Friday, December 19, 2014

Question For APA Candidates? OK Here It Is.

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"

I got a message today that I should craft a question for the American Psychiatric Association (APA) candidates.  It is election season and the LinkedIn forum is apparently the place for political debate.  I can recall asking a question last year along with James Amos, MD (The Practical Psychosomaticist).  The questions had to do with Maintenance of Certification (MOC) and the arduous recertification schedule that was essentially invented by the American Board of Medical Specialties.  Dr. Amos has done more to maintain this issue at a high level of visibility than any other psychiatrist.  That includes looking at the paucity of evidence that it is superior to life-long learning and CME as we all know it.  I  went to LinkedIn to look for my post from a year ago and it wasn't there.  The earliest post is from April 29, 2013.  This is a forum that was suggested to replace the long running member-to-member (M2M) listserv managed by the APA.  It was in M2M that members learned their concern about the MOC issue would be ignored despite overwhelming support on the basis that only 25% of the members voted and a 40% vote was required to pass the measure (see supplementary info below).

The events associated with that vote continue to bother members greatly.   It is seen as a continuing symptom that APA membership does not translate into any support for front line psychiatrists.  We have witnessed decades of increasing rationing and onerous regulations that have been basically brushed off at the level of the APA.  There has been minimal activity in responding to politicians, regulators, and businessmen.  It seems that whatever these special interests want to do - the APA is willing.  We had a billing and coding debacle in the 1990s with the rest of medicine.  Instead of pointing out that this was a purely subjective scheme designed to allow the persecution of any physician, the stance of both the APA and the AMA was "we will give you what you need to be better billers and coders."  We have had three decades of managed care utilization review, prior authorization, and pharmacy benefit managers and the response from the APA has been literature on how to be a better managed care psychiatrist.   There was a lawsuit against some managed care payers for a lack of parity but I don't think there is any evidence that the members who were forced to provide free care have gotten much benefit from that.

The most telling event about where the APA and AMA are at is their full scale cooperation with the PPACA (aka Obamacare) and so-called collaborative care.  In many if not most of those models of care, a psychiatrist collaborates with primary care physicians in treating depression or anxiety in their clinics.  In many of the models, the diagnosis hinges on a rating scale determination of depression or anxiety.  The rating scale score is the diagnosis.  The treatment modality is a medication - usually an antidepressant.  In some models the psychiatric consultant never sees the patient.  I just realized it, but this is all eerily similar to managed care reviewers several states away telling attending psychiatrists how to manage their patients.  This is managed care - a business centered model of providing medical care.  A model that many (myself included) do not consider a valid method of providing medical care.  And yet, the President of the APA and several other psychiatrists promote this as a model of care.  What physician would do 4 years of residency training to sit in an office, look at rating scale scores, and recommend antidepressant doses?  Why would you train all of those years and know all of that theory for such a simple task?

That simplistic collaborative care model captures the primary problem in psychiatric leadership today.  Here we stand at a crossroads.  We are studying the most complex organ in the body and we clearly know more about it now than at any point in the past.  The literature in brain science as it applies to psychiatry is growing exponentially.  We have some of the best thinkers in the world in all areas of the field ranging from pure neurobiology to psychopharmacology to imaging to neuropsychiatry to medical psychiatry to community psychiatry to psychotherapy.  There is so much to learn about the brain and psychiatry and what are we doing with it at a global level?

Nothing as far as I can tell.  The leadership of the APA is locked into a mindset from the Clinton administration.  The APA is acting like we have a responsibility as a profession to address bloated mental health statistics and provide population-based psychiatric care to the masses.   We have a responsibility to provide cost-effective care to the masses.  We have a responsibility to fight stigma wherever we find it because this is the real reason why people, governments, and insurance companies discriminate against psychiatrists and their patients.  We have to grin and bear it when some clown attacks the profession despite the fact that thousands of our colleagues go to work everyday and many toil with inadequate resources, impossible conditions, a lack of cooperation and they still get the job done.  Thrown into the breech with no support, front line psychiatrists are still getting the job done.

The APA on the other hand has done very little to support that effort.  APA officials seemed to breathe a sigh of relief about the vote on the MOC issue.  I heard one of them speak about it at a local meeting.  She told us all about how the new certification fees were really not a windfall for the American Board of Psychiatry and Neurology (ABPN).  This was really an expensive process after all.  I finally learned that this was really an initiative by the ABMS and that participating boards did not really have a choice.  If most of the boards voted for recertification all of the boards had to participate even if they voted against it.  I had learned about 10 years ago that the American Board of Obstetrics and Gynecology ( ABO+G) had a robust program that consisted of didactic material every year that was designed to bring all members up to speed.  A test was taken every year on that well defined information.  At the time there was no MOC and to me it seemed like an ideal program to assure that all members of a particular specialty were up to date and studying relevant information about what was important for the specialty.  For a while, I promoted this model as the preferred model for ongoing professional learning.    The APA does provide a similar program called Focus that could naturally fill the same role.  Typical MOC exams are not on a focal body of material and the pass rates are high.  Candidates of all specialities typically take time off of work (an off of vacation) to study for these examinations in addition to paying high examination fees for a test that is designed for the test makers and not the test takers.  A test of random facts for the purpose of recertification is not the same thing as a test for professionals to assure they are all up to the same standard.

