The Goldwater Rule and Political Commentary

The New York Times recently ran an opinion piece by Robert Klitzman, MD on "Should Therapists Analyze Presidential Candidates?"  He provided a good review of the Goldwater Rule, that was put in place after an embarrassing poll of psychiatrists decided that Barry Goldwater was not fit to be president of the United States.  I did not hear much about psychiatrists during the 1964 Presidential election because I was in the eighth grade at the time.  Our civics class was engaged in a detailed version of Risk that allowed us to rule different countries and act like world leaders.  It was the height of the Cold War.  There were a couple of buildings in town that were designated fallout shelters.  In those days there were announcements about nuclear tests and when the radiation cloud would be passing over town.   As a kid, I can remember thinking that nuclear war was imminent and the government was trying to send us the message that it was survivable.  I did not realize that was propaganda until at least a decade later.  The Johnson campaign was able to capitalize on that zeitgeist with the famous attack ad at the top of this post.  It was an interesting ad because Senator Goldwater was never mentioned.  But the implications were very clear - elect Goldwater and there would be nuclear war.  Some political analysts believe that this was the first significant attack ad in American elections.  The reality of Barry Goldwater stood in contrast to the media portrayal.  He was in the Senate for 5 terms ending in 1987.

That was the context for the poll of psychiatrists by Fact magazine that concluded Goldwater was "psychologically unfit" to be president.  Dr. Klitzman lists a number of quotes from some of these psychiatrists and writes a very informative article on both the Goldwater Rule and subsequent modifications for the profiling of political leaders.  He cites the profiling of Saddam Hussein by Jerrold Post, MD, the first psychiatrist to develop expertise in this area.  He goes on to list a number of profiles of historical figures as well as non-psychiatrists in the news who do not hesitate to offer diagnoses of political figures or criminals who they have never personally examined.  Senator Goldwater sued Fact magazine and was awarded damages but that happened 3 years after the election was over.  The American Psychiatric Association rewrote a section of the ethics manual that became known as the Goldwater Rule in response to the Fact magazine poll.

The Goldwater Rule is technically a section in The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.  Here is the section copied directly from that manual:

Section 7.3

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

There have been a lot of debates about how the rule should be reworked so that psychiatrists can share their expertise with the public.  The rule as it is written seems to depend on the lack of an examination or a release ruling out the public presentation by a psychiatrist.  I would not have a problem with the section being written to say that psychiatrists should never offer an opinion in the media about a person of interest and it all comes down to conflict of interest considerations.  Commenting on national television is a case in point.  There seems to be no shortage of therapists who seem quite willing to present their analysis of body language or speculation about diagnoses in the absence of any examination of the patient.  Psychiatrists should not engage in this activity, because it is basically speculation and not based on any scientific or clinincal method.  Assuming the psychiatrist has conducted an examination, the issue of authorization looms large in the rule.  Should a psychiatrist ask a patient for a release just to present their diagnosis or formulation to the public?  I don't think so.  The only leeway I am willing to grant is for research purposes as authorized by an Institutional Review Board using deidentified data.  An interested public or media representatives does not come close to the threshold for maintaining confidentiality.  Any psychiatrist knows that reporters do not want general statements about mental illness or psychiatric disorders, even if they present their proposal like that in the first place.  Once the interview starts, they want speculation about the person of interest and that should be unacceptable for psychiatrists.

There is the potential case of a person who may really want this information out in the media and I would question that intent if there was an active legal case.  Would the psychiatrist be getting the authorization as part of a larger legal strategy to get favorable public opinion?  I do think that commenting on stories that are already out in the press, and making a point about those stories is perfectly acceptable.  I have done that here on this blog, pointing out that I have no personal knowledge of the person involved or their psychiatric diagnosis, but that the issue has broad implications for the field and therefore merits discussion.  The commentary here has been about Greyhound therapy and the way that violence and aggression are approached in community and state hospitals.

The context is important.  Psychiatrists are trained to operate in a very specific environment.  They are supposed to determine who has significant mental illness and then treat those people in hospital and clinic settings.  Those methods are not generally applicable to people who don't have mental disorders.  This is a limitation of psychiatry that most people don't understand.  In the absence of clear biological markers, psychiatric disorders are defined as conditions that cause impairment in academic, family or personal life.  Many of the politicians in this case (including Senator Goldwater) had no such impairment.  The comments presented about him were essentially another version of an attack ad.  There was no reason to suggest he had any diagnosable condition and the other technical terms used are even more vague in the absence of a clearly defined disorder or problem.

