Imagine you broke your arm and needed an X-ray. Now imagine that your physician was required to perform the X-ray, as well as every other diagnostic test that might be required without the help of trained technicians--for you and every patient that entered her practice. Certainly it's possible. But most primary-care physicians leave the X-raying and lab tests to other professionals so that they have more time to spend with patients. It's an accepted practice that's intended to provide better quality patient care.
So, shouldn't the same be true for neuropsychologists who rely on tests and assessments to diagnose their patients? Shouldn't they be allowed to use skilled technicians to administer those tests under their direction?
The APA Practice Directorate says yes--and has supported several state psychological associations in defense of this practice. "The use of testing technicians impacts patient care; it allows the psychologist to see more patients, more efficiently," says Billie Hinnefeld, JD, director of legal and regulatory affairs in APA's Practice Directorate.
However, in New York, Oregon, North Carolina and Arkansas, state licensing boards have, at various points in the past few years, prohibited the use of technicians in psychological testing--although in two of those states, those prohibitions have recently been dropped with the help of APA.
Interpreting the law
The questions surrounding the use of testing technicians came up in 1999 in North Carolina because the state licensing board felt it needed to regulate the practice of using nonpsychologist assistants. In the other states, the issue has cropped up for different reasons.
More specifically, some state boards, when implementing licensure rules, "interpreted scope of practice laws in their states to indicate that only licensed psychologists should be able to provide testing services," says Neil Pliskin, PhD, chair of the practice advisory committee for Div. 40 (Clinical Neuropsychology). "That goes against a long tradition that dates back to the 1940s of using a professional and technical model for data-gathering," he says.
That model, he adds, is also endorsed by professional organizations that represent neuropsychology, including the National Academy of Neuropsychology (NAN) and the American Academy of Clinical Neuropsychology.
NAN says the use of technicians "helps maintain the objectivity of data collection and minimizes potential for bias associated with clinical judgment."
And without technicians, Pliskin says, patient care would suffer. "President Bush's New Freedom Commission highlighted the lack of access to care," Pliskin says. "One of every two people who need mental health services don't receive them. If clinicians were required to spend time administering tests, they would have less time available for interviewing patients and coordinating care."
Pliskin is quick to add that while testing professionals are responsible for collecting data, it's the psychologist's responsibility to supervise and interpret the tests. Indeed, APA's Ethics Code and the General Guidelines for Providers of Psychological Services also dictate the same--that accountability for the services provided when using technicians ultimately falls on the psychologist.
The ethical codes provide this safety net to protect patients. In some cases, though, consumer protection may be the root of the testing assistants controversy. Antonio Puente, PhD, Div. 40's past-president, speculates that in New York the board may be leaning away from allowing testing technicians based on rumored incidents of fraud by psychologists--allegedly, some patients claim to have been billed for psychological services after undergoing testing without ever actually seeing their psychologist. Both Puente and Pliskin argue that the misconduct of one or two professionals shouldn't adversely affect the entire profession.
Meanwhile, in North Carolina and Oregon, the state psychology associations, with support from Div. 40 and the APA Practice Directorate through letters to the licensing boards, have resolved the issue in favor of using nonpsychologist testing technicians. In Oregon, new legislation clarified the licensing law. And in North Carolina, psychologists were able to change board members' minds.
But in New York and Arkansas, efforts are ongoing. APA and other organizations lobbying for psychology are committed to achieving appropriate resolution in these states.
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