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Among several critical issues APA will have to confront in the next few years is how to reverse the recent decline in the number of its dues-paying members, according to the Association’s new medical director, Steven Mirin, M.D. Particularly troubling is that the decline is most pronounced among APA’s younger members, many of whom drop out in the transition from resident to early career psychiatrist, he noted.
In his first address to the Assembly as medical director at its meeting last month, Mirin said that he was also concerned about the number of international medical graduates, women, and minorities who "apparently become disaffected with APA," deciding that it is not meeting their needs.
"While it is clear that APA does a great deal both for individual members and for the profession, our capacity to communicate what we do, and how effectively we are doing it, clearly needs to be improved," he stressed. He vowed to make this a "major priority" for APA staff.
Mirin went on to applaud APA’s government relations efforts and the positive changes they have brought about for both psychiatrists and their patients. He said that while the majority of APA members "express justifiable concern and anguish over market-driven attempts to ration care to our patients, . . .the situation would be far worse without the vigorous efforts of APA—carried out in concert with other groups of mental health care professionals, patient advocates, and key legislators."
Mirin highlighted last year’s passage of the Domenici-Wellstone bill, which mandates parity in lifetime and annual insurance caps for mental illness treatment, as an example of how such "strategic alliances can affect legislative and social change."
These hard-fought successes in ensuring fairness for mentally ill patients and their families must not, however, deter APA and its allies from "the need for eternal vigilance," Mirin cautioned. For proof of this, one has to look only at the Clinton Administration’s recent "waffling" over closing loopholes in the rules governing how employers fulfill their obligations under Domenici-Wellstone, he noted (Psychiatric News, November 17). APA responded to White House inaction with a Capitol Hill press conference to explain why the Clinton Administration should quickly close the loophole and in response has garnered "clear evidence that our voices were heard," Mirin stated.
Another critical area in which Mirin pledged vigilance concerns attempts by other mental health disciplines to enlarge their scope of practice without following the same rigorous educational route that physicians do.
"The most egregious example of this," he said, is the attempt by some psychologists to gain prescribing privileges by legislative fiat. "This is first and foremost a patient care issue," Mirin stressed. "The fact is that a short primer in biochemistry, physiology, and psychopharmacology is no substitute for medical training. . . ."
APA’s goal will continue to be to "fulfill our professional and moral obligation to advocate on behalf of our patients, to enhance their access to care, and to ensure that their care is of a quality we can feel proud of," he said.
A major part of this advocacy must be directed to ensuring that psychiatrists "receive adequate reimbursement for the care they deliver, without having to compromise their patients’ confidentiality in the process."
"We must do a more effective job of communicating that treatment works, in some instances far better than treatments in other areas of medicine; that the costs of mental health and substance abuse care are predictable; and that an investment in the care of our patients pays important dividends," Mirin pointed out, "not only to patients and their families, but to their employers, our government, and to society as a whole."
He assured Assembly members that APA’s agenda will include efforts to guarantee that "future caregivers, teachers, and researchers" receive the training support necessary to prepare them to join the profession. "Our young people are the lifeblood of our field and the lifeblood of APA," he said.
Also addressing the Assembly representatives was APA President Herbert Sacks, M.D., who took the opportunity to trace some of the Assembly’s recent history and explain why he thinks the Assembly "is in danger of losing its compass."
From the vantage point of the individual who monitors Assembly recommendations through the Board of Trustees, Sacks said he is seeing an increase in the number of action papers the Assembly passes that are "ill focused, unclear, and raised more questions than the issues they hoped to resolve."
He traced this in part to the rise of the influence and responsibility accorded to the Assembly Executive Committee, which came at the expense of "the raucous but informative floor debates" that had previously characterized Assembly business. At the same time, Sacks noted, the seven Area Councils were also gaining power, further muting Assembly floor debates.
The latest phase of the Assembly evolution has seen the introduction of reference committees that review proposals in specific topic areas prior to floor discussion. Sacks told the Assembly that he believes that while this concept works at the AMA, it has further drained the Assembly’s political process of the "excitement" it once exhibited and "fragmented. . .the close working relationships" that were fostered when Area Councils did much of the work of refining and negotiating proposed actions.
Sacks likened the reference committee process to managed care, which, he said, "has painfully taught us about the deficits of internal reviews and the virtues of independent external reviews."
He suggested as well that enacting these "radical changes. . .without examining the historic substrate of the Assembly" has led to an imbalance with the Board of Trustees, leaving the Board’s Assembly representatives continually having to remind Trustees that "the Assembly is an important player in the governance."
The APA president called on the Assembly’s Committee on Planning and "a coterie of Assembly leaders, past and present," to begin addressing the "infrastructural fissures" that have compromised the level of Assembly debate and reduced the effectiveness of its voice.