Presidential Address: The Doctor-Patient Relationship

“The Doctor-Patient Relationship” was the theme for the 2000 APA Annual Meeting. I selected this theme because of the central importance of the doctor-patient relationship to our work. The relationship with our patients provides the context for our diagnostic evaluations and all our therapeutic interventions, and the last century has been marked by tremendous advances in our understanding of the importance of this unique relationship to the process of treatment and recovery from illness. The expansion of our knowledge from clinical research, combined with clinical wisdom, has enhanced our ability to foster the skills necessary to observe, understand, and maintain a therapeutic partnership with our patients.

During residency training, most of us were taught that our therapeutic relationships with our patients begin not just during the first treatment session, but at the moment we first meet our patients. After 25 years of clinical experience, there is no question in my mind that this is true. During my psychoanalytic training neither I nor my supervisor, Dr. Hans Loewald—recognized as one of the outstanding clinician/theoreticians of modern psychoanalysis—could understand why a patient I had treated for nearly 2 years, who was extremely verbal, never missed a session, and was never late, seemed to be so disengaged. It was not until nearly 2 years after beginning analysis that we discovered that my patient had misinterpreted something I had said during an evaluation session as meaning I would only provide treatment for 2 years. I learned, but not until nearly 2 years later, that my patient’s apparent disengagement was because of a fear of getting too involved before I broke off analysis. I mention this case because it illustrates the fact that this individual had developed a personal relationship with me, clearly colored by past history and experiences, from the very beginning of our discussions and even before formal treatment had begun.

All experienced clinicians have likely had parallel experiences, which highlight the central importance of the therapeutic relationship to our clinical work. That this core of our work forms the context for all our endeavors is obvious to clinicians and patients. In recent years, however, restrictive managed care practices and government and industry interference with the privacy of communication with patients and the confidentiality of medical records have impinged on the sanctity of our relationships with patients. Changes in medical and psychiatric education have also understandably focused more curriculum time on technological and scientific advances but at the expense of attention to our role as healers.

I will review some of the important issues that I see affecting the doctor-patient relationship now and in the future.

Changes in the Delivery System

As mentioned previously, changes in reimbursement for psychiatric treatment have clearly brought into focus the intrusions into the doctor-patient relationship by our system of reimbursement for health care services. While the problems have been more intense in the last decade, they are not really new. Many psychiatrists remember how clinical relationships and treatment approaches were affected in the 1960s and 1970s by insurance policies that reimbursed only for inpatient care but not for outpatient care. The present level of interference between doctor and patient will not change until there exists a reimbursement system that places the patient and physician, working together, in control of collaborative treatment decision making. APA is working tirelessly to help bring about this change. The recent appointment of Lloyd Sederer as APA’s Director of the Division of Clinical Services; our new multiyear, multimillion-dollar business initiative; our ongoing work with practice guidelines; and our evolving work on quality indicators are examples of our efforts.

Scope of Practice and Workforce

Inappropriate restrictions on the scope of practice by psychiatrists as a result of some managed care policies and proposed government regulations regarding workforce needs in the country are also a source of stress in our relationship with our patients. While in some parts of the country and in some sectors of practice the present problems of managed care cause great distress among our colleagues, there is no nationwide evidence that there is a surplus of psychiatrists. It is clear that decisions about the workforce are being made in a highly politicized atmosphere with little attention paid 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 have inadequate access; for example: 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.

Workforce needs also relate to the appropriate scope of practice. Furthermore, workforce projections are based on a series of assumptions that can be easily manipulated, such as how many hours a week we work, how many of those hours are devoted to patient care, how many minutes we see each patient, and what scope of practice is involved. Psychiatrists must work to ensure that the ongoing debate focuses not only around appropriate access to high-quality care but also on an appropriate scope of practice for psychiatrists. I have no question that decisions about treatment should be made by physicians who evaluate the patient, not by insurance company clerks sitting in front of a computer screen, often in another state.

The APA Committee on Workforce has just concluded a survey of members’ views about the appropriate knowledge and skills base, that is, the scope of practice, for psychiatrists. It has been over a decade since APA undertook such an effort, and the preliminary results of the survey were presented in the “Psychiatric Scope of Practice and Its Implications” workshop during the 2000 APA Annual Meeting in Chicago. This data, soon to be published, and information from our Practice Research Network can be used by APA in advocacy and public education efforts in support of open access to high-quality care by psychiatrists and treatment decisions made in partnership between patients and their physicians.

