Pennsylvania Psychiatrist - January 2018
By Gail Edelsohn, MD, MSPH, DLFAPA
Best wishes for a healthy and rewarding 2018! In thinking about my message, I realize there are two content areas I wanted to cover. The first being, what are the most pressing issues facing PaPS members and those individuals we care for and how has the Society responded and advocated relative to these concerns; and second, two articles that are high on my list from 2017 that I thought were worth sharing.
No one can escape the impact of the opioid crisis whether professionally or on a more personal level. From the adult struggling with addiction to the baby being treated for Neonatal Abstinence Syndrome, to the family members separated from loved ones while undergoing treatment, while incarcerated or by death is what is taking a toll on family members, friends and patients. By now, you have read about Governor Wolf declaring the heroin/opioid crisis as a statewide disaster emergency and the thirteen initiatives that are planned over the 90-day timeframe. I urge you to read the details of these initiatives previously distributed to all members and also to read Executive Director and Lobbyist Deb Shoemaker’s article in this issue that highlights and provides her commentary on the governor’s plans. The PaPS will continue its advocacy work regarding the treatment for substance use disorders while being mindful of unintended consequences of proposed legislation that is not tied to any new resources or funding.
A number of prioritized issues and the work by the PaPS to address them are summarized in the article “What has the Society Done for you Lately” also in this issue. Scope of practice expansion will remain an issue for psychiatrists.
In my opinion, the public will put psychiatric expertise and quality of care against access to care. I’ll just add a bit more on Maintenance of Certification (MOC) to acknowledge the efforts of the PaPS, the Philadelphia chapter (MOC survey postcard), and Area 3 representatives which had a significant impact on bolstering the work of the APA with regards to advocacy for MOC reform. Additional reform is needed, but the pilot project using a journal article-based assessment as an alternative to the high stakes 10-year secure examination is a start. I am grateful for ongoing dedication of our members who volunteer their time and work side by side with our committed administrative staff to stay abreast of the key issues that impact psychiatrists and to advocate on behalf of all psychiatrists in Pennsylvania.
I had a longer list of “top picks” for articles but have learned it’s better to keep it short. So back in June 2017 I read “The Addicts Next Door,” an article by Margaret Talbot in the New Yorker and had circulated it to some colleagues. While it details the tremendous toll of the opioid crisis on the lives of residents in Berkeley County, West Virginia, it could have easily been a small town in rural PA. The article delves into the day-to- day existence of those impacted from all sides, those trying to treat and rescue, and those in need of help. It also impacts the resentment of some who view using naloxone to revive a person as a wasted effort, the limited treatment slots and financial barriers, and those trying to understand what is Medication Assisted Treatment.
The whole concept of addiction as a disease is alien to some who have been taught to see addiction as a moral failure. The cultural conflict is captured in the article by the following, “Many people in the Panhandle have embraced the idea of addiction as a disease, but a vocal cohort dismisses this as a fantasy disseminated by urban liberals.” We know in psychiatry that personal narratives are powerful and this article documents them exquisitely. I highly recommend “The Addicts Next Door” and encourage you to share it.
My second pick is an editorial and comes from a more traditional psychiatric publication, JAMA Psychiatry, December 2017, “Evidence-based Pragmatic Psychiatry - a Call to Action” by Martin P. Paulus, MD. This article defines Evidence-Based Pragmatic Psychiatry (EPP) as “the umbrella term for the application of scientific findings of insights into mental health to improve diagnosis, prognosis, and treatment of mental health conditions.” I was taught to embrace evidence-based medicine and I still seek out those treatments. I also know these approaches don’t always transfer strongly from the lab or carefully controlled protocol to real life treatment settings. The five P’s (no this is not an extension of the four P’s of formulation) being patients, providers, payers, policy makers, and problem solvers (researchers) typically share very little overlap when it comes to priorities and incentives. The author provides criteria that aid in evaluating if a study truly meets the benchmark of EPP. The EPP framework addresses some tough questions about clinical research and how to make it really meaningful for the individuals we strive to accurately diagnose and treat.
