It is APA election time again. The deadline for voting is very near, so I encourage anyone who has not sent in his or her ballot to vote. In this column, Lev Gertsik, M.D., describes his reactions to the election issue of Psychiatric News and his thoughts about the election. This is Dr. Gertsik's first time voting as an APA member. His essay is provocative, challenging, and a spirited query about all of the candidates' positions.

Dr. Gertsik is a third-year resident at the UCLA/San Fernando Valley psychiatry residency program. Before beginning his training in the United States, he practiced general psychiatry and psychotherapy in Russia for 10 years. Dr. Gertsik, a former resident fellow of the American Psychoanalytic Association, is coordinating a new discussion group on the interface between the neurobiology and psychodynamics of affect regulation for the analytic meeting in San Diego in May. He will then remain to attend APA's 1997 annual meeting.

Keep an eye out for further information in this column about activities specifically for residents and fellows attending the annual meeting. Many interesting special events are planned. Please feel free to call me at (919) 286-4517 or e-mail me at hegger@psych.mc.duke.edu to discuss issues, ideas, and proposals.

Helen Egger, M.D.
Member-in-Training Trustee

By Lev Gertsik, M.D.

This year is my first chance to vote in an APA election, and I was really looking forward to it. Unfortunately, reading the candidates' statements in the recent election issue of Psychiatric News made me nervous.

Most of the statements were focused on managed care: candidates spoke about the current crisis and about how the bad guys in the insurance industry brought the crisis upon us; about how we need to explain to the public and the legislature that they are bad and we are good, so the public and the legislature will regulate their power; and. . . . Actually, I am confused about what should happen next. Should we return to pre-managed care status quo?

I am aware that many APA members are bothered by managed care abuses. I know that the candidates' pre-election declarations are written to get elected. I am also acutely aware of the fact that candidates usually mislead us when they tell us only what we want to hear. In a time of crisis we cannot afford to be misled.

The crisis in our profession is very serious, and my generation of psychiatrists will be hit hardest by it. It is crucial that APA continues to define the roots of this crisis and make efforts to reverse the dismantling of effective and humane psychiatric practice. Unfortunately, many candidates imply that were it not for the relatively small group of greedy managed care executives, we would be fine.

I am afraid that the reality is much more complicated. For example, aren't some managed care executives also members of APA? Dr. Eist wrote a brilliant satire about them in his column in the January 3 issue, but he did not acknowledge that he was writing about dues-paying members of APA. He also stopped short of proposing how these people should be treated within APA.

Are we going to fight managed care as a fact of life or only managed care abuses? Are all managed care influences on psychiatry deleterious? Did not the expansion of managed care bring to our attention the issues of medical necessity and cost-effectiveness, which were largely neglected in the era of the "silent" insurance? Is there a possibility for a mutually acceptable compromise between psychiatry and managed care insurance plans, and, if there is, what do candidates envision? As I read the election issue, I did not find answers to these questions.

How do I know that the candidates for whom I vote will be able to negotiate effectively with government and business interests that are involved in the regulation of health care? Recent defeat of two California initiatives, invented to restrain HMO's, showed me that society is very reluctant to mandate regulatory interference with managed care affairs.

I believe that psychiatrists must take partial responsibility for the current crisis. We as a professional group must subject ourselves to merciless self-scrutiny to find out why we were so unprepared and so vulnerable to current changes. How did the idea of replacing psychiatrists with a combination of nonpsychiatric M.D.'s and non-M.D. therapists develop? Did we not, to some extent, contribute to this assault by reducing the biopsychosocial model to a contentless slogan; by oversubscribing to reductionistic, biological theories; by allowing a theoretically unfounded and practically senseless split between pharmacotherapy and psychotherapy? Unfortunately, many in society think that the services we currently offer are not of the highest quality and that they can be delivered by others at a lower cost. We would be better off countering this perception by improving what we have to offer to patients and their families and not by continuing to convince ourselves that we are innocent victims of managed care.

We live in a time of crisis, but also a time of hope. The accumulating evidence that social experience largely shapes brain structural development provides scientific grounds for reintegration of biological and psychological treatments. If we manage to do it, we can demonstrate that we are irreplaceable. This takes commitment to patients, to rigor, to research, and to honest appraisal of what is outstanding and what is outdated in our practices.

I am not ready to cast my vote. I want to hear more from the candidates on the issues I have raised. I hope that our discussions do not stop with the election declarations, but continue on the pages of Psychiatric News, at APA meetings, and elsewhere.

(Psychiatric News, March 7, 1997)