The Patient Advocacy Movement and Electronic Communications

The nature of the partnership between the doctor and patient is also changing in the context of this era of electronic communications. We have a continuously better informed public, who now have many sources of information, in addition to their physicians, regarding psychiatric diagnosis and treatment. This clearly plays a role in the nature of our relationship with our patients. To help provide the highest quality, most up-to-date information regarding psychiatric illnesses, diagnosis, and treatment, in mid-1999 APA joined with the American Medical Association and six other medical specialty societies to develop a public information multispecialty web site called Medem.com, which is now planned to come online in the summer of 2000. This initiative will provide an unparalleled opportunity for us to communicate directly with the public and better inform our present and future patients. Over 30 million people each month visit the World Wide Web to look for health information, and over 50% of those are seeking information regarding psychiatric illnesses—nearly 200 million visits per year.

Our alliance with patients outside the treatment setting also provides tremendous opportunities for us. We have an army of patient advocacy groups looking to us for leadership in the mental health arena, and we have tremendous opportunities to help our patients if we make greater organizational efforts to ally ourselves with our natural constituency groups. Such alliances will provide significant political support in Congress and in the state legislatures for the hundreds of bills that have been introduced over the last several years to support parity, patient protections, and confidentiality.

I am extremely pleased that this year Kentucky has become the 30th state to pass mental health parity legislation. There is no question that the role of patients and their families in advocating for this legislation was central to the passage of the bill, and the partnership between patients and mental health professionals provided a synergy that guaranteed this legislation’s success.

During a year in which we have had tremendous national visibility in support of mental health care, with the June 1999 first-ever White House Conference on Mental Health, the December 1999 release of the first-ever Surgeon General’s Report on Mental Health, and Mrs. Clinton’s spring 2000 initiatives regarding mental health treatment for children resulting in plans for a national White House conference on the treatment of childhood psychiatric disorders in the fall of 2000, we have had unparalleled opportunities to work with our patient and family partners to advocate for the highest quality treatment and the preservation of the doctor-patient relationship.

Impact of DSM-IV

There is little doubt that we have made tremendous strides over the last 20 years in advancing the ability to make reliable and valid diagnoses of psychiatric illness. DSM-IV represents the latest step in this tremendous record of advancement in our approach to clinical diagnosis. But it also illustrates one of the dilemmas that concerns me. When I was a resident, DSM-II was the nosological bible, and even as first-year residents, we knew that it was very inadequate. While we have had tremendous gains in our ability to structure a meaningful classification of illness, DSM-IV still provides a symptom-cluster approach, and we are still a long way from an etiologically based categorization of illness. I am very pleased that the National Institute of Mental Health has already committed to work with APA in the development of DSM-V and to help support research that will allow us to develop a more etiologically based system of diagnostic classification.

It is true that DSM-IV is a five-axis approach to diagnosis and that issues of precipitating stress and general level of function are included in it. But nowhere in DSM-IV is provision made for understanding the role of psychological conflict or developmental distress in the emergence of the symptoms we see. Nowhere is the capacity for symptoms to have symbolic meaning taken into account. This, I believe, has resulted in a significant problem. While we are, I believe, doing a very good job of training our present resident colleagues to do a thorough diagnostic examination based on DSM-IV symptom checklists, I fear we are not doing a very good job with these other aspects of understanding.

Residency Training and Education

What is the impact of changes in DSM and in the delivery system? We are in danger of training a generation of psychiatrists who lack even the most basic psychotherapeutic skills or a framework in which to understand mental health functioning from a psychological perspective. And I am not talking about training sophisticated psychotherapists or psychoanalysts. I am talking about training people who have the same expertise in understanding and managing the therapeutic relationship as they do in managing medications. And there’s certainly very little curriculum time presently devoted to helping residents maximize their empathic skills.

Some might say this isn’t too important, that with our increasing understanding of brain structure and function, future psychiatric practice relies primarily on somatic, not psychotherapeutic, interventions. We know that treatment works best when it occurs within the context of a caring and trusting therapeutic relationship. We know that such a relationship provides, among other things, opportunities to discuss problems of compliance with treatment. There have been several recent reports that reveal that over one-half of all prescriptions in the United States are either not filled or not taken properly. This information illustrates clearly that compliance with treatment and how we use the doctor-patient relationship, even when our interventions are primarily somatic or pharmacologic, are of central importance to excellent care (1).

Few psychiatrists are unaware of the economic forces that have affected academic medical centers over the last several decades or the changes in reimbursement regulations or in care delivery systems that have all put increasing pressure on psychiatry faculty members to generate revenues through direct patient care. This has not only meant less time available for teaching, even from committed clinicians, but also a shift in the role of the resident and faculty member in supervised clinical care.

