Response to the Presidential Address

Before I begin, I would like to thank our President, Dr. Marcia Goin, for doing such a superlative job. She has demonstrated incredible compassion, dedication, energy, and leadership. As but one example of Dr. Goin’s leadership, she has raised our awareness of a difficult and often neglected subject—the criminalization of people with mental illness. She deserves our great respect and admiration for all her efforts on behalf of the American Psychiatric Association and our patients. Please join me in a moment of heartfelt thanks to Dr. Marcia Goin.

I want to acknowledge my deep appreciation to my loving and supportive family—my father, Dr. Oscar Miron; my husband, Dr. Arthur Riba, who has been incredibly wonderful; our talented daughters, Alissa and Erica; my sister, Deborah Silberman; and all my relatives, friends, and colleagues who have joined me for this very special occasion.

I also want to thank Joel Cogen, who provided me with wonderful experiences in lobbying and the political process; Allan Tasman, Lee Blair, David Goldberg, and James Bozzuto, who taught by example; Al Herzog, Roger Meyer, and Mahlon Hale, for their mentorship; Jay Scully, John Oldham, Leah Dickstein, Richard Balon, and my University of Michigan colleagues Ken Silk, Tamara Gay, Tom Carli, and Elaine Pitt, who are most generous with their wisdom; and John Greden and Linda Gacioch for their ever-present help and support. Thank you.

Let us begin.

Members and friends of the American Psychiatric Association, my thoughts go back to a patient, a 14-year-old girl. Her case illustrates one of the three key goals we should pursue in the coming year—excellence in education. This girl was admitted to our inpatient psychiatry unit during my third-year psychiatry clerkship. Suddenly, she could not walk or talk. Members of her family said she had recently been put in a cold body of water as part of a long, boisterous religious ritual. Neurology colleagues found nothing wrong, anatomically or physiologically. We reached a simple conclusion: this must be a conversion disorder.

In the safe environment of the hospital, and using a variety of therapeutic modalities, we were able to help this girl resume her normal functioning. Two weeks later, however, the young girl was readmitted, with symptoms very similar to those at her first hospitalization. It was then that I realized how complicated it really was to help a patient.

There was, of course, much more to this story that we learned during her readmission—trauma and sexual abuse problems we had not explored earlier. With help from my supervisors, I came to better understand how and why we had come to premature closure of the patient’s diagnosis during the first hospitalization.

These were important lessons in my early and growing awareness of how difficult it was to be a psychiatrist—that things aren’t necessarily what they seem and that sometimes, perhaps oftentimes, patients cannot or perhaps don’t want to tell us, or are unable to clearly articulate what the problems are.

In medicine, it is always difficult to come to a correct diagnosis, but often there are objective tests—whereas in psychiatry, you sometimes have only the information the patient tells you. My work with this patient began my lifelong focus on patient care and the need for us to fight for the obligations we have pledged to fulfill for our patients. That is also an underlying tenet of the American Psychiatric Association and the link to why this organization is so important to me, and to all of you.

My teachers met with me, with my patient, demonstrated techniques, helped arrive at the differential diagnosis. My teachers and supervisors never gave up on me and, more importantly, never gave up on the patient.

The case of the 14-year-old girl illustrates one of my three main goals as your APA President:

It is essential that we not allow ourselves, because of financial or other pressures, to surrender the opportunity and privilege to teach students and residents. While it is more labor intensive and certainly not as efficient to have a student or trainee to teach and supervise, it is also the best way to nurture those who will follow and ultimately take over in the demanding work we do.

It is critical that APA support and recognize the many faculty and residents who are on the front lines of teaching and educating the next generation of psychiatrists. I hope that in the coming year, we will be able to develop ways to recognize our teachers and mentors and highlight the important role they serve. This will be a major priority. To this end, it has been almost 20 years since APA mounted a major national summit on the subject of psychiatric education.