The technical jargon used by psychiatrists is generally meaningless to the public.   Terms that I hear quite a lot of these days include narcissism, psychopathy, and even antisocial personality disorder.  I can imagine that the next step of interested viewers is to look up the "criteria" for these traits or diagnoses online.  When looking them up, the same mistake is duplicated - the viewer is reading words on a page describing an experience they have never experienced.  A significant number of viewers will conclude that they may have the same problem or at least they know a lot of family members and coworkers who do.  Making all of this jargon readily available has been a greater disservice than a service to the public.  

And finally, at least in the case of Goldwater - the fact that most psychiatrists are Democrats cannot be ignored.  The last time I heard any analysis of this point psychiatrists were described as the only medical speciality that was predominantly Democrats.  From listening to the political commentary of some of my colleagues,  psychiatrists are no more immune to standard political biases or rhetoric than the average person.  It is a major problem to have a conservative Republican analyzed by the political opposition.  That should be an obvious point but I don't see any of the pundits these days disclosing their political affiliations.      

Psychiatry is a medical speciality that is meant to be practiced like all other branches of medicine - behind closed doors.  Medicine is supposed to be practiced for the benefit of the patient and not the physician.

We should never lose sight of that.



George Dawson, MD, DLFAPA



References:

1:  Robert Klitzman.  Should Therapists Analyze Presidential Candidates?  New York Times.  March 7, 2016.

2:  R. Ginzburg (ed).  1,189 Psychiatrists Say Goldwater Is Psychologically Unfit To Be President.  Fact Special Issue; September-October 1964; pp 24-64.



Disclosure:

Not a Democrat or Republican.  I will leave it at that.

Data On Drug Price Comparisons - And The Myth Of Compromised Physicians

See Attributions For Reference

ND = no data

The response to my last post so far was as predicted by what I said in the post.  It is very difficult for people to get around the idea that they have heard for the past two decades - namely "Damn you Big Pharma!"  Over the past 20 years we have repeatedly heard all of the concerns about physicians essentially being bribed by Big Pharma in the form of speaker's fees, free lunch, various trinkets, ghost written research, and free vacations.  We have seen physicians criticized by a member of Congress for failing to disclose income from sources outside of their academic appointments.   We have seen psychiatrists selected out from other physicians with regard to Big Pharma financing despite the work of a well known non-partisan watchdog showing that they are nowhere near the top of the list in terms of total reimbursement or frequency.  Many people have made a career out of adding various conspiracy theories to the basic Big-Pharma<->physician conspiracy and how it has added unnecessary costs to the health care system, put patients at unnecessary risk,  and compromised professional ethics.   The only major change that I have detected is the elimination of the free lunch at Grand Rounds.  I do so appreciate that.  There was nothing that triggered my misophonia more than the sounds of mastication while I was trying to listen to the lecturer.  Now that all of those evil Big Pharma incentives have been eliminated and the risk of public shaming is in place through at least two databases, it would follow that Big Pharma should be hurting - right?  We should finally be getting reasonable priced pharmaceuticals - right?  Not if the following slide from the Kaiser Family Foundation is to be believed:

See Attribution Section Below For The Full Credit For This Graphic

It seems that the public shaming of physicians and eliminating the various forms of the Big Pharma free lunch have not led to the Utopian state of better pharmaceutical pricing.  The really telling information is in the tables at the top.  This data is widely quoted in a number of sources, but is also readily available from the original source.  The US has the market cornered when it comes to the absolute maximum drug prices.  In some cases other countries are only paying about a quarter as much.  My table also removed the maximum prices in the US that are in some cases much higher than is quoted in this table.   This data illustrates why taking physicians out of the equation has has done nothing.  Of course it will be interesting to look at the data over  time databases and make sure that there is the expected lack of correlation.  This data as well as the data on prescription pricing explodes the myth that physician collusion with Big Pharma had anything to do with pharmaceutical company profits.  For years we have had to tolerate vague rhetoric from Pharmascolds like: "If they (Big Pharma) didn't get a return (on their various trinkets, meals, other incentives) - they wouldn't do it."  There was the associated argument that getting free pens would make you start prescribing the advertised drug like you were a Big Pharma Manchurian candidate.  Neither of those arguments had any traction with me, but then again I had not talked with a pharmaceutical rep in over 20 years.  Compare these arguments with the clinical reality that physicians face every day and that is being harassed by managed care companies if they do not prescribe the least expensive drugs.  Any physician prescribing only the latest antidepressant would spend most of their time on the phone with pharmaceutical benefit managers.  They would not be able to practice.

