Q: Maintenance of Certification. What is Dr. Blinder’s position on Maintenance of Certification? Most of my colleagues are boycotting the exams and will not vote for a candidate that isn’t committed to reforming the extortion and time wasting of MOC, the scandal of the conflict of interest from the professional societies who sell CME. Please consider what matters to stakeholders. Many of us are not going to renew membership if this does not get fixed this year. We are done paying money to societies that are taking advantage of us. My impression is that this issue is a hot potato and no one is really going to take a stand despite how this is no good for patients.
A: I understand our members’ frustration, burdens upon them, and irritation with the current MOC process. I am opposed to the current MOC process as it exists now and to the burden it places on members. As APA President, I will assure a fair, rational, practitioner acceptable process for indicating currency in knowledge and competence. I support either an acceptable dialogue with ABPN or seeking an alternative process that is empirically validated and free from conflict of interest both from the specialty organization and the outside examining agency. We need an evolving project to achieve this ambitious goal and hope our patients will be the beneficiaries.
Q: Value of APA membership. The high cost of APA membership and questions about matters such as the effectiveness of the APA Board and Assembly contribute to serious doubts that APA membership offers enough to warrant its considerable annual dues. How would you see addressing issues of APA membership cost and value in a fashion that would lend support to efforts of subspecialty organizations to encourage their members to join or continue as APA members?
A: In the years that I have been a representative in the APA Assembly, I have always worked closely with colleagues representing what we termed the “allied and affiliated organizations.” As an adult and child psychiatrist, adult and child psychoanalyst, and eating disorder specialist, I am very aware of the need to reach out to colleagues in all of the subspecialties to encourage their input to APA, and to acknowledge the special concerns regarding training, practice, recognition, and reimbursement for their work. For a period of time, I chaired an APA caucus for psychiatrists treating eating disorders. Along with other colleagues, I supported movement toward creation of special sections in the APA Assembly to give greater representation and impact for a number of major subspecialty organizations that would qualify for Assembly representation. By the major budget staff, size of membership, and longevity of its national recognition and presence, the APA can and must serve as our strong and effective representative to state and national government and to the public at large. Many active APA work groups and committees are vigorously pursuing members’ areas of concern regarding recertification, access to care, expanded models of integrated and collaborative treatment, funding for education and research, and the mentoring of our students and advancing our early career psychiatrists. Within APA we have to continue to strive for increased intercommunication among all of our members to their representatives and to their national leadership so that all voices are heard, all interests represented, and the full value of psychiatry and all of its subspecialties are advanced and recognized. In my priorities for APA, I envision members with an individual home page linked to APA with their interests accounted for by research reports, a direct connection to councils and committees in which they have interest, receiving progress reports of activity and actions, an ability to pose questions and dialogue, an easy and direct connection to their Assembly and Area Representatives, and to the APA medical director and staff. Other proposals for modification of dues structure to account for individuals belonging to multiple subspecialties have been discussed and will require further analysis, planning and determination of feasibility. The APA must be our unified, strong, clear voice to our country and international colleagues, for all that we value in our profession, for the satisfaction and meaning of our membership and their practice and research activities, and most importantly for the benefit of our patients.
A: For over three decades, I have been a member and worked diligently on the clinical faculty at University of California, Irvine teaching seminars on eating disorders, integrating psychotherapy and pharmacotherapy, obsessive compulsive disorder, and the history of psychiatry. In addition, I have actively been involved in the clinical and psychotherapy supervision and mentoring of Residents, frequently involving them collaboratively in research projects and encouraging their interest in innovative treatments and activities in providing service to the broader community through consultation to medical clinics, and patient based support groups. As a child psychiatrist and past Director of Eating Disorder Research and Treatment at University of California, Irvine, I have encouraged Residents and Fellows to be involved in multidisciplinary collaborative care with health professionals that support and extend our efforts in psychiatry. I have also tried to encourage an in depth understanding of the history of psychiatry with its pitfalls and misadventures. Along with my colleague, Joseph Mawhinney, MD (Area 6 APA Representative and Chair of APA Access to Care Workgroup), I have worked diligently to involve Residents and Fellows in understanding the multiple roadblocks we face in achieving parity and extending the best that we can offer of our medical psychiatry competence and training to the community. The first of two items I would like to specifically mention are an Action Paper in the APA Assembly that I co-authored with Dr. Mawhinney which we hope will create a special APA commission to study and implement curricula and changes in residency education that will emphasize integrative and collaborative care and the expanded role of the psychiatrist in multiple medical settings. Secondly, it has been my privilege to be the Editor of the APA Workgroup Access to Care Newsletter, which has been circulated widely and will continue to inform all of our members of progress in this area.