Furthermore, the explosion in neuroscience research and available grant funds to support such work has led to an emphasis on faculty members with the potential to garner research funds and a relative de-emphasis on those who rely primarily on clinical services to provide salary support. These and other forces led to a mass exodus of psychoanalysts and psychoanalytically informed clinicians from departments of psychiatry in the 1970s and 1980s. Many departments of psychiatry today have little access to those psychiatrists most expert in teaching the understanding of psychodynamic principles and techniques—empathic listening, appreciation of symbolic meaning, the role of trauma in symptom formation, and understanding transference and countertransference—that so much affect the doctor-patient relationship.

Furthermore, the explosion in the knowledge base of psychiatry in the last several decades has led to intense competition for curriculum time, producing a situation in which there is decreasing curriculum and supervisory time devoted to psychotherapy training while there are fewer faculty members available to teach it and advocate for curriculum time. Also, the competition for what psychotherapy training time is available is now intensified with the growth of newer and more research-tested psychotherapy techniques, such as cognitive, behavioral, and interpersonal psychotherapy. Twenty-five years ago it was still not uncommon for psychoanalysts, for example, to be directors of every clinical service and of both medical student and residency education programs. Although I am not suggesting a return to that era, there is no question that in that environment residents would be exposed to a particular way of understanding their patients no matter what patient they were seeing or in what setting. When a supervisor today underemphasizes the role of empathy as a way of listening for the psychological aspects and symbolic meanings in a patient’s presentation of his or her concerns, we lose essential data necessary to fully understand our patients and to manage optimally the doctor-patient relationship.

I am pleased that the Residency Review Committee in Psychiatry has recently put into place a requirement that beginning in January 2001, residency programs will have to attest to the competence of every graduating resident in several forms of psychotherapy. This will provide an important impetus to improve the excellence of our educational programs and the knowledge and skills base of our residency graduates. I am also pleased that APA will be taking a leading role in working with the association of chairs, the association of training directors, the Association for Academic Psychiatry, and our major clinical subspecialty groups in helping to address how we define, teach, and assess these necessary core competencies.

Scientific Advances

If you believe that our neuroscientific advances will obviate our need to attend to the relationship with our patients or psychotherapy issues, think for a moment about the findings in the field of neural plasticity. This body of work clearly shows that environmental and developmental experiences, not just genetic endowment, influence brain structure and function, which may be continually remodeled throughout life. Furthermore, we now know that contrary to previous thought, new brain cells are generated throughout life from stem cells near the ventricles and that these new cells migrate to different brain regions. We will undoubtedly, at some point in the future, learn to control these processes with more precision than is now possible. It is true, however, that interpersonal experiences, such as a therapeutic relationship, can alter brain function in the same way as medications—shown most dramatically in Lew Baxter’s work with patients with obsessive-compulsive disorder. So, if anything, these scientific advances reaffirm my belief that for the foreseeable future, psychotherapeutic skills and the ability to develop and utilize a therapeutic relationship remain essential parts of our treatment armamentarium.

Information Technology and Electronic Communications

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 relationships with our patients 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, for example, bring us closer to the point when it may be moot to ask if experiences in a virtual environment are “real” or “valid.” For example, behavior therapists are now using virtual reality programs to treat phobias. Furthermore, as computer logic systems advance to a point where artificial intelligence systems mimic human mental processes, our ability not only to understand but to modify mental processes will take a quantum leap.

We are on the cusp of an abrupt transition to a new, mostly manmade developmental environment. We know the tremendous advances being made in genetics and the likely impact on physical and mental status. We should anticipate a parallel ability to recreate and modify ourselves mentally through advances in information technology. Direct brain-machine interfaces, in fact, have already been developed: cochlear implants for hearing-impaired individuals, similar systems for blind persons, and peripheral self-controlled stimulators to treat depression. Previously only in the realm of science fiction, these devices eventually may be used to modify memory or change other patterns of emotional responsiveness. Control of such technology will likely become one of the most critical societal decisions of the information age and will have an impact on our relationship with our patients of a magnitude that is difficult to even assess.

Although there is tremendous excitement as we explore meaningful ways of using present computer systems in our research, educational, and clinical missions, at some point, as more and more of our world is formed and modified by electronic information, we will have to face these issues. The science fiction writer Phillip K. Dick continuously investigated the nature of reality and its potential modification by means of technology. In his imagined universes, machines designed as simulacra of humans often showed 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.

