Patient-Safety Concerns Don't Delay Implementation of Prescribing Law

Louisiana regulators heard one more round of comments on the state's new law governing prescribing privileges for psychologists in November and expect to implement rules governing prescriptive authority soon.

“The rule should become final on January 20, barring any unforeseen problems,” said Brenda C. Ward, executive director of the Louisiana State Board of Examiners of Psychologists.

Representatives of APA and other medical groups again registered objections to the draft regulations at the hearing, while officials of the Louisiana Psychological and American Psychological associations offered their support. However, the board made no substantive changes to the draft.

David Edward Post, M.D., a Baton Rouge psychiatrist and president of the Louisiana Psychiatric Medical Association, acknowledged the duty of the psychology examiners board to implement the new law, but also said that proposed regulations “fail to protect patients, fail to establish adequate training requirements, and do not address access-to-care issues.”

Patient safety could be compromised because the proposed rules do not require prescribing psychologists to have any contact with a physician during training or to undergo any medically supervised clinical experience with patients, he said.

The proposed rules demand “successful graduation with a postdoctoral master's degree in clinical psychopharmacology” or the equivalent, including instruction in anatomy and physiology, biochemistry, neurosciences, pharmacology, psychopharmacology, clinical medicine/pathophysiology, and health assessment, including relevant physical and laboratory assessment. No supervised practicum is required, according to Paula Johnson, deputy director for state affairs in the APA Department of Government Relations.

The California School of Professional Psychology, a division of Alliant International University in San Francisco, already offers one such training program in Baton Rouge in cooperation with the Louisiana Psychological Association. The two-year program is held on weekends, costs $9,500, and claims 195 graduates as of 2004. Such bare-bones instruction and a lack of clinical experience concern Post and other physicians.

“It's hard enough to be a psychiatrist and do a good job with medications,” said Jeanne Estes, M.D., a psychiatrist and president-elect of the East Baton Rouge Parish Medical Society. “The psychologists think they can waltz in after two years of part-time training and know what we learned in medical school.”

Post also expressed concern regarding special populations.“ Psychologists should not be allowed to prescribe to children and the elderly, who have physiologic and pathophysiologic differences well beyond the scope of the training,” he said. He also raised concern about patients with mental disorders and comorbid conditions like diabetes and cardiovascular disease.

The draft rules also contain no provisions to provide more access to care for underserved populations by inducing or requiring prescribing psychologists to serve in rural or inner-city communities, he added. Access was a prime argument proffered by psychologists in favor of prescribing.

Even the phrase designating psychologists licensed to prescribe medications for the management of “mental and emotional disorders” came under fire. The term “medical psychologist” prompted objections from the Louisiana Council of Child and Adolescent Psychiatry, arguing that patients might confuse “M.P.s” with “M.D.s.”

The Louisiana law also lacks a provision requiring prescribing psychologists to carry malpractice insurance, raising the possibility of higher malpractice liability premiums for physicians working with medical psychologists, said Estes.

The lack of medical expertise among members of the psychology board troubled Post, as well. No recognized medical organizations—such as the state medical society or a medical school—will have any role in overseeing practitioners covered by the new law, he said. This has drawn opposition by other medical organizations as well.

“We believe that the present rules do not provide adequately for the safety and protection of patients,” said Vincent Culotta Jr., M.D., an obstetrician/gynecologist and spokesperson for the Louisiana State Medical Society, in an interview. “There's no real definition of `consultation' with physicians, and if that is not adequate, then patients may not get the best medications or may have problems with drug-drug interactions.”

“We hope that there will be no problems, but we remain very concerned,” he added.

The psychology board took note of the written and oral comments, but largely dismissed objections, saying that it lacked any authority to change the statute. The board said it “welcomes the new challenge of regulating medical psychologists and believes the proposed rules will assist the board in carrying out its mandate.”

APA will look at the final regulations to see whether they conform to the law, said APA's Johnson. Major discrepancies between the final rule and the statute may provide an opportunity for further challenges. ▪