Response to the Presidential Address: Advocacy for Our Patients and Our Profession

Thank you. It is with great pleasure that I assume the Presidency of the American Psychiatric Association, following in the footsteps of the outstanding leadership provided by Dr. Michelle Riba. Dr. Riba has brought psychiatry and medicine closer together through her active involvement in the subspecialty of psychosomatics, has highlighted the importance of college mental health and suicide on campuses, and during difficult times, has led the Association with sensitivity, courage, and good humor.

For me, the path to the Presidency of APA has been a long and winding professional journey, a real mental health marathon.

From my residency days in Boston and my work as a community psychiatrist…to Washington, D.C., where I led the federal Community Mental Health Centers Program and helped Rosalynn Carter in her fight to expand access to care.

Then on to the National Institutes of Health, where, as Director of Behavioral Medicine, I puzzled over the psychiatric manifestations of a new immune system disorder called AIDS. From there to the staff of the American Psychiatric Association, where, as Deputy Medical Director, I gained a true appreciation of our complicated and challenging profession.

For the last 19 years, I have run a nonprofit psychiatric hospital system in Maryland, in an era of transformation for the psychiatric hospital. On my watch, our average length of stay dropped from 80 days to 10 days. We survived by expanding our services into community-based settings, special schools for youth, general hospitals, housing, and rehab. And now we are the largest psychiatric care system in Maryland, treating almost 40,000 individuals a year in 33 locations throughout the state.

During this entire time, I have continued to treat patients, publish papers on the economics of psychiatry, and escalate my involvement in APA. This involvement culminated in five campaigns for national office, including a very memorable one 10 years ago, which I lost to my friend Harold Eist.

After this election, I considered restarting my psychoanalysis. But instead, I hit the campaign trail again. Maybe that was a mistake, and I should have returned to the couch.

During these last several campaigns, I spoke with hundreds of psychiatrists about the issues you face and the challenges you have to meet.

Many of you assailed the abuses of managed care. Others expressed concern about the threat of prescribing by psychologists. Some criticized the excessive influence of pharmaceutical companies, others bemoaned the stigma that pervades not only the mentally ill but also the profession that treats them.

I have tried to keep all of these challenges in mind as I have prepared to assume the Presidency of APA. As today has approached, I have asked myself what I can give back to a profession that has given so much to me.

And I have concluded that I gain nothing by mincing words.

Today, I have a simple and candid message. All of the various issues that you and I have discussed over the years are important and deserve APA’s effort and attention.

But none can be solved without addressing a more fundamental problem—a crisis of credibility for American medicine and American psychiatry.

If we step back and survey the health care system, it is not difficult to see what is wrong.

One problem is access. Millions of Americans need care and cannot get it. There are 45 million Americans without health insurance. There are another 20 to 30 million whose coverage for treatment for mental illness is so minimal that they are essentially uninsured.

A second problem is cost. Twenty years ago, health care represented about 10% of the gross domestic product. Today, it is nearly 15% and growing. By 2014 it is estimated to approach 20%, with $3.6 trillion being spent on health care.

The third problem is quality. How well we care for patients is rarely measured and even more rarely reimbursed.

Problems with access, cost, and quality—these are the three sides of an iron triangle that undermines care, satisfaction, and medical progress.

In the face of these challenges, the question everyone asks is, “What should be done?” Yet this may be the wrong question to start with. There is a blizzard of policy proposals that sit unadopted, because nobody has the moral authority to pull together a winning political coalition.

So I would like to draw your attention to a more fundamental question: Who can be trusted to lead?

In one corner, we hear the voice of consumers arguing that the patient and family know best.

In another corner, there are the insurers and employers who tell us to follow the Golden Rule. He who has the gold makes the rules.

In a third corner, large pharmaceutical companies claim that the key to the future is research innovation, and the key to innovation is adequate investment—which requires them to charge high prices.

And then there is our profession.