The 1999–2000 APA Year in Review

During this year I have been honored and gratified to serve as President of APA. This has been a year of tremendous accomplishment and change as our Association moves to work even more aggressively to enhance our ability to provide excellent clinical care to our patients and to serve our members. I feel great satisfaction and pride in what APA has accomplished as the new century and millennium have begun.

This has been a terrific year for advocacy, and I was honored to be asked to represent APA three times at the White House: last June at the White House Conference on Mental Health, in December for the release of the Surgeon General’s Report on Mental Health, and in March when Mrs. Clinton and the Surgeon General announced their initiatives regarding children’s mental health.

It was timely and, in fact, overdue that we at APA moved to substantially enhance our advocacy efforts. Government relations and public affairs activities were coordinated in a manner not previously done, and substantially more resources have been devoted to our government relations advocacy efforts. The new Commission on Public Policy, Litigation, and Advocacy, whose formation passed at the March Board meeting, will provide the structure for the allocation of new resources in the advocacy arena.

The new resources to which I am referring come about as a result of the substantial budget reallocation the Board of Trustees passed in October. This reallocation will provide nearly $25 million over the next 10 years for new activities in government relations, public education, revenue sharing with District Branches and state societies, and substantial dues relief for early-career psychiatrists (the group from which we have had the greatest falloff in APA membership).

Of course, as I have mentioned numerous times during this past year, this reallocation could not have come to pass without the APA membership’s approval of our corporate reorganization. Many people, especially District Branch and state society leaders and APA public affairs staff, have worked extremely hard to ensure that the Bylaws changes that will allow our reorganization to go forward were passed by the membership. The nearly 95% “yes” vote reflected what a great job everyone did and will allow us to move ahead with our plans.

There are a number of other significant actions this year of which I am very proud. A few of the ones I feel are most important include

• A multiyear, multimillion-dollar initiative to work in partnership with the business community to improve the benefits for mental health and substance abuse treatment provided by employers. Mr. Larry Kraus, past Senior Vice President for the U.S. Chamber of Commerce, has joined the APA staff to help lead these efforts.

• The consolidation of APA and APPI publishing activities into the American Psychiatric Publishing Group. This restructuring will help us maintain our leadership position in psychiatric publishing and enhance the efficiency of our publishing operations.

• The sale of our interest in our headquarters building and investment of the proceeds from the sale. This and other fiscal management activities gave us a budget surplus for 1999 and allowed us to continue the moratorium on dues increases that has been in existence for a number of years. This moratorium has resulted in an effective reduction in dues rates of 10% when the effects of inflation are taken into account.

• We operationalized two new committees to improve relationships between national APA and District Branches and state societies: a Board Committee on District Branch Relations and the District Branch Advisory Committee, composed of District Branch and state society executives. The work of these groups was enhanced by new electronic communications tools.

• The Board’s action to ensure the future stability of the professional liability insurance program endorsed by APA.

• A substantial new investment in the electronic communications and information technology infrastructure, including APA’s cofounding role in Medem.com, our multispecialty, public education web site project.

• The recruitment of Darrel Regier, M.D., an internationally renowned psychiatric researcher, to head the American Psychiatric Institute for Research and Education and the APA Office of Research. We also increased our commitment to development activities with the hiring of a permanent, full-time Development Director for the American Psychiatric Foundation.

Acknowledgments

One of the best things about being APA President is that so many members of my family and colleagues have been able to share the experience and provide moral support. Special thanks go to my parents, Goodman and Zelda Tasman. I have said before, but it is still true, most of my good qualities come from them. My brother Norman and his family, his wife Alice, my nephews Aaron and Jason, my Aunt Harriet Waldman, my Uncle Leo and Aunt Arlene Shalinsky, my cousins Alyse Jones, Sheryl Rosenberg, and their families, and most important, Cathy and the next generation of the Tasman family—my kids Josh, David, and Sarah—all made this year’s successes possible. Cathy, Josh, David, and Sarah have been astute observers of APA political processes, and each helped me directly in my APA work. I couldn’t have run for office, mastered computer technology, or written all of my speeches without their help.

Most important, I want to thank my partner in all things and my wife, Cathy Tasman. Cathy’s support has meant more to me than I can put into words. Her incredibly hard work chairing the Elsa Barton Scholarship Fund for the American Psychiatric Association Alliance over the last several years has been a concrete reflection of how much we share in our commitment and values in support of those who are disabled by psychiatric illness and their families.

