs, but all conform to, and usually exceed, the APA's minimum recommendation of 300 contact hours of didactic work in neurosciences, anatomy, physiology, and biochemistry, pharmacology and clinical pharmacology, and physical and laboratory assessment. Readers should understand that the requirements in pharmacology alone greatly exceed that in standard medical curriculae. A medical school course in pharmacology and clinical pharmacology generally does not exceed much more than 100 contact hours, of which perhaps no more than 10-15 are likely to be in psychopharmacology. This is all the classroom training in psychopharmacology any American physician is likely to receive in their entire medical education.

     As we have noted, one of the central arguments Robiner et al have employed is that the training of psychologists must mimic that of physicians in order for them to prescribe safely. Once again, some necessary suppositions must stand before this argument succeeds. These are: a) that the provision of psychotropics by psychologists represents the practice of medicine; b) that the training of physicians is adequate for effective provision of psychotropics, and c) that NPHCPs have been, due to lack of sufficient training, unable to attain the same standards of practice that physicians demonstrate (i.e., the patient safety argument, to which we now turn).

          The Dog in the Night-Time

          Inspector Gregory: "Is there any point to which you would wish to draw my attention?"

          Holmes: "To the curious incident of the dog in the night-time."

          Inspector Gregory: "The dog did nothing in the night-time."

          Holmes: "That was the curious incident."

A. Conan Doyle, Silver Blaze

     Regarding patient safety, it must be acknowledged that there are relatively few systematic studies of patient outcome with NPHCPs. Those that have been completed have demonstrated outcomes that were equivalent to, or better than, those of physicians. In briefly researching this question, we were unable to locate any objective reference documenting that the practice of NPHCPs was in any way less satisfactory than that of physicians (Catlin & McAuliffe, 1999; Cooper, Henderson, & Dietrich, 1998; Cooper, 2001; Durie, Roland, Roberts, & Leese, 2000; Mundinger, et al., 2000; Rudy, et al., 1998; Wallace et al., 1999). Indeed, it is far more common to find evidence that the addition of non-physician practitioners to a treatment team enhances patient satisfaction and outcome (Gattis, Hasselblad, Whellan, & O'Connor, 1999; Leape, et al., 1999; Schmidt, et al., 1998).

     Finally, several reports exist to demonstrate that, rather than extensive pre-requisite training, the addition of easily used technology (computerized prescribing and electronic records; Armstrong & Chrischilles, 2000; Hunt, Haynes, Hanna, & Smith, 1998) or other on-site interventions (Gonzales, Steiner, Lum, & Barrett, 1999) are effective in reducing physician error.

     The experience of the PDP fellows, as Robiner et al., acknowledge, has also demonstrated that those practitioners, (even those who completed the two year vs. the three year curriculum) do not compromise patient safety - and all of the PDP graduates have been practicing in an unsupervised manner for a number of years now. We also have historical data from earlier psychopharmacology demonstration projects that clearly indicate that NPHCPs, even those without baccalaureate degrees, and despite the fact that they were practicing with drugs (tricyclics, phenothiazines) that were far more toxic than agents in common use today, did not compromise patient safety, and, with an absolute minimum of training (weekly seminars and rounds) engaged in practice patterns that were identical to those of their physician trainers (Platman, Dorgan, & Gerhardt, 1976a, 1976b).

     Thus, data affirming suboptimal outcomes are absent in both the specific case (there has been no systematic scrutiny of the outcomes of psychologist prescribers, albeit considerable observational and anecdotal data and copious data collected during their training) and in the general case (though there are admittedly few large-scale, well-designed analyses of the practice outcomes of NPHCPs). We therefore believe it is appropriate to argue that the very absence of data suggests that these groups practice safely and effectively - if they did not, the outcry from physician interest groups and patient safety groups would be deafening. The fact that the dog has not barked suggests that the patient safety argument is a specious one.

     We next must turn to the question of whether the training of physicians is sufficient to allow medical practitioners to prescribe safely and effectively. Here the evidence is uncertain at best, as the Institute of Medicine (1999) report cited by Robiner, et al., suggests with its findings of high rates of iatrogenic morbidity and mortality, often associated with inappropriate prescribing and has been further documented in other large-scale analyses of the quality of health care provision in the US (Agency for Healthcare Research and Quality, 2001; Committee on Quality of Healthcare in America, 2001) . More compelling for our purposes is a recent large scale survey of patients who had been prescribed antidepressant medication and the primary care physicians who had prescribed the medication. Patient surveys revealed that the vast majority of patients taking antidepressants achieved suboptimal results, very frequently discontinued their medications, and did not feel adequately informed by their physicians about the medications and their side effects. On the other hand, a majority of physicians felt confident that they had appropriately described the medications and possible adverse effects to the patients. (National Depressive and Manic Depressive Association, 2000). Other recent studies pointing to suboptimal prescribing patterns among physicians indicate that physicians were generally unaware of the costs of the drugs they prescribed - in one case, that over 1/3 of the physicians surveyed did not know that Medicare would not cover the cost of prescription drugs (Reichert, Simon, and Halm, 2000). But suboptimal prescribing is different than suboptimal training (although we would argue that the proof is pretty much in the pudding here), so let us briefly examine this latter issue.