The third argument was the moral one.  That it was somehow unethical to work for a pharmaceutical company or accept anything from them because it represented a conflict of interest.  Notice I did not use the term appearance of conflict of interest.  That is because the Institute of Medicine has decided for all of us that it is so hard to determine a real conflict of interest from the appearance of conflict of interest - why bother?  Consider it all to be conflict of interest.  To me that always seemed like a variation of the automaton argument - I have accepted pizza or a pen and now I can no longer think for myself - I will just automatically prescribe the suggested drug.  Nobody ever examined the strong reinforcement associated with the idea that:  "I don't eat the free lunch and therefore I am morally superior to you."  That unexamined thought seemed palpable on many blogs and websites where daily outrage about these practices was common.

The fallout from this lack of examination has been significant:

1.  Fewer physicians wanting to work with the industry - medicine is probably the only technical profession that makes this suggestion.  In many professions standards are set by active collaboration with industries.  I don't know how a pharmaceutical company can look for new molecular entities without an eye to problems that clinicians encounter and a solid knowledge of the shortcomings of current therapies.  You can't find that in a lab.

2.  Overgeneralizations about psychiatry based on the predictably negative press - psychiatry takes more of a negative hit on just about anything than the rest of medicine.  The Myth of Compromised Physicians has allowed an absurd level of criticism to be leveled at the field and ignore even basic realities that psychiatry specialty organizations and psychiatrists are hardly the most involved specialists with Big Pharma.  You would not get that impression by reading the popular press or the various antipsychiatry sites in the Internet.

3.  An absurd emphasis on evidence based medicine - as though that could somehow save us from the evils of Big Pharma or ourselves.  There have been endless politically biased analyses to prove that psychiatric treatments do or do not work.  In many cases, the result of the study can be predicted by the author's bias.  In many cases the author's bias is evident even without financial conflict of interest disclosures, all that you have to do is read their previous writing.  Many of these papers are foregone conclusions.  They naturally add nothing to the field because they either lack scholarship or that was not their intent in the first place.  They miss on three standards.  The first involves the intent of regulation of drugs in the United States and the science of pharmaceutical research.  There are no perfect drug trials and the results don't have to be perfect to get approval.  In some cases the results are far from perfect and the drug is approved, even against the vote of the involved scientific committee.  Safety considerations are often clarified in post marketing surveillance.   The second involves the positive experience of clinicians using the drug.  Drugs are often prescribed off label with great success and experienced clinicians have often treated many more patients by themselves than were in the original trial.  They may have better results in the trial largely by their experience using the drug and more comprehensive treatment than is available in drug trials.  There are many reasons why the experience of clinicians using the drug would be expected to be better than the trial, but the trial is considered the gold standard of whether or not a drug "works."  The third involves the safety considerations of the physicians using the drug.  There have been some studies that go back and look at all of the side effects of the drug in clinical trials and try to recalculate risks or side effects and adverse outcomes or to prove the pharmaceutical company or researchers were covering something up - they weren't transparent.  Any clinician who studies the FDA approved package insert for the drug and pays close attention to what their patients tell them, will know much more about the dangers of the drug and its side effects, how to detect and treat them better than any group of people reading research reports.  To think otherwise is folly.  

4.  A serious lack of appreciation of what the real problems are in clinical trials and that is biological heterogeneity.  Any number of polygene determined illnesses will understandably not yield positive and uniform results with great effect sizes in response to a treatment.  I don't care if the illness being studied is depression or asthma or diabetes mellitus.  Why is that shocking or surprising?  Why would it be surprising that some researchers want to break these large heterogeneous groups into small subgroups and see if the treatment response can’t be refined?

5.  A stunning lack of examination of the real problem.  That real problem is quite simply special access to all levels of government on the legislative and regulatory side by industry lobbyists.  Industry in this case includes insurance and managed care companies, and pharmaceutical companies.  Physician professional organizations have no similar access.  Nothing guarantees profits more than lobbyists sitting in a smoke-filled room and writing legislation that regulates your industry.

Take physicians out of the loop and what do you have?

The most expensive prescription drugs (by far) in the world.



