2020 Spring Highlights Meeting: Presidential Address

Good afternoon, and thank you for tuning in and being part of the Spring Virtual Meeting starting with this opening session. It is an honor to address you as I conclude my term as APA President.

None of us will ever forget 2020 and the coronavirus pandemic, which has created a new normal which we never could have imagined. I work in New York City, which so far has experienced the worst of the epidemic in the U.S. We have lost colleagues, friends, and neighbors. The heroes of this pandemic are the health care professionals and workers who risked and, for some, sacrificed their own health and well-being, as well as that of their families, to minister and care for their fellow human beings. I especially want to acknowledge the heroism of our residents and fellows, many of whom interrupted their training to help provide acute medical care in the hospitals and ICUs, being a visible reminder that we are physicians first.

This epidemic has made it an imperative that health and mental health care become a national priority. The complacency and predictability of the world that was previously a part of our day-to-day lives is gone.

For the frontline responders, the trauma of witnessing so much illness and death will have lasting effects for many. Amid the epidemic, one of the greatest needs of our fellow health care professionals, after their need for personal protective equipment, was for counseling and treatment. We were there, as well as psychologists, social workers, nurses and nurse practitioners, counselors, and support staff, to continue to meet the needs of our patients and colleagues. The entire mental health workforce had to be mobilized, and interdisciplinary collaboration was all that allowed us to cope with the health and mental health emergency. We will need this full workforce to cope with the psychiatric effects after this epidemic passes as well.

My year as your president now feels like a long-ago chapter of my life, but it was a busy and fulfilling year. I would not have been able to do it without the full support and encouragement of my Chairman at Montefiore and the Albert Einstein College of Medicine, Dr. Jonathan Alpert. I want to thank Dr. Alpert for affording me the opportunity to take this rewarding journey as APA President and giving me the time I needed to do this job.

I also want to thank my family: my wife Andrea and my children, Marisa, Daniel, Elizabeth, and John. The APA presidency is an honor but also requires a great deal of travel and investment of time. Throughout it, they encouraged and supported me. And Andrea and I were so proud to watch our daughter Marisa and her team at Mt. Sinai present at the Fall IPS meeting in New York City.

To the Board, Dr. Levin, and the Administration of APA, thank you for helping me achieve what I did this year and for all you do, day in and day out, on behalf of psychiatry. Their efforts, often behind the scenes, need to be praised and recognized. And thank you to Dr. Phil Muskin and the Scientific Program Committee for a meeting which unfortunately has undergone radical surgery to transform it into a virtual online meeting. You succeeded at fulfilling my theme and put together an outstanding program, which I expect our members will appreciate in its reduced form.

My appreciation as well to Dr. Tristan Gorrindo and APA staff who adapted to the necessity of canceling our in-person meeting but worked tirelessly to create this webcast and a psychiatry on-demand version of the annual meeting. APA is a wonderful organization which demonstrated its adaptability to a crisis.

Now, I’d like to speak briefly about my year as president and some of the goals that drove us through the year.

When I spoke to you last year, I mentioned three priorities: improving quality, promoting access, and reducing stigma. All three have been a part of my presidential year. The focus on quality was incorporated in the theme of this meeting—Advancing Quality: Challenges and Opportunities. Enhancing quality is a highly complex undertaking. Quality means very different things, depending on your vantage point. But improving actual quality in education, clinical care, and research is the key to many of the issues we face.

I fear we have lost control over the definition of quality. Today, many mistake measurement and documentation for quality. Albert Einstein was prophetic when he said, “Not everything that counts can be counted, and not everything that can be counted counts.”

Electronic medical records have made data readily available but have not yet really impacted quality. But the state of current EMRs have created another challenge. Physicians spend an increasing amount of time on documentation. A study released in February in the Annals of Internal Medicine looked at 155,000 physicians and found that on average, they were spending 16 minutes per patient visit on EMRs, which translates into hours in front of a computer instead of with your patients. A Rand survey found EMRs take more time than paper records and that notes were less clinically useful.

Many of us remember, EMRs were promoted as the tool for improving the quality of care. And there are many pluses: they make it easier to retrieve test results, order and monitor prescriptions, and view other physicians’ notes. But for hospital systems and practices, we know there’s another bottom line: increasing billing revenue.

Whether that’s actually working for the hospitals is questionable, given the expense and operational cost of these systems, but for doctors, it’s become a burden. I fear that EMRs are doing little for quality and are contributing to the problem of physician burnout.

