Response to the Presidential Address

Let me add my personal welcome to that of Dr. Robinowitz. Welcome to colleagues from many countries all over the world. Welcome to psychiatrists from academia, private offices, courts and prisons, general hospitals, alcohol and substance abuse programs, community health centers, and, yes, managed care systems. Welcome to our psychoanalysts and our psychopharmacologists, our child psychiatrists and our geriatricians. Having each one of you here enriches our meeting, our organization, and our profession.

With me here today is my husband, Harold; our daughters, Hanna and Eve; Eve’s husband, Ben Schmerler; and their daughter, Sophie Anne. Harold Stotland and I met as undergraduates at the University of Chicago and married almost 45 years ago, just before I entered medical school. There were four women in my class. My mother-in-law had to explain to her friends how her son could “allow” his wife to go to medical school. For some reason, Harold Stotland never thought of it that way. Harold did not just “allow” me to go to medical school. He has supported me in my struggles and applauded my every success. Harold insists that I would have done okay without him. Maybe so, but it would have been that—just okay. Thank you, Harold Stotland.

I wish my mother were here to receive my thanks. In the immigrants’ world in which my mother grew up, the daughters left school and went to work so that the sons could continue their educations. My grandmother managed to feed her family on the cow’s lungs the butcher threw away, so that her four daughters could finish high school along with their three brothers. My father died when I was 8 years old and my mother had to support me and my two little brothers. In order to become a schoolteacher, she became the first and only member of her family to graduate from college. In our world, there were no people with advanced degrees. The only doctors we knew were the ones who took care of us when we were sick. Girls did not go to medical school. But my mother was her mother’s daughter. For my high school research paper, I found a topic in a science magazine. I can still tell you a good deal about hypothermia. I did the research for my paper in the library of a local hospital. I vividly remember walking home late one evening, looking up at the stars, and hoping so very hard with all my heart that I could be a doctor some day. My good fortune fulfills generations of dreams.

After I finished my training, mentors like Hazel Mrazek, Carol Nadelson, Mary Jane England, Leah Dickstein, and Stuart Yudofsky had aspirations for me in academia and in APA. Mentorship brought me to this podium. Now it is up to me, and to you, to mentor those who come after us. We must pay special attention to our upcoming international, women, and minority colleagues. Our Committee on Women provided my initiation into APA. It took 140 years for APA to elect our first woman president. I will be the seventh. At least half of our medical students and residents are women, but the gender balance does not follow them up the academic and administrative ladder, where we need their ideas and perspectives. We need to give them maternity leave, child care, and reasonable working hours. And yes, we can.

My theme for the coming year is “Shaping Our Future.” Is that a realistic goal? The American Psychiatric Association is the oldest and one of the largest medical specialty societies in the United States. We have brought about major social change. Ten years ago, there was no bright young movie star writing a book about her postpartum depression. When people with untreated mental illnesses committed crimes, newspapers did not print editorials calling for better mental health care. Thanks to our efforts, to the courage of public figures who have spoken about their illnesses and recoveries, and to Mental Health America, the National Alliance for Mental Illness, and other advocacy groups, today most of the American people recognize that psychiatric illnesses are real, that treatments are humane and effective, that health insurance should not be discriminatory, and that investment in research improves care. They are worried, as are we, about the psychiatric casualties from Iraq and Afghanistan. We changed public perception and that is changing our laws. We will have a mental health parity act, and that will be just the beginning.

So we can shape our future. That will take education, advocacy, and sincerity. Which kind of health care system will offer the future we want? A system that does not force us to ask about insurance coverage before we ask about symptoms, a system that does not discriminate against our patients, a system that respects their privacy, a system that pays us fairly and promptly, a system that spends our money not on obstacles to medical care but on medical care. In the coming year, we are going to educate ourselves. There will be information about the pros and cons of different systems—in Psychiatric News , on our new web site, and at our scientific meetings. A study published recently in the Annals of Internal Medicine revealed that 59% of physicians in the United States and over 80% of psychiatrists favor laws to establish national health insurance. At our October Institute in Psychiatry in Chicago, there will be a debate between single payers and the plan proposed by the American Medical Association. Learn, and then tell us what you think. Reaching consensus will not be easy, but it is essential . If we take no position, we have no power to shape our future.