George Dawson, MD, DFAPA




Supplementary:

Doctor databases: These databases are there to list payments to physicians from pharmaceutical or medical device manufacturers.  I refer to them as public shaming databases because that is  what they are used for in the press and blogosphere.  There are also obvious comparisons for similar databases that exist for Congress and the obvious fact that transparency doesn't work.  Feel free to look for my name, but I can tell you in advance that you won't find it:

Open Payments - The Official US Government Web site - https://openpaymentsdata.cms.gov/

ProPublica - Dollars For Docs



Attributions:

1:  The Table "2013 Drug Prices In Various Countries" is from a report by the International Federation of Health Plans.  The report is titled: "2013 Comparative Price Report Variation in Medical and Hospital Prices by Country."  It is quoted in many places including the reference below and the report is freely available as a PDF document.  It was accessed on 1/30/2016.

2:  The graphic of "Growth In Prescription Drug Spending......" was downloaded as a Power Point Presentation entitled Attachment-Rx-Spending-and-Use-UPDATED 12.31.2015.  Author is The Henry J. Kaiser Family Foundation. It was accessed on 1/30/2016 and is used by a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

The Luck Of The Ethical Researcher

“My point here is that when discussing an actual case, the ideological wars melt and people from multiple sides of a debate can usually agree. "Clinician trumps Ideology." 

From 1BOM March 30, 2015 post.



Not sure that I follow that line of thinking.  That has not been my experience in psychiatry or any other medical specialty.  There is plenty of ideology and a lack of technology across the board.  There is also the dirty little word that nobody likes to see affiliated with medicine and that is politics.  As far as I can tell a lot of the ethical debates in medicine are all politics. I can point out several on this blog.

There is also the question of uncertainty.  I can recall being a grunt in a new drug protocol that I will not name but I will say it is in a therapeutic class almost never prescribed by psychiatrists.  My job was to do the medical and psychiatric evaluations and assure that the patients were medically fit to continue the protocol.  Part of the weekly screening was an ECG. I looked at this patient’s ECG, determined it had been changed and told the monitor that I was stopping the protocol.  The monitor got very angry at me because the patient was 2/3 of the way through the protocol and would not count as a completed patient.  I referred the patient immediately to a medicine clinic and they agreed the ECG was changed.  The patient was advised to come back for routine follow up care.  They could not comment on the study drug and they did not recommend any acute care. The monitor remained angry, but I stood my ground and the patient was taken out of the study and referred back to medicine.

A week later the patient had a major medical complication and ended up in the ICU. The monitor and the chief investigator both thanked me for taking the patient out of the protocol at that time – one week later.  The monitor apologized for getting irate with me.

So the rub is – am I more “ethical” than the monitor (who was not an MD) or am I just lucky? Uncertainty certainly can make you look like a hero or a zero in a hurry in medicine.  In this case an internist did not have any reason for concern even though the ECG was clearly different. Was the ECG change causally connected to the ICU incident?  Was it casually connected to the study medication?  Or was the decision to stop the protocol more related to my blue-collar anti authoritarian roots?  To this day nobody knows (but as I age I am more inclined to credit the roots).

And what if I had no markers and the person had stayed in the protocol and ended up in the ICU on the study medication?  Certainly the company and the FDA would have investigated the study and me and my methods.  Would I have been vilified as just another researcher working in the interest of a pharmaceutical company?  Would it have been good press for somebody trying to benefit at my expense?  My only thoughts at the time were in the interests of the patient.  But that difference in course could have been career changing for me, despite the fact that my only interest then and in the past 30 years has been patient safety.

Situations like this are easily politicized and there is a very porous boundary between politics and ethics.

George Dawson,  MD, DFAPA

Supplementary 1:  For the whole story go to the 1BOM blog and start reading at the link.

Shut Down The Psychiatric Gulags - Don't Build More!

On my drive home from work yesterday, I heard an outrageous story about a judge ordering LA County jail to build 3,200 psychiatric beds to treat mentally ill inmates in that facility.  As is typical of MPR, I could not find the link today but I did find the link to this LA Weekly story , that basically brings people up to speed.  It is a typical journalistic approach with the human interest component.  In this case the human interest portion was interesting to me, because I have heard these stories hundreds of times from people I have treated who have been incarcerated with a few variations.  The most significant variations have to do with suffering acute alcohol or drug withdrawal and not being assessed or treated for that problem and not having access to maintenance medications that have proven effective for the specific mental illness.  The current plight of the mentally ill in the LA County jail system and increasing judicial pressure on the basis of rights violations for the lack of treatment led county supervisors to vote to build what was called the most expensive building project in county history.  From the article:

"That day, county supervisors ........ voted to spend nearly $2 billion on a long-sought jail to replace notorious Men's Central, a facility that federal investigators say is plagued by suicides, abusive conditions and violence. The funds will build a two-tower compound given the ungainly name "Consolidated Correctional Treatment Facility."

