Response to the Presidential Address: Opportunities and Challenges for Psychiatry

Before I begin, let me introduce a few people to you. With me today are my parents, Goodman and Zelda Tasman—most of my good qualities come from them; my bad qualities are probably my own doing—Harriett Waldman, my favorite aunt; Cathy, my wife, who has been my partner in all things; and Josh and Sarah, the next generation of Tasmans. David is studying for finals and isn’t here in person. I am so proud of all of you. I can’t thank you enough for your tolerating all the time my professional work has taken away from time I would have otherwise spent with you. Your support and love have helped me succeed more than anything else.

My APA work succeeds because of the efforts of many colleagues, especially those at home in the Department of Psychiatry at the University of Louisville. I’d like you to meet the person who really runs the department, my assistant, Joan Lucas.

There are so many people who are standing with me—people like Jerry Kay, Ray Cohen, and Dan Winstead—and sharing the credit for my being here today that I cannot possibly name all of them. But three I must mention. Michelle Riba and Jim Bozzuto are friends and colleagues whom I can’t recognize enough for their advice, their support, and their friendship. Barry Sherman is someone none of you know, but he may be the one most responsible for my being here today. Barry was in the eleventh grade and president of our local B’nai B’rith youth group when I joined as a very shy and very insecure ninth grader. Somehow, he told me later, he saw a potential spark of leadership in me and, playing the role of big brother, nurtured that potential into its first reality. I was lucky—firstborn children usually don’t get to have a big brother.

My talk today is both a reply to our President and a statement of my hopes for the coming year. Responding to Rod is easy, because his generosity of spirit, his inclusiveness, and his well-organized and thoughtful leadership have set a high mark that will be difficult for anyone to repeat. I feel doubly lucky because during my entire year as President-Elect, we have worked together to bring our shared vision for APA and our members into reality. Many of the hopes I have had for my Presidential year have already come to fruition because Rod reached out and incorporated my agenda into his own. The APA strategic goals you have in your hands will be one of the legacies of Rod’s presidency. I am proud of our accomplishments—our vision of transforming APA is well on its way to becoming a reality, and I look forward to next year and working with Dan Borenstein, our next President-Elect, in the same way.

As we look forward to next year and to the opportunities and challenges the new millennium will bring, let me share a brief reflection. Just over a hundred years ago, Freud finished working on two manuscripts. One, The Interpretation of Dreams, would become a seminal work in the development of psychoanalysis and twentieth-century psychiatry. The other, “A Project for a Scientific Psychology,” was put, with much frustration, into a bottom drawer and not discovered by the psychiatric community until the 1950s, years after his death. In “A Project,” Freud was trying to develop a framework to describe the neurophysiological basis for mental processes. He claimed to have given up on this attempt because of the inadequate state of understanding of the central nervous system at the time. Nonetheless, his quest to understand the neural basis for mental functioning has been a central endeavor of psychiatric research in this century.

I have little doubt that Freud would be both amazed and gratified about the dramatic gains in our knowledge base over the last century. And in spite of the economic difficulties facing all of medicine, I have no doubt that this is the most exciting time in history to be in psychiatry. Our profession is robust, and our knowledge base is expanding dramatically. I don’t need to tell you that research advances in many areas—ranging from molecular genetics, functional neuroanatomy, neurochemistry, and neurophysiology to new psychotherapeutic and psychopharmacologic interventions and new systems of treatment—are transforming our understanding of brain function and the etiology, diagnosis, and treatment of psychiatric illnesses. Work in neural plasticity, for example—with findings that developmental experiences, not just genetic endowment, alter brain structure and function— has reinforced our view that the best approach to psychiatric understanding and intervention is the bio­psychosocial model, which has formed the core of our approach for decades.

With the continued expansion of our knowledge base from increased federal and private support, and as the only clinicians trained with expertise in bio­psychosocial understanding and intervention, our roles as providers of sophisticated psychiatric care and coordinators of treatment should be enhanced. While our interventions for biologically based brain dysfunction will become more effective, patients will still require both psychotherapeutic and psychosocial treatments to help them live in a new world of perception and experience, now no longer affected by the symptoms of their illness.

I am going to focus my remarks on four specific areas in psychiatry’s future: clinical practice, the workforce, the patient advocacy movement, and information technology. I’ll then take a few minutes to review APA’s strategic planning goals.

I’ll start with clinical practice. We are all aware of the problems in delivering high-quality care that have been brought about by the present form of managed care. The managed care focus on cost containment at the expense of quality is an approach that I do not believe will persist. You know that there has been an in­creasing flurry of newspaper and magazine articles over the last several years outlining the difficulties in both the finances and the practice of the present form of managed care and the public’s increasing demands for change.