Second, we will have to advocate for our position. We have to walk the halls of state capitols and testify at legislative hearings. We are going to have a new administration next January; we need to educate them about what our patients need. We have to write opinion pieces and letters to the editor, talk to reporters, and speak at our schools and in our houses of worship, where they are desperate for mental health information. There, people will see for themselves what caring and competent people we are. I know what it is like to feel intimidated about speaking to legislators and the public. But if we do not provide mental health information, somebody else will. So, with the help of APA staff, I’ve testified in Congress and appeared on Oprah , CNN, and even Fox News. Your APA staff can help you, too. That is the second step.

Finally, and most importantly, we have to speak from our values—from our hearts. People do not respect us as much as they used to. Some of the reasons are beyond our control. Third party payers demand we spend less time with our patients and more time filling out forms and begging for authorizations. But we became psychiatrists in order to help people. While others partied, we studied. While others earned, we went into debt. While others went home, we stayed at the bedside, taking responsibility for life and death decisions. We sit with our patients, absorbing stories of horrible trauma and heart-wrenching symptoms. When I was responsible for the care of patients in the Illinois State Department of Mental Health, I went to see one of our hospital medical directors, Joe Parks. On the wall across from Joe’s desk, where he could see it whenever he looked up, he had hung a sign. The sign said, “How will it affect the patients?” Our power to shape our future comes from that dedication. We shape our future by taking informed positions, advocating for them, and speaking from our hearts.

You may have taken it for granted that I said “patients.” Some of our patients want to be called “consumers.” I think I understand why. But a consumer buys a product or service from a seller who acts in her own interest. A physician acts in the interest of her patient. A seller closes the shop and goes home for the day. A physician is responsible for a patient 24 hours a day. A seller is not trusted with a buyer’s most intimate secrets and feelings or expected to keep a buyer’s confidence. Those are sacred obligations. When I am sick, I want to be my doctor’s patient .

But back to the future. We are working on DSM-V. We bring to it the perspectives of scholars and clinicians, “lumpers and splitters,” and child psychiatrists and geriatric psychiatrists, as well as psychodynamics, environment, and biology. DSM sets the standard for diagnosis in much of the world and we set a very high standard for DSM. Over a thousand experts will engage in nearly a decade of intensive literature review, field trials, and discussion. We will circulate drafts and make revisions. All of you and members of the public will be able to comment via a dedicated web site. We are in the midst of a revolution caused by public and legislative concern about the influence of the for-profit sector on the entire field of medicine. We have anticipated and addressed questions about conflicts of interest in the DSM process. The abolition of conflict is a myth. Anybody who does not have any conflicts does not have any interests. What we can do is to be very clear what those interests are. It has not been easy, but the disclosure and vetting process we have developed is unprecedented and unrivaled.

The November elections offer us a major opportunity to shape our future. We spend more per capita on health care than any other country in the world—without producing more health. What are we doing wrong? Health care costs go up, increasing the number of uninsured, who do not seek care until their problems are catastrophic. Our emergency rooms are clogged with patients for whom there are no resources. Our jails and prisons hold more people with mental illnesses than our hospitals. We have to fill Congress and the White House with people who will do something about that.

Meanwhile, right now, people with schizophrenia have an average lifespan 25 years shorter than the general population. We are often their primary health care providers. We are the only physicians with mental health expertise and the only mental health clinicians with medical expertise. We know how to establish relationships and we know how to use sphygmomanometers, lab tests, and brain images. We can help our primary care colleagues make accurate diagnoses and provide first-line treatment. APA will help us maintain our skills with annual updates in psychiatry and general medicine. It is our job to give you the tools you need to do your job.

Most of the people in this country with mental illnesses do not get any treatment. They are not “patients,” but they are our responsibility—not ours alone, but ours. I believe that when we shape our future, we should begin with our responsibility for those who are least able to help themselves: the poor, members of minority groups, and people in rural areas and inner cities. APA has brought together on our web site information about an array of creative and effective state projects that bring psychiatric care to underserved areas, including telepsychiatry, psychiatrist “circuit riders,” and insurance coverage for psychiatric consultation to primary care professionals, as a resource for you as you address the underserved areas in your states.