According to the article it will be a 4,860 bed facility,  3,260 (67%) beds of which will be dedicated to treating prisoners with mental illness.  My most recent post on the matter includes information that LA County jail has 19,386 inmates and that recent epidemiological surveys suggest that 30-45% of inmates have problems due to severe mental illness and impaired functional capacity.   That suggests that unless public policy changes, the most expensive building project in LA County could be overwhelmed by demand before it gets started.  The author in this case points out the folly of building this tower.  It is basically the folly of building any large psychiatric facility in the absence of any other infrastructure, but in this case compounded by the fact that this is in fact a jail and not a treatment facility.  There is really no evidence that the problematic aggressive or suicidal behavior will be any better in a new "two-tower compound" with the same jail atmosphere and mentality.

I have previously posted about the plight of the mentally ill being incarcerated in America and the fact that county jails are currently our largest mental institutions.  It is a basic collusion between governments at all levels and the business community to enrich corporations that have been set up to "manage" the American healthcare system.  As usual, the most vulnerable people are "cost shifted" out.  Cost shifting refers to cost center accounting that basically leads divisions within the same organization to try to save money on their budget by shifting the costs to somebody else.  In managed care systems it can lead to all kinds of distortions in care.  It also happens with outside agencies.  I was told about a situation where workers in one county actually dragged an  intoxicated patient over the county line and into another county so that patient would no longer be their  financial responsibility!  Cost shifting is the end result of these perverse incentives.

There is perhaps no better example than incarceration rather than hospitalization.  There are estimates as recent as from a few days ago that treatment and possible hospitalization may cost $20,000/year as opposed to incarceration costing $60,000/year.  In both cases the taxpayers pick up most of the tab.  The cost shifting has occurred from insurance companies and health care systems to the correctional system.  If an insurance company can dump a patient with a severe mental illness into jail, it doesn't cost them a thing.   If that same patient is hospitalized they may receive a one-time DRG (Diagnosis Related Group) payment of about $5,000 irrespective of how long the patient stays.  The hospital incentive is to get them out in 5 days whether they are stable or not to maximize profit.  When they are discharged, the patients are generally expected to go to appointments to discuss their medications.  Clinic profits on these visits are minimal but the main problem is that many of these appointments are missed - in some cases up to 50-60%.  Many of these patients lack stable housing and they frequently end up back in the emergency department and back in the hospital.  Hospitals now have bottlenecks in the emergency department and many people are discharged back to the street.  The cycle of ineffective care continues.

I can attempt a brief analysis of the problem as I watched it unfold during 23 years of inpatient practice.  I will demonstrate how things have changed to the detriment of patients with severe mental illness.  Consider the hypothetical case of Mr. A.  He has diagnoses of depression, schizophrenia and alcohol dependence.   He recently ran out of his usual medications and started drinking.  He became progressively depressed and stopped talking with his family members.  They went over to see him and noticed he has a loaded handgun on his table and was talking about shooting himself.   They called the police who came, confiscated his handgun, noted that he was acutely intoxicated and sent him to the local hospital emergency department.  How has the management of this scenario changed over the past 30 years and why?

In the early 1980s, Mr. A would have been assessed as a person who was high risk for ongoing suicidal behavior (depression, schizophrenia, alcoholism and acute intoxication) and admitted to a psychiatric unit.  The psychiatrist there would have done everything possible to stabilize all three conditions even if it meant civil commitment to a long term care institution.  The length of stay (LOS) would have been on the order of 20-30 days comparable to many current psychiatric LOS in the European Union.

By the late 1980s, a managed care company would have called the hospital or psychiatrist in charge.  They would initially demanded that the patient be discharged to a county detox facility.  They would claim that alcohol withdrawal detoxification was not a psychiatric problem, and therefore the patient does not meet their "medical necessity criteria" for inpatient hospitalization.  If that was ineffective they might say that he was no longer "acutely suicidal" or "imminently dangerous" two additional medical necessity criteria.  In the end they always win, because they just stop paying and the administrators force the clinicians to discharge the patient.  The length of stay is now down to less than 1 week and the patient may not be stable at all at the time of discharge.