The APA has just completed a much criticized multi-year effort of revising the DSM and producing the DSM-5.  I think that has been a good effort and with the associated online material it is a definite advance relative to previous editions.  That does not mean I am in agreement with everything in the book, or think that all of the diagnoses in that text exist.  I do think that it covers all of the major diagnoses and severe mental illnesses that psychiatrists treat.  On an academic and clinical level the APA needs to do much more.  Hospitals and clinics currently are being run by administrators with mixed agendas.  We are seeing business people conduct psychiatric care.  The APA used to provide comprehensive guidelines for the treatment of aggression in inpatient settings.  It used to have timely treatment guidelines describing the role of psychiatry and what the standards of care are.  By abdicating that role, we now have business organizations and nonprofessionals dictating care for people with severe mental illnesses.  We have psychiatrists who have to defend their care against those nonprofessional guidelines every day.   That is hardly the expected behavior of a professional organization.

Any psychiatrist should be concerned about the fact that their professional organization does not seem to support the members doing the work of psychiatry.  Any psychiatrist should be concerned that the APA does not vigorously defend the profession and that it seems to have adapted the pseudoscientific methods of governments and managed care organizations.  Any psychiatrist should be concerned that the APA has adopted the questionably valid ABMS preparatory school model of professional education that is unfocused and a waste of time and money.  Any psychiatrist should be concerned about the fact that we have some of the greatest minds in American medicine in our medical institutions and our professional organization is lurching back to the Clinton administration of the early 1990s.  Back to the time when a few political insiders thought that managed care was a good idea.  All of these things considered the question I will post to the candidates is:  

"Why are there no leaders with vision in the APA who can focus us on the best science and the best psychiatry to provide treatment for individual patients with severe mental illnesses?"
That is how I was trained and how every psychiatrist I know was trained.  It is time our professional organization consistently gives us what we really need.

George Dawson, MD, DFAPA

Supplementary 1:  This was the APA 2011 election report I got on the following referendum to basically eliminate patient feedback and maintain a cognitive exam very 10 years.  Although the APA maintains that it requires a vote of 40% of the voting members, the vote to support these measures exceeded the votes for the President Elect and the Secretary (both national candidates) by 1373 and 1388 votes respectively. (Reported February 18, 2011)

The APA was petitioned by members to hold a referendum on the issue of informing the ABPN as follows regarding its proposed maintenance of certification requirements.

1) The patient feedback requirements for the purpose of reporting to the Board is unacceptable, as it creates ethical conflicts, and has the potential to damage treatment.
2) The requirements other than a  cognitive knowledge examination once in 10 years, regular participation in continuing medical education, and maintenance of licensure, pose undue and unnecessary burden on psychiatrists.
Member Referendum
5,525 (80%)
Do not support
1,418 (20%)

The referendum did not pass. APA received ballots from 25% of the voting members.
The APA Operation Manual states the following regarding member referendums: “The adoption of a referendum shall require (a) valid ballot from at least 40 percent of the voting members, (b) the affirmative vote of at least one-third of all the voting members of the Association, and (c) the affirmative vote of a majority of those members who return a valid ballot.

Supplementary 2:  Another one of the sorry miscalculations made by the APA and its officers is the image it projects to potential trainees.  Applying the dynamic I point out in this post, any potential resident ends up asking themselves:  "Why would I want to join a speciality that seems to want its members to have less expertise than they used to rather than more?  What other speciality does that?"  I tried to address that as a response to a current resident written on his blog and for some reason the response was never posted.  You can read his original post here and my response below:

The most significant reasons why psychiatry has the image problem that you discuss is that the profession is politically inept and our largest professional organization is not addressing the problems that psychiatrists face on a day-to-day basis on the front lines. The biggest front line problem is that practically all systems where psychiatrists work have mercilessly slashed resources for treating the mentally ill. We also seem to attract a number of ideas from critics that are not helpful. The example you posted about a prescriber with watered down qualifications is a case in point. In what other specialty does anyone suggest that the practitioners of the future should be less qualified?

