Board Selects Medical Director, Debates Ethics Reform

The APA Board of Trustees dealt with a variety of issues at its June 25-26 meeting in Charlottesville, Va., including interviewing candidates to replace Steven Mirin, M.D., as APA medical director. Trustees have begun negotiating contract terms with the candidate they selected, but the individual’s name will not be announced until negotiations are complete.

The Board discussed a report of the Task Force on Ethics Regulations and Ethics Education presented by task force chair Jeremy Lazarus, M.D., recommending an additional framework for handling ethics complaints filed against APA members.

Ethics Complaints

The Trustees approved in principle a “triage model” that would offer district branches two avenues for responding to ethics complaints against a member. In one option, alleged violations and enforcement of ethics standards would be handled much like they are now, but with a few modifications, such as adding a statute of limitations and additional alternatives for resolving cases.

District branches would also be able to handle ethics cases through a new framework, referred to as an “educational enforcement” model. In this option a member charged with violating APA’s ethics code would cooperate with his or her district branch in reviewing the complaint and pursuing ethics education if recommended by the district branch. An existing procedure similar to this one allows cases to be closed without a finding and may include suggestions for ethics education.

Among the advantages of this nonadversarial model Lazarus cited were reducing the cost of ethics proceedings, eliminating the need to file reports with the National Practitioner Data Bank or a state licensing authority since there would be no change in a member’s status (only suspensions and expulsions are reported to the data bank), and eliminating the need for meeting due-process requirements and hiring legal counsel. There would be no appeal mechanism in this model.

In contrast, he noted, the suggested model would make it far more difficult to drop members found guilty of serious unethical behavior, could weaken deterrence, and could discourage complainants from bringing ethics charges to the attention of a district branch if they feel no serious penalty awaits violators.

The Board agreed with the task force that allowing district branches to select the appropriate model in each case was a positive move, even though the inconsistency in district branches’ methods for evaluating and punishing unethical conduct could present a problem. There are currently, however, variations in the way district branches adjudicate complaints. Some trustees also acknowledged that the model most likely to be selected—especially for “less-serious offenses” and first-time violators—would be the educational-enforcement one.

The Board referred the report to the Ethics Committee to work out implementation and other details, including how to educate district branches about the new option. The committee will then forward it to the Assembly for approval, with the final version coming back to the Board before the new procedures can go into effect.

Other Actions

The Board also voted to

• rotate future annual meetings among the following cities selected because of their ability to accommodate a meeting the size of APA’s, the cost of putting on the meeting, and geographic location: New York, Washington, D.C., New Orleans, Atlanta, San Francisco, San Diego, Honolulu, and Toronto. The Trustees also agreed to evaluate whether Las Vegas should be added to the roster.

• “take under advisement” an Assembly action paper calling on the Board to limit the new medical director’s first-year, total compensation package to $350,000.

• ask Ronald McMillen, the CEO of American Psychiatric Publishing Inc., to report on economic issues involved in including the American Academy of Child and Adolescent Psychiatry’s (AACAP) practice parameters in the compendium of its practice guidelines that APA publishes. The APA Steering Committee on Practice Guidelines recommended against such an inclusion because the AACAP parameters are not “evidence based” and “disease focused” in the same way as APA’s are. At-large Trustee David Fassler, M.D., who is an AACAP member, said, however, that AACAP’s parameters “represent expert consensus of current assessment standards in child and adolescent psychiatry. They include a review of research and information on current practice patterns and trends and go through an extensive approval process.” He noted that the format and methodology are different from APA’s guidelines in that they are “more of a comprehensive review, largely designed for practicing clinicians. Not all of the material is or can be ‘research’ or ‘evidence’ based.”

• reject a proposal that would have allowed district branches to decide whether to allow their list serves to be vehicles for APA election campaigning.

• provide cash grants to several district branches to assist with legislative or legal advocacy issues. The payments will go to the New Hampshire Psychiatric Society to support a legal brief in a case in which a psychiatrist was found liable after a patient committed suicide following a psychiatric hospitalization; to the Nevada Psychiatric Association for establishing a political action committee and hiring a lobbyist in anticipation of a psychologist-prescribing bill being introduced in the state legislature; the Psychiatric Medical Association of New Mexico to pay for a lobbyist who assisted in its unsuccessful attempt to defeat a psychologist-prescribing bill; and to the Vermont Psychiatric Association to assist with legal analysis of issues related to a health system’s decision to segregate psychiatric patients in a facility away from the rest of its medical services.

• approve for publication a report on psychiatric emergency and crisis services developed by the APA Task Force on Emergency Psychiatry. Noting a significant lack of consensus on what emergency and crisis services should look like, the report suggests models that facilities can adopt to organize and provide psychiatric emergency services. It offers models to address the organization of such services in several categories, including in medical emergency settings, psychiatric emergency facilities, mobile psychiatric emergency or urgent care services, and psychiatric emergency or urgent care residential facilities. The report is available on APA’s Web site at www.psych.org/downloads/PsychEmergServices.doc.

• endorse a position statement and resource document on pharmacy benefit management and managers (PBMs) developed by the APA Committee on Managed Care. They describe how skyrocketing drug costs and various attempts to rein them in have affected psychiatrists and their patients in terms of interfering with decision making and compromising confidentiality.

The statement puts APA on record opposed to PBMs’ switching a patient’s medication without the approval of the treating physician and against “fail-first policies,” in which physicians are compelled to try medications on a formulary before they can prescribe one not on the approved list. The statement also calls on PBMs to “provide an ‘easy pass’ to physician specialists prescribing medications within their specialty.” This would allow the specialists to avoid some of the authorization bureaucracy imposed by PBMs and insurers. In addition, APA wants PBMs to include psychiatrists in formulary review boards that evaluate psychotropic medications.

• approve a position statement titled “Access to Comprehensive Psychiatric Assessment and Integrated Treatment,” which condemns the practice of some primary care physicians and managed care companies to refer patients needing mental illness care to nonphysicians for their initial visit. The statement stresses that when this occurs, “psychotherapy may then begin without benefit of a comprehensive, biopsychosocial assessment,” opening up the possibility that a patient’s condition could deteriorate when such an evaluation is delayed.

• agree to a pilot program to allow early career psychiatrists to have their membership dues automatically charged to their credit card in monthly installments for the 2003 billing cycle.

• back the establishment of guidelines that cover instances in which members and staff would have to identify their relationship to APA when they contribute articles for a commercial publication.

• change the name of the Committee on Public Policy, Litigation, and Advocacy (COPPLA) to the Committee on Advocacy and Litigation Funding (CALF).

• approve an APA position statement on reactive attachment disorder, which has already been endorsed by the Assembly. The disorder, which affects a small number of children, causes them to have “problems or severe disruptions in their early relationships,” the statement notes, and “many have been physically, emotionally, or sexually abused.” It says that “care must be taken to distinguish [the disorder] from one of the pervasive developmental disorders, such as autistic disorder.” The statement also discusses treatment techniques and advises parents or caregivers on seeking evaluation and treatment for affected children.

Many of APA’s position statements are posted on the APA Web site at www.psych.org/libr_publ/position.htm. APA members may access a summary of Board actions at www.psych.org/members/bot/bot.cfm under “Members Corner.” ▪