Posts Tagged ‘Richard Ratner’

BY Richard Ratner, M.D., FASAP

Greetings, ASAPers from the aftermath of the annual APA Scientific and Business Meeting in New Orleans! I’m happy to report that the city, at least the part that has always attracted the tourism dollar, is back and up and running.  For signs of Katrina you must go outside the central business district, which a few people did on a bus tour showing the devastation still in place. However, the convention center, hotels and happily, the restaurants are either still there or back with vigor. It was also too early in the life of the oil spill for that to have had any effect the city’s mood or food supplies.

Registration was definitely down this year, which it always is relative to the blockbuster cities of New York and San Francisco that historically draw the largest crowds.  How much of this is due to the virtual extinction of the pharmaceutical industry-sponsored symposia that traditionally dominated Saturdays and Sundays is hard to say, but to the credit of the scientific program committee, there was a great deal of high quality stuff to attend.  With the exception of Sunday, when a good number of people found they could not get into sessions they wanted to see because the rooms could not accommodate them, things evened out subsequently, and I heard no further complaints.

• But what of the Assembly?

As those hardy followers of this occasional column know, the Assembly is the “legislative” arm of the APA, representing the rank and file membership primarily through the District Branches and State Associations, but also though membership by various affiliated organizations like ours, each of which have a vote.  Most of the leadership of the APA rises through offices in the Assembly, including most of the current Board, though with the exception of APA president Dr. Schatzberg.

The Assembly’s role is to serve as a voice for the membership, which it does at least in part by having members submit action papers. They are considered, sometimes altered, and often passed for reference to the Board of Trustees, where hopefully, they will be considered and followed. Perhaps the most talked about issues this year involved not action papers but one position statement regarding the relationship of psychiatrists to the pharmaceutical industry and a talk given by Larry Faulkner, head of the ABPN.

• Pharmaceutical Industry Relationship

A statement put together under Paul Appelbaum’s chairmanship lays out guidelines for what we should and should not do with  regard to the industry.  Much of it is unobjectionable and even overdue, but the devil is in the details, and some of them stuck in the craws of Assembly members.  At the heart of the objections is the implicit notion that psychiatrists are rather passively influenced by drug company initiatives, including the visits of detail persons and various little gifts like pens, mugs, and sandwiches for lunch.  Proponents argue that Pharma itself has adapted some of these changes, that the document represents guidelines rather than ethical rulings, and that the APA is going along with the rest of medicine in producing guidelines of this sort.  Some people saw the conflict as one of older vs. younger colleagues, but this by no means fit every case.  In the end, the Assembly again did not approve of these guidelines but sent them back to the Trustees for further consideration.

• Maintenance of Certification

The other issue causing a stir was the description of the structure of the soon-to-arrive “maintenance of certification” guidelines, as described by Dr. Faulkner.  Among a variety of other things, they include a section in which physicians will apparently have to seek satisfaction ratings from their patients!  It does not appear that anyone has thought through whether this segment of the process is appropriate for psychiatrists, and most of the concerns expressed had to do with this provision.

Just when those older physicians like me who have been long grandfathered into lifelong certification thought we could relax, comes the news that the Federation of State Medical Boards has embraced in principle the notion of making the maintenance of one’s actual medical license contingent on patient satisfaction ratings.  This means that some means of gauging “patient satisfaction” may find its way into all of our practices sooner or later.  And, of course, all of this comes down when physicians’ incomes are under great pressure with added concerns about the effects of the new Health bill as it unfolds.

• DSM5

On another matter, DSM5 is now entering field trials, as the period for commentary on the information posted on the website has now closed.  However, the website is still running for anyone wishing to see what the thinking of various committees are.

Some good news was that the APA is again in the black after some ferocious cost-cutting (including layoffs of notable numbers of APA staff) and after a significant recovery of the stock market since last year.

• APA Professional Liability Insurance

Those of you who have had malpractice insurance through the APA should by now know that the APA is changing its endorsement.  PRMS, which had been the chosen agency, had decided it did not want to continue to insure only APA members. For the APA, this was a deal breaker, since this insurance is a membership benefit.  Accordingly, APA went back to the market and, after further research and evaluation, has announced that the new official APA agency will be American Professional Insurance Co.  Those of you insured through AACAP will know them as the agency that insures AACAP members.  It will probably take time for the new company to be able to insure in all states, but when money is at stake, companies can be timely in arranging to do business.

Some other action papers of note addressed the situation that physicians cannot readily rescind prescriptions at the pharmacy when a patient’s circumstances change, which the Assembly felt should be allowed.  We were surprised to learn that our President does not now send condolences to the family members of service members who die by suicide, as he does with those who die in the line of duty, so an action paper urged APA to lobby to get this changed.  The Assembly also voted to ask mail order drug houses to provide less than 90 days of prescription medication without a financial penalty to the patient, if a psychiatrist does not feel it is safe to provide the patient such a large amount.   It also voted to have APA ask to have the entire area of Evaluation and Management Codes revised so that psychiatrists can use them for both inpatient and outpatient visits.

