APA 2010 President-Elect Candidate Responses

APM President David Gitlin, MD, FAPM asked the two candidates for APA 2010 President-Elect to respond to five issues of concern to the Academy. The questions and their responses are below, which are intended to help you be as fully informed as possible about the candidates' views on these matters as you make your choices in the election. APA members are reminded that ballots must be received by 5:00pm EST Friday, February 5, 2010. The two candidates and their websites are: Donna M. Norris, MD — www.donnanorrismd.com John M. Oldham, MD — johnmoldhammd.wordpress.com For more information about the election, see 2010 Election on the American Psychiatric Association's Web site.

1.	We are interested in stronger collaboration between the APA and the APM; what plans do you have to improve the collaborative relationships between ABPN-approved psychiatric subspecialty affiliate organizations and the APA? How would you plan to assure that their voices and expertise be heard at the highest levels of the APA?
	NORRIS: Today we stand on the brink of reform to the health care delivery system, and the profession must be prepared to identify opportunities to expand access to needed mental health services by collaborating closely with our colleagues in psychiatric sub-specialties as well as the medical specialties. As the medical society representing over 35,000 psychiatrists, the APA has advocated for increased access to health care for all, including children, the elderly, individuals with persistent mental illness and substance use disorders as well as individuals with co-morbid medical conditions. As APA President-Elect, I will ask that the APA President call for a meeting of members of the allied psychiatric and psychiatric subspecialty organizations to discuss plans to address the anticipated increased utilization of psychiatric services under health system reform. It is clear that in order to achieve these goals we must maintain close alliances with our subspecialty colleagues and our primary care colleagues and together use our creative ideas to move forward to address these challenges. The APA has embarked on work to build strong collaborative alliances with allied psychiatric groups. This is a process we can build upon to maximize our profession’s ability to deliver psychiatric services in non-traditional settings. The recent meeting of the Academy of Psychosomatic Medicine held in November 2009 was notable in its discussion of successful models that expand the delivery of psychiatric services to greater numbers of patients in coordination with primary care physicians. There is also an APA Task Force actively working on these concerns. As APA President, I will continue this initiative and plan that our advocacy and legislative efforts are supportive of building on collaborative and integrative models of care between psychiatry and primary care. As APA President, I will continue this work and plan that our continued advocacy and legislative efforts are supportive of important initiatives such as these.	OLDHAM: I believe that ABPN-approved psychiatric subspecialty affiliate organizations, and ACGME-accredited subspecialty training programs, are critically important for our field. I am board certified in forensic psychiatry and have personally launched two forensic residency programs—one at Columbia and Cornell in New York, and one at the Medical University of South Carolina. We have recently begun an addiction psychiatry residency at Baylor College of Medicine, and we are currently applying for a forensic residency, and for a residency in psychosomatic medicine, in collaboration with MD Anderson Hospital. Subspecialty organizations such as the Academy of Psychosomatic Medicine, American Academy of Psychiatry and the Law, American Academy of Child and Adolescent Psychiatry, American Academy of Addiction Psychiatry, American Association for Geriatric Psychiatry and others provide essential intellectual communities for psychiatrists with shared subspecialty interests, as well as powerful voices to advocate for the needs of special patient populations. The APA must sustain support for these subspecialty interests through the Assembly Allied Organization Liaison Committee and through APA components, such as two that I am currently a member of—the Council on Research and Quality Care, and the Steering Committee on Practice Guidelines.


2.	Currently Psychiatric Subspecialty Fellowship programs are struggling to fill their available positions. Potential trainees find the requirement to repay their student loans (or accrue significant interest while in training) difficult. What ideas do you have to make subspecialty training more appealing/affordable?
	NORRIS: With the rapid advances in scientific knowledge and our understanding of this importance to psychiatric medicine, this is a very exciting time to be a psychiatrist. For new medical students and those finishing their training, this is also a time of significant debt. The fact that loan repayment is a prominent consideration in physicians’ plans for advanced training is shared by all subspecialty training programs. In response to this, APA and other subspecialty organizations have lobbied Congress for debt relief for physicians seeking additional subspecialty medical training. In the most recent health system reform draft bill (Senate HSR Bill H.R. 3590 ( Patient Protection and Affordable Care Act), workforce provisions authorize up to $1.15 billion in FY2015 for scholarship and loan repayment, the establishment of a loan repayment program for pediatric subspecialties and mental and behavioral health service providers working in underserved areas. Additional provisions in the bill address the “establishment of a primary care extension program to educate and provide technical assistance to primary care providers about evidence-based therapies, preventive medicine, health promotion, chronic disease management and mental health”. With this language, it appears that advocacy to promote the psychosomatic liaison relationship with primary care physicians in terms of education, health promotion, and mental health is in line with the goals of this legislative initiative and should be advocated by APA and AMA in support of the bill.	OLDHAM: Extended training is difficult for potential trainees to finance under ordinary circumstances, coming on the heels of debt from medical school and limited income during general adult residency training—but especially so these days. Federal loan repayment programs are options to consider. NIH has a number of loan repayment programs, in which enrollees earn a regular salary for at least 2 years of participation in research, and a substantial amount of loan repayment is provided per year. In addition, the National Health Service Corps Loan Repayment Program provides designated amounts of loan repayment in exchange for 2 years of service in a health professional shortage area. The APA should advocate for expansion of these programs to subspecialty populations with special needs, as well as explore potential foundation funding opportunities for new loan repayment programs.


