A Challenge to Candidates in APA's 1999 Election

By Jerome A. Collins, M.D.

Each year the candidates for APA elected office tell the membership what they stand for and what they intend to do if elected. This year I would like to raise some "bottom up" questions and issues that concern the "grass roots."

I live in southern Maine, where we have recently had to cope with considerable penetration by managed care, and we are bracing for more to come. Our attitude and our morale have benefited greatly from an APA leadership approach that conducted an aggressive anti-managed care campaign in the last few years. We also benefit from the fact that we live and work in a small-town atmosphere, where predators (such as the more egregious MCOs) are more readily identified and get talked about (publicly and privately). The talk often leads to action.

After discussion with several local psychiatrists and considerable personal reflection, I think that the following issues are "hot" for psychiatrists, both locally and throughout the U.S.:

1. Psychiatric morale and spirit: This is the most important issue for organized psychiatry today, because if we lose our morale, sense of identity, purpose, and fighting spirit, we've lost ourselves, and we will be inadequate in the important battles we must fight for our patients. In any long-term fight, there is always a danger of burnout, depression, battle fatigue, and identification with the aggressor. In our battle with managed care, there may occur, over time, a wearing down of hope and a sense of powerlessness.

   Recognizing and addressing the issue of flagging physician morale and offering encouragement and hope are vitally important functions of our APA leadership-so important that I believe that there ought to be an APA task force on physician morale.

   With the campaign for APA's 1999 election under way, I am calling on APA candidates to explain how they see this issue and how they propose to address it.




2. The doctor-patient covenant: This is another important piece of ground that APA must defend. If we lose this, we lose our identity as physicians and healers. The doctor-patient relationship is subject to daily assaults from the financial interests that underwrite and manage health care. There are constant ideological attempts to downplay this relationship and to reinvent it as a higher-level service worker whose loyalties are to corporate America.

   Core issues are the ethical imperatives of privacy, confidentiality, and informed consent that must be integral to this relationship. The relationship is also threatened by managed care's unceasing attempt to usurp physicians' decision-making authority.




3. A new joint commission on mental health and mental illness: This is an idea about which a number of us have thought a great deal. It has been about 40 years since our country took a formal, systematic look at the needs of the mentally ill and how to address them.

The plans developed in the early 1960s by the last national joint commission to examine this issue went to Congress and became the basis for the Community Mental Health Centers Act, a blueprint designed to move the treatment of the mentally ill in a bold new direction.

I would suggest that services for the mentally ill in all parts of the U.S. have never been in a greater state of disarray and neglect than they are now, that there is really no national policy for treating the mentally ill (other than Darwinian survival), and that this policy vacuum is being filled by the insurance industry.

I propose that the APA president, after extensive consultation with various groups interested in the care of the mentally ill, draft an open letter to the president of the United States, with copies to the national media, as well as other health, social service, and patient advocacy organizations, calling for the establishment of the Second Joint Commission on the Mental Health and Mental Illness of our citizens. It should spell out the needs, goals, and the process for achieving those goals.

An alternative to this approach would be for the APA president to convene a conference of the best minds in the country in mental health, social service, public welfare, and patient advocacy to develop a statement of national need and to suggest goals and a process for meeting the need.

It is a daunting prospect to start such an undertaking; however, there is a huge groundswell of discontent on health/mental health matters from Maine to California. No one is happy with the present system, and in the end, we are all patients. APA and its individual members should proactively offer leadership on this issue.

We need to hear from APA candidates about how they intend to get upstream on this problem. If they do not favor a national joint commission, they should describe alternatives for establishing a humane, national policy for the mentally ill.

I am sure that as all of you candidates travel around the country, you must be besieged by people with "great ideas." It is a huge responsibility to sort it all out and come up with actions that will constitute an important legacy long after the election is over.

We APA members and voters also have a responsibility. We must inform ourselves. We need to know where all the candidates stand on these issues.

The above challenges to the candidates come out of a deep appreciation for what APA has accomplished in the last few years for the profession and our patients. Yet though a great deal has been accomplished, we cannot rest on our laurels. Difficult times demand strong leaders. Tell us where you stand.