Describing a change in the governance structure of the Association, the speaker of the APA Assembly was in a reproving mood.

"Despite this [change], established to obtain `grass-roots' participation in the affairs of the Association, far too few of our membership have used this machinery."

The speaker was one C.N. Baganz, M.D., and the year was 1955, the first year that the Assembly speaker's report was published in the American Journal of Psychiatry_but he might as well have been speaking in 1996.

From its inception in 1952, the APA Assembly has been the mechanism of choice within the Association for enhancing the voice of the "grass-roots" psychiatrist in the policymaking apparatus.

And today, as in Baganz's day, improved communication and greater involvement of members in the Assembly and district branches is getting a great deal of attention from APA leaders; it was a prominent theme at last year's Leadership Conference convened by then APA President Mary Jane England, M.D., and continues to be reiterated by candidates for office in the APA governance structure. APA recently completed the first leg of a communications initiative with the launching of its World Wide Web site at , which allows members to e-mail their questions and comments directly to staff.

Is the Assembly succeeding in its task of representing the typical member, sometimes described as beleaguered and besieged? Is the Assembly structure accessible, comprehensible, and meaningful to the practicing psychiatrist?

"Because it is closest to the district branches, and because it incorporates a number of minority and underrepresented groups, the Assembly is better able than any other component in the Association to represent the diverse APA membership," said the Assembly's immediate past speaker, Richard Harding, M.D.

Harding echoed the words of a number of Assembly leaders, long-time members, and new members-in-training who drew a portrait of the 238-member representative body as remarkably diverse (in practice type and political orientation if not in gender and ethnicity), far more effective than is widely acknowledged, and largely open and accessible_to those members who make the effort to access it.

Far too many APA members do not make that effort, leaders told Psychiatric News, and the Assembly and Association governance structure are mysteries to many members.

Moreover, the Assembly may be too large, and the process of enacting policies may be too unwieldy, causing good ideas to be passed around interminably between components and committees.

This year a subcommittee on internal organization of the Joint Board/Assembly Task Force on Strategic Planning_charged with devising ways to save the APA members money and streamline the governance structure_delivered a report to the Board of Trustees suggesting substantial reductions in the size of the Assembly and APA's components.

Toward a Unicameral System?

The subcommittee also recommended the formation of a "unicameral" governing body, merging the Board of Trustees and the Assembly.

Harding, a member of the subcommittee, and Richard Bridburg, M.D., chair of the subcommittee and another former speaker, told Psychiatric News that the subcom-mittee's suggestions would entail sweeping constitutional changes and are not likely to be carried out immediately.

"Most people desire a reform," Harding said, "but there is not a great desire for a revolution."

But Harding and Bridburg said the changes suggested in the subcommittee report, including the movement toward a unicameral governing body, may take place incrementally.

Roger Peele, M.D., the 1986-87 Assembly speaker, said he supports the idea of a unicameral governing body and agrees that the Assembly may evolve in that direction over time.

"I think the structure of APA is a bit too complex," Peele said. "The typical member has very little information about the way APA is organized, and many probably couldn't identify the Assembly and its role."

Others stated the matter more bluntly.

"I don't think the average member has the foggiest notion of the structure of APA, and as long as I can remember, members have felt distanced," said Irvin M. Cohen, M.D., parliamentarian of the Assembly under two speakers and the 1987-88 speaker of the Assembly. "I have a suspicion that the majority of APA members don't even know there is an Assembly, or if they do, how to use it. But it is the nearest thing in the Association that we have to what purports to be a scale model of the membership, and I think it is."

Assembly at Work

"Quite arcane and mysterious" is how Nada Stotland, M.D., Assembly representative for the women's caucus, described the appearance of the governance structure to the typical member.

Stotland said that Assembly representatives may report to their district branch council, but may not report anywhere to the rank and file.

"When you vote for [an Assembly representative]_and there are quite a few incumbents_you don't know what their record is in terms of their voting," Stotland said. "Their bio will tell you where they trained or what they do, but it doesn't say how they voted or even whether they showed up for the meeting."

Moreover, what actually happens at an Assembly meeting_the process of moving an "action paper" through to approval_can be daunting. A great deal of the most vigorous debating, as well as political horsetrading, goes on in Area Council meetings, where action papers are discussed before the Assembly considers them; voting on the floor of the Assembly sometimes seems to ratify only what was decided in Area Council meetings.

"Even representatives in the Assembly take one or two meetings to understand what is going on," said Gerald Flamm, M.D., the 1989-90 Assembly speaker.

Grass-Roots Perceptions

That the work of the Assembly is only vaguely appreciated by members was borne out anecdotally in interviews with psychiatrists_chosen randomly from APA's computerized data base_who did not appear to have any institutional involvement with the Association.

