State boards consider Rx recommendations

The distinction between making medication recommendations and actually prescribing has become hotly contested.

By Rebecca A. Clay

An agitated resident endlessly wheels her wheelchair through the hallways of a Florida nursing home. The attending physician calls a neuropsycho-logist for help in determining what?s wrong with her.

The neuropsychologist spends a day at the facility observing the woman?s behavior, reviewing her chart, interviewing staff and conducting tests. At the end of the day, he writes up his findings in a report suggesting that the physician consider whether the patient?s medication might be contributing to her restlessness.

To the Florida Psychiatric Society, that report constitutes proof of practicing medicine without a license. To the psychologist involved, the report represents the fulfillment of his professional obligation to share his observations with a physician who has requested his feedback.

'Am I supposed to ignore what I see?' asks the psychologist, who wishes to remain anonymous because of the psychiatric community?s attacks. (See sidebar below.) 'My role as a consultant is to be a helpful observer. I?m not making the medical decisions.'

That distinction between making medication recommendations and actually prescribing has become hotly contested. In January, the Massachusetts Board of Registration of Psychologists issued an advisory opinion stating that psychologists? scope of practice does indeed include offering medication recommendations to prescribing physicians.

'Please be advised that it is the opinion of the Board that a psychologist may offer a medication recommendation to the prescribing physician about a patient he or she has evaluated when such recommendation is within the boundaries of his or her competence based on his or her education, training, supervised experience or appropriate professional experience,' board chairman Dennis K. Norman, EdD, wrote. 'It is then incumbent on the physician, based upon all of the evidence before him or her (which may include the recommendations of the psychologist), to decide what, if any, medication or medical treatment to prescribe.' The Florida Board of Psychological Examiners is considering the same question. The American Society of State and Provincial Psychology Boards even devoted part of a recent training meeting to the topic.

Massachusetts

The Massachusetts decision was prompted by the state Department of Public Health?s concerns about psychologists making medication recommendations in nursing homes.

'They tried to make it psychology?s problem that the attending physician was basically rubber stamping the psychologist?s recommendations,' says Elena Eisman, EdD, executive director of the Massachusetts Psychological Association (MPA). 'Our response was, `Gee, that doesn?t sound like psychology?s problem as long as the psychologist is clearly identified as such and the physician makes the final decision about the prescription.?'

Nonetheless, the Department of Public Health asked the board of psychology for a ruling. Eisman wrote the board a letter explaining how psychologists? ability to make medication recommendations actually enhances the quality of mental health care provided by nursing homes. To bolster MPA?s arguments, APA?s Practice Directorate reviewed the case law.

APA has found some case law that tends to support the legality of nonphysicians making medication recommendations, says Elizabeth A. Cullen, director of legal and regulatory affairs at APA.

One legal precedent was a Florida attorney general?s decision concerning medical interns and residents, who are not licensed to practice medicine. In keeping with common practice in hospitals, the decision allowed these students to make out prescriptions as long as those prescriptions were then countersigned by a licensed physician.

Another case APA reviewed involved a nonphysician who opened a cancer clinic, where both he and a physician examined patients. When the question arose whether the entrepreneur was illegally practicing medicine, the court said no.

'According to that court, as long as the physician was the one who conducted the physical examination and made the ultimate decision about what treatment was appropriate, the physician is the one who?s practicing medicine,' says Cullen, adding that APA will be broadening its research in this area.

Florida

Psychologists working in Florida nursing homes have also found themselves accused of practicing medicine without licenses. In November, the Florida Psychiatric Society used its newsletter to declare war on psychologists making medication recommendations. Saying that these recommendations posed a 'tremendous potential danger to our patients,' the article urged psychiatrists to report nonphysicians making medication recommendations to the state?s Board of Medicine.

The Florida Psychological Association (FPA) responded quickly. The association contacted the Florida Board of Psychological Examiners and asked them whether medication recommendations are a legitimate role for psychologists who have the right background. The board has agreed to review the matter, says Antonio T. Carvajal, FPA?s executive director. 'Although it?s still up in the air, I feel pretty positive that the board is going to come out on our side,' he adds.

Rebecca A. Clay is a writer in Washington, D.C.