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If Not Now, When? If Not Us, Who?: Part 2

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Photo of Morgan T. Sammons, PhD, ABPP, who wrote this article.

As I am fond of observing, the profession of psychology grew up in the rough and tumble world of the academy, not the sedate environment of tradesmen’s and craftsmen’s guilds from which sprang healthcare professions like surgery and pharmacy. Rather than being subject to the laws of supply and demand or consumer opinion, our field was shaped by disputation and the intellectual fads reigning within the ivied walls of the university. Academic disciplines are not driven by market forces, so their persistence depends largely on the intellectual success of a cadre of learned adherents to a particular body of knowledge. They are also less susceptible to public opinion, though any academic endeavor has always been subject to the approval (or, if you will, the whims) of its financiers. In earlier years such approval may have come from church hierarchies, nobility, or the wealthiest of merchant patrons. Today, funding of academic programs often depends on the taxpayer’s will, increasingly influenced by crusading politicians (viz., the current debate over critical race theory).

But most healthcare disciplines are hybrid, responsive to both academic pressures and market forces. Around a decade or so ago, medical educators began to act upon a situation that had been apparent for many years—the recognition that the structure of medical education institutionalized a century earlier with the Flexner report was suboptimal to the training of physicians. Rigid course requirements for core concepts in medicine like anatomy, physiology, and microbiology led to an instructional environment not inaccurately characterized as facts flung at half-awake students in a darkened auditorium (whether or not half the students were awake or all of the students were half-awake was not, as far as I know, investigated). Those students’ only measurable task was to successfully regurgitate said flung facts on course examinations or the first parts of their medical boards and then promptly forget them, which they should have because most such facts, as dear as they were to the heart of the microbiologist or biochemist who taught them, had little bearing on sound clinical practice.

Thus medical education began a remarkable transformation. The building blocks in basic medical education (anatomy, physiology, pathology, microbiology, histology, neurosciences, pharmacology, and others) that were previously taught in monolithic, semester-long courses that occupied the vast majority of the first two years of medical education are no longer recognizable as such. At Duke University Medical School, for example, all these courses have been consolidated into a single 10-month course called the Foundations of Patient Care, which teaches these subjects and integrates them with clinical skills and education in health disparities. In other words, clinical correlations don’t have to wait—it’s the fundamental expectation that these courses will be taught within a clinical framework that examines not only how the doctor approaches the patient but also thinks about how the patient approaches the doctor. Duke is not alone. Most leading medical schools are adopting new curricula. The American Association of Medical Colleges has redone its accreditation standards to reflect these changes.

These changes are fundamental to a current discussion of paramount importance to our profession: What defines a doctoral-level psychologist? Medicine found that a radical revamping of the core curriculum was necessary to optimize physicians’ training. Psychology should, I think, do the same. In fairness, we must acknowledge that the Commission on Accreditation has not been idle. The move in 2016 toward competency-based education was significant. Although it has not yet resulted in any radical restructuring of the curriculum it provided a more flexible framework to work with. But this flexibility may have a true negative side if it allows master’s trained practitioners to claim the same competencies that define doctoral-level health service psychologists.

It’s time to take the next bold step and institute major curricular reform for health service psychology. With due deference to our academic colleagues, such reform must address the critical needs of the practice community. The Duke medical curriculum hints at some of the resistance we might encounter from our academic friends—partially dwelling in the phrase “a 10 month sequence.” Altering the established semester-long educational framework employed by most universities is likely to be one of the tallest hurdles to overcome. But if we are really a health service discipline it is vital to rethink this. We simply don’t have the luxury to conform to the leisurely pace of instruction that marks most graduate education. The semester system is yet another vestigial component of our roots in colleges of arts and sciences. If we ask the taxpayer to fund the production of more health service psychologists, it is only right that we make such education as efficient as possible.

Equally importantly, if we are serious about reducing graduate student education debt, we must change. Professional education in psychology must become more efficient and cost-effective. Why make summertime education optional? Why force the student to pay (and delay licensure) for a largely fallow year devoted to completing the dissertation? A trimester system of three 14-week blocks would allow for year-round education that could incorporate practical training from the inception of the curriculum. It could dramatically shorten the period of time a psychologist in training spends in school. From an average of 7 years of post-baccalaureate education, we can quite easily envision a 4-year curriculum (inclusive of clinical training) leading to the doctorate. If medicine can shorten its basic science curriculum, there is no reason why psychology cannot prepare students for the predoctoral internship experience in three years. There is no reason we cannot take the medical school model and develop a 10-month course called Psychological Foundations of Care that incorporates our basic sciences—cognitive and affective bases, social psychology, developmental psychology, biopsychology, and psychopathology. If we insist on retaining a dissertation-like requirement, why not conceptualize it as the summation of acquired psychological knowledge applied to the solution of real-life patient complaints? In such a way, the dissertation can be integrated into a new, focused curriculum rather than remaining as a vestigial nod to our arts and sciences roots. If medicine is moving toward greater efficiency in training, why should not we?