Our field plays a central role in the public health of the nation—addressing homelessness, substance abuse, family violence, depression, anxiety, and posttraumatic stress. Given APA’s historic interest in developing and expanding the modern neurosciences and integrating neuroscience-based concepts into health care, it is critical for us to determine how best to teach neuroscience to our students and residents. We must ensure their ability to critically read the literature, use evidence-based medicine, and apply new knowledge throughout their clinical and research careers. It is also important for students to see patients over a longer period of time, to have continuity of care, and to establish a relationship with patients. Students and residents need to see if treatments work, whether families can accommodate to change, and how schools and jobs allow for positive reentry.

To promote excellence in medical student and resident education, APA will plan two major conferences: one focused on medical student education, the other on residency training. Working with our allied organizations, we will address themes of mentorship, competencies, minority recruitment and underserved populations, and funding for education. The goal is to usher in a new excitement for the collaboration of APA with our academic teachers and leaders. At a moment when psychiatry is enjoying a resurgence as a specialty of choice among medical students, it is incumbent upon all of us to provide students and residents with the best education. At the same time, we must assure the public and ourselves that our graduates are competent and excellent physicians. So my first goal is excellence in education.

My second goal originated from an experience that occurred when I was an intern and relates to the interface between medicine and psychiatry.

I was called to the emergency room at around 2:00 a.m. to evaluate a woman, in her 30s, a single mother of two young children, with no insurance. No family or friends accompanied her to the hospital. She presented with complaints of almost every organ system. She said her scalp itched, her eyeballs burned, her chest ached—all the way down to the soles of her feet, which were prickly and numb at the same time. My resident and I admitted her to the psychiatry inpatient service, thinking that the patient was hysterical, had a severe personality disorder, was psychotic, or was malingering. The patient was also demanding medication for pain. We added drug seeking to the differential diagnosis and immediately ordered a toxicology screen. With time and direction from attending physicians and medical consultants, the patient’s diagnosis turned out to be a severe form of systemic lupus erythematosus and she was transferred to the medical service.

Yet again, I learned a number of lessons from my patient. She had a severe medical condition, but it presented with symptoms that overlapped with psychiatric symptoms. As I came to better understand, there are many psychiatric and medical problems that are interwoven and that can mask one another. Making the diagnosis was not enough for my patient—for she had a long road ahead of her, contending with both her psychiatric and medical problems.

So the case of the 30-year-old woman with lupus illustrates the second of my three main goals:

A major group of patients, therefore, who deserve the attention of psychiatrists are those patients who have chronic medical as well as psychiatric problems, which fall into the field of psychosomatic medicine, our newest psychiatric subspecialty. Some researchers are asking, “Which comes first: chronic disease or depression?” It is a complex relationship, and in the past 10 years, for example, depression has been linked to stroke, heart disease, cancer, diabetes, and hypertension. Is depression a risk factor for these illnesses, is it a marker, or is it an effect of having a chronic illness and the treatments of those illnesses? In other words, what are the connections?

Throughout my career, I have had the privilege of caring for patients who have cancer and are referred by their oncologists for psychiatric evaluation and treatment. Patients with cancer may have mood problems, anxiety, or other symptoms that could be related to previous psychiatric problems, to chemotherapeutic agents, surgery, radiation, or other cancer treatments, to the tumors themselves, or to a combination of factors. Cancer or any chronic medical condition affects families, children, marriage, job status, self-image, sex, finances, and functionality. Part of our work is to help our medical colleagues address the emotional issues of such patients, since it is so simple to think, “Who wouldn’t be depressed or anxious under similar circumstances?” Or the “Don’t ask, don’t tell” scenario that so easily becomes the default for busy clinicians who are on tight schedules, rather than questions about mood or how the patient is really doing, which could slow down the examination.

