Facing historic mental health inequities, social injustice, climate change, COVID, and limited workforce development, our system of care – psychiatrists, other providers, and patients are overwhelmed. The APA must respond, providing leadership committed to practical solutions. I have had decades-long experience in multiple positions where problem-solving, engagement, partnership and advocacy have led to the creation of innovative systems of care. I have served in multiple leadership roles translating vision and intent into action.
I am committed to a change in process and products; the APA must address the following issues:
Racism/social injustice: Embrace self-assessment, courses of study, action plans, and objective metrics to hold ourselves and our leaders accountable; Transparently recruit, support, and appoint to M/UR members to APA components; Prepare our workforce to treat those who are victims of the trauma of racism, social injustice, climate change, and the ravages of COVID.h
Stigma and parity for patients and clinicians: Advocate and educate decision-makers and the community; Support legislation, insurance, and judicial reform to improve parity and maximize reimbursement.h
Limited workforce: Develop concrete, practical strategies to increase the numbers of clinicians to meet the needs of every person living with mental illness.*h
Unengaged psychiatrists in the APA: Maximize intergenerational strengths to engage and utilize our innovative, energetic Resident Fellow Members and Early Career Psychiatrists; Use Life Fellows and members as mentors; Offer value to members by offering timely development and distribution of products that are meaningful. Fix the flawed MOC process to minimize expense and maximize life-long learning; Listen to the members. Listen to the members. Listen to the members.h
Continue the Fall meeting of the APA, which offers a safe space for passionate dialogue, mentoring, networking, and development of evidence-based action plans for change in the community.
- Climate change and mental health: Direct the new APA Committee on Climate Change and Mental Health to create a strategic action plan for APA. The Climate Psychiatry Alliance evaluates candidates on this issue. See my Tier #1 rating from the Climate Psychiatry Alliance: CPA Newsletter January 2020
To learn more about my and the other candidates platforms please see the December 2020 AGLP (Association of LGBTQ Psychiatrists) to review its election issue, where APA candidates were asked to respond to a series of questions: http://www.aglp.org/newsletterPDF/AGLPNewsletterDecember2020.pdf
*Elaboration of Platform on Workforce Development/Scope of Practice
The issues in psychiatry related to Scope of Practice are long standing and complex; resolution of these is a critical issue for the field of psychiatry. I think there are folks who believe those concerned about scope of practice are primarily focused on protecting one’s practice (not wanting to lose patients to a mid-level clinician. I disagree; everyone with whom I have communicated is sincerely concerned that allowing non-physicians to be clinical mental health providers might leave patients vulnerable to inadequate care.
I think we can all agree that there exist limited numbers of psychiatric physicians, particularly for children and adolescents, those with developmental or intellectual disabilities, geriatric patients, BIPoC patients, community mental health center and FQHC patients, jail and prison patients, and patients with limited financial resources or inadequate insurance. Let me remind you: the APA’s first stated mission is to “provide the highest quality care for individuals with mental illness, and their families.”
Instead of focusing solely on scope of practice, I believe the questions we need to answer are:
- How do we create a sufficient, competent workforce to provide the necessary, quality care each patient deserves?
- How do we ensure that every patient living with ADHD, LD, autism, developmental disabilities, anxiety, PTSD, struggling with the consequences of crises, poverty, trauma, domestic violence, mass violence, bullying, climate change, grief, depression, bipolar disorder, substance use disorders, personality disorder, psychosomatic disorder, schizophrenia or other psychosis, or dementia (to name just a few) gets prompt access to evidence-based quality mental health care?
- And how do we ensure such care in rural areas, to folks with no or limited insurance or financial reserves, to those who are homeless, to those in jails and prisons?
Vis a vis Scope of Practice I believe that:
1. Psychologists should never be given prescribing rights.
2. There are talented, competent CNPs/PAs who have received specialized psychiatric training to evaluate and diagnose mental health problems, and many prescribe appropriately, with MD supervision. However, competence standards are negligible or so fluid that one cannot assume competence just because someone is an NP or PA. Stringent guidelines for training, quality of care guidelines, and meaningful supervision must be in place to utilize “mid-level clinicians.” We must be vigilant when insurance companies move care provision to said clinicians without those guidelines in place and enforced
3. There are not enough psychiatrists to provide prompt access and welcoming quality care to every person living with mental illness. Why is that? Too few medical students choose to go into psychiatry (and note there are limited number of psychiatry residency slots). Too few choose to receive specialized fellowship training. Providing care in under-resourced situations all too often results in salaries that are lower than average (and often insufficient to pay off medical school loans). Many of my colleagues choose to provide cash-only reimbursement outpatient care for their practice (this is an observation, not a judgement). Too few choose to live in rural areas, or to work with patients in challenging situations (homeless shelters, ACT teams, jails or prisons). All contribute to insufficient numbers of psychiatric physicians.
So, do we say no one but psychiatrists can see, evaluate, and treat those living with mental illness? Of course not. The workforce shortage in psychiatry is profound and having huge untoward consequences. Patients are delayed in seeking care or cannot even access it if providers don’t exist or have no openings. These deficits often result in costly Increased utilization of emergency services, inpatient services, the criminal justice system, or increased morbidity and mortality. It simply cannot continue.
I suggest there are a variety of solutions that could make significant inroads in the provision of psychiatric care.
- As noted above, utilize CNPs and PAs who have received specialized psychiatric training, meeting clinical competency standards, and who receive meaningful supervision from a psychiatrist
- Utilize collaborative, integrated care models with multidisciplinary teams (typically psychiatrists working in medical clinics).
- Provide curricula and psychiatric educators for family practice, emergency medicine, pediatric and internal medicine residencies, so our medical colleagues can be sentinels for identifying (and referring) complicated patients, and learn how to handle simpler anxiety and depression cases
- Lobby the RRC and GME so that training in mental health care provision is a required part of residency training in family practice, emergency, and internal medicine residencies. This will enhance competency and hopefully reduce stigma related to misperceptions regarding mental illness.
- Adopt locus of care/utilization of services (LOCUS) screening assessments of patients so we can identify what kind of patients need what kind of care.
- Accept that there exist master-level social workers, licensed clinical counselors, marriage and family therapists, and Ph.D. psychologists to whom patients can be referred (see LOCUS), who can provide evidence-based appropriate therapy (need to assess and assure their skill sets and competency levels).
- Longer term:
- Increase medical student interest and recruitment into psychiatry, expand the number of psychiatry resident trainees (and please, make sure we are recruiting a diverse population of trainees).
- Additional funding to pay for these slots (from the federal government, perhaps some can come in the form of student loan repayment for service in under-served areas).
- Work with insurers (including CMS Medicaid and Medicare) to provide sufficient reimbursement so that practitioners can make an adequate living. How can we entice residents to choose to work in hospitals, state hospitals, jails, prisons, community mental health centers, and FQHCs if their compensation is significantly smaller than other types of practices?
- Ensure that resident training in challenging settings is fulfilling, supported, exciting, and well supervised.
Of course, these are not all the challenges, nor all of the solutions. I would make workforce development (implicit in that is identification of scope of practice issues, with solutions offered) a Presidential Task Force issue if elected.
Please contact me if you have comments, questions or suggestions. I would treasure your input and your vote!