a very long drought…

Posted on Wednesday 23 April 2014

One wouldn’t have to read much here to realize that I’m no particular fan of the American Psychiatric Association or its current President, Dr. Jeffrey Lieberman. With him, it’s not anything personal. I just don’t much like people who speak and write with a conclusion that they want me to reach, and attempt to sell it. I don’t mind his having opinions, but I do mind not hearing anything that I don’t already know woven into some conclusion I can’t imagine agreeing with. But then I read something I did like yesterday in the psychiatric news. It was an article about a talk Dr. Summergrad, the APA President-Elect, gave to the Directors of Residency Training at their annual meeting recently. That’s a job I held for for a while and would’ve continued had psychiatry not gone in a direction I didn’t understand [as in "stand under"]. The articleis there for the reading, but I want to say a word about what Dr. Summergrad says [see Summergrad Addresses Training Directors on Development of Physician Identity].

There were two things on the table for the training directors. First, there’s a push for documenting and rating in training programs – some call for objective criteria, data by which to judge individual residents and their programs. Second, there was a an issue about "resident duty-hour restrictions" – putting limits on the number of hours residents can be required to work. I thought it was kind of funny that those same things were on the agenda at that same meeting thirty years ago when I was in the audience. I guess some things never change.

But it’s not the issues, but the way he approached talking about them that I want to write about. He called his talk, Going to Sea: Psychiatric Education in an Era of Accountability. He talked about the modern need for accountability and objective measures, about everything – what was good about it. And he discussed the fact that the obsession wasn’t going to go away – sort of a "don’t fight it, it’s here to stay" point of view. But the thrust of what he had to say  was music – don’t confuse these bean-counter requirements with what really matters in a training program – that the residents develop an identity as physicians focused on the needs of their patients, not their own. It’s really quite impressive what he has to say. I haven’t heard anyone in a high place in psychiatry talk like that in years. I wanted to say, "what’s a guy like you doing in a place like this?"

Paul Summergrad ... at the symposium on conflict of interest in academic medicineMaybe I like him because he did too many training programs – internal medicine, psychiatry, psychoanalysis, with some fellowships thrown in to boot [like I did]. Maybe it’s because he has a longstanding interest in Zen Buddhism [like I do]. Perhaps his watching Nordic Noir television shows [like I do] has something to do with it. But I really think it’s his ability for straight talk, and the fact that he seems to know what’s really important in a trying time that draws me towards him. There’s a badly taped presentation at the University of Florida [The Future of Psychiatry] that you might like to watch as well.

I don’t know much more about him than I’ve said except that he’s the Chairman at Tufts, but it’s not his credentials that impress me. And I don’t know what he’s done, so it’s not his accomplishments either. And I’m so cynical about the APA in general right now and I don’t know what he might do as APA President that will lead to any changes. But he shows signs of being the real deal, and considering the alternatives, that’s a breath of fresh air after a very long drought. Let’s hope it’s a patch of blue
    April 23, 2014 | 12:01 PM

    Accountability? We have been hearing that from managed care for years:


    Measurement is one thing if it is meaningful and quite another if measurement is a subjective set of measures that result in the oppression of physicians. Take a look at the PQRS system that the APA put together for CMS. The penalties for not doing all of the paperwork is all part of the mantra “don’t fight – it’s here to stay”.

    April 23, 2014 | 1:27 PM

    you need to calm down dr dawson,

    some measurements aren’t public yet. so just siddown and chill out. when it’s ready you’ll know. getting all blustery over a well-written response to an extremely thoughtful piece, which outlined the delicacy and importance of measurement in psychiatry, isn’t going to help.

    i really liked the article written by summergrad.

    April 23, 2014 | 1:40 PM

    Wasn’t Obama a breath of fresh air, and now just another politican full of, hot air? Leaders are puppets or manipulators until proven otherwise, and the APA is no different in their behaviors and actions than what we see of the Republocrats leading, or rather ruling, this country.

    yeah, I know, harping as usual. Just trying to keep you grounded, don’t want that optimism and hope to get ya too high, the fall could kill ya!

    April 23, 2014 | 5:20 PM

    I would be interested in hearing the behind-the-scenes political machinations at the APA that got Summergrad nominated. Has the roster of compromised candidates been finally exhausted? Is he somebody’s best friend?

    James O'Brien, M.D.
    April 23, 2014 | 7:26 PM

    I think Dr. Dawson nailed this in another post. He could be the second coming of Thomas Jefferson, Maimonides, Benjamin Rush, Paul Meehl, Lawrence of Arabia, whatever, rolled into one and there is nothing that he can really do in a one year term. The APA is structured to make its Presidency and influence irrelevant (except in the case of the DSM cash cow, and that’s a negative). In the case of the current occupant, that is a good thing. I’m hearing nothing from him that doesn’t sound any different from a mangled care hack or Zeke Emanuel. The proper reaction to some of his speeches by the rank and file in my mind is something that can’t be said at a professional meeting. Obscenity deserves obscenity.