By the 1990s, the patient might not even make it to the inpatient unit.  By now psychiatric departments are continuously burned by managed care companies, especially in the case of any patient who is acutely intoxicated at the time of admission.  Many have closed their doors.  Many departments have strongly suggested that the emergency departments send any intoxicated patients directly to county detox units if they are available.  The counties respond by refusing to take any patients on any intoxicants than than alcohol and even then the patient has to blow a number on a breathalyzer consistent with acute alcohol intoxication.   At any point in this process a decision can be made to just send the patient home.  There are various ways the patient can access more firearms at that point or even get the original firearm that was confiscated.  There are also various ways that the patient can end up incarcerated including going back home, drinking and getting arrested for disorderly conduct or public intoxication.  A more complicated situation occurs if the patient is intoxicated and wanders into a neighbor's home or place of business.  I have seen people end up in jail for months on trespassing charges in these situations.   And that brings us in to the 2000s where it is much more likely that a person with severe mental illness will be incarcerated than even make it to the emergency department.  In the 2000s the patient may end up stranded in the emergency department for days or sent home with a bottle of benzodiazepines to handle their own detox if they can deny that the are "suicidal" consistently enough.  There is also the mater of inpatient bed capacity.  Fewer beds are full constantly because bed capacity has been shut down due to managed care rationing and people are often released because there will be no open beds in the foreseeable future.  The LOS in many cases is now zero days, even for people with severe problems.

How did all of this happen?  How did the care of mental illness and addictions fall to such a miserable standard?  It is documented in many posts on this blog.  Professional guidelines were compromised and treatment infrastructure was destroyed by the managed care industry and the politicians who actively supported and continue to support it.  Professional organizations don't stand a chance against pro business state statutes,  commissions stacked with industry insiders, and federal legislation that protects these companies from lawsuits for interference with care.  Even a travesty as basic as prior authorization for generic drugs is unassailable.  I don't understand why these basic facts are so incomprehensible to people in the field.  Just a few hours ago, 1BOM posted a Hall of Shame of entities the original authors claim are failing people with severe mental illness.  This list completely misses the mark and is probably a good example of how deeply entrenched the mechanisms are to prevent treatment  and shift costs away from states and health care companies.

There are countless easy solutions to the problems, but the companies in power literally do not want to spend a dime.  The patient with severe mental illness can receive comprehensive community services and be maintained in their own housing at a cost of $10, 000 to $20, 000/year for clinical services.  That same patient costs corrections departments $60,000 per year.  That patient currently costs managed care companies nothing if they can transfer their care to a local state-funded Assertive Community Treatment (ACT) team.  Managed care companies incur the same cost if the patient is transferred to the correctional system.  If ACOs come to fruition and all of the chronically mentally ill are enrolled, it should be an easy matter to make the managed care companies responsible for both the costs and the patient.  A simple court order to pick up the patient from jail and stabilize them in the community could suffice.

Erecting more gulags won't work.  They are effective only for enriching health care companies that profit by denying care for those with severe mental illnesses and addictions.  They are also another hidden health care tax on the taxpayers who are already paying far too much in hidden health care taxes.




George Dawson, MD, DFAPA

Graphics Credit:  ConceptDraw Pro - this graphic was included as an example with this software.

Stigltiz Commentary and The Implications for the Politics of Psychiatry

Nobel prize winning economist Joseph Stiglitz came out with a recent commentary of the economic recovery and why things are not a rosy as they seem.  He points out that many of the structural problems with the economy including predatory lending and credit, abuses by the credit card industry and abuses by the credit reporting industry are still in place.  In addition there are inadequate capital reserves and no real limits on the kind of low risk speculation by certain parts of the financial services industry - the basic problem that started everything 5 years ago.  I have been posting in political forums for the past 15 years that the American economy at times seems to be based on a fantasy rather than the way a real economy should work.

We have taken an alleged retirement system (401K, 403B) and turned it into a windfall for the financial services industry.  Instead of an actual retirement system, we find that the average American is not able to put away nearly enough to retire and in the process ends up paying significant fees to financial services companies.  In return for these fees they receive the standard boilerplate about no guarantee against losses and frequently have very poor investment choices since they are determined by their employer.  At the same time, low risk retirement vehicles like money market funds are paying negligible amount of interest.  Rather than being a reliable retirement system this is essentially another tax on the American people to fund the financial services industry.  Retirees are left with the option of accumulating cash only or putting their retirement funds at significant risk all of the time in order to accumulate enough capital to retire.