EMRs capacity to store data has driven what has been called “measurement mania.” Measurement is problematic in psychiatry where we are especially reliant on a patient’s report of subjective symptoms. But a measurement-focused mindset can creep into areas where it begins to muddy the view of overall outcomes, or worse, incentivize behaviors that ultimately become detrimental to the goal at hand.

Measurement is important, but it is not a simple solution for determining either treatment or quality. A laser-like focus on symptoms doesn’t necessarily relate to actual outcomes. Does it matter whether you’ve reduced a symptom of a patient’s illness if they’re still not able to hold a job or can’t function in their lives? You can argue that it’s good to cure or lessen a symptom, but not if it obscures our perspective of our patients’ overall well-being.

Another well-meaning initiative that may lead to unintended consequences is universal screening. That’s the idea that everyone who goes to a primary care practice, presents to an ED, or is admitted to a hospital should get asked a few simple questions to determine if they’re at risk for suicide. The concept has found many supporters amid the suicide epidemic.

But when we demand medical personnel with no mental health expertise or training administer a checklist to identify possible suicide risk in their patients, we are asking for false positives. We as psychiatrists know how incredibly challenging it is to predict suicidality, and asking overworked ED staff or PCPs, who haven’t had the training to figure it out in the few moments they have with a patient, is inappropriate.

Those false positives can turn into overbooking of mental health professionals, which in turn can lead to less care for those most in need of treatment. That’s why I find universal screening of concern. But again, it’s an example of measurement driving the practice of medicine—we’re asking, “Did you check the box on whether the patient is suicidal,” not “Is the patient well?”

We most certainly need EMRs, as the epidemic has demonstrated, and better targeted mental health screenings. There may be an analogy in education, where tests, while needed and well-intentioned, can start dictating curriculum and the phenomenon of teaching to the test. In psychiatry, ignoring health disparities, poverty, poor housing, unemployment, abuse, and neglect will increase scores on a PHQ-9, which are not going to respond to repeated adjustments of medication.

We have to ask ourselves, What really is quality? It should not be how much the care costs or the production of quarterly treatment plans, which regulators or payors use to judge the quality of care. We need to think about quality in terms of improved patient short- and long-term outcomes, maintenance of or improved quality of life or functional status. We need to be focused on helping patients with severe mental illness live better lives.

This is a battle which is ongoing. Productive discussions occurred on Capitol Hill and with the Joint Commission, but unfortunately the COVID epidemic has delayed many of those efforts.

Improved access was another priority. When we look at the number of people with severe mental illness in this country, 40% receive no treatment in the course of a year. Hundreds of thousands are incarcerated or homeless. Our mentally ill suffer as well from marked health disparities. How do we as psychiatrists reach them with care that makes a difference? If we can improve their access to comprehensive care, then we are achieving the noblest goals of psychiatry, and indeed of any medical profession.

There are many obstacles to achieving this vision. Caring for patients with serious mental illness requires teamwork and collaboration. We had an historic meeting at the APA headquarters in January. The APA Task Force on Interprofessional Collaboration brought together all the organizations representing the many mental health disciplines, from peer counselors, advanced practice nurses, social workers, physician assistants, cognitive-behavioral therapists, and NAMI, to name only a few of the participating organizations. There was universal agreement that collaboration is an essential requirement to care for individuals with serious mental illness. This meeting was a powerful and first step in developing and agreeing to principles of collaboration around which we can coalesce and a demonstration of the leadership APA can bring to a long-standing major public mental health crisis. There is a whole lot wrong with our health care system. Collaboration isn’t the whole solution, but it is a step in the right direction.

If there is one lesson from the COVID epidemic, it is the altruism and selflessness demonstrated by all health care professionals. We worked together for the treatment of severely ill patients. In mental health, interprofessional collaboration is essential as well to help ameliorate the shortage and maldistribution of clinicians.

We are faced with multiple tragedies in our country, not just coronavirus: most people with severe mental illness are winding up incarcerated, homeless, or on probation. The loss of human potential is breathtaking. This reality is something that should deeply shame our society.

As psychiatrists, we possess the knowledge and expertise and must be central to this endeavor. It is my belief that we have to help lead this effort. Ultimately, it is only by working together that we will begin to solve this problem. We must as well work to eliminate inadequate insurance reimbursement, the absence of needed psychiatric beds and community resources, improve housing for the mentally ill, and increase treatment in our jails and prisons and alternatives to incarceration.

The intricacies of practicing medicine within the nation’s health care system have been brought to the fore by the COVID epidemic. We are faced with daunting problems. There are times this year when I’ve admittedly felt discouraged. For instance, we have not succeeded in convincing CMS to add significant funding for more psychiatric beds for the very sickest of patients or to rescind their enforcement of ligature rules—yet!