The next annual meeting of the APA is in May 2011 in Honolulu.  There may be some concerns about how many will register there, since they were already accepting hotel reservations for next year at this meeting, which I don’t recall ever seeing before.  Oh well, to quote the Hawaiians’ all-purpose (hello, good-bye, go in peace, etc., etc.) greeting, Aloha from your ASAP APA Assembly rep—me.

Richard Ratner, M.D.

Folks:

So the APA Assembly met again in November at the JW Marriott in Washington, DC.  It’s unclear whether it will ever meet again in its current form because of APA’s seriously declining revenues from the loss of big Pharma advertising and participation at annual meetings.  During the past year, the Board of Trustees laid off at least 12 people, cut 20 positions, combined or disbanded some committees, and has left others to die on the side of the road.  One of these was the Committee on Psychiatric Dimensions of Disasters (CPDD), whose members have been passionately trying to reconstitute, possibly as an Assembly committee.  The trustees mandated a $200K reduction in the Assembly budget, and then as the meeting began, directed that an additional $200K be cut.

Finances

The Assembly went about cutting expenses via a variety of proposals, which included changing to one meeting per year, cutting out the deputy representatives from the Assembly, or keeping everyone on board but requiring that all the delegates pay some or part of their own travel expenses to Washington each November (Nobody is paid to attend the other Assembly meeting that takes place just before the annual scientific meeting in May).

Ultimately, the Assembly voted to de-fund most of the dep-reps, reduce representation from certain parts of the country, eliminate certain meetings and travel budgets, but continue to meet twice yearly.  Further cuts are entirely possible. One bright light at the end of the financial tunnel is DSM-V.  When it comes out it will doubtless prove another windfall for APA (DSM IV was a gift that even now keeps on giving).

Ethics

With all the attention on state of finances, there was less time and energy left for other initiatives.  One, the approval or rejection of the Draft Report on Relationships between Psychiatrists and the Pharmaceutical/Medical Device Industries, was put off for reconsideration until the spring.  This document, dubbed the “Appelbaum report”, if passed will have the status only of “recommendations” rather than ethical precepts.  In other words, members would have the option to ignore them if they so choose.

There has been a lot of controversy over this document.  It basically frowns on nearly any “perk” traditionally extended from industry reps to psychiatrists, including “gifts”, even of “token value”, food of any sort paid for by drug companies, and involvement in many consulting arrangements.  The real objects of the guidelines are colleagues who have gotten too dependent upon drug company money and who are likely to shade their research or clinical presentations, not to mention involvement in other forms of potential conflict of interest

Many of the rank and file among us are upset by the guidelines, which not only imply but virtually state that the presence of pens and pads in our offices and luncheon sandwiches over which reps make their pitches adversely influences our behavior to our patients.  My view is that the colleagues who have made such Draconian recommendations necessary are the relatively few who have allegedly sold out in big ways and have reaped rewards of a different order of magnitude than pens and pads.

Nonetheless, the temper of the times, coupled with the misbehavior or a few, have brought these recommendations about.  The AMA and other groups have already enunciated similar guidelines, and for its part, Pharma seems to have cut far back on its own.  If APA were to reject them, we would likely be singled out for abuse by all the usual critics of organized psychiatry.  They are in any case, recommendations only, and after an opportunity to vent their frustrations, I expect the Assembly to approve them.

Other Issues

Among motions that were passed was one calling on the APA to “endorse and promote “patient” as the official and appropriate term for psychiatrists to use in referring to those persons they diagnose and treat. It should be clear to all readers where that resolution came from.  A position statement was also passed cautioning against the abuses implicit in what was called “high volume” psychiatric practices, where individuals are simply not given enough time for any meaningful treatment.  Another motion that passed calls on the government to do away with the “don’t ask, don’t tell” provision for dealing with homosexuality in the ranks of the military.

One other measure passed requested that APA look at the issue of so called “me-too” medications.  Many organizations would like to limit their formularies to only a couple of antidepressants or antipsychotics, complaining that the numerous other medications in those classes are simply “me-too” and as such are not needed.  All of us with actual experience have found that, whatever the reason, some of these meds will work when others, closely related, will not.  To either not keep them available or to discourage research and development is a negative outcome that this action paper hopes to prevent.

The Assembly will meet again in May 2010 in New Orleans, site of the next annual scientific meeting.   Before then, elections will be held, with Donna Norris and John Oldham running for President-elect, and David Fassler and Paul Summergrad running for Treasurer.  As usual, this issue of the ASAP newsletter contains the president-elect statements for us to read before voting.

Until then your trusty APA rep/liaison is signing off.  Hope to see you all in March in LA and in May in New Orleans.