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By Ami Albernaz
The authority of psychologists to direct patient care in hospitals
is often ambiguous and sometimes contested. Those who favor such
privileges say that they allow for continuity and consistency of
care, while others say they have little practical effect. In the
17 states in which hospital privileges for psychologists are on
the books, it is individual hospitals that ultimately decide how
they are carried out.
The issue has recently come to a head in California, where in spite
of a state law granting psychologists hospital privileges, psychologists
are said to be shut out of primary care duties within hospitals.
Some hospitals there are reluctant to turn over primary patient
care to psychologists, leaving these responsibilities solely to
psychiatrists. The California Psychological Association is considering
legal action to enforce the law.
While the California case is an example of the inconsistencies
in enforcing hospital privileges, similar ambiguities exist in some
New England states. Connecticut is the only one of the six states
to have a hospital privileges law on the books. Yet it has had little
practical effects, says David Greenfield, Ph.D., who was instrumental
in the passing of the legislation.
"The law is fairly watered-down," he says. "It says that hospitals
can offer privileges, not that they have to." (California's ruling
is similarly non-committal, stating that "A patient may receive
both medical and psychological treatment. Nothing in the statutes
requires that if he receives both, the physician…must be 'the captain
of the ship.'") Even where hospital privileges are extended to psychologists
in Connecticut, Greenfield says, they are not always straightforward,
for several reasons.
"The market has changed considerably since the law was passed,"
he explains. Because of the terms of insurance plans, hospitalizations
now tend to be short, which makes it unfeasible economically for
psychologists in private practice to travel to and from hospitals
to administer patient care. Meanwhile, both private and hospital
staff psychologists have restricted autonomy in determining the
courses of care for their patients.
"Nursing practice laws haven't been updated to reflect hospital
privileges for psychologists," Greenfield adds. "So I can say, 'This
patient is to be admitted or discharged,' and it doesn't matter,"
since older laws governing whose orders nurses can act upon have
not been changed.
A larger issue, he suggests, is prescription privileges. If psychologists
had such privileges, patient care would be less fragmented. "You
[now] need two authorities [the psychologist and a medical doctor]
instead of one, so it gets complicated," he says. "If we had prescription
authority, that would probably be more of a help."
Because Connecticut's hospital privileges have had little practical
effect, Greenfield knows of few psychologists who use them. In part
because of the sorts of obstacles that Connecticut psychologists
still face, there has not been a call for hospital privileges in
other New England states.
Massachusetts psychologists have not pursued privileges because
hospitals make the final call anyway, says Elena Eisman, Ed.D.,
executive director of the Massachusetts Psychological Association.
Sheila Comerford and Kirsten Singleton, executive directors of the
Maine and New Hampshire Psychological Associations, respectively,
say the issue has been dormant in their states. In states without
hospital privileges written into law, some individual hospitals
have decided to include psychologists on their medical staffs.
The Maine General Medical Center in Waterville has 23 credentialed
staff psychologists, as well as others who work on a consulting
basis. "Their privileges are quite extensive," says Jan Quattrucci,
manager of medical staff services for the center. While the psychologists
do not have admitting privileges, they are permitted to advise as
to the course of care for their patients. "In general, the psychologists
[affiliated with the center] who work primarily in private practice
do not use the privileges often, but they will use them to allow
for continuity of care should a patient of theirs be hospitalized."
Quattrucci adds that the Waterville center is by no means reflective
of the state as a whole. "Another Maine hospital may do things very
differently," she says.
In the absence of a concerted effort to inscribe hospital privileges
for New England psychologists into state law, the granting of those
privileges will likely remain with individual hospitals. Greenfield,
however, says that other hospital-related legislation has been of
more use. He notes a Connecticut law through which psychologists
can legally hospitalize patients against their wills. "That probably
has done more to benefit patients," he says. As for the future,
he adds that prescription authority is what is needed for psychologists
to truly have authorities in hospital settings.
"From a hospital's perspective, psychologists are social workers
with greater senses of entitlement," he says. "We can test, but
testing is just not a bargaining chip at this point."
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