The time I’ve spent working for APA over the last several years has been wonderful and gratifying in many ways, but one of the prices for this experience has been less time with Cathy and my kids. Hurried conversations from airports and hotel rooms, missed parents’ nights at school, and faxed editing comments about college application essays don’t really take the place of being at home. Understanding and tolerance from Cathy, Josh, David, and Sarah, more than anyone else, have made it possible for me to succeed.

Some specific other people are due thanks as well. The Board of Trustees took to heart the theme of our retreat last summer, “Leading Through Change,” and worked diligently and creatively to translate our Association’s goals into practical reality. I’m especially appreciative of Al Herzog, Speaker of the Assembly, for his support and leadership throughout the year. One of the highlights of the year was the opportunity to work closely with Steve Mirin, our Medical Director. Steve’s dedication, intelligence, and energy have already benefited APA in ways that few will ever fully appreciate, and I know this will continue into the future. Troy Thompson and Pedro Ruiz, the Program Chairs for APA national meetings this year, both did an outstanding job, as shown by the success of the 1999 Institute on Psychiatric Services meeting in New Orleans and the 2000 Annual Meeting in Chicago. All the other APA staff, especially those involved in the Governance Office, the Office to Coordinate the Annual Meeting, and the Meetings Management Office, do a wonderful job. Brennan Peterson, Carol Lewis, Cathy Nash, and Olga Damschen deserve special thanks.

Particular thanks go to all my colleagues in the Department of Psychiatry and Behavioral Sciences at the University of Louisville. You have maintained a standard of excellence in all we do with understanding and graciousness when my attention was directed to APA activities. I want to especially single out Joan Lucas, my Administrative Assistant in Louisville, who not only managed all my departmental work, but added on all my APA work in her usual unflappable and unbelievably competent way. I don’t know how I would have gotten through the year without Joan’s help.

Finally, the support of friends has made any success I have had possible. People like Michelle Riba, Jim Bozzuto, Jerry Kay, Ray Cohen, Dan Winstead, and many others too numerous to mention all share some of the credit for my accomplishments.

Closing Thoughts

The heart of our profession, and the reason I became a psychiatrist, is to care for patients. At the 1999 Annual Meeting, in my President-Elect address, I briefly talked about my work with one patient who stands out to me out of the over 1,500 patients I have treated. This person was severely troubled by significant personality problems, very serious anorexia, and nearly constant suicidal and self-destructive wishes. I have little space to describe our work together, but we both worked hard to develop and maintain a therapeutic relationship that 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 have 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 can assure you that I and the Board of Trustees have committed all of our energy this year to working to ensure that every psychiatrist now in practice and every psychiatrist to come has the opportunity to provide, as I did with this patient, whatever care is necessary to serve the best interests of those who come to us in need.

The beginning of the new millennium is an extraordinary time to refocus our attention on the timeless importance of our relationship with our patients. This emphasis is essential to ensure that the future practice of psychiatry integrates the best of our humanistic traditions with the latest scientific advances. We are dedicated to enhancing all aspects of the doctor-patient relationship, in psychiatric and medical education, research, treatment, ethics, the expanding importance of the patients’ rights and patients’ advocacy movements, and our use of public education and government relations, to preserve and better understand how to use this central and essential aspect of our therapeutic role. With the 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 a major role in determining the future direction of our profession.

My year as President of APA ended with the close of the 2000 APA Annual Meeting. I have been lucky to serve at a time when our future is bright, and we have the resources at hand that will allow us to continue to make tremendous progress in our clinical, educational, and research missions. I wish Dan Borenstein, our incoming President, Richard Harding, our new President-Elect, and the rest of the new Board of Trustees the best of luck in continuing to move forward to carry out our goals.

Being APA President has been a wonderful, once-in-a-lifetime experience. I have met thousands of people and traveled to many places that I would not have been able to visit otherwise, and I have been proud to represent our Association. I have tried hard to give back to APA a fraction of what it has given me throughout my career. And although my term as President has come to an end, my commitment has not, and I look forward to continuing to work with you over the coming years to ensure that we enhance the highest standards of our profession and the relationship we share with our patients.

Presented at the 153rd annual meeting of the American Psychiatric Association, Chicago, May 13–18, 2000. Dr. Tasman, 128th President of the American Psychiatric Association, is chair of the Department of Psychiatry and Behavioral Sciences, University of Louisville. Address reprint requests to Dr. Tasman, Department of Psychiatry and Behavioral Sciences, University of Louisville, 500 Preston St., Bldg. A, Room 210, Louisville, KY 40292-0001; [email protected] (e-mail).