Sunday, February 24, 2013

Crickets from the APA

"The best way to predict the future is to create it." - Peter Drucker

The annual convention is approaching and the American Psychiatric Association (APA) has decided to train a few psychiatrists from each district branch to teach about the new DSM5.  They think that is sufficient to fill the demand from organizations and groups who want assistance with DSM5 training and implementation.  They also think that the threat of litigation is enough to protect the DSM copyright and prevent other self declared trainers from going around the country and training people about the DSM5.  That is more critical than you might think.  Let me explain why both of these thoughts are problematic wrong and describe a more optimal course of action that could still be implemented before the May convention.

First of all let me say that the ideas I am posting here are not new.  I have inquired directly from the APA as a member both at their Washington Offices and through my District Branch (DB).  The lack of response prompted the “Crickets” title from the APA because cricket chirping is about all I am hearing about any initiative other than the APA’s original plan.  There are many sources of failure possible by restricting the training.  The obvious one is that psychiatrists are busy.  The failed billing and coding system generally means that psychiatrists are seeing a lot of patients and spending even more time on billing, coding, and documentation.  That leaves very little time each week to study for recertification exams, train future psychiatrists and medical students, and participate in other professional activities.  Given how thin psychiatrists and other physicians find themselves spread, it might be reasonable to have a bureau of trained DSM5 experts at each DB to cover the potential demand.

I first got interested in this issue when a large health care organization asked me about the availability of consultants to assist them in their nationwide implementation.  The DSM IV is currently implemented in their electronic medical record (EMR).  Several calls directly to the APA did not produce any results.  I identified myself as a member and that did not make a difference.  I contacted my excellent DB Executive who I had worked with during my term of being the DB President.  She is extremely knowledgeable and widely networked within the organization.  The question I proposed was whether the APA would consider opening up the convention session to all psychiatrists through the DB and certifying anyone who has taken the course.  Still no response.

Absent the response I have the following suggestions about how to train DSM5 trainers in the interest of the APA and its mission and preserve the copyright integrity of the DSM5:

1.  Expand the training in May to all DBs and to as many psychiatrists as want to take the training.
2.  Provide password access to all of these psychiatrists to the DSM5 web site for the purpose of ongoing learning.  The DSM5 site was quite good in providing the rationale for suggested changes and prospective trainers could benefit from ongoing access to this material.

3.  Provide educational materials (PowerPoints) to all of the trainers through access to a training web site.

4.  Develop a course specific to administrators and companies who need IT implementation information and have that readily available.

5.  License DSM5 to corporations in the same way that psychiatrists with online subscriptions can access it.  UpToDate has provided a good example of the continuously updated online reference rather than serial textbooks being the direction forward.  There should be no need for update cycles and massive political events to herald updates.  The DSM and all psychiatric guidelines need to be systematically reviewed and updated if APA technology is to be seen as the definitive reference for the biomedical diagnosis and treatment of major mental disorders.  Updating every 10-20 years will not survive in the day of Internet technology.  There is also a lot less drama involved when UpToDate updates its content.  That is consistent with being a resource for physicians and by physicians.  

All of these recommendations can be done and anything less than following through on these recommendations leaves the APA seriously compromised and not competitive in the future.

George Dawson, MD, DFAPA


  1. Nay. George, you've opened a can of more worms than you describe. Your limited solution is too little/too late to yield benefit over investment. Your accurate perspective probably won't be accepted or even grasped where vision is needed. In this "day of Internet technology", when even secretive information technology enterprises use social media for product development, the top products for general use are open-source. The highly evolved updating process is a judicious combination of: continuous transparent feature creation and tweaking by lots of Users; constant User comment that is taken seriously; tons of online help by volunteers; and frequent fixation of primary, secondary and tentative versions (e.g., "alpha", "beta", etc.). Copyright explicitly grants free access, use, and permission to create tailored versions. Stakeholders attempting power plays are marginalized (Developers move off to create independent branches and Users follow: e.g., the shift from "OpenOffice" to "LibreOffice". The APA's obsolete proprietary model is unsustainable, moribund. Its product is criticized as beholden to "insurance company" interests. The APA's image has been degraded by the very public controversy aroused. You are right that DSM will not survive and APA can no longer compete in the mental health market. Though gangrene calls for ablation, and though the DSM has clearly dragged psychiatry down, the APA has become so financially attached to it that divestment is not even considered. OK, I'm being a nay-sayer, but what if, in reality, grasping at straws won't suffice?

  2. While not claiming to know all the details, i must disagree with my friend and collegaue M.P. who says DSM has dragged down APA and/or psychiatry itself; although there is a deficiency of transparancy within APA's way of doing things, i do not make this comment in connections with the DSM itself. I may or may not want to revise my reactions after using said Book. BTW, i still think the only way for APA to go is to sell only , to disseminate only, the hard copy book. I think all the hackings show that any electronic version will likely be 'hacked, altered, misapplied, and disseminated' to the great confusion, and probable harm, of all. LKRichrds, m.d.