As always, please feel free to contact me about your ideas, concerns, and suggestions at email@example.com.
Bullying in Mental and Climate Disorders
By Edward C. Leonard, Jr., MD, DLFAPA
Anthony Chaney’s Runaway: Gregory Bateson, the Double Bind, and the Rise of Ecological Consciousness tells how an anthropologist tried to understand the world and its people. It is the kind of career-oriented biography that I like. Often such books are about individuals whose fame was promoted by their institutions, but when this book was becoming a doctoral dissertation, it had to overcome an advisor’s critique of the subject’s significance, and I see that point. Bateson did create interesting ideas, but his efforts to study the ideas lacked needed rigor, success, and usefulness.
Bateson never had a university home or senior academic rank but he was clever. He had interesting colleagues and he tried to cure schizophrenia. (I admire everyone who tries to cure schizophrenia!) Much of his public recognition came from participation in several lengthy conferences, one being the two-week 1967 “Congress on the Dialectics of Liberation” in London. In the 1970s, I was attracted to his double bind concept and read articles by him and his collaborator, Jay Haley. I thought I saw double binding in interviews with some of my young “designated patients” and their parents.
Maybe it’s a stretch but I see Chaney’s book as a study of bullying by certain humans and environments (that’s the ecology reference in the title). What should an adult who repeatedly confuses a child be called, if not a bully? Bullies may thrive best against children trapped in small spaces, like nuclear families and school rooms. One might think some double-binded children would try to run away, but I never heard of an effort to see if runaway children were more likely to have had prior double-binding experiences. The “runaway” in the title refers to how communication hampered by double binding may become out of balance and oscillate toward breakdown.
Bateson wrote and talked of possible environmental disasters, including global warming and the greenhouse effect. Is the environment bullying the animals and plants who can’t leave earth? Chaney is particularly good at explaining what Bateson and his peers meant in their jargon-hampered work, but perhaps most interesting, is the cast of characters with whom he worked: R.D. Laing, Frieda Fromm-Reichmann, Allen Ginsberg and many others. Margaret Mead was his first wife and he was her third and final husband. Bateson had two more marriages after divorcing Mead. Bateson’s father established the modern field of genetics and coined the terms genetics, allele, and zygote. He named Gregory after Gregor Mendel, whose works he translated into English. He hoped his sons would work in genetics, but the oldest died in World War I and the middle son committed suicide. Psychiatrists will enjoy learning about Gregory Bateson’s career and times in Anthony Chaney’s beautifully detailed book.
By Deborah Shoemaker, Executive Director and Lobbyist
A New Day is Coming… Will We Be Ready to Embrace It?
Another year has begun. Another chance to start afresh and dedicate oneself to new goals, renewed optimism for a better future, and to create a “new and improved” self for those you love and the ideals that frame your life’s work. If you are like me, this annual renewed optimism lasts for about a week into the new year, when something or someone alters my perspective. As of this writing, it is two weeks into 2018, and I remain ready to embrace this new day. Maybe it is because of a recent acceptance speech I heard from a certain “rumored presidential candidate.” Or maybe because the sun has finally come out after a few weeks of bone-chilling freezing weather. Regardless of the reason, a new day is coming, and we must face the new realities whether we like it or not.
In Pennsylvania, that new day came on January 10, 2018. Governor Wolf decided to take the bull by its horns and take the next step in tackling the heroin and opioid overdose public health crisis by declaring a disaster emergency. Yes, this is unprecedented, first time ever a public health emergency rose to an official disaster emergency in the commonwealth. Yes, it is an election year (stating the obvious). Yes, the governor has done more than any previous PA governor to fight this crisis, putting significant financial resources into expanding the use of Medication Assisted Treatment (MAT), creating Opioid Use Centers of Excellence, funding/encouraging the availability of naloxone to first responders, and to families who have a loved one suffering from this biological disease (just to name a few). Yes, a handful of other states have also declared a state of emergency to fight the scourge of opioid and heroin diversion, misuse, and fatal overdoses. But why do we need this official disaster emergency? If you ask Governor Wolf, he feels that this 90-day period is needed to temporarily suspend regulations that “create barriers to treatment/prevention, prevent first responders and others from saving lives, and reduce efficiency of our response.”