We are in the process of starting a huge health care mandate know as the PPACA or more popularly as Obamacare.  It will create a large influx of capital into the healthcare system based on coverage mandates.  The American health care system is currently the most expensive system of health care in the world.  The standard model used by the federal and state government has been to use managed care companies as intermediaries to contain costs.  There should be no doubt that model is a near total failure.  Recent data for example suggest that a couple nearing retirement should have an additional quarter of a million dollars saved for health care expenses during retirement beyond the cost of Medicare.  The health care system in this country can be viewed as a second tax on the American people.

How do Americans end up with two additional taxes being levied on them in addition to the usual income, Medicare, Social Security, sales, and property taxes?  How does it happen when we have a supposed radical element of one of the major parties working on fiscal responsibility?  I think it comes down to one American institution and that is the US Senate.  The Senate is full of aging, wealthy politicians who have worked for years to develop a power base in Washington and keep it.  They are completely out of touch with what the American people need and pass laws that will largely benefit the businesses that they are heavily lobbied by.  In some cases, they wrote the laws to invent the industry.  The disconnect of this group from the public was evident during the recent stand off to shut down the government and nearly default on our creditors.  In other words they risked the world economy to make a point instead of fairly representing what the average American wanted at that time.

How does all of this apply to the politics of psychiatry?  I can illustrate by looking at a few seminal events that apply to all front line psychiatrists and how their professional organization - the American Psychiatric Association (APA) responded:

1.  Managed care and the disproportionate rationing of psychiatric services:  Apart from Harold Eist, MD and a recent lawsuit against a managed care company there has generally been silence on this issue.  Some literature was generated regarding how to work with meager rationed resources but nothing about how to fight back as managed care became a government institution.  The APA's support of collaborative care means we have come full circle and the APA is explicitly backing a managed care model that involves treating patients without actually seeing them.

2.  The response to accusations of conflicts of interest related to the pharmaceutical industry:  There was a well known initiative against some prominent psychiatrists, the motivations for that initiative are still unknown.  It is well known that many academics in many university departments have contracting arrangements with industries in order to supplement their salaries.  It is well know that some professions charged with determining industry standards insist on industry representation in meetings where those standards are written.  It is known that many professional organizations got more support from the pharmaceutical industry than the APA.  The response to the attack from a Senator was to basically acknowledge that his attack was accurate and proceed with an appeasement approach that allowed critics of psychiatry to use this as additional rhetoric against the profession and any psychiatrist with a contracting arrangement.

3.  The Maintenance of Certification (MOC) issue:  This issue was forced by the American Board of Medical Specialties (ABMS) based on limited research.  The APA immediately aligned themselves with the ABMS despite considerable complaints and a petition by the membership.

The three examples given about are some of the main political issues for psychiatry, particularly the average working psychiatrist and the APA.  To say that the interests of most psychiatrists are not represented by the APA is a massive understatement.   Like the U.S. Senate, the APA seems almost totally disconnected from the people it is there to represent.  I have heard many reasons over the years about how the actual structure of the APA is the problem.  But nobody seems to want to remedy that problem.  I attended a seminar at one point where an APA official explained the MOC issue and how it would actually create a financial burden for the American Board of Psychiatry and Neurology (ABNP), despite the obvious fee generation to take a commercially monitored and administered test.  If it really is that burdensome -  why do it in the first place?  The initial rationale was that the public demanded it.  It seems that there is now solicitation for public support.  Who would not support an initiative to improve the competency of doctors - even if there is absolutely no evidence that a multiple choice exam with a high pass rate does that?

I think it is highly likely that the political structure of the APA is very similar to the political structure of the Senate.  While there is no lobbying there are ideas and affiliations based on those ideas.  Any political structure that is so far removed from what its constituents want it driven by cluelessness, conflicts of interest, or a divine mandate.  It is only logical to conclude that like the Senate, the issue is conflicts of interest.  In the 21st century, patriotism is no longer the last refuge of a scoundrel - accountability is.  The APA would do well not to follow the Senate on that course.

George Dawson, MD, DFAPA

Joseph Stiglitz.  5 Years In Limbo.  Project Syndicate, October 27, 2013.

Psychiatric opinion on same-sex marriage is more acceptable than an opinion on violence and aggression

I was surprised to see an insert in my psychiatric newsletter this month describing the efforts of four major mental health professional associations in opposing an amendment to the state constitution that would exclude same-sex couples from legal marriage.  The Minnesota Psychiatric Society, the Minnesota Psychological Association, the Minnesota chapter of the National Association of Social Workers, and the Minnesota Association of Marriage and Family Therapists produced this document that in essence says that there are no research findings to suggest that children from same-sex parents differ from heterosexual parents in outcomes.  The newsletter editor's column explains that there is apparently no policy on the MPS taking a stance on political and societal issues.  She put that question out to the general membership.  MPS President Bill Clapp, M.D. stated the issue succinctly:

"The MPS Executive Committee was painfully aware that the development of a consensus statement regarding marriage amendment could not possibly represent the diverse opinions of all Minnesota psychiatrists.  On the other hand we felt a responsibility to act faithfully in representing our many patients who believed the marriage amendment violated their civil rights and was overtly discriminatory". 

