Medicine's Turf Wars
Specialists without M.D.'s are pushing for more medical power. Are they ready--and are you?
Power of the pad
The right to write prescriptions is the subject of another skirmish. The psychologists pushing for prescribing privileges in Tennessee and five other states will point to the gains they've made in New Mexico in 2002 and Louisiana last year, perhaps their best evidence and best way to assure doubters that they know what they are doing. In New Mexico, for example, psychologists have to take 450 hours of classes in psychopharmacology and other sciences, as well as log years of supervision and collaboration with physicians in order to prescribe. Advocates will also be holding up a Department of Defense experiment that followed the patients of 10 psychologists trained to prescribe medications, a demonstration that ran from 1991 to 1997 with program graduates going on to prescribe medications in conjunction with other kinds of therapy to active and retired members of the military and their families. The federal government and outside evaluators concluded the psychologists were indeed trained to provide safe pharmacological care. But psychiatrists argue about the results anyway. They say that the DOD training was more comprehensive than the training specified in legislation pushed in the states.
But Elaine LeVine, a Las Cruces psychologist, who helped persuade New Mexico's Legislature to give her colleagues prescribing privileges, says far from endangering her patients by writing them prescriptions, her patients will do better when she can choose their meds. She has no problems with psychiatrists--when enough of them are available for patients. It's physicians without mental health training but with a prescription pad who give her pause. While a patient may see his primary-care provider for only very short visits, she notes, psychologists' patients may spend an hour a week in therapy.
As the two professions debate the finer points, Carmen Catizone, who has seen a lot of prescription pads, chuckles. Catizone, executive director of the National Association of Boards of Pharmacy, has seen many professionals duke it out over nonphysician prescribing privilege, including his own group. Pharmacists used to only make and hand out medications but today have authority to vaccinate patients in 37 states and can prescribe "morning after" emergency contraception in California, New Mexico, Alaska, and a handful of other places. Pharmacist prescribing generally is authorized under collaborative agreements with physicians but also allows pharmacists to monitor patients' ongoing conditions.
In the late 1960s and 1970s, the prescription battle was waged between M.D.'s and doctors of osteopathy. Today, like M.D.'s, D.O.'s have unlimited, independent prescribing authority in every state. In the early 1980s, optometrists battled ophthalmologists for the privilege. Now, optometrists can prescribe at least some eye-related medications in every state. Physician assistants, a profession devised by physicians to work under their supervision, had a much easier time in the early 1990s obtaining the ability to write prescriptions under the auspices of M.D.'s. Nurse practitioners have gotten some level of prescribing privileges in most states. Such battles cool as few significant problems are found and as more states grant a particular profession prescribing privileges. Instead, organized medicine focuses on preventing professions just starting to seek prescribing authority from getting it.
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