Unlike consumers, we understand the basics of illness and how to treat it. Unlike insurers, our duty and our Hippocratic Oath are to the patient and not the payer. Unlike drug companies, we recognize that innovative pharmacotherapies are just a small part of the successful management of illness.

Only the psychiatric profession can provide access to care, manage the costs, and ensure quality.

Only doctors are willing to justify the care we provide, respond to the needs of our community, and fight for those who are disenfranchised.

Only doctors have the moral and intellectual authority to break this iron triangle.

Yet, we are failing to lead.

In my view, the problem is not that we don’t have the right ideas or solutions. The American Psychiatric Association supports access to universal health care and fights for the patients. Let me quote from our vision statement:

The problem is not our policy positions. It is that our profession lacks credibility and leverage.

When we speak, too few listen.

And to a large extent, we have only ourselves to blame.

Let me explain.

We do not ensure quality in our own ranks. Our system of self-discipline is erratic, inconsistent, and also not in the public interest. We allow an unacceptable rate of medical errors in our practice, even as we campaign for tort reform.

We have let the biopsychosocial model become the bio-bio-bio model.

As a profession we have neglected the uninsured, the poor, the needy, and the seriously and persistently mentally ill.

We allow gross disparities in health care for racial and ethnic minorities even as we ask for better reimbursement.

We have addressed the challenge of managed care erratically. Many of us opt out of managed care altogether. Others acquiesce to unreasonable limits on the quality and quantity of care.

We have allowed ourselves to be corrupted in this marketplace with lucrative consulting to industry, speaker panels, boards of directors, and visits from industry representatives bearing gifts.

We compromise the core value of confidentiality in an effort to guarantee payment and stay on managed care panels.

We are seen, above all, as an interest group, a trade association, and too often we have behaved like one.

So, in my view, the central issue facing American psychiatry is our credibility. The health care system is in crisis and there is a leadership void. But the days of ringing a bell and expecting to be in charge because we’ve gone to medical school are over.

We must earn back our moral authority.

We must regain the public’s trust.

Let me suggest three steps to this goal:

First, we must recommit ourselves to advocating for our patients. Individuals with mental illness are stigmatized, mistreated, and ignored. We must strongly advocate for better care in battles with insurers and discussions with policy makers. The unconscionable cuts in federal Medicaid passed recently by Congress will hurt our patients first and foremost. Medicaid is the safety net program for the seriously and persistently mentally ill. They will be neglected during this period of fiscal retrenchment unless funding is restored.

Our advocacy must extend beyond the doctor-patient relationship to broader issues of the public health. Thousands of youth are incarcerated unnecessarily each night because community mental health services are not available. This must be psychiatry’s concern.

Adults with mental illness are shot and killed by police who have little or no training to deal with them. This, too, must be psychiatry’s concern.

We will not always agree with the consumer movement. But we can do much more to show that our disagreements are born of our judgment, not our self-interest. We must make creative alliances with such groups as the Alliance for the Mentally Ill and the Mental Health Association in pursuing our objectives. The advocacy of Nada Stotland, APA Trustee, with the Mental Health Association is one example of psychiatric advocacy at its best.

Our second step toward credibility is to create and enforce ethical standards to make the rest of our nation take note.

While there are many ethical areas for improvement, let me briefly mention the topical issue of the relationship between psychiatrists and the pharmaceutical companies. It is my view that these relationships have been rife with the appearance of conflict of interest and, frankly, with conflict of interest itself.

These topics are becoming better known to the public. We must stay ahead of the curve, evaluate arrangements, provide guidance, and set standards. We must strengthen the integrity of our continuing medical education. Ultimately, we must recognize that pharmaceutical companies, as profit-seeking companies, make offers that can and must be refused.

Our third step is to defend our core professional values, including confidentiality, academic inquiry, and scientific integrity.

It is not proper in an age of terrorism to insist upon total confidentiality of our records. But it is appalling that the government, through the Patriot Act, has the right not only to see our records but also to forbid us from telling our patients of this breech. Speaking up for confidentiality, even if we have a lone voice, is absolutely essential to our credibility and our professionalism.

