01 Apr Legislating the Right to Practice Medicine
A brilliant physician recently wrote this letter to educate legislators. We can all learn from her words, whether a physician, legislator, or patient. She has graciously agreed to allow us to reprint her letter:
SUBJECT: GIVING TALK THERAPISTS THE RIGHT TO PRACTICE MEDICINE BY THE VOTES OF LAWMAKERS (and skipping medical school and residency in the process)
I am a physician who specializes in psychiatry, and am I writing you regarding [legislation you are considering in Connecticut, SB 966 AAC]. I am not a Connecticut resident, and I have no economic advantage or disadvantage from this bill passing or failing. I do feel it is within my jurisdiction as a physician to express my concerns, given that my DEA license is Federally issued. Also, the rigorous standards for becoming a physician in the US, including our four-part USMLE licensing exams, are exactly the same for all physicians in every state. In addition, my specialty certification is from the American Board of Psychiatry & Neurology, a national medical board. The practice of medicine is highly standardized nationally. This recent advent of state-by-state divvying up medical powers to the highest bidding lobby by legislatures is new and, frankly, unethical.
It is a disservice to patients who are having lawmakers decide who gets to play doctor in the place of a real doctor. A similar parallel would be if physicians proposed a bill to allow paralegals the right to ‘trial privileges’ due to the large number of cases held up in DA offices around the country.
The greatest evidence of this ‘medicine up for sale’ is the language of this bill which suggests that “prescribing” is a separate privilege than the practice of medicine. It may be useful for the constituents to know that there is no carve out in medicine for the act of ‘prescribing’. Medical schools do not offer a separate ‘prescribing’ class at night or online that allows students to skip the other 3.5 years of rigorous schooling and the four years of tireless residency at 80 hr/week. Prescribing medications is a complex, high-risk treatment modality that is embedded within the practice of medicine. And psychiatrists are medical doctors who have completed that training.
What is most concerning is that the public, whether they are patients in Connecticut or California, are having the wool pulled over their eyes so that insurance companies can once again get away with not meeting Mental Health Parity laws. Yes, “Psychiatrist” and “Psychologist” sound similar. But, I am quite certain that the constituents of Connecticut are smart enough to know that psychiatrists are medical doctors, and that psychologists have no medical training, rather, they are talk therapists.
Americans deserve more, especially those with mental illness. Suicide is the 2nd leading cause of death for teenagers and the 11th leading cause of death overall. The life expectancy in the US dropped for the first time since WWII, despite a historic low in tobacco use and 2.2% drop in cancer deaths. The reason? Suicides and overdoses. Psychiatry is not about happy pills. It is about life and death, just as much as cardiology is about life and death.
Speaking of happy pills, [psychiatric medications] are some of the most dangerous medications we have on the market. While the American Psychological Association lobby will have legislators convinced that these are as easy to prescribe as skittles, most psychotropic medications have an FDA black box warning on them. [The FDA black box warning is the strictest labeling requirement that the FDA can mandate for prescription drugs. First implemented in 1979, black box warnings highlight serious and sometimes life-threatening adverse drug reactions within the labeling of prescription drug products.]
The brain it seems, is actually connected to the other organs–like the heart, the kidneys, the liver, the the thyroid. About 90% of what a psychiatrist does is rule out an organic cause of psychiatric illness, such as a malignancy, thyroid disease, temporal lobe epilepsy, dementia, paraneoplastic syndrome, or anticholinergic side effects from other medications before even assigning a psychiatric diagnosis. It is extremely complicated to diagnose and utilize psychotropic medications safely in a population who is already at risk. Those with mental illness have a lower life expectancy at baseline by as many as 10-15 years.
And that is why one has to be a medical doctor to practice medicine in the field of psychiatry.
Why on earth would we think it would be safe to replace 8 years of medical training with even one year of a pharmacology class? Is it because these are mentally ill patients? Would we do this with cardiac patients? To address a shortage–perhaps give the echocardiogram techs ‘prescribing privileges’? Why should this be different given the mortality of mental illness?
Further, if one really wants to increase access to physicians–one needs to look to Congress to expand residency positions, as they hold the purse strings. Increase infrastructure and reimbursement for telepsychiatry, which is an effective modality that doesn’t require expanding the scope of talk therapists.
Perhaps most important is the ability to [establish] true informed consent with a patient—a critical component of good care–especially when prescribing psychotropic medications to the mentally ill. If someone is prescribing medications with enough risk to summon a black box warning from the FDA, they should be able to address all the issues raised (risk of teratogens, Steven Johnson Syndrome, SIADH, nephrotoxicity, hepatotoxicity, 2D6 interactions including those with Tamoxifen, neurotoxicity, prolonged QTc interval and Torsades de pointes, tardive dyskinesia vs EPS vs akathisia, vs an acute dystonic reaction such as laryngomalacia, and metabolic syndrome–DM2, HTN, and hyperlipidemia). Without the foundation of medical knowledge gained in medical school and residency one cannot claim to have established informed consent.
There are only shortcuts to acting like a physician. Americans, including those in Connecticut, deserve real physicians, not those acting the part. Psychologists are critical members of mental health teams, given the expertise they bring in the therapeutic modalities. Our patients would benefit greatly by more access to such treatment options. Given the opioid crisis and its effects on the life expectancy, the last thing we should do is to hand therapists prescription pads.
Sincerely,
Torang “Torie” Shatzmiller Sepah, MD
Diplomate, American Board of Psychiatry & Neurology
Pasadena, CA
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