Let alone for a moment the question of whether or not, as I contend, the prescriber therapist is the sina qua non, the vital profession, if we are to integrate and advance our knowledge of the mind and the brain, of the combination of applied neuro-plasticity and psycho-pharmacology, if we are to meet the needs of evolving humanity. Let’s just assume we wanted to create at least some new outpatient prescriber-therapists, for whatever reason; to not allow the profession to simply die away. Lord knows as it stands today precious few psychiatric residents have any intention of being outpatient prescriber-therapists.
If we want more how can we do it? Is it even possible? How long would it take?
The best answer seems to me to be three-fold, involving short-term (2-4 years) middle term (5-8 years), and longer term (a decade or more) plans that could create the required corps of 50,000 prescriber therapists within a generation. And it might essentially be free, requiring only minimal start up money, pumped into universities’ hospitals and medical schools to create educational programs, broad internship programs that connect re-training professionals with vulnerable populations in special low fee settings spread ubiquitously throughout our communities, and the redrafting of the laws around professional boundaries and licensing requirements.
Oh really?
Phase I (2-4 years): Grandfathering Seasoned Therapists as Prescribers
In this initial phase, 50 of the nation’s largest university centers should be given grants to create 18-month to 2-year programs to allow senior therapists to prescribe, at first under the supervision and guidance of the experienced prescriber therapists that will be training them, and then ultimately independently.
There are over 90, 000 psychologists in America, many have been working with medicated patients for years. They are a vast untapped resource, their current business model of long term weekly therapy is economically unsustainable and under siege. It will be infinitely easier to train psychologists and Ph.D.s or very experienced social workers to prescribe properly than it will be to train general practitioners to diagnose and prescribe properly themselves, forget making them offer the initial essential adjunctive psychotherapy.
This effort would be the lowest of low tech, no fancy expensive machine, no materials, no buildings. Any space in which two people can talk and write notes to pharmacists will do. The only cost is personnel. Our university system, the crown jewel of American culture, is what makes us what we are, it’s what makes us the envy of the world. Let’s put our money here for once, instead of on bombs and airplanes and reading each others’ emails.
Of course there will be lots of objections to this from institutional psychiatry; but they are self serving and hollow. They don’t want the job, residents are simply not choosing to become therapists and they can’t get Americans to fill even half the training slots they already have. They hide behind issues of safety and training (really, power and money), but they’re just protecting land (turf) they no longer have the personnel to farm.
But I’ll ask you this. If we challenge Harvard and Yale, and Stanford and Duke, U of T and T.U, the University of Michigan and Ole Miss, Wisconsin and the University of Arizona to quickly and safely turn our senior therapists into prescriber-therapists, say 50 per year per center, that’s 2,500 new prescriber-therapists per year, and we throw them some pocket change to get started, (say one day of what it cost to pursue the two fruitless senseless Bush Wars) given to each of 50 major university centers, do you think they couldn’t do it?
Don’t you think they should?
Imagine with me for a few moments, if you will, the first of a fair number of probably unachievable social engineering fantasies. It could cost so little.
Let’s say we choose 15 experienced prescriber-therapists for each program, and arrange to utilize 25% of their time, say ten hours per week, in which to both teach in lecture settings (a little) and supervise four experienced therapists becoming prescribers. Each student/therapist offers 25% of their time to see patients in their mentor’s practice. Patients are on some medicare or medicaid or the VA. The mentor/student prescriber-therapist accepts a reduced fee from the government (say 60 per cent of usual), and the pair at first splits the fee.
The mentor, if this works right, should receive 120% of the income he would have received seeing patients instead of supervising and teaching. The experienced therapist works at first for only a third of his usual fee, but only ¼ time, and their education is free. As a three- or four-year training period progresses the government fees gradually return to normal, and the percentage to the mentor decreases gradually each year, as he takes newer students.
Ultimately I believe every prescriber-therapist should have a more experienced supervisor to whom he tithes 5% of his income, and this supervisory relationship should be transparent to everyone, and every single patient should have the right to walk into their prescriber therapist’s supervisor’s office to discuss their treatment any time they like. (Further extended utopian fantasies on this point to follow).