Several said they knew who their district branch representatives were and had a "general idea" of the goals of the national organization, but they did not know with any specificity what the Assembly was doing or how the representative body worked.

A Louisiana psychiatrist said he did not know who his DB representative was, adding that he believed APA is "a bureaucracy unto itself." He stated that he paid his dues because he enjoys receiving the American Journal of Psychiatry and because he buys his malpractice insurance through the Association; he intimated that, with the malpractice premium rising, he might reconsider membership.

An Ohio child and adolescent psychiatrist said she was familiar with her DB representative, and that the representative was faithful in reporting back to district branch members at regular intervals.

"How effective they are at making changes is another question," she said. "It seems to me that the American Academy of Child and Adolescent Psychiatry has given back more information to its members about what they are doing. I have a better sense of their lobbying efforts and what they are trying to do for children. . . ."

She said that ideally she would like to be provided with "quick, bullet-point outlines of what was discussed and decided and how it affects me. . . . We need the information, but also an action plan about what I can do to help a [given] effort."

Continual Referendum

"The Assembly has to dedicate itself to a continual referendum from the members," said Harding. "We hammer away at the idea of communication, but people think that if [the actions of the Assembly] are reported in Psychiatric News or in a DB newsletter, then the job is done."

He said Assembly representatives must actively seek out the input of constituents, and report back the achievements of the Association.

Others said the difficulty of reaching members stems in part from the nature of psychiatric practice itself.

"Psychiatry is mainly an outpatient operation, and it always has been," said Lawrence Kline, M.D., Area 3 deputy representative to the Assembly Executive Committee. "Psychiatrists are isolated in their offices. They don't get together like surgeons, who meet together regularly in their hospitals, making it much easier to communicate with them from above."

Kline and others strongly defended the achievements of the Assembly and the Association, especially with regard to managed care.

"In my opinion the Assembly has led the way with respect to the remarkable changes in American medicine that have come from the institution of for-profit managed care," he said. "The Assembly is accessible, but the unfortunate fact is that many members do not know what APA has done, period . . . . Many members say, 'What does APA do?' as if APA does nothing. It's unfair and untrue."

"I think the problem is not just with our organization," said Stotland. "I think there are forces at work that are bigger than any organization. . . . Passing an action paper doesn't do much unless other mechanisms are employed to make an impact on the world. . . . The rank and file read that we passed this or we passed that and they think, 'So what? I still can't treat my patients the way I want to'."

Said Cohen, "I think members look at this father figure, APA, to provide strength and power, and when it doesn't, then they become disillusioned."

The Future

In countless ways, the Assembly has successfully represented the diverse APA membership on issues that have a dramatic impact on the psychiatric profession: support for the development of practice guidelines; establishment of a litigation fund to combat the worst aspects of managed care; formulation of policies affecting residency training; and structural changes in APA, such as the recent institution of the Commission on Psychotherapy.

Many of these strides will have their most profound influence on psychiatrists who will be practicing in the next generation.

So how does the Assembly look to its youngest members?

"Residents-in-training know more about the Assembly than they did 10 years ago," said Paul Loop, M.D., Area 4 member-in-training representative to the Assembly, who enthusiastically affirmed the value of psychiatry residents' becoming members of APA.

Loop said he believes the Assembly does a good job of representing the membership, though its composition_largely, he said, of "older white males"_is not reflective of the changing face of psychiatry.

He noted that of the 12 members of the Residents Committee, which he chairs, most are women, minorities, or international medical graduates.

Residency training issues, of course, are uppermost in his constituents' mind, especially the preparation of trainees for dealing with managed care. Many residents want such training but don't receive it in their residency programs, Loop said.

He added that early career psychiatrists find it difficult to get on managed care panels that require board certification, a process that can take up to two years.

Among the first generation of physicians to enter medicine never having known what it is like to practice without managed care, Loop's constituents are less interested in trying to destroy managed care, he suggested, than in learning how to make it work.

He said Assembly members, many of them older physicians in private practice, tend to be "slanted against managed care, and understandably so."

Still, he said, there is vigorous support from many representatives for providing managed care training to residents and for speeding up the certification process.

Generally, Loop said, residents want APA to work with managed care, while using the litigation fund and other mechanisms for aggressively fighting the most offensive aspects of the new health care environment.

Regarding the Association's response to managed care, many of those interviewed agreed that the best testimony to the representative nature of the Assembly is the heterogeneity of views about that subject.

While the Assembly continues to be the best bastion of support for the private practitioner holding out against a changing environment, they said, it is also increasingly represented by those committed to making managed care work in the interests of the patient_a true composite of a diverse, if not divided, profession.

"That is the pleasure of working in the Assembly," said Harding. "Debate there is very knowledgeable. The mix of views helps all of us understand this ongoing debate between patient-centered and population-centered care."

Richard Karel contributed to this article.

(Psychiatric News, September 20, 1996)