I recently sent an all-member email detailing many of the thirteen initiatives the administration plans on embarking during this period. Here is a link to the official press release. Do some of these proposed initiatives make sense? Of course. Do I think revising the current physician general standing order to allow first responders to leave behind naloxone for those individuals unwilling to present at an emergency department or treatment facility? You bet. Do I think expanding access to MAT by waiving regulatory requirements to permit dosing at satellite facilities even when counseling remains at Narcotic Treatment Programs (NTPs) is beneficial? If a physician is a crucial part of the process and leads the treatment team for the individual needing treatment. Do I think face-to-face physician requirements for NTP admissions to allow the initial intake review by a Certified Nurse Practitioner (CRNP) or Physician Assistant (PA) to expedite the intake process should be waived? Well, of course I would rather a CRNP or PA do it than say a non-medically trained health care provider (we will leave it at that.) However, this is where I get a little nervous. Will the quality of solid evidenced-based treatment be compromised? Will we be giving false hope to families thinking they are getting the most appropriate treatment for their loved one, then 72 hours later discharging from an emergency department because we do not have an inpatient bed for them? Do we have the appropriate resources to handle those individuals with significant physical health needs along with their substance use needs who voluntarily seek treatment and cannot get appropriate care? Will this temporary suspension of regulations help those you all see dying slowly day by day because of their decade-long struggles with substance use and mental health needs? I think not.
These are the things that keep me up at night and wear on my soul as I prepare to meet with state legislators and state officials, interact with my colleagues and explain why there is no “silver bullet”, no one-size fits all approach to solving this heartbreaking public health crisis. Although I am grateful for the dedication that this administration has to tackle this epidemic head-on, there must be a rational, evidenced-based, comprehensive approach to successfully eradicate (or reduce) fatal overdose deaths. Some members have asked me why now? One member sarcastically noted that policymakers cared less during the crack/meth crisis in the late ‘70s, but now that it is hitting rich white people (and legislators’ families I might add), everyone cares. I totally agree. No one is immune from experiencing loss of loved ones from some sort of substance use-related death. I am no exception. I lost an uncle, two cousins (one as recent as mid-November), two grandfathers, and a close colleague from complications related to either extended alcohol, drug, or tobacco use (or a combination of all the above). One of my dearest friends was recently discharged from an inpatient substance use facility and is enjoying his first few months of sustained sobriety. Governor Wolf interacts with families every day struggling to get their loved one into treatment. We cannot distance the personal stories from reality. It is heartbreaking to see those we love struggling to stay sober, or not being able to recognize their need for life-saving, life-sustaining treatment. Recovery is possible, as all of you keenly know and see daily. However, without providing all the tools in the toolkit, we are doomed to fail. If we do not have enough inpatient beds now for those who want treatment, will relaxing regulations do the trick without the financial wherewithal to sustain treatment? Without coerced treatment for those refusing treatment, what security measures will keep someone into treatment? Who will be there to pick up the pieces when an individual is released from a detox facility without a place to live, place to eat, place to get outpatient treatment? These are questions that need to be answered even beyond the disaster emergency period by not just policymakers, but everyone committed to solving this public health crisis.
The new day began yesterday. Rest assured, your Society will stay at the forefront of these important discussions, providing vital practical clinical expertise and guidance to policymakers regardless if they accept it or not. As Martin Luther King, Jr. said, “If you can’t fly then run, if you can’t run then walk, if you can’t walk then crawl, but whatever you do you have to keep moving forward.” Change is coming, whether we like it or not. Embrace it with both hands. Be part of the solution, not the problem. Ask me how to get involved.