As a profession, we must now complement our focus solely on the managed care companies and also address more specifically how decisions on mental health coverage are made. We must educate corporation CEOs, purchasers of health care, and public policy decision makers about the long-term corporate and public benefits of parity coverage for mental health, and we have several initiatives underway to accomplish this. While I do not feel that it is likely that we will return to the pre-managed-care era, I have no doubt that psychiatrists can and are beginning again to play an increased decision-making role in systems of care, as they already are in Seattle, Chicago, Louisville, Pittsburgh, San Diego, Los Angeles, Boston, and Connecticut, to name just a few places.

Clearly, APA must play a greater role in providing clinicians with the tools to regain leadership in clinical decision making and care delivery and the backup necessary to sustain an activist position. One of those tools is better data; we need more understanding of the etiology of illness, development of etiologic-based diagnostic classification, treatment matching and outcome data, and service systems data.

Even in the present environment, however, there are many specific clinical areas where there are major opportunities. Let me just name a few. It has been estimated that of the 7 million children annually who have an episode of acute psychiatric illness and are in need of care, only 20% see a child psychiatrist, and 50% have no access to treatment at all. The aging of our population, with the baby boom bulge over the next 20 years, provides tremendous opportunities for geriatric psychiatry.

Forensic psychiatry and addiction psychiatry offer major and growing opportunities for us, especially in our public sector programs.

The intersection between medicine and psychiatry provides new horizons for psychiatry. I have no doubt that we have a major contribution to make in the care of the medically ill, and I am equally sure that this improved care will result in better compliance with treatment, better self-management by the patient, better quality of life, higher functional capacity, and reduced long-term costs.

You are well aware that many states have begun to move their public sector Medicaid populations into managed care programs. This has been accomplished, generally, through contracting with large for-profit managed care corporations, but some states have gone a nonprofit route; programs with significant psychiatrist leadership have already been organized in Pittsburgh, Galveston, Los Angeles, Louisville, and Boston, among others.

Let me turn to a second major issue that influences our future—that of the workforce. In 1997 the American Medical Association and five other major medical organizations published a position paper that declared, with no backup data, that there were too many physicians in the United States and that to deal with this, the number of residents in training should be decreased to a level of U.S. graduates plus 10%. As you are also aware, many of these proposals have been coupled with a proposed requirement that 50% of all slots be directed toward primary care programs. Under such proposals we could lose as many as 40% of our training slots in psychiatry. While in some parts of the country and in certain sectors of practice, the present problems with managed care have caused great distress among our colleagues, there is no nationwide evidence that we have a surplus of psychiatrists.

As chair of the APA work group on workforce issues for the last 3 years, it is clear to me that decisions on the workforce are being made in a highly politicized atmosphere with little attention to whether patients have access to high-quality psychiatric care. We know that, in fact, there is no such thing as universal access. Many patient populations at present have inadequate access. Examples are children, the elderly, those in jails, prisons, and public sector programs, those living in rural areas, those with severe and persistent illness, those with dual diagnoses, those living in poverty, and members of many minority groups.

In addition, workforce needs relate to appropriate scope of practice. While most commercial managed care programs state that our appropriate scope of practice should be limited to medication management, I have no question that decisions about treatment should be made by the physicians who evaluate the patient, not by clerks sitting in front of a computer screen in another state. Workforce projections are based on a series of assumptions that can be easily manipulated. These assumptions include such basic issues as how many hours a week you will work, how many of those hours will be devoted to patient care, how many minutes you will see each patient, and what scope of practice is involved. We must work to ensure that the ongoing debate focuses not only on appropriate access to high-quality care but also on an appropriate scope of practice for psychiatrists.

Regarding the effect of the patient advocacy movement, we have an army of advocacy groups looking to us for leadership in the mental health arena, and we have tremendous political opportunities if we make greater efforts to ally ourselves with our natural constituency groups; such alliances will provide significant political support in Congress and for the hundreds of bills that have been introduced into state legislatures over the last several years to support parity, patient protections, and confidentiality.

Last month I was honored to stand with leaders from the National Mental Health Association and the National Alliance for the Mentally Ill as Senators Wellstone, Domenici, and Chafee introduced the 1999 mental health parity bill in the Senate. One thing we have learned in the past few years is that we must take an activist position regarding public and corporate education and advocacy for our patients and our profession. To accomplish these aims, I am committed to forging closer links with our patient advocacy allies and devoting more resources to public education and government relations.

The last area that I’d like to discuss is the influence of information technology on our field. We have clearly come to a time in history when it is taken for granted that human physical presence is not necessary for communication. The increasing use of telepsychiatry is an example of this. This poses interesting challenges for psychiatrists as we contemplate the future of our profession in the information age.

Except for unforeseen societal catastrophe, there is little question that computing technology will continue its exponential rate of development. The advances in “virtual reality” devices, as an example, bring us close to a point when it may be moot to ask if experiences in a “virtual” environment are “real” or “valid.” For example, some behavior therapists are now using virtual reality programs to treat phobias. Further, as computer logic systems advance to a point where “artificial” intelligence systems mimic human mental processes, our ability to not only understand but modify mental processes will take a quantum leap.