“Yet” is the important part. There have been many times this year where APA has taken a stand, has been successful, and has made a difference for the patients and the families we ultimately serve.

We continued our strong advocacy for the children who have been separated from their parents at the U.S. border. We made our position clear and built upon what Dr. Stewart started during her tenure as the situation continued to unfold. We made public statements, participated in legal cases, and worked with members of Congress and the Administration to stress the importance of meeting the physical and mental health needs of these children.

We didn’t shy away from using our voice as psychiatrists in the mainstream media to call attention to issues impacting our practice and quality. In one instance, I spoke to The New York Times about the questionable practice some pharmaceutical chains have adopted of defaulting to 90-day prescriptions in lieu of following doctor’s orders. We were the sole medical society cited in that piece, and I was proud to have been a part of it.

We spoke “on the record” about how some policies, designed to minimize ligature risk, have caused some psychiatric units in hospitals to close or reduce beds. These were instances where we were the voice of medicine about important issues that impact our practices. We used these clinical examples to reinforce our message on the Hill.

Congress and the administration heard from the APA in person several times this year. Importantly, APA joined with the Group of Six, which represents more than 600,000 doctors calling for mental health parity as well as issues impacting maternal health. Mental health parity impacts the patients being cared for by our colleagues throughout medicine as much as it does us. Everyone understands what the lack of access to mental health care means for their patients.

We also offered the Hill ideas and solutions. Just a couple months ago, I chaired a joint Capitol Hill briefing with the American Academy of Child and Adolescent Psychiatry to educate members of Congress and their staff about telepsychiatry. Showing members of Congress how the technology works when it’s used thoughtfully, particularly in rural areas, is vital to the federal investment in this important innovation.

In this election year, as members of Congress and their staffs turn over to an extent, it strikes me how important the education we can offer them is. We cannot rely on a partisan Washington to make the right choices for mental health care. They desperately need our expertise in navigating these issues.

A word or two about the partisanship of Washington. The discourse, especially among our political leadership, can be toxic. It is not in the best interests of APA to be viewed as engaging in this partisanship. Probably the only issue prior to the COVID epidemic on which Republicans and Democrats agreed was that there is a mental health and substance use crisis which needed to be addressed. The election and the COVID crisis may slow our initiatives, but we will ultimately prevail. Certainly, the success and need for telepsychiatry will help it remain as a treatment option.

Over the course of these past 2 years while I served as President-Elect and then President, I have remained optimistic for our future. We’ve seen bipartisan decisions to fund research about gun violence, something we and other physicians had backed for a very long time. We’ve seen strong funding for minority fellowships, for the National Institute of Mental Health, NIDA, NIAAA, and SAMHSA, and we’ve seen H.R. 6 pass, which made strong steps to combat the opioid epidemic.

To me, it’s very clear: no matter what happens over the course of this summer and in November, APA and my successors in leadership must continue this advocacy, educate our lawmakers, and take advantage of bipartisan agreement whenever we can.

Lastly there is reduced stigma and discrimination against mental illness. During my presidency, APA continued to be an important voice in combatting the prejudice surrounding mental illness. After dramatic violent events inspired many politicians—regardless of their party—to spout rhetoric that was harmful toward people with mental illness, we spoke up on behalf of our patients and the need for more mental health services.

Many of our members participated in a series of reports on “CBS This Morning” that aired this summer about mental illness. That work—which is all our jobs—continues, and I think that the psychological trauma and distress that has been so much a part of the pandemic for so many people in our nation will lead to changes in our society where there will be a better understanding of what mental illness is, what it means in people’s lives, and the importance of receiving treatment.

One of the things that really struck me in my presidency this year was understanding how powerful APA’s voice is. I had the opportunity to represent the APA on three continents and met with leaders of psychiatric societies from around the globe. It became evident to me how highly regarded the APA is internationally. They look to the APA for our stewardship and leadership on mental health.

You should all be proud, but it was also humbling. It reminded me that we all have an important role to play in being part of the APA. If I leave you with one last thought, it is this: all of us as the APA membership are essential to the future of the profession. Please continue to raise your voice and demonstrate the highest professionalism as psychiatrists in service of the well-being of our society and patients. Be involved in this powerful organization. It does make a difference.

It has been a great honor to serve as your president this past year. We are a diverse organization with many points of view, but I know we are unified in our desire to provide the best care we can to our patients.

Thank you very much, and I wish you and your family good health.