A: My vision for our future is addressed in a short essay entitled entitled The Evolving Face of Psychiatry: Demons, Molecules, and Genes on this website
A: For many years I have been an active member of the APA Scientific Program Committee. In that capacity, I reviewed the workshops, new research, and Resident and Fellow poster contributions. Every effort was made to encourage innovative projects and concepts related to diagnosis, treatment, and the providing of care to the community. I have edited four textbooks over the years involving advances in child and adolescent psychiatric diagnosis and treatment, eating disorders, and most recently Integrating Psychotherapy and Pharmacotherapy: Dissolving the Mind-Brain Barrier.
As noted previously, I am involved and committed to advancing access to care to the entire community, removing roadblocks and determining how best to work with evolving concepts of access to care organizations and integrative care and medical home models. I have served in the past as chairman of a major psychiatric in-patient department in a large general hospital and was actively involved in consultation liaison service with colleagues in multiple medical specialties. I am very sensitive and aware of the skills and competencies that are necessary and we must teach and develop to collaborate effectively with our medical colleagues for the benefit of all our patients. A short paper on my website entitled The Changing Face of Psychiatry: Demons, Molecules, and Genes might be of interest to you.
A: The education and clinical training for Residents and Fellows in the next decade must emphasize the critical role of the psychiatrist in expanded medical settings, understanding of integrated and coordinated multispecialty and multidisciplinary treatment, and partnership with related health professionals will be essential. In all areas promoting access to care, quality diagnosis, treatment, and patient safety will be paramount. Promoting a joint MD/MPH degree during medical school training would be a great step forward. In retrospect, I wish I had pursued an MPH in my career. Educating the public and lobbying national and state legislative bodies to recognize the shortage of psychiatrists (child and adolescent psychiatrists, adult general psychiatrists, and subspecialty areas such as geriatrics, veteran’s medical services, and consultation liaison) in providing the specialized diagnosis, treatment planning, and care necessary for a healthy society should be an ongoing major effort of the APA at every level. Taking a critical and broad view of collaborative and partnership efforts with health professionals such as psychiatric nurse practitioners, medical social workers, and health planning and coordinating professionals will be an important focus of study and recommendations.
Q: Future of Psychiatry Subspecialties. While child psychiatry offers trainees the chance to receive greater financial remuneration and job security upon completion of fellowship training, the ability of other psychiatry subspecialties to recruit trainees does not necessarily come with these benefits. Given that many trainees finish residency with considerable debt, do you see a role for the continued existence of psychiatry subspecialties such as addictions, geriatrics, forensics, and psychosomatic medicine? If so, how would you help to make subspecialty training more appealing and feasible for today’s graduates?
A: As a child and adolescent psychiatrist, adult and child psychoanalyst, and past Director of Eating Disorder Research and Treatment at University of California, Irvine, I am very much aware of the challenges confronting subspecialty training recognition and integration into the broad tent of psychiatry.
Training requires dedicated funding of fellowships, often sacrifices of additional years of restricted income, and uncertainty that health systems or colleagues will recognize or understand the benefits to patients of the added expertise and range of treatment options being offered. All Residents should receive orientation to subspecialties and an overview of the knowledge base required, trends of research advances, and the range of treatments offered. All medical school treatment centers and tertiary care clinic organizations should strive to create and fund psychiatry subspecialty positions in order to be designated as a comprehensive quality department of psychiatry.
At annual meetings, the APA should continue to emphasize subspecialty tracks such as symposia, workshops, and courses for the general membership. The American Journal of Psychiatry should rotate in every issue a section reporting advances in subspecialty research and treatment to increase dissemination and recognition to the general readership. Finally, we should work toward refining and reforming the treatment and evaluation codes for reimbursement to reflect the additional knowledge and approach to clinical complexity, case formulation, and treatment planning contributed by the psychiatric subspecialist.
Q: Relationship with Other Mental Health Care Providers and Primary Care. Psychiatry continues to be at odds with psychologists, social workers, licensed counselors, and other mental health care providers due to issues of “professional territory” and differences in reimbursements. At the same time, primary care providers and other physicians often cannot discern the difference between one type of mental health care provider and another. What are your thoughts about addressing the tension between psychiatrists and other mental health care providers? How would you address the image problem psychiatry experiences with primary care and other physicians?
A: For many years we have struggled with “turf battles” involving encroachment on our specialized prerogatives including diagnosing, prescribing, and admitting to hospital care. I have participated with colleagues in California, as both Assembly Representative of my District Branch and Area 6 Representative, actively working in the APA Assembly in defending and clarifying our vital role in patient care against ill-considered legislation and alteration of state regulations.
Our emphasis on patient safety and the knowledge and expertise provided by the psychiatrist in diagnosing and treating complex medical psychiatric disorders and providing effective safe medication regimen has been successful in most instances in countering potential adverse consequences to patient care.