We are on the cusp of an abrupt transition to a new, mostly human-created developmental environment. We know of the tremendous advances being made in genetics and the likely impact on physical status; we should also anticipate a parallel ability to re-create and modify ourselves mentally through advances in information technology. Even more amazing, direct human brain-machine interfaces are now being developed—the best known examples are cochlear implants for use in the hearing impaired and similar systems for the blind. Also, some of you are aware of recent success in an animal model in accomplishing the growth of dendrites into very small plastic implants in the brain and the results of experiments in which paralyzed patients use self-modulated alterations of brain waves to “write” messages with a computer. While now only in the realm of science fiction, devices to modify memory or change patterns of emotional responsiveness may be developed within the period of the careers of young psychiatrists already in practice.

Control of such technology will likely become one of the most critical societal decisions of the information age. The coming political battles over confidentiality of patient records are only a beginning of this ongoing debate. However, we have many issues to address and many useful applications of technology to implement, even with all of our concerns in mind. At present, our use of computer technology in psychiatry in clinical care, education, and research is in its infancy. Computer use for “number crunching” has revolutionized research, but computer modeling of mental processes is primitive.

In the clinical arena, there is the potential that information systems can be used for great improvements in clinical care as a result of large-scale treatment matching/clinical outcome research and other types of clinical and basic research. However, threats to confidentiality of patient records, because of the widespread transmission of clinical information across computer systems, is now a major concern.

Educational uses of technology are also in the earliest stages of development. Especially in psychiatric education, the experiential mode of learning forms the heart of our training. What can be appropriately learned through “virtual” experience remains a fascinating challenge for educators who find great potential in new educational tools.

Thus, we have an unparalleled set of challenges as information technology and psychiatry intersect. There is tremendous excitement as we explore meaningful ways of using present computer systems in our research, education, and clinical missions. At some point, however, as more and more of our world is formed and modified by electronic information, we will have to face the issues I have just raised. The science fiction writer Philip K. Dick continually investigated the nature of reality and its potential modification through technology. In his imagined universes, machines designed as simulacra of humans often show themselves to be more “human” than their flesh-and-blood counterparts. Our profession of psychiatry, placed in the role of arbiter of sanity and reality, both by virtue of our training and by societal sanction, must face the challenge of preserving the “human” within an increasingly mechanistic world. This task will become of more and more central importance as our world undergoes the chaotic and often painful transmutation into the next iteration of the information age.

Let me now close by taking a minute to discuss how APA is moving to address the many changes now confronting us. As most of you know, for the last several years APA has been engaged in a strategic planning process. Thanks to Rod Muñoz, Dale Walker, Richard Harding, and many others, this effort is complete, and the Board of Trustees has already taken action to begin to implement the recommendations of the broad-based review that has been in process. The Board affirmed five strategic goals for APA, which you can read on your handout.

As you see, we have an ambitious agenda, but one that reflects the stated priorities of our members and that is essential for our future. This coming year will be marked by the implementation of many major initiatives, a number of which began last year.

The heart of our profession, and the reason I became a psychiatrist, is to care for patients. Of over 1,500 patients I have treated, one stands out to me. Over a 10- year period, I provided continuous treatment and care to a young woman severely troubled with significant personality problems, very serious anorexia, and nearly constant suicidal and self-destructive wishes. I have little time to describe our work together, but we both worked hard to develop and maintain a therapeutic relationship, which provided the context within which we were able to keep her alive and address and overcome many of the problems that disabled her. I am proud of many things I’ve accomplished in my career, but none has been more meaningful or important to me than my work with this patient. Each of us has a similar story we can tell, and I promise you that I will commit all my energy to work to ensure that every psychiatrist now in practice and every psychiatrist to come has the opportunity to provide whatever care is necessary to treat those who come to us in need. Because of the centrality of our therapeutic relationships with patients to this work, to ensure that the future practice of psychiatry integrates the best of our humanistic traditions with the latest scientific advances, and to emphasize this timeless core of psychiatry, I have chosen “The Doctor-Patient Relationship” as the theme for next year’s annual meeting.

While there are clearly many other important issues to discuss in more detail regarding the future of psychiatry, suffice it to say that I believe the future is very bright. We now have the resources at hand that will allow us to continue to make tremendous gains in our ability to provide excellent treatment for our patients. Some of what we are now learning we could only dream about just 10 or 15 years ago. With all of the chaos and turmoil in the health care system swirling around us, we often lose sight of how much say we really have in determining our future. I am optimistic and confident that we will continue to play the major role in determining the future direction of our profession, and I look forward to working with you over the coming years to ensure that we continue to enhance the highest standards of our profession.