But first, of course, we have to define what it is that a doctoral-level health service psychologist is supposed to do. To best accomplish this, I believe we should avoid the discussion of what separates master’s-level from doctoral-level psychologists. That is a bit of a red herring thrust upon us by the move to accredit master’s programs. If we focus on the key issue of defining doctoral-level health service psychology the rest will fall into place.

Here, however, let me raise a caution: As I have said, the move by the Commission to a competency-based accreditation system has positive aspects, but unless those competencies are clearly articulated to define a doctoral-level psychologist, they may actually threaten the profession. There are many more master’s-level than doctoral-level mental health providers. But these are separate professions with their own academic structures, accrediting entities, and separate boards determining their scopes of practice.

So what is a health service psychologist? In the past, this generally meant a psychologist who had taken sufficient coursework to qualify for a doctoral degree and had, in addition, completed sufficient pre- and postdoctoral clinical training to be a competent provider of applied psychological interventions. That’s no longer an adequate definition. I believe we should instead define a health service psychologist as a doctorally educated provider having the capability of acting as an integral member of a multidisciplinary health delivery team, focusing on the evaluation and treatment of emotional disorders and the complex interplay between emotional and physical well-being. In order to function as a full-fledged member of a health service delivery team, the health service psychologist must possess expertise in the etiology and treatment of emotional disorders and a working knowledge of common states of health and illness. We can no longer pretend that physical disorders are beyond the ken of psychology. If it is expected that every member of the health care team have a working knowledge of common physical disorders (even though the management of their physical components may be left to other qualified members of the team), why should psychologists be exempt? So we must add this to our curriculum. But we also recognize that patient care skills come from one source only—direct patient experience. And patients with emotional disorders are sufficiently complex that I doubt you can provide sufficient experience in a six- to eight-month or even a year-long practicum. Critical thinking in patient care develops only with extensive patient exposure and comprehensive supervision.

What separates a doctoral-level psychologist from a master’s-level psychologist is not only foundational knowledge but depth of training. It’s well demonstrated that you can equip a practitioner with skills to be an excellent psychotherapist in two years’ time—we’ve known for many years that psychotherapy skills don’t take seven years to impart. But doctoral-level health service psychologists aren’t just psychotherapists. Indeed, that may be an increasingly minor part of what they do. Viewed in that light, it is not clear that you can train an excellent psychodiagnostician in two years, nor is it demonstrated that you can achieve an understanding of core psychological science and its critical integration into clinical training in four academic semesters, even with accompanying practical experiences. It then follows that you may be able to train a competent mental health provider in two years, but you cannot train a health service psychologist in that time.

A few years ago, Drs. Gilbert Newman, Emil Rodolfa, Robert McGrath, Cristine Diaz, Gary VandenBos, and I sat down to take a stab at rewriting the graduate curriculum to better prepare psychologists to work in organized healthcare delivery systems. Our curriculum acknowledged that to be a full member of a health delivery team, we needed to incorporate knowledge of physical disease processes into the curriculum. We also needed to focus on multidisciplinary training as well as those aspects that made the psychologist a uniquely valuable member of the treatment team. We integrated health psychology throughout the curriculum and envisioned ethics as taught from an applied, multidisciplinary perspective. With clinical training beginning in the second semester, our curriculum was scoped at five years, inclusive of the internship. It’s probably time that we revisited that curriculum with an eye to both incorporating a 10-month foundational course and shortening it by a year.

What I’m proposing is not a one-size-fits-all model. Not all psychologists are going to be members of a healthcare delivery team. Nevertheless, I believe that they should possess the requisite abilities to do so. I’m also acutely aware that the model I describe doesn’t adequately cover the scope of practice of some licensed psychologists, notably school psychologists. While I cannot speak with expertise on their curricula, it is already in large part a more specialized curriculum more closely tailored to school psychologists’ occupational requirements than the general psychology curriculum. Nevertheless, I’m sure that planners in school psychology education are examining methods to streamline their curriculum. It’s really time that all of us educating doctoral-level providers did.

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