Patients also worry about bringing up emotional issues to their oncologists. They worry about the stigma of having psychiatric problems. And the stigma can be perceived as very real. Specifically, patients worry about not getting adequate doses of chemotherapy if they raise the issue of depression or other serious mental disorders. Patients worry about what their oncologists might think of them if they admit a substance abuse or alcohol problem. The possibilities to enhance our care of patients with chronic medical illnesses is tremendous, has been relatively untapped, and is but one example of the importance of the help that psychiatrists can provide patients while working together with our medical colleagues.

Through enhanced educational opportunities, more medical students and residents will have career pathways to continue their training in serving patients in all types of settings—outpatient clinics, hospitals, nursing homes, and hospice facilities. This is good for our patients and good for our field.

It will be my privilege as your APA President to work with allied and advocacy organizations to advance the field to better care for our patients in this important area of the interface between psychiatry and medicine. So my second goal is developing psychosomatic medicine.

My third goal relates to an experience during residency that provided me a window into the value of clinical research. It was the usual practice that whenever a patient was evaluated in the psychiatry emergency room, the patient had to first be “medically cleared.” I started noticing that almost every patient was, in fact, medically cleared. Or was it that there were a lot of patients who did have medical problems and were screened out before coming to psychiatry? In other words, how many patients were not medically cleared? And what happened to them? Did the medical clearance process have value? With the help of several faculty members, my fellow residents and I wrote a protocol to review this issue and wrote a paper that, after many, many, many rewrites, was finally published in a peer-reviewed journal (1).

This very minor success story included the vital ingredients that should be available to all of our trainees:

This example therefore serves to illustrate the third goal of my presidency:

We will be assisting the National Institute of Mental Health (NIMH), under the leadership of Dr. Thomas Insel, to tackle the problem of the paucity of patient-oriented adult and child psychiatrist investigators—those who have the ability to translate groundbreaking discoveries in neuroscience into meaningful treatment advances for patients suffering from mental illness. In other words, to take research from “bench to bedside.” Why is this so important?

Because if we don’t develop a better way to train, mentor, and educate psychiatry students and residents to develop research careers, psychiatric research will no longer be undertaken by physicians but will be performed by others lacking patient orientation and dedication.

The Institute of Medicine, funded by the NIMH, recently completed a study titled “Research Training in Psychiatry Residency: Strategies for Reform” (2), and I was honored to serve on this committee. Drs. John Greden and James Leckman will serve as co-chairpersons of the newly created National Psychiatry Training Council. The American Psychiatric Association looks forward to new and effective strategies for reform and applauds NIMH in their efforts to strengthen and support the development of psychiatric patient-oriented researchers.

We have many excellent models of psychiatry training programs that are able to support and train residents for research careers. But we need to do better. To have the support and leadership of NIMH in this effort is a huge investment and vote of confidence from NIMH in our field and in our future.

I hope that you believe, as I do, that it is important for our organization, the American Psychiatric Association,

Members and friends of the American Psychiatric Association, the founding members of the organization that came to be APA, at many previous meetings, including those here in New York City dating back to 1848, sought to create a medical community to

And we share in that vision and promise today. They underlie my three goals as your president: 1) promoting excellent medical student and resident education in psychiatry, 2) developing the field of psychosomatic medicine, and 3) training patient-oriented psychiatrist-investigators. With your help and support in the coming year, we will make substantial progress toward achieving these goals.

Thank you very much.

Presented at the 157th annual meeting of the American Psychiatric Association, New York, May 1–6, 2004. Dr. Riba, 131st President of the American Psychiatric Association, is Associate Chair for Education and Academic Affairs and Clinical Professor, Department of Psychiatry, University of Michigan, and Director of the PsychOncology Program, University of Michigan Comprehensive Cancer Center. Address reprint requests to Dr. Riba, Rm. F6236, MCHC, Box 0295, Department of Psychiatry, University of Michigan, 1500 East Medical Center Dr., Ann Arbor, MI 48109-0295; [email protected] (e-mail).