Wednesday, November 27, 2013

Fantasy Foundation For The Preservation of Psychiatry

Psychiatry is on the ropes.  The content of this blog illustrates the prevalent biases against the field that all eventually trickle down to less resources to work with and managed care companies rationing those meager resources in order to make money.  One of my favorite fantasies lately is to think about what I would do to save psychiatry if I ran a foundation with significant resources.  I have thought about it long enough and hard enough to come up with a number of guideposts:

1.  Save the teachers - probably the most beleaguered people in the field these days are the teachers of psychiatrists.  There are a lot of bloggers out there complaining about the "ivory tower" academics who just don't know how life is on the front lines.  The usual gripe is that they make too much money or are in some kind of shady consulting deal.  How dare they dictate to the rest of us how to practice?  That has not been my experience, and I have probably taught as much to medical students and residents as the next guy.  I see people trying to make a living and teach at the same time.  I see people needing to meet absurd "productivity" expectations and teach at the same time.  Teaching in generally is not counted as "productivity" in a managed care environment.  I see people who give up their ability to type up more patient notes at noon so that they can give a lecture to mostly disinterested medical students or fatigued residents.  They end up typing those notes at night on what is supposed to be their own time.

When I ask myself what would help them the most it comes like a flash - free high quality graphics for PowerPoints.  I have a parallel blog with some ideas, but there is nothing like great graphics that are free to use and save your faculty hours of sleep trying to come up with their own and not violate somebody's copyright.  You would think that professional organizations, like the American Psychiatric Association (APA) would support this idea.  Like everybody else, they produce downloadable PowerPoint slides for their major journals.  If you read the small print, you are supposed to go to the CopyRight Clearance Center and pay a fee.  I paid a fee of $45 for a lecture to a class of 12 and $85 to lecture a class of 42.  That was to project the slide and include it in my PowerPoint for the day.  I currently give about 32 lectures a year.  Considering the reimbursement I get for the lecture, it is not a commercial presentation, and I have been paying lots of money to the APA for about 30 years - you would think I could get a break.  As the head a a great foundation, I would purchase the rights to several good resources like Blumenthal's Neuroanatomy Through Clinical Cases or Atlas' MRI of the Brain and Spine and make them freely available to any instructors of psychiatrists.

2.  Free neuroscience conferences - there need to be much better basic science courses to bring clinical psychiatrists up to speed on the latest neuroscience and how it applies to the field.  Typical conferences are centered around some clinical activity that most of us are doing anyway.  Do we really need to hear more about something that we are doing everyday?  Something that we know everything about including the usual limitations?  Why not expand back into a consciousness based discipline looking at innovative ways to conceptualize problems and solutions.  Neuroscience is critical to that and there are several very articulate voices in the area.  I would plan a conference every years that was free to psychiatrists for 2 - 4 days of neuroscience.  There is a lot of neuroscience out there and I would ask some of the top journals like Nature, Science, Neuron, Biological Psychiatry, and Molecular Psychiatry to submit a program of Neuroscience for psychiatrists.  I would award the grant competitively to the best submitted program.

3.  Free computerized psychotherapy and an affiliated institute of psychotherapy using computers - I previously posted about John Griest's work in computerized psychotherapy and its effectiveness.  The whole point of the post was to emphasize a significant source of non-medication based treatment that is essentially not limited by manpower requirements.  There are several groups who have implemented this already, but to my knowledge none of them are major U.S. health care organizations or managed acre companies.  The commonest managed care approach is to give everyone a non specific depression rating scale, call that a quality marker, and then put as many people on antidepressants as soon as possible.  There is enough IT available that a foundation could take the lead in this area, develop the programs, and accept referrals from psychiatrists across the country for specific types of computerized psychotherapy.   

4.  Free clinical workgroups -  I have posted on the University of Wisconsin Memory Clinics collaborative clinical network across the state that focuses on maintaining a high level of expertise in all of the cooperating clinics for the diagnosis and treatment of Alzheimer's Disease and other dementias.  There is no reason that model cannot be extended to Depression, Bipolar Disorder, Post Traumatic Stress Disorder, or Attention Deficit Hyperactivity Disorder.  When people talk about collaborative care, they are usually talking about a managed care model that marginalizes psychiatrists.  A recent post suggested that some of the promoters of the managed care model have challenged naysayers to come up with an alternative.  I am a naysayer to anything that resembles managed care and the UW model is definitely a competing model that emphasizes psychiatrists at the top of their game in diagnosing and treating mental disorders.  That would be my priority over a managed care model that is so watered down, you don't even need a psychiatrist on the premises.

5.  An independent certification process - The American Board of Medical Specialties (ABMS) has a chokehold on all board certification processes with the exception of the American Board of Addiction Medicine (ABAM).  ABAM has their own certification and recertification process.  The current controversy involves the recertification process and whether it should be a standard blind exam with no learning aspects and a review of patients in a physicians practice or not.  I have posted some details about this to show how highly politicized it has become.  There is really no good evidence that recertification beyond the usual CME requirements is needed.  Although the American Board of Psychiatry and Neurology (ABPN) and the APA has gone along with ABMS ideas, most members find the process onerous and not conducive to learning, especially when they are in a labor intensive work environment that allows little time for study.  Any professional organization should be innovative enough to come up with an ideal process that would keep members up to speed professionally while not intruding on their limited time.  My foundation would develop a recertification system based on the APA's Focus journal an develop a process that would allow members to study on their own time and recertify by taking the Focus examinations.  It should eventually be possible to incorporate modules from the ongoing neuroscience seminars and what is learned in the computerized psychotherapy lab as study modules.

Using these innovations and hopefully more, my foundation would seek to improve the technical expertise of all psychiatrists, highlighting what is possible for the future and bring every clinician out of the current misery of political overegulation and managed care overproduction.  The whole idea that we currently have a professional organization and a specialty board that are not protective of psychiatrists is one thing.  The idea that they are actually doing things that are counterproductive to the ongoing professional education of psychiatrists and increasing burnout by creating a more stressfull practice environment is another.

My fantasy foundation would hope to reverse those trends.

George Dawson, MD, DFAPA

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