3.	The high cost of APA dues in addition to state psychiatric association dues likely drives the attrition in membership from the APA. What ideas do you have to streamline costs while improving inclusiveness to improve the value of APA membership to the individual member?
	NORRIS: In these difficult economic times, concern regarding the cost of association dues is a frequently asked question. With the recent reduction in the number of components within the APA, direct member involvement in the work of the profession has also been significantly reduced. Members all across the country have made their concerns known to the leadership, with many offering ideas on how to improve inclusiveness and add value to continued membership in the association. Some of the ideas I would consider as President-Elect include requesting that the President: 1) appoint a committee of members to survey the general membership regarding membership dues and benefit structure and make recommendations for changes consistent with member preferences; 2) consider a structure for establishing joint membership discounts with allied psychiatric organizations (such as APM); and, 3) develop work groups with allied psychiatric organizations to work on projects of mutual interest and importance to improving quality of psychiatric care utilizing online or video technologies to facilitate the work at minimal cost. As noted earlier, it will be important to meet regularly with allied psychiatric subspecialty groups who have experience with providing coordinated psychiatric care based on the best evidenced based models currently available. As we stand on the brink of reform to our nation’s health care system it is more important than perhaps ever before that we work closely with our psychiatry subspecialty colleagues to assure the best possible care is being provided.	OLDHAM: Sustained efforts have been made by the APA to minimize dues increases for its members, in spite of unprecedented fiscal challenges, and similar efforts are being made by state psychiatric associations. There are many valuable benefits that membership in the APA provides, such as continuing education, access to reasonable malpractice coverage, participation in APA and Assembly components, councils, and committees to improve quality care for our patients and to partner with other medical specialty organizations. At the recent meeting of the Assembly, I stressed my view that the APA is a membership organization and that we must protect member participation with innovative strategies (e.g., exploring new technologies such as videoconferencing) during these financially challenging times.


4.	How will you advocate for the integration of psychiatry into the medical home in the current health care debate?
	NORRIS: There is some research evidence to support that integrated health care, using models with primary care physicians, case managers and psychiatrists is successful with optimal use of psychiatric expertise and significantly improved patient outcomes. One of the major challenges with this research is that the support for it has been primarily through time limited grant or foundation awards. As President-Elect I will call for creation of a work group to develop guidelines that the APA will promote as an acceptable standard of care for this new model of health care delivery. Working with groups such as APM, the APA must ensure that as discussion of this model moves through the health reform debate, promising practices promoted by APA, APM and other psychiatric organizations are incorporated into the program design.	OLDHAM: The concept of the medical home, in my opinion, is compelling and a model of care that the APA should closely monitor and shape, to be sure that there is appropriate participation by psychiatrists. One of my priority concerns in my position statement published in Psychiatric News (posted on my website) is that “fragmented care is not quality care.” Too often these days, any patient faces a bewildering menu of disconnected options, seemingly driven by the particular body part needing attention, but with no captain to steer the ship. We are all patients, and we must advocate responsibly as agents for our own care, but there is a lot to be said in favor of a “one stop shopping” medical model that facilitates provision of and access to essential care, including psychiatric care.


5.	How do you plan to develop coordinated efforts with other medical specialties—especially primary care disciplines (Family Medicine and General Internal Medicine)?
	NORRIS: In order to develop coordinated efforts with primary care and other medical and mental health specialists, it is necessary to hear their ideas of how to best meet the health care needs of our patients. As President-Elect I will convene discussion forums to hear what these groups see as the major impediments to care, their ideas for how we might address these concerns, ideas for how we can address issues of financing and reimbursement for coordinated care, and strategies for training future psychiatrists to work across the traditional boundaries that have separated psychiatry from the rest of medicine. We need to have all physicians interested in delivering the best quality care to individuals with mental illness working together to assure that changes with any health reform include our best ideas to meet the complex needs of the patients we serve.	OLDHAM: My first priority in my position statement is to stress that psychiatry is part of the House of Medicine, and that the mainstream medical nature of psychiatric disorders is incontrovertible. For nine years I have represented the APA as a member of the AMA Physician Consortium for Performance Improvement (PCPI), and I have been a member of the PCPI Executive Committee for six years. Working side by side with physicians from primary care, internal medicine, family medicine, pediatrics, and specialty care has been a wonderful opportunity to collaborate with these colleagues. I have been impressed by their broad recognition of the importance of identifying psychiatric and behavioral disorders in their patients and by their eagerness to partner with psychiatry to provide appropriate treatment for their patients. We must explore all opportunities such as these to work together with colleagues in all of medicine.

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