    April 23, 2014 | 9:02 PM

    What is the purpose of the APA President? For whom is he a mouthpiece? The DSM leadership? Who are the real powers-that-be? Somebody is directing the use of the org’s lobbying $$.

    April 24, 2014 | 9:17 AM

    Great post, and he sounds promising. What I find troubling is the idea of developing physician identities in residents. Which identities? Those of what most people think of as “good doctors”, or those of doctors who are asked to function in today’s healthcare system? I’m not sure the two are compatible.

    James O'Brien, M.D.
    April 24, 2014 | 12:07 PM

    I wonder how Lieberman and his coauthor would react if someone in private practice came to Columbia and gave a lecture about how the faculty needs to make a “leap of faith” and change the way the do things, because they aren’t seeing enough patients and academics is too wasteful. I don’t see why their editorial doesn’t deserve the same hostile reaction.

    Leaps of faith are for suckers at tent revivals. Scientists demand proof. How did that leap of faith for deinstitutionalization work out 50 years ago?

    April 24, 2014 | 12:07 PM

    “…or those of doctors who are asked to function in today’s healthcare system?”

    I’m not sure this is even possible considering that you’d have to not be human in order to function well in it.

    April 24, 2014 | 5:06 PM

    Which identities? Those of what most people think of as “good doctors”, or those of doctors who are asked to function in today’s healthcare system? I’m not sure the two are compatible.

    Health care credentials that are evidence-based and working would require different evidence and different approaches to getting evidence in psychiatry. As long as a patient being doped to the gills, so being incapable of being a bother to anyone is evidence of success, and given the APA, DSM-5, and the still-reigning paradigm of bio-psychiatry, “objective measures” of how much of what drugs are being prescribed by training doctors may be considered to be evidence of effectiveness. It would suit the drive for algorithms, the drug industry; and Lieberman who, in spite of his current job title, is employed as a shill for drug manufacturers who is willing to dope three year-old children, if that’s what it takes to expend the base for which the drug industry can expand its “targets”.

    April 24, 2014 | 5:54 PM

    To put it in terms used by a medical doctor who sees the whole medical industry as an arm of BigPharma where polypharmacy rules:

    For many years, pharmaceutical companies paid doctors ‘honoraria’, which is just a posh word for money. The doctors happily stuffed said honoraria into their bank balances, and no-one seemed much bothered. You did not need to declare any financial interests, and the only limitation on how much you got paid was your perceived value to the companies.

    Your value was measured in a few different ways:

    1. Ability to influence other doctors – your status as an ‘opinion leader’
    2. Your quality as a speaker at meetings and/or ability to set up and run
    clinical trials
    3. Your influence within the healthcare system i.e. do you advise Governments
    on treatment, do you sit on committees that advice NICE, or the Food and
    Drugs Administration (FDA)
    4. Your position on Guideline committees. Can you play a key role in writing
    the guidelines that other doctors have to follow e.g. drug x a must be used
    first line in all patients with condition y.

    These things are, of course, all linked. As an expert you start on rung one and two, and then move onto three and four. Your progress up this ladder requires very close links with the industry. You cannot influence other doctors if you haven’t done research, and it is very difficult to do research without industry funding. If not impossible.


    We all know where Lieberman is on this list of industry salesmen. Why bother with anything he has to say, in any capacity, other than to note that he is a shill who has no interest in doing anything but promoting drugs and questionable conditions used to prescribe drugs. If anything he says does not serve his primary mission, assume he’s saying to make himself palatable, which is likely a net negative for people being diagnosed with the fictitious and genuine disorders of psychiatry who are prescribed drugs that have not been properly tested.

    All “evidence” based on industry “research” is primarily too worthless to bother with the task of sorting the wheat from the chaff. All guidelines based on that research are little more than a booster for the sales of drugs that have not been properly tested, and possibly to treat a condition that has no real medical evidence to support it’s existence as a pathology in need of treatment. at all, much less drug intervention; but has opened up a whole new world for BigPharma to “treat” or to “prevent”.

    April 24, 2014 | 7:37 PM

    You know what is so pathetic about academic leaders? They become so insulated and devoid of dealing with the day to day matters of real psychiatric practice, they think their clinical conferences and occasional star appearances at residency sites of clinical care make them wonders and heir apparents to Freud type modelings.

