In this issue
Psychopharmacology and psychiatry: Both/and, not either/or, in better serving the underserved community needs
By Manuel Fernandez, PsyD
Contra Costa County is one of the largest counties in Northern California that is culturally rich and much diverse when it comes down to race, age, socioeconomic status (SES), sexual orientation, religion and cultural beliefs. The density of the population is higher in some sectors of the county than others and communities continue to expand to remote areas ( United States Census Bureau, 2013) . As the communities expand, the need for services increases in areas where the medical demands are high and the resources are scarce ( Community Health Needs Assessment, 2013, p. 34) . One of the major concerns in this county is providing services that are suited for the different needs of such diverse population. Just to mention a few, the Latino population usually complain of having difficulties in receiving medical and psychiatric services due to lack of providers, insurance coverage, financial difficulties, feeling that they are misunderstood and believing that they are not treated with the best evidence-based practice. Furthermore, when it comes down to psychiatric services the demand for bilingual and culturally sensitive clinicians is now a major problem in all sectors of this county. To mitigate for the need of vulnerable disadvantaged communities, other medically trained clinicians such as nurse practitioners, physician assistants and medical psychologists or psychopharmacologists are, in many available ways, successfully providing these services due to the high need and unavailability of psychiatric services.
This article distills personal experiences in the medical field as a practicing psychopharmacologist in a suburban area in California. The underpinning premise of this recount is based on the first core general principle of the psychology ethics code -Beneficence and Nonmaleficence. This principle emphasizes on the awareness to do no harm and includes providing better patient care. Throughout my years of practice as a psychopharmacologist, I encountered few psychiatrists that reminded me of this particular ethical tenet implying that my practice and services were in violation of such ethical standard. Mostly, these perceptions would subside after engaging in conversations about the medical aspect of psychopharmacology.
My certification in psychopharmacology included the guidance and clinical supervision of John Echols, MD, chair of psychiatry at the County hospital where I completed my psychopharmacology rotations, cases, and clinical practice. While at the county hospital, I worked in the psychiatric consult liaison (CL) service. Echols is someone who strongly supports the idea that psychologists, after getting the necessary medical training to prescribe, can effectively do so because of the rigorous American Psychological Association (APA)-accredited doctoral training programs to become psychologists and the clinical exposure to deal and treat severe psychiatric conditions. Echols was not only the person who motivated me to pursue training in psychopharmacology, he also heighten and broaden my knowledge in medicine with his lectures and practical exposure to severe medical cases that didn't necessarily required a psychiatric consult at the hospital. He is someone I can now call a mentor.
During my tenure working for the Contra Costa County Hospital, the value added by the psychiatric consultation services I provided became eminent to attending physicians and medical residents, including the medical staff who were very appreciative of my services. Precisely, earning my credibility from colleague physicians was the result of successful psychiatric case consultations and interventions that provided me with the practical experience to share the medical knowledge I gained through my training. Echols played an influential role in the way I performed my duties as a psychopharmacologists, and he demonstrated his complete trust in my decisions and recommendations. Collaboration with medical providers was supported with monthly psychiatry meetings attended by all the psychiatrists in the county and led by the psychiatric medical director. I had the opportunity to give lectures about the pharmaceutical management of chronic pain conditions and comorbid psychiatric conditions to them; these experiences led to greater collaboration and increased awareness of the role of psychologists who become psychopharmacologists in the medical field. However, my experience changed abruptly after I accepted a position as a therapist by an outpatient clinic in the same county and left the hospital.
The outpatient clinic that hired me served residents with demographic characteristics that had adverse implications for health and wellness. According to the Community Health Needs Assessment (2013), 13 percent of the residents in the Richmond area live in poverty, and 16 percent lack health insurance coverage. I was enthusiastic about the opportunity to serve vulnerable communities; however, I had a rough experience integrating and leveraging my psychopharmacological training to meet the needs of the population due to deeply rooted mindsets that prevailed within the clinic. Throughout my three-year endeavor at this clinic, there were times that I was blamed for working “out of my scope of practice.” The need for psychiatric services is immense in this part of the county; thus the notion of psychopharmacologists is still widely misunderstood by medical practitioners. Hierarchical, top-down institutions are still mainly governed by the belief that only psychiatrists are able and should be allowed to prescribe psychotropic medications. Seldom, senior management clinicians like Echols dare to step out of the box adopting and integrating new and more provocative theories that at the end of the day can shift the philosophical foundation of archaic institutions. Although there were several people who supported my knowledge and recognized the need for psychopharmacological interventions, in the process of advocating for these services, their efforts came to a halt by the leadership in the county. For instance, a visiting psychiatrist, who came to the clinic while the other psychiatrist was on vacation, knew about my training based on previous encounters at the hospital. One day he was overbooked and asked me to see a Latino girl and her family seeking psychiatric services after a hospital discharge. I saw the patient and did the medication recommendation to which the psychiatrist prescribed under his name and then he cosigned the psychiatric encounter. Months later the clinic's psychiatrist found out what happened and complained to his superior. The visiting psychiatrist was told not to do it again. Even though the encounter was successful, and the needs of the patient were met, which demonstrated a better patient care, none of it mattered. They would have preferred that the patient rescheduled.
In retrospect, many of these experiences make me ponder about what the real misunderstanding is about this profession. Is it about providing the services the patients need or is it about just not letting other clinicians help the cause because of a turf political battle? These roadblocks only impact the people we serve. At the end, the underserved become even more affected. The complaints I heard are that psychologists don't get the medical training necessary to prescribe psychotropic medication. Well, that is true! That is why the APA has implemented the post-doctoral degree in psychopharmacology which includes clinical rotations. Psychologists go through a rigorous training and medical rotations that other clinicians are unaware of to become psychopharmacologists. Even when I explain that I am a psychopharmacologist and there is the acceptance from other clinicians, they still believe that my training didn't include medicine or knowledge about the different areas in medicine and review of systems (ROS) until this is clarified several times.
Currently, my experiences with primary care physicians and attending physicians and residents at the hospital where I work as a psychopharmacologist is very rewarding. They continuously express their appreciation by the services psychopharmacologists provide. At first it requires explanation about the work we do as they always ask: “What is a psychopharmacologist?” to which my reply is: “We are the new breed in psychiatry.” At this hospital, I provide services to patients that are in dire need for psychiatric services who come from different cultures and SES and my patients express feeling understood and leave with a clear understanding about the medications they are taking and about all the possible side effects; something that I hear in my practice from patients as not being the case when they visit other prescribing clinicians who spend less time with them.
Connecting with the underserved populations in ways that can directly make a positive impact in their well-being is paramount in clinical practice. It also involves accepting change; accepting new ways. Ultimately, what matters is that the patients get the care they need by providing better patient care and not by stopping services because of the unavailability of psychiatrist when there are other medically trained clinicians that can do the job. Psychopharmacologists prove on a daily basis in California and in other states that they can do the job safely as well as any physician with this expertise.
Manuel Fernandez, PsyD, is a psychologist at Kaiser Permanente and a psychopharmacologist at Sutter Delta Medical Center.
Community Health Needs Assessment. (2013). Retrieved July 1, 2015, from http://share.kaiserpermanente.org/wp-content/uploads/2013/09/Vacaville-CHNA-2013.pdf
United States Census Bureau. (n.d.). Retrieved July 2, 2015, from http://quickfacts.census.gov/qfd/states/06/06013.html