Let me address for a moment the needs of the underserved in other countries. In April, I was part of a psychiatric delegation to Cambodia. This country of 14 million people, devastated by war and slaughter, has 26 psychiatrists and 10 inpatient psychiatric beds. The four psychiatrists in the 350-bed general hospital earn $40 a month. The pharmacy serving their 150 outpatients a day is a bare little room with occasional supplies of chlorpromazine. The priest caring for hundreds of orphans with HIV/AIDS asked us whether AIDS causes neuropsychiatric symptoms. I sent a request right from that meeting in the Cambodian hospital to APA on my Blackberry. Within a day, our staff had sent scientific papers to Cambodia. We are the richest country, with the largest number of psychiatrists in the world. We have an obligation to help those less fortunate. Using modern communication tools, we can share our wealth of information around the globe.

Then there are the people who are at risk of developing mental illnesses. They are our responsibility too. Several years ago, I was asked to serve on a government panel to promote women’s health. The group decided to address mental health prevention or mental wellness. I said, “but we do not know how to do that.” I was wrong. I learned about successful interventions that help children develop conflict resolution skills, resist bullying, and build resiliency and programs that help teachers and pediatricians screen for early signs of problems before they become full-blown mental illnesses. In the future, we have to turn these demonstration projects into social policy.

APA has to prepare us for the psychiatry of 5 and 10 years from now. What will replace your cell phone, Palm Pilot, e-mail, and iPod? What new diagnostic and treatment approaches will there be?

Our future is going to include some things we have doubts about, like so-called “pay for performance.” There are few aspects of medical “performance” that are both measurable and meaningful. But the idea of paying for performance has a strong appeal to the public. I think APA has made the right decision under the circumstances—to sit at the table with our colleagues in other specialties and develop standards to shape the future of pay for performance: demanding evidence-based criteria and the flexibility to adapt our care to the needs of individual patients. If we had refused to participate, others would be making the decisions that will determine our future.

We became physicians because we wanted to understand and treat the whole person: body, mind, and soul. We earned our place in the house of medicine. We work every day with other mental health professionals: nurses, social workers, counselors, and the thousands of dedicated psychologists who want to do what they were trained to do. But there are those who want to break into our house. They want to prescribe medications without the education and experience to know what they are doing. We have lost a couple of fights with them, but we have won and will win many more.

Then there are those who want to burn our house down. Scientology is not only science fiction, it is an organization determined to destroy us. It influences our legislatures, our Food and Drug Administration, our schools, and our media as a moving force behind the unwarranted “black box warnings” that discourage people from taking treatments they need. Direct challenges to Scientology provoke ruinous lawsuits and no-holds-barred vilification. Our strongest defense is a public armed with accurate information about psychiatry—and Scientology. That information is on the world wide web; we will help you share it with your colleagues and your communities.

The future will bring more tough issues like abortion, same-sex marriage, and the treatment of so-called “detainees.” We will take positions when issues affect our patients and when the issues fall within our areas of expertise. Access to abortion affects our patients who are victims of sexual violence, who conceive during psychotic episodes, or who can only be stabilized on large doses of medication. There is no credible evidence that abortion causes psychiatric illness. But while we spend years developing a scientific basis for psychiatric diagnoses, a so-called “abortion trauma syndrome” has been invented to frighten patients and influence legislatures and judges. We have to provide the facts so that our patients can make decisions based on their own values.

One of our core values is to do no harm. Denying people rights on the basis of sexual orientation harms them. Coercive interrogations harm detainees. We are healers, not inquisitors. Under the leadership of Past President Steven Sharfstein, we led the medical and mental health professions with a crystal-clear policy: we will not participate in those interrogations.

We can shape a future in which we do well by doing good, a future in which we and our patients can thrive. Millions of people need our care. Our expertise is unique and precious. In the end, we will not be defined by what legislators do or do not allow others to do. We are defined by what only we can do.

Being a psychiatrist is the best job in the world. It calls for every bit of intellect and every particle of compassion that we can muster. Every day there is more to learn, but what riveting stuff it is: human behavior, thinking, feelings, relationships, and the workings of the human brain. Every day we worry about our patients, endure hassles, and work harder for less money—but every day we relieve human suffering. Our compassion and our expertise give our patients hope and lives with jobs, families, and self-esteem. That is what we do. That is who we are. Never before have we been able to do so much for so many. And now and in the future, we will.