    And yet, at the end of the day following years of not doing consistent and reliable patient care interactions, they have no f—–g clue that patient care isn’t so cut and dried from their years of crafting a skill they don’t practice anymore. Psychiatry has a level of “street smarts” that won’t ever come solely from a textbook or academic pontifications from sterile laboratory studies and extreme presentations of psychiatric pathology you won’t see on a day to day basis.

    You couldn’t pay me a fantastic salary to go back to academic medicine, the ego and patriarchal bullshit that roams those halls are lost in the sea of green money that pharma has tarnished beyond recognition. The colleagues you appreciate and respect are the grunts in the field, who see the truly ill and impaired and those patients who just want to get better and resume their lives of health and function.

    But, you won’t find those patients in CMHCs either, no, those arenas are now filled with just excessively pathological dependency, entitlement, and raw drug seeking. A therapist asked me this afternoon have I seen a difference in my work in CMHCs the past ten years, and the answer was rather quick and simple: “patients just want drugs, want a pass for handling any responsibility, and want approval that the status quo is fine”.

    I work now at a place where over 70% of patients are on benzos, over 25% are on stimulants, with some overlap with the benzos, and easily 40% are on 4 or more psychotropics. This is not what I signed up to do back in 1990, no, the karma gods are laughing their freakin’ heads off when I chose psychiatry over psychology so I could have access to medicine as completing the options to offer for patient care. Now ALL I HAVE is medicine to offer for patient care. And even trying to provide any therapy or even patient education with handouts and direction to get into therapy with other reliable sources is just received with sneers, dismissals, and frank minimization and deflection.

    Mental Health care for the masses is a joke now, and led by these jokes at universities and organizations like the APA and AMA. People like us at these blogs and threads who really want to make a difference, who are we kidding, as long as the corrupt and inept run the show, there are no choices, no options, besides what SSRI or Antipsychotic to pick today that failed last week.

    Am I beyond jaded, cynical, and devoid of hope? You betcha. Because I am surrounded by too many whores and cowards who have no clue or interest to take a real stand.

    Having watched the “Ten Commandments this past week in honor of Passover, I love when Nefreteri asks Rhaamses “do you hear laughter, Pharaoh?” No, it is not the laughter of slaves or dead pharaohs, but the laughter of providers who knew better and were able to retire or just die with honor and a fulfillment of working their careers and not be tarnished and tainted by the money of drugs.

    We live in a status woe, and continue to let the discussion run overall by those who relish the woe staying intact and just benefiting the few and elite.

    Yeah, the rant is over, another week gone to hell!

    April 24, 2014 | 7:46 PM

    Uh, right on, Joel.

    Still, I wouldn’t blame managed care for all the excesses in psychiatric treatment. There are plenty of cash-only psychiatrists doing exactly the same things — short on appointments, long on drugs.

    James O'Brien, M.D.
    April 25, 2014 | 1:56 AM

    Here’s a question I have for the academic tenured types with low or nonexistent patient responsibilities. If I take on ten times as many patients and do less thorough work with each of them (or not even examine them), what happens to my malpractice risk? Do you want to consult with the forensic psychiatrists on your staff to help you answer that? Or does common sense (I don’t know where that’s hidden away in the ivory tower) answer the question? Still think I should take a leap of faith?

    April 25, 2014 | 7:39 AM

    From my experience, opting to not take psychotropic drugs when a doctor has prescribed them is a difficult endeavour. Passing the buck isn’t the only motivation for taking drugs or accepting a psychiatric diagnosis, there is also the desire to be the “good” patient — compliance also being a marker of being informed and on the side of the forces of light, I mean EBM.

    Separately, isn’t it better to help few than to harm many. Work where you manage to help just a few people is not bad work.

    April 25, 2014 | 8:45 PM

    Measures can be problematic We have performance measures based on rather weak evidence. [Note that they change the titles before they post on KMD.com, so this title may not be what the author intended.]

    I guess it is great to catch the few incompetent, lazy, greedy or misinformed, with standards, yet, personally, I would like to be left alone to work out with my physicians what is best for my particular mind and body.

    James O'Brien, M.D.
    April 26, 2014 | 12:20 PM

    Summergrad seems like a step up from the current occupant. Keith Ablow has written favorably about him. The problem is the position is ceremonial, a nice addition to a CV, but in terms of real impact it doesn’t matter. Maybe if he had a four year term. Still, I’d feel better if the Pres were in private practice with skin in the game. Still feel the only medical org really representing private practice is AAPS.

    April 26, 2014 | 11:03 PM

    I’m sort of tired of the valorization of sleep deprivation. I have a friend who is a physiologist who works half-time with a sleep specialist in a sleep lab. I told him a story about an ER attending who was complaining about the reduced hours, and my friend bristled. He said, “Have them come look at our data on functioning after sleep deprivation.”

Sorry, the comment form is closed at this time.