     Critics of psychologist prescribing often point to the lack of a strong prerequisite background in biological sciences as an impediment to effective post-doctoral training. But is a strong biological sciences background necessary for psychologists to safely prescribe? Again, the data are not convincing. Certainly it was a common argument by psychiatrists that four years of premedical education, four years of medical school, and a psychiatric residency were necessary for the safe prescription of psychotropics. This argument was effectively squelched when it was pointed out that the vast majority of psychotropics are prescribed by non-psychiatrically trained physicians (Zimmerman & Wienckowski, 1991).

Data suggesting that extensive prerequisite training in biological sciences is unnecessary for safe practice comes from an analysis of scores on medical board examinations comparing scores of medical students with science and non-science backgrounds (Koenig, 1994). There were no significant differences in scores between science and non-science majors in clinical areas such as internal medicine, surgery, and psychiatry, nor were there significant differences in total scores between the two groups.

     It should also be recalled that among the generation of psychiatrists who ushered in the modern psychopharmacological era, were so-called "90 day wonders". In the aftermath of WWII, when the demand for mental health services among returning veterans was high, general physicians completed 3 month residencies in psychiatry in order to meet this demand - and many of these 90 day wonders later became leaders of their profession (Scully, 1995), and evidently "safe" (at least by prevailing standards) prescribers of psychotropics.

     More recently, the field of psychiatry has come to be dominated by international medical graduates, many of whom lack standard American prerequisites for entry into medical school, and many of whose medical schools' curriculae are far less rigorous and systematic than those of their American trained counterparts. In general, only around half of all first year residency slots in psychiatry are filled by graduates of US medical schools. In 1998, 54% were so filled (Weissman, 1998), in 2000, 52%, and 2001, 56% of first year psychiatry residency slots under the matching program were filled by US seniors (Lostumbo & Beran, 2000, 2001). The remainder were filled by American graduates of foreign medical schools, graduates of osteopathic programs, and international medical graduates. As Weissman pointed out, results of the yearly match underestimate the number of international medical graduates in psychiatry, in 1998 approximately 300 international medical graduates obtained psychiatry residencies outside the match. Because of questions concerning the quality of psychiatric residency training and of the qualifications of many applicants (most US applicants to psychiatry residency programs come from the bottom quarter of their classes and most international medical graduates achieve low pass rates on their medical boards), some eminent psychiatrists have recommended that, at the present time, medical students not seek residencies in psychiatry (Rapoport, J., personal communication, as cited in Hobson & Leonard, 2001).

     Whether the practice standards of these psychiatrists differs from that of American trained psychiatrists is the subject of some controversy. One thing is certain: the addition of these physicians to the health care workforce via the J1 visa and other programs, which was advocated on the basis that they would augment scarce resources, has not ameliorated the scarcity of psychiatric services in rural and other underserved areas.

     Opponents of psychologists prescribing often raise the curious argument that psychologists will lose their core identity and begin to behave like physicians (cf., Adams & Bieliauskas, 1994). But psychologists who seek to prescribe argue that their practice will be fundamentally different than that of medically trained prescribers, and more reflective of a truly psychological model of mental health service provision. This school believes that, by virtue of their dramatically different orientation to the treatment of mental disorders, psychologists will incorporate medications into a comprehensive range of behavioral interventions and never neglect the latter for the convenience of the former. The limited experience of the PDP graduates to date suggests that indeed this is the case, and they maintain their fundamental identity as psychologists, have not succumbed to the medical/psychiatric model, and have not devolved into pill-dispensing automatons. So herein lies a paradox. Prescribing psychologists, it seems, do maintain their fundamental identities, but some anti-prescribing psychologists, by resurrecting and apparently endorsing the hoary arguments used for decades by the medical profession to stifle the practice of NPHCPs, behave more and more like the physicians they accuse prescribers of wanting to become.

     One of us recently published data indicating that support for prescription privileges has grown within the profession, to the point that approximately 2/3rds of psychologists surveyed endorse the notion (Sammons, Gorny, Allen, & Zinner, 2000). We also observed that the percentage of psychologists opposed to prescriptive authority remained relatively stable over time, at approximately 25% of all survey participants. While passionately defending the right of others to endorse opposing views, we would suggest again that these data indicate a consensus has been reached by the profession, and that unanimity is not required to move forward. At the same time, we would humbly submit that if Dr Robiner and his colleagues are truly concerned about the ability of psychologists to safely and effectively prescribe, they redirect their considerable energy and evident expertise towards collaborating in the development of sound, university based training programs that enable psychologists to accomplish this goal.

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