By Usman Hameed, MD, CPPS President
The Central chapter organized a movie night and CME event based on “The Soloist” during the month of October. The movie was followed by an engaging discussion regarding the impact of mental health issues on psychosocial functioning, the associated stigma, limited resources and support systems.
In December, the chapter held a holiday social and awards ceremony. Douglas A. Ockrymiek, DO, DLFAPA, FAAFP received the presidential award for the year 2017-18 in recognition of his services and dedication to the progression of psychiatry.
Douglas A. Ockrymiek is an adult and geriatric psychiatrist that practices in Lancaster PA. He is medical director of Behavioral Health Care Corporation and is a consultant to the Samaritan Counseling Center. He is a native of New Jersey and is board certified in family medicine, adult and geriatric psychiatry. Dr. Ockrymiek has been an active member of Central Pennsylvania Psychiatric Society, formerly serving as President. He is a PaPS Council Representative. Dr. Ockrymiek’s practice focuses on psychodynamic therapy with adults and understanding the connection between mind, body, and spirit. Dr. Ockrymiek has a special interest in considering the spiritual dimension and is currently enrolled in a two-year program in spiritual direction that includes training in Jungian psychology.
By Elizabeth Ramsey, DO, WPPS President
Greetings from our snow-covered region! We experienced record-breaking snowfall over the past month particularly in Erie County. Thank goodness for snow tires and four-wheel drive! Our chapter enjoyed several events in the past few months. In October, we gathered for the Allied World Insurance sponsored risk management program, “Minimizing Risk When Treating Suicidal and Violent Patients,” expertly presented by Doris Fischer-Sanchez. The group of psychiatrists, including residents, engaged in a lively discussion regarding various clinical encounters and best practices. We all left with greater recognition of risks related to suicidal/violent patients and better knowledge of firearms and suicide.
On November 30, our region held its first Resident Poster Night which featured research presented by residents from the Lake Erie College of Osteopathic Medicine’s (LECOM) Psychiatry Residency Program at Millcreek Community Hospital and LECOM medical students. The posters encompassed a variety of topics such as mood disorders, anxiety disorders, psychotic disorders, and substance use. LECOM co-sponsored this educational event and provided a healthy dinner. The event was attended by many local psychiatrists, including prior graduates, and representatives from the residency program. The winners were: 1st Place Dr. David Figueroa for The Efficacy of Osteopathic Manipulative Treatment on Patient Anxiety Levels in the Adult Inpatient Psychiatric Setting; 2nd Place Benjamin Swanson and Katelyn Miller for A Case Study in Cannabinoid Hyperemesis Syndrome: An Uncommon Presentation of Marijuana Abuse; and 3rd Place Dr. Chrisalbeth Guillermo for A Case of Pseudobulbar Affect with Peduncular Hallucinosis. Our chapter looks forward to continuing this event for years to come.
Due to the competent leadership of the residency program, the LECOM Psychiatry Residency Program is now part of the American Psychiatric Association’s 100% Club! We are encouraged by the greater involvement of the residency program and aspire to further strengthen our collegiality. It is our hope we may continue to keep trainees in our region after graduation. In 2018, we are eager for greater member participation across our broad geographic spread.
Our next educational event will be “Dinner and a Movie: Hungry Hearts” in March. Please look for details on our website. If you have any comments or suggestions about how our chapter may be of better service to you, please let us know. If you are interested in a leadership position with the Western Psychiatric Society, please contact me as soon as possible.
Pittsburgh News and Notes
Events of Interest to PPS Members
Friday, February 9, 2018, 1:00 pm-4:30 pm
Live-streaming for remote participation or on-site participation and interaction with legal and clinical PTSD specialists
The Cyril H. Wecht Institute of Forensic Science and Law at Duquesne University Forensic Friday Program on Civilian and Military Post-Traumatic Stress Disorder
PPS Membership Chair Dr. Burton Singerman will discuss his recent civilian and military PTSD cases with criminal components. An attorney for the mental health and veteran’s court as well as the assistant prosecuting attorney for southwestern Pennsylvania will join the discussion on how the PTSD disorder impacts sentencing protocol.
