Psychiatrists' Intervention Wins Scope-of-Practice Battles

Working down to the wire, psychiatrists in Hawaii and Illinois beat back legislation that would have allowed psychologists to prescribe medications—and learned important lessons in the process.

In Hawaii, psychiatrists and their allies were able to engineer the defeat, albeit a very narrow one, of a psychologist prescribing rights bill when supporters failed to assemble a majority in the state Senate, reported psychiatrist Jeffrey Akaka, M.D., of Honolulu.

The Senate president could not cast a tie-breaking vote in the 12-12 deadlock because he had already voted in favor of the provision.

The House version of the bill was voted down earlier in committee, so the double defeat meant that the question of prescribing rights was stopped for the year.

Akaka attributed the result to good professional lobbying and hard work by physicians, residents, and patient advocates. They were assisted by members of the Oahu chapter of the National Alliance for the Mentally Ill, psychiatric residents at the University of Hawaii Medical School, and the president and executive director of the Hawaii Medical Association.

The prescribing bill was defeated, Akaka explained, “by educating the legislature, by phone calls, testimony, and face-to-face visits in their offices on multiple occasions prior to the hearings and votes.”

Testimony Sways Illinois Lawmakers

Meanwhile, a prescribing bill in Illinois never came up for a committee vote when the psychologists' chief lobbyist retreated after realizing that he didn't have the votes for passage, said Joan Anzia, M.D., president of the Illinois Psychiatric Society.

Anzia testified in opposition to the bill, backed up by the presence of a dozen residents and attending psychiatrists from around the state. She also had help from psychologist Michael Flynn, Ph.D., of the consultation-liaison service at Jesse Brown Veterans Affairs Medical Center in Chicago, who recalled observing the complex interaction of medical and psychiatry illnesses and emphasized medical training as necessary for safe prescribing of psychiatric medications.

Many lawmakers had changed their views and their probable votes following the day of testimony, Anzia said.

Victors Share Lessons

Both Akaka and Anzia said their experience in the legislative arena this year has taught them the value of building and retaining long-term relationships with their state lawmakers to advocate more credibly for policies they support.

In Honolulu, Akaka worked the halls of the legislature in the week before the bill came up for a vote, helped by Elaine Heiby, Ph.D., a University of Hawaii at Manoa psychology professor who opposes prescribing by psychologists, and by Dan Ulrich, M.D., a psychiatry resident at the university.

Even earlier, the Hawaii Psychiatric Medical Association held its annual reception for legislators. About one-third of the legislators showed up, allowing the psychiatrists to present their views and nurture rapport with the lawmakers. They raised patient-safety concerns, but also pointed out that allowing psychologists to prescribe drugs after 18 to 30 months of part-time, self-devised study amounted to “crash-course prescribing,” in Akaka's words.

In addition, the psychiatrists set out to address directly the issue of rural mental health care. Until about five years ago, psychiatry interns and residents were offered stipends by the state's Adult Mental Health Division in exchange for work after training in state hospitals or rural mental health clinics on a year-for-year basis, said Iqbal “Ike” Ahmed, M.D., a professor of psychiatry at the University of Hawaii and the former residency program director. In addition, during their fourth-year public psychiatry rotation, residents could go on a weekly basis to rural mental health clinics for up to six months. Travel was funded through the Adult Mental Health Division. (Current options for this rotation during residency still include Hawaii State Hospital, mental health centers, and other community agencies and sites on Oahu.) The funding for the state stipend program and travel for the public psychiatry rural rotation was discontinued due to budget cuts. Beginning in 2000, federal funding was provided to the Tripler Army Medical Center psychology program to send psychology trainees to rural settings to work with primary care physicians. Currently, three civilian interns now work from Tripler, said Lt. Col. Rebecca Porter, director of psychology fellowship training there.

Lydia Hemmings, executive director of the HPMA, has met with state Rep. Josh Green, M.D. (D-North Kona), an emergency room physician and vice chair of the House Health Committee, who wants to set up a task force on rural care. She has also discussed reinstatement of the rural psychiatric resident program with Sen. Suzanne Chun Oakland (D-Honolulu), vice chair of the Senate Health Committee.

The lead sponsor of the psychologist-prescribing bill, Sen. Roslyn Baker (D-Maui), will likely introduce similar legislation next year, said Hemmings, so HPMA members must continue their contacts with lawmakers.

In Illinois, Anzia attributed the prescribing-rights bill's demise to good lobbyists and a steady campaign to educate legislators on matters that psychiatrists believe are important. “This is not rocket science,” said Anzia. “It's pretty easy stuff. We just haven't done it.”

Like psychiatrists facing the prescribing question in other states, Anzia said that the Illinois Psychiatric Society and its counterparts have to learn to play the legislative game better and more comprehensively.

“We need to have an ongoing relationship with legislators,” she said. That means psychiatrists should work year-round to make known their views, even when the legislature is not in session. One senator told Anzia that meeting informally with lawmakers was a good way to establish relationships and exchange points of view.

“The issue isn't just content,” said Anzia. “They want input and feel offended if we don't talk with them.”

The profession may need to lay a lot of basic groundwork before discussing fine points with lawmakers. The same senator told Anzia that psychiatrists were perceived as older white men who treat rich, white patients. They were seen as aloof and not caring as much about their patients compared with mental health professionals. For that reason alone, said Anzia, bringing a young, ethnically diverse group of residents and staff psychiatrists to the hearings in Springfield may have helped their cause.

Educating psychiatrists is a critical factor, too, she said. One Illinois psychiatrist told her, “We didn't think it was serious until we got your third e-mail.” ▪