That type of nonsense only happens in psychiatry and it is completely inconsistent with current research. In this weeks’s Neuron there is a perspective on Computational Neuropsychiatry. As neuroscience becomes more relevant to daily practice psychiatrists need that level of training in addition to medical and psychotherapy skills. We seem to have a lack of visionaries right now who can put all of that together.

I would encourage psychiatrists of the future to be thinking more along these lines, than the rationed managed care model of care that is currently being promoted. It turns out that “cost-effective” psychiatric care is frequently the same as no care at all.



  1. If you had a patient with an abusive husband who kept trying to change him, and she kept coming in with a black eye, what would be your advice?

    1. It would depend on why she was seeing me in the first place. In my experience very few women in this situation end up seeing psychiatrists because of domestic violence. Many happen to be referred to psychiatrists because they were seeing physicians who attempted to treat the effects of domestic violence with medications and they are referred to psychiatrists to seek out the ideal medications. Some have comorbid depression, anxiety, substance use or personality problems. If I determined the interpersonal violence and chronic associated stress was the cause of the problem, I would refer her to therapists and advocates to help her with that problem. If I thought she was either not safe or unable to make that determination I would refer her to a women's shelter to assure her safety. I have not generally had a problem helping women in this situation identify the problems and solutions.

      If I thought she had a treatable psychiatric disorder, I would provide that treatment myself or consider referral to a psychiatrist affiliated with more women's specialty services. If I thought she had neuropsychiatric problems associated either with traumatic brain injuries or other life events - I would probably assess and treat myself if the practice setting allowed me to order the kind of evaluation that I needed – but my guess is most practice settings do not.

      In other words I would do what psychiatrists have been doing for about 50 years and probably record the same mental status exam that psychiatrists have recorded for 90 years. That is of course if the clinic I was working in did not mandate a PHQ-9 and a citalopram dose for a score of >9. It goes without saying that I could also be restricted to a “med check” and be told by my clinic manager that I am “only supposed to talk about meds” and not her traumatic experiences. I might not even have a choice in what I say to the patient if she is told in the clinic: “Our psychiatrist will only talk to you about medication. He doesn’t do therapy.” Or more coding appropriate: “I can only talk about one problem. You have to come back to discuss another problem.”

      I guess I should not assume best practices from the 1960s in the era of dumbed down psychiatric care.

  2. It was a metaphor. The APA is not going to change. It is run by people whose interests are different from and sometimes hostile to the typical member. Their bread is buttered different from ours. The point was it's hopeless to expect in game adjustments from someone or a group who has never shown any willingness to change. Why should someone with tenure rock the boat? Just give the same tired speeches about stigma and parity while ignoring the seriously mentally ill in practical terms.

    1. Dr. O’Brien, I understand you were drawing similarities here b/t victims of domestic violence and professionals who are victims of the APA, but I'm curious on why you call this a metaphor instead of an allegory? It’s an honest question; my English is poor. And, now, after having just waded through Google results of allegories, metaphors, analogies and similes, I'm more confused than when I started.

      Anyway, back to the subject of your comment. When problems are intractable, I am predisposed to your approach. I have to say it is pretty much my entire approach. However, after contemplating the choices that different people make, I’m of the mind to let others fight the battle how best they see fit.

      There are those that think it best to starve the beast from outside and those that think it better to do so from within. It appears that if the rank and file left, the APA would collapse or at least the illusion of it would, and yet, you’d be met with the same argument that if everyone that disagreed with it, joined it, they could turn it around (assuming voting was not rigged). This type of debate always seems to end at an impasse.

      I admit I have no clue about the APA; my thinking comes largely from reading history and watching politics. And what it has taught me is how important it is to support your allies however they choose to fight. My twist on last century’s famous maxim: The only thing necessary for the triumph of evil is for good men to do nothing - because they are busy arguing with each other.

    2. I think psychiatry would be better if there were no APA at all. It is intractably dysfunctional. The APA leadership is condescending and abusive and is fighting against the interest of the average psychiatrist. I see them as an enemy of private practice and intellectually dishonest. Witness their response to managed care. Collabo-care means the psychiatrist is replaced by a computer program. Next to internal medicine, I don't know of any specialty so self destructive. The radiologists don't act like this and ABA and lawyers are much savvier toward their members.

      We could be like psychology, where enough psychologists got fed up and started a rival group. Only 15% of physicians belong to the AMA, maybe APA will get the message if 85% of members leave.

      Not to mention that the money I've saved by not belonging to APA and local chapters for thirty years will pay for two kids' college education.

  3. To clarify: I would have thought Lieberman's bizarre endorsement of Collabo-care, which will effectively make private practice obsolete would have been the final straw, but somehow community psychiatrists keep paying dues to the APA.