Sharfstein Challenges Psychiatrists To Help Reform Health System

Psychiatry has a “crisis of credibility” and must work to regain the public trust, said incoming APA President Steven Sharfstein, M.D., at the Opening Session of APA's 2005 annual meeting in Atlanta.

In a candid speech interrupted several times by applause, Sharfstein challenged the profession to reclaim its “moral authority” and take the lead in reforming a badly broken health and mental health care system.

He is president and chief executive officer of Sheppard Pratt Health System in Baltimore, Md.

Sharfstein said the organization and delivery of American health care are beset by problems of access, cost, and quality—the “three sides of an iron triangle that undermines care, satisfaction, and medical progress.”

“In one corner, we hear the voice of consumers arguing that the patient and family know best. In another corner, there are the insurers and employers who tell us to follow the Golden Rule—he who has the gold makes the rules.

“In a third corner, large pharmaceutical companies claim that the key to the future is research innovation, and the key to innovation is adequate investment—which requires them to charge high prices.”

But Sharfstein said it is the psychiatric profession that alone can provide access to care, manage costs, and ensure quality.

“Only doctors have the moral and intellectual authority to break this iron triangle,” Sharfstein said. “Yet, we are failing to lead. The problem is not our policy positions—it is that our profession lacks credibility and leverage. When we speak, too few listen. And to a large extent, we have only ourselves to blame.”

Uninsured Being Neglected

The new APA president said that psychiatry, like medicine generally, had fallen short of its calling in vital areas.

“We do not ensure quality in our own ranks. Our system of self-discipline is erratic, inconsistent, and also not in the public interest. We allow an unacceptable rate of medical errors in our practice, even as we campaign for tort reform.

“We have let the biopsychosocial model become the bio-bio-bio model,” he continued. “As a profession, we have neglected the uninsured, the poor, the needy, and the seriously and persistently mentally ill. As a profession, we have allowed gross disparities in health care for racial and ethnic minorities even as we ask for better reimbursement.”

Sharfstein said as well that the profession's response to the challenge of managed care has been erratic—opting out of managed care systems altogether on the one hand, and acquiescing to unconscionable limits on care on the other hand.

Moreover, the for-profit, market-based system of health care has lured physicians away from their commitment to patients and the public, he said.

“We have frequently allowed ourselves to be corrupted in this marketplace with lucrative consulting to industry, speaker panels, boards of directors, and visits from industry representatives bearing gifts,” he said. “We have compromised the core value of confidentiality in an effort to guarantee payment and stay on managed care panels.

“Our profession is seen, by many, as an interest group, a trade association, and too often we have behaved like one.”

Advocacy Extended to Public Health

Outlining steps to reverse this state of affairs, Sharfstein paid special homage to the late Jay Cutler, J.D., longtime director of APA's Division of Government Relations and a friend of Sharfstein's.

First, he said, individual psychiatrists, and the profession, must reclaim the role of advocate for patients—a role that Cutler exemplified during his leadership.

“Our advocacy must extend beyond the doctor-patient relationship to broader issues of the public health,” he said. For example,“ thousands of youth are incarcerated unnecessarily each night because community mental health services are not available. This must be psychiatry's concern.”

A second step, he said, is to create and enforce ethical standards that would be a model for the nation and the rest of medicine. He drew special attention to the issue of the relationship between psychiatrists and pharmaceutical companies.

“It is my view that these relationships have been rife with the appearance of conflict of interest and, frankly, with conflict of interest itself,” he said. “Ultimately, we must recognize that pharmaceutical companies, as profit-seeking companies, make offers that can and must be refused.”

A third step is to defend core professional values, including confidentiality, academic inquiry, and scientific integrity. Sharfstein characterized as “appalling” the U.S. Patriot Act's provisions that allow the government to see patient records while also forbidding psychiatrists from informing a patient about the breach.

He called for defense of the core value of scientific integrity against fringe groups and their spokespersons that have attacked the validity and integrity of psychiatry.

Sharfstein ended his remarks by challenging APA members to get off the sidelines and put their professional values to work through advocacy.

“If you are already shaking your head, let me console you with a little cognitive-behavioral therapy. Just keep reminding yourself that my term, as any presidential term, is only a year....

“But if you share my concern about our profession and its future, I urge you to become more involved in APA. Urge your colleagues to join APA and give back. Become active at local and national levels, and advocate.

“This is not just a goal worthy of our profession—it is the only goal worthy of our profession. Let us all `give back through advocacy.'” ▪