However, the future lies not in defense struggles but rather in proactive analysis and planning for the needs of the community and evolving the best models in which we can provide access to quality treatment. Integrative and collaborative diagnosis and treatment models in an extended and variety of medical settings is a pathway we should pursue. We must study and implement the effective models that exist and brainstorm additional creative approaches. The foregoing will involve partnership with a variety of health professionals including nurse practitioners, treatment planners, health counselors, medical social service, home care providers, and close collaboration with our primary care colleagues. With this approach, individuals with a spectrum of training and competency will appreciate and value their roles in a cooperative endeavor and the effective contribution they provide best. We must emphasize training for a future of integrated and collaborative care to our Residents and Fellows and at the same time preserve options for more intensive individual patient treatment utilizing the integration of pharmacotherapy and an expanded evidence-based toolbox of psychotherapies. In the past year, with my colleague Dr. Joseph Mawhinney, now Area 6 APA Assembly Representative, we authored and the APA Assembly passed an action paper calling for the establishment of an APA commission on integrative and expanded models of psychiatric care. The commission, when appointed, will have representative leaders in psychiatric education, practice, research, and public health to plan for the Resident and Fellow training, funding, man power, and treatment models for the future.
Q: Medical Home vs. Homelessness. Psychiatry does not have a defined role in the medical home despite data clearly showing that unrecognized, untreated, and undertreated mental illness contribute to tremendous amounts of suffering, increased health care utilization, disability, and health care costs. This concern extends well beyond the seriously mentally ill with medical comorbidities to include those with anxiety, depression, and other common disorders. How does APA help psychiatrists to claim a role for the treatment of these patients with comorbid medical and psychiatric illness?
A: With over a decade as Director of Eating Disorder Research, I am very much aware of the medical co-morbidity of psychiatric disorders and the need for consultation, communication, and comprehensive treatment planning. Several years ago, I edited a comprehensive text entitled The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment. The 42 chapters include contributions to the evolution of the human diet, the development of eating behavior, neurobiology of appetite and eating including food preference, eating disorders in oncology, during pregnancy, and the menstrual cycle, and even a chapter on dental complications. I believe we need to work toward dissolving the mind-brain barrier and the mind-body barrier, understanding that illness is a multilevel dysregulation, as was insightfully stated by Karl Menninger more than half a century ago, and a disruption in our “vital balance.” Improving our training programs in psychiatry, primary care, and all medical subspecialties to include the fundamentals of behavioral medicine including behavioral phenotypes, developmental adversities, psychosocial casualty, and traumatic influences will be an important step in overcoming artificial boundaries and improving communication and collaboration.
- Encourage Access to Care at all levels of practice. As Affordable Care Act and Accountable Care Organizations evolve, assure that quality treatment is delivered and practitioners’ and patients’ interests are protected.
- Continue to fight against encroachment of non-physicians upon our practice of psychiatry. I have fought for patient safety in California for two decades resisting encroachment on several levels including prescribing. As President I will defend our specific competencies and emphasize all that we have to offer to patients. We also need to evaluate models of care and effective integrated practice models that will demonstrate our social responsibility while assuring patient safety.
- Continue work toward full parity, elimination of formulary restrictions, and creative models of integration with primary care.
- Assure a fair and rational practitioner acceptable process for re-certification. I understand our members’ frustration with the MOC process. I will advocate for our members to have a practitioner friendly, valid, and clinically meaningful and useful MOC process. I support changes in dialogue with ABPN. MOC should be empirically validated and free from conflict of interest both from the specialty organization and the outside examining agency. We need an evolving project to achieve this ambitious goal and hope our patients will be the beneficiaries.
- Continue to promote equitable member representation in governance throughout APA.
- Encourage increase in research and treatment of women’s mental health issues.
- Assure that concerns of women psychiatrists are addressed.
- The education and clinical training for Residents and Fellows in the next decade must emphasize the critical role of the psychiatrist in expanded medical and community settings. Understanding of integrated and community coordinated treatment in partnership with related health professionals will be essential. In all areas promoting access to care, quality diagnosis and treatment, and patient safety will be paramount.
- Utilize an APA based personalized homepage to enhance APA membership connection and involvement in areas of organizational, educational, and community interest.
- Encourage DSM-5 use and modification to reflect the symptoms of psychiatric disorders and diagnostic concerns of clinicians. Collaborate with NIMH to transition from categorical to research based diagnoses.
- Work toward a productive relationship with Pharma that promotes research for new products, understanding our principal of patient safety over marketing interests. Discourage direct marketing of medications to the public.
- Continue open communication between APA Board of Trustees, the Assembly and all Councils and Committees.
- Continue integration and streamlining of APA activities and functions.
- Expand utilization of information technologies to promote public interest which will assist our efforts to increase funding for psychiatric research. As APA President, I will work toward greater connection between APA, our membership, NIMH, and the general public.