Register here: www.duq.edu/forensics
Monday, February 25, 2018 6:00 pm-8:30 pm, Grand Concourse, Pittsburgh
PPS CME Workshop
Telepsychiatry: Managing the Risks
Presented by PRMS
Philadelphia Psychiatric Society News
From Your Membership Chair
Kenneth J. Weiss, MD, DLFAPA
Dear APA Fellows from the Philadelphia Chapter,
As chair of the chapter’s Membership Committee, I am writing to you about elevating your APA status to Distinguished Fellow. Unlike achieving Fellow status, which you may have initiated online, a Distinguished Fellow application is handled by our District Branch, the Pennsylvania Psychiatric Society. Although there are nearly 300 Fellows in our chapter, only two were elevated in the past year. Many of you would qualify, and we urge you to take action. Please go to APA’s website and see how you can be the next Excellent Distinguished Fellow.
More information will be provided about Distinguished Fellow from PaPS in February.
What has the Society Done for you Lately?
Deborah Shoemaker, Executive Director and Lobbyist
As I encounter members at chapter, state and national meetings, I am often asked, “what do you do for the Society” or “what is the Society working on for me?” I often ask more questions back about the members areas of interest, practice setting, interest in advocacy/policymaking, interest on the state or national level, their years in/out of residency, and most importantly, ask them to promise that they will stay in Pennsylvania (I am somewhat kidding). Your district branch is very fortunate to have a full-time executive director and two lobbyists (in-house and contracted) and a full complement of team members dedicated to your interests daily (many other district branches have part-time staff). The Society is extremely successful because of dedicated volunteer members serving as state and chapter leaders, committee chairs and representatives on state and national advisory committees and councils.
In 2017 alone, the Society’s efforts included the following:
At the federal level:
Strongly advocated for meaningful Maintenance of Certification (MOC) reforms
Strongly advocated for continued sustainability of the Affordable Care Act (including representation on the PA Provider Advocacy Coalition, a statewide healthcare provider coalition dedicated to opposing any replacement/repeal initiatives that compromise quality care)
Five members serve as APA Area 3 representatives at APA Assembly, along with members representing critical APA Components and leadership roles at Area 3, Assembly and on APA Executive Committee
Submitted Five Distinguished Fellow applications for APA approval (to be recognized at 2018 APA Annual Meeting in New York City)
I have worked closely with APA staff to create mental health parity secret shopper survey for certain commercial insurers doing business in the commonwealth
At the state level:
Strongly advocated against proposed legislation seeking to amend the Mental Health Procedures Act (MHPA) to allow for involuntary commitment for substance use needs and/or would lessen the standard for Assisted Outpatient Treatment without additional resources within the community
Strongly advocated for proposed legislation to create a voluntary state Mental Health Bed registry
Strongly advocated against the prohibition of ECT for children under the age of 18 years of age
Strongly advocated against scope of practice expansions for non-physician health care professionals in areas that would negatively impact quality patient care
Supported our specialty colleagues and the PA Medical Society on areas of mutual concern (including scope of practice expansion, Out of Network/Surprise Billing, psychiatric bed tracking, involuntary commitment for substance use, prior authorization, etc.)
I have served on two governor-commenced workgroups dedicated to proposed consolidation/unification of four state departments (Aging, Drug/Alcohol, Health and Human Services)
I represent the Society on the steering committee for the recently-created Coalition for CommonHealth
I serve as vice-chair of the PA Department of Human Services Office of Medical Assistance Programs’ Medical Assistance Advisory Committee (MAAC) and chair of their Fee-for-Service Subcommittee
I represent PaPS on an opioid workgroup comprised of PaPS, PA District Attorney’s Association, PA Medical Society, the Hospital and Healthsystem Association of PA, PA Pharmacists Association, and Overdose Free PA that meets on a regular basis on substance use issues
PaPS members and I serve on a variety of advisory committee and councils for PA Departments of Drug and Alcohol Programs, Health, Human Services, Transportation and the PA Commission on Crime and