xxAACP Newsletter, Volume 12, Number 1, Winter 1998
APA Presidential Candidated Respond to AACP Concerns
THE CANDIDATES:
Allan Tasman, MD
Allan Tasman, MD, is Professor and Chair, Department of Psychiatry and Behavioral Sciences at the University of Louisville School of Medicine. An AACP member, he is also a member of the GAP Committee on Psychiatry and the Community, and was a member and chair of the Connecticut North Central Regional Mental Health Board -- he was twice commended for his public sector advocacy efforts in Connecticut. He is also President of the American Association of Chairmen of Departments of Psychiatry and Vice President of the APA. Dr. Tasman has a website at http://louisville.edu/~a0tasm01
Robert Michels, MD
Robert Michels, MD, Walsh McDermott University Professor of Medicine, Cornell University Medical College. He is a past President of the American Board of Psychiatry and Neurology, past President of the American College of Psychiatrists, past Predident of the American Association of Chairmen of Departments of Psychiatry, and a former member of the Board on Mental Health and Behavioral Medicine at the National Academy of Sciences, Institute of Medicine. He is the author of more than 200 scientific articles, and is or has been a member of several editorial boards and is chairman of the editorial board of a major textbook, Psychiatry.
1. The APA has traditionally been perceived as being concerned with the interests of the private psychiatric practitioner. Do you think that this perception has been accurate, and if so, how would you envision an evolution of the APA's focus in the future? If not, what must be done to change this perception?
Dr. Tasman:
As a member of the American Association of Community Psychiatrists, and one who has devoted a substantial proportion of my career to community psychiatry work, I am well aware that APA support for community psychiatry and public sector psychiatric programs has often taken a back seat to advocacy for other aspects of psychiatry. Given the critical needs of patients with severe and persistent pssychiatric illness, who are largely treated in public sector programs, and the devastating impact of the move of public sector programs into managed care, it is essential the APA take a more aggressive position regarding support for public sector/community psychiatry. What must change is not merely a perception of support, but a change in priorities. My history of work in support of community psychiatry programs, both in my own professional career and in my role as APA Vice President, is a clear indication of my commitment to future action. More support for public sector programs is already a key part of my platform.
Dr. Michels: For many years, psychiatrists were viewed by both the public and the profession as solo private practioners working individually in their offices. Even when this perception was no longer true, it continued to guide the APA's structure and its agenda, particularly since it did reflect the reality of the practices of many of the senior members -- those who held leadership positions in the organization.
Today the average psychiatrist, particularly the average younger psychiatrist, is either an employee or member of an organized group. There have always been organized groups in the public and private not-for-profit sectors, but now even the private for-profit sector is rapidly being transformed into organized systems with staff psychiatrists or contract workers. The APA must reflect the reality and the heterogeneity of its members. In order to achieve this, it is necessary to convert its current oligarchic structure, with a small group of senior dedicated colleagues remaining in power, while others, equally capable, younger, and from different backgrounds, are excluded. Many years of devoted service to the APA is a reason for our respect and gratitude, not for appointment to an additional leadership position.
2. International medical graduates are over represented among those who provide services to state hospitals and other public systems of mental health care. In light of current national activities which could very easily result in reduction in the number of psychiatric practitioners, particularly in the public sector, what should the APA do to assure adequate and appropriate coverage of these practice sites?
Dr. Tasman: Public sector psychiatric programs have historically suffered from significant workforce recruitment problems. Decreases in state and federal support for community-based psychiatric programs and impending restrictions on international medical graduate psychiatrists will make this problem even more critical. We know that decisions regarding the workforce are being decided in the political arena at the present time. Strategies to address these problems must therefore focus primarily around government relations and public affairs activities. We must work aggressively to assure that federal and state government support for community psychiatry programs is a priority in the hierarchy of APA lobbying. The development of incentive programs encouraging psychiatrists to work in community psychiatry settings should be a centerpiece of such efforts.
Dr. Michels: The current national policy on our medical workforce divides physicians into two groups, generalists and specialists, and argues that we have too few of the former and to many of the latter. This is a seriously flawed proposition, and thus a poor guide for public policy. There are many different kinds of specialists, and while we may have to many specialist surgeons in Boston, we have too few public sector psychiatrists caring for the chromically anc persistently mentally ill in most of the United States. The APA should take the lead in guiding professional medial organizations, such as the AMA and the AAMC, and the public, to reformulate the problem. Our goal should be to ensure quality care for all of our patients, even as our workforce is readjusted. This means recognizing that specialist physicians are a hetergeneous group, and that plans to readjust the workforce must be rejected as unjust unless they provide for continued and improving care for the least advantaged.
3. What would you propose doing about the large number of individuals suffering from severe and chronic mental disorders who have been shunted into jails and prisons and are receiving inadequate care there?
Dr. Tasman: We must develop new resources to address the problems of individuals in forensic settings who suffer from psychiatric problems. This will involve a variety of approaches. First, we must work to ensure that patients whose primary problem is psychiatric, not criminal, but who may first be identified within a forensic setting or a criminal justice system, are appropriately diverted at an early point to psychiatric services rather than criminal justice programs. The development of drug courts to divert individuals with substance abuse or dual diagnosis problems into psychiatric services and away from the criminal justice system is a successful example of the kind of programs which must be developed. Further, we must work in the political arena to develop public support for adequate psychiatric services for incarcerated individuals with psychiatric problems, especially those suffering from chronic, persistent mental disorders. Legislative and litigation approaches must be part of our strategy. The development of services in Kentucky required litigation to require the state to provide more adequate funding for programs to divert individuals with psychiatric illness from the criminal justice system and into psychiatric treatment. The role of the APA in this matter must be strengthened and geared to place more emphasis on this issue. As APA Vice President, I have supported the establishment of a section on correctional psychiatry to help focus the development of the APA's agenda in this area.
Dr. Michels:
Many years ago John Talbott and I pointed out that we had not really deinstitutionaliized most of the patients in our large public hospiitals, we had only transinstitutionnalilzed them to non-medical institutions such as jails, prisons, and residential families. The need for psychiatric care does not diminish as one changes one's address! The cost of delivering adequate psychiatric care to citizens living in jails and prisons is significant, but the cost of not providing it is immense. We must collect data on the epidemiology of psychiatric -- including substance related -- disorders in these populations, the effectiveness of treatment, the treatment costs and savings, including cost-offsets in the social welfare and criminal justice system, and the costs of no treatment. This information, used effectively, will win this struggle. Even legislative budget committees interested in the narrowest economic considerations want to reduce costs, and we can help them achieve their goals while furthering the profession's most humanistic mission.
Back to Winter 1998 Table of Contents