I think there are a number of issues relevant to this opinion that are interesting to contemplate.  First and foremost is bias in the media.  Over 2 years ago the MPS partnered with two other mental health organizations The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education in producing a statement on violence prevention.  That statement highlights the lack of mental health resources, lack of training in dealing with these incidents, and the lack of quality standards in assessing and treating patients having problems with violent and aggressive behavior.  That statement was rejected by the newspaper editor. The only reason given was a potential conflict of interest because we were advocating for research and that nonspecific advocacy was viewed as a problem.  In the two years since the statement was produced, it is clear that the issues we raised are as important as ever.  My first question is why that statement pertaining to issues that mental health clinicians and the organizations involved deal with on a day by day basis was not acceptable and a statement on a purely political issue was.

I personally voted against the constitutional amendment and think that any reasonable person would.  None of my criticisms of this initiative outweighs the value of getting the research literature out there for public consumption.  It may have been useful to provide a link to all of the available research in an easily accessed format like Medline.  

On the other hand after treating violent and aggressive people and people with severe mental illnesses and addictions for 23 years, it seems like using a professional organization to take a political position on same sex marriage is a stretch.  One could argue that anything that affects the nurture of individuals is relevant to psychiatry, but there are probably few psychiatric societies that take positions on those topics.  I do think this illustrates that the media is much more willing to accept psychiatric opinion on a purely social and political issue, rather than an issue that is immediately relevant to the practice of psychiatry.

I have two minor objections about this initiative. First, it is too easy. The majority of psychiatrists are Democrats and psychiatry is the only medical specialty where that is true. It is fairly predictable that the majority of psychiatrists would support this initiative.  It is good to know that the position is supported by scientific data but I don't think that fact or the fact that psychiatrists support a political measure would carry any weight with voters.  Given the negative press associated with psychiatry and the tendency of the press to to cast psychiatry in the worst possible light, there is also the question of possible backlash against any measure supported by organized psychiatry.  The negative press about the DSM5 and antidepressants are two good evidence based examples.

My second objection is that there are numerous problems that affect psychiatric practice on a day-to-day basis where there should be immediate and very aggressive political action. Some of these topics have been ignored for decades at both the state and national levels. If I had to come up with a top 10 list (no particular order) it might look something like this:

1.  The intrusion of managed care into the practice environment.

2. The intrusion of pharmacy benefit managers into the practice environment.

3. The intrusion of managed care practices into government-funded programs.

4. Mismanagement of public facilities.

5. Mismanagement of quality measures at the population level in the state of Minnesota.

6.  The lack of timely care of acute psychiatric problems (considerable overlap with number one above).

7. Poorly thought out guidelines for reimbursement of psychiatric care emphasizing low quality high volume medication focused practices as opposed to psychosocial treatments that are often as effective.

8. Lack of uniform application of civil commitment statutes on a county by county basis.

9. Lack of crisis intervention services in more than half of Minnesota counties.

10. Inadequate residential services for people with chronic mental illnesses, addictions, and children with psychiatric problems.

In terms of a guiding principle, a professional organization needs to advocate for what adversely impacts its members every day. When you have issues on the above list that are not only pressing but have been pressing for two decades the question becomes: "Why has nothing been done?"  It is much more uncomfortable to do something relevant to every practicing psychiatrist than something that most psychiatrists would have done anyway.

The other factor is that none of the issues on the list was ever voted on.  This is a key dimension in American politics.  Business lobbyists working behind the scenes at the state and federal levels generally get what they want flying under the radar.  They are there every day pushing a pro-business and in many cases pro-government agenda.  The last thing they want is any political reform that actually tips the balance in the direction of patients and physicians.

There were no referendums or amendments put up for a vote when the Minnesota statutes were rewritten to favor managed care companies.  That is where the heavy lifting is for professional groups in American politics and that is where MPS needs to be.

George Dawson, MD, DFAPA

Daniel Christensen, Kathleen Albrecht, Bruce Minor and Bill Clapp.  Children parented by same-sex couples do just fine.  StarTribune October 28, 2012