Another core value is academic inquiry. As a scientific profession, we need data. It is unacceptable for any drug company to withhold clinically important information from us and our patients. Thanks in large part to the efforts of Dr. David Fassler, another wonderful advocate for American psychiatry, APA has made great progress in access to data. We continue to fight for legislation establishing a registry for all clinical trials.

And then there is the core value of scientific integrity. On the fringes of the political spectrum are individuals who want to shut down mental health as a field, maybe because it involves medications, or it involves vulnerable groups in our society, or they believe there is no such thing as mental illness.

Sometimes these fringe individuals and organizations are surprisingly close to the political centers of power. For example, a member of Congress, Representative Ron Paul, is crusading against psychiatric care for children. He claims that psychiatric diagnosis is inherently subjective, that psychiatric treatments frequently ruin the developing brains of children, and that mental health screening in schools has—and I quote—“no place in a free and decent society.”

Let me send a message today to Representative Ron Paul, a physician. As President of the American Psychiatric Association, I support a “free and decent society.” A society where all youth and their families can obtain care for devastating mental illnesses. A society where parents have the freedom to seek such care without the stigma that you spread with your ignorant attacks.

Threats to scientific integrity are also coming from government agencies that our profession has long respected. Just a few months ago, officials at the Substance Abuse and Mental Health Services Administration demanded that researchers presenting a study about the suicidality of gay, lesbian, bisexual, and transgender individuals not use the words “gay,” “lesbian,” “bisexual,” and “transgender.”

Now, some might say that we need to overlook such incidents and defer to those in power to avoid losing some of the little perks that an Administration can offer. This type of thinking is penny wise and pound foolish. If we abandon our core principles, then we lose our moral and professional authority—which is the light we must use to lead.

Telling researchers to delete the words “gay,” “lesbian,” “bisexual,” and “transgender” was a profound insult, not only to all of us who support the rights of gays and lesbians, but to science itself. When asked by the Washington Post to respond to scientists’ concerns, the Administration’s spokesperson took offense at protests from—and I quote—“these people.”

We need to send a memo.

TO: Anyone who will try to interfere with scientific progress on mental health and psychiatry

FROM: The American Psychiatric Association

MESSAGE: We are “these people.”

During my Presidential term, I will work on psychologists’ prescribing, malpractice, parity, and other issues. Above all, I will work tirelessly to enhance the credibility of our profession.

If you are already shaking your head, let me console you with a little cognitive behavior therapy. Just keep reminding yourself that my term, as any Presidential term, is only a year. No one person can do too much damage.

But if you share my concern about our profession and its future, I urge you to become more involved in APA. Urge your colleagues to join APA and give back. Become active at the local and national levels, and advocate.

This is a message that I know would have pleased my good friend, Jay Cutler, who served as the chief lobbyist and advocate for the American Psychiatric Association for over 25 years. Jay died just a few weeks ago. When I visited him in the hospital, on the day before he died, he apologized to me. He said he was sorry because he knew that he would not make it to Atlanta to hear this speech. That’s the kind of person Jay was. My commitment to advocacy is inspired by Jay’s example.

In Jay’s honor, let us set a goal of transforming psychiatry, setting examples for American medicine, and ultimately remaking our flawed health care system.

This is not just a goal worthy of our profession. It is the only goal worthy of our profession. Let us all “give back through advocacy.” Thank you very much.

Presented at the 158th Annual Meeting of the American Psychiatric Association, Atlanta, May 21–26, 2005. Dr. Sharfstein, 132nd President of the American Psychiatric Association, is President and Chief Executive Officer of Sheppard Pratt Health System, Baltimore, and Clinical Professor and Vice Chair of the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Address correspondence and reprint requests to Dr. Sharfstein, Sheppard-Pratt Health System, 6501 North Charles St., Towson, MD 21204-6819; [email protected] (e-mail).