This shouldn’t be hard. Prescribing isn’t rocket science. There are five major classes of drugs, and a few dozen outside of that used frequently. It’s all pattern recognition. With a little seed money (while the practices of the students build) and some determination and vision we could be popping out the needed folks at 2,500 per year within five years, assuming we don’t run out of experienced therapists who want the job.
Phase II (5-8 years): Accelerated Sub-Specialty Nurse Practitioner Programs
We talked about turning our therapists into prescribers. Nursing schools are now the only profession producing new prescriber-therapists, not too many, mind you, and they are not training them as I wish they would.
First off, there are now about 110,000 NP’s, about 90% in primary care setting, and most of those prescribing in the same manner that their (supervising) slightly better paid medical primary care colleagues do. Only 3% of NP’s are psychiatric NP’s, about 3,000 prescriber therapists (they average 9 years experience, average age 54). I tried to find out how many training slots exist; my search engines fail me. Can’t be more than a couple-three hundred, if that.
I think it makes sense to admit that a psychiatric nurse practitioner who chooses at the outset of nursing school to an become outpatient prescriber therapist might best be trained differently from a pleuri-potential nursing student who may wind up as a floor nurse, or an OR nurse, or a nurse anesthetist, a nurse midwife or a primary care NP.
We might rethink a nursing curriculum to include psychology courses, and training in meditation and hypnosis, and rotations and in individual and group therapy in settings where they will be working in, as opposed to hospitals where they won’t or at least shouldn’t.
Ultimately I envision a fluid system where certification as a psych NP will be open to any nurse at any stage, provided they take whatever coursework and training is deemed necessary. The training and certification should be most rapid when started at the beginning of what should be a 5-6 year program, but credit should be given somehow for nurses at other stages to catch up and transfer over Again I believe this could be done very cheaply, by using existing practitioners as supervisors and paying then with the care provided economically by their supervisees. As I see this, both the therapists and the NP who receive this (largely free) education make an extended commitment to continue to practice in their training site for an extended period, say ten years total, with significant financial incentives to stay put afterwards.
Phase III (Long term): The Redesign of Psychiatry and the Creation of a New Profession
We have dental school. We have podiatry school. How about an outpatient brain doctor school?
Once again, I think the basic idea to accept is that if we are willing to start at the beginning, with 18 year olds who have a sense of calling, and we want them to be talented prescriber-therapists with long careers, we could easily design a much more efficient and effective way to train them.
To get into medical school we ask premed students to spend about one year taking physics, chemistry and calculus. Completely useless to the prescriber therapist. They really don’t care at all what else you study. In medical school the first two years are in the classroom, at least a third or more is again just not germane to a prescriber therapist.
It takes 12 years to make a psychiatrist, college med school and residency, that’s with no delays, and yet by the time they are finished they mostly don’t know much or care much about psychotherapy, if they believe in it an all, and they certainly have no intention of doing it.
How about a different track altogether: philosophy, psychology, sociology, group therapy, psychodrama, religion, and clinic work early on, 20 year olds binding with kids they’ll take care of for the next 8 years, as they progress through their training. Again cadres of low-fee therapists.
No need to eliminate traditional psychiatry. Imagine two parallel tracks, with easy packages provided to move from one track to the other at the growing practitioner’s wish, traditional psychiatry located in hospitals, running institutions, the traditional medical school curriculum, and a second track running alongside with a different curriculum, all neuroscience and interpersonal relatedness. Much less equipment, much less expense, in the second track, no cadavers, just classes and supervised therapy, pretty much paying for themselves.
Remember please, above all, that over and over and over it has been shown that even small amounts of psychiatric care applied consistently over time routinely pays for itself, many times over, in decreased general health care costs.
If we can recognize how cost-effective enlightened mental health care can be then to me it stands to reason we should invest in creating the most skilled broadly trained cadre of mental health prescriber-therapists we can.
This is of course the hardest of hard sells, a pipe dream from The Attention Doctor. All three of the notions above are radical and unlikely in the extreme.
Has it been 100 years since osteopathic medicine was born? Could something like that happen today?
It would require a movement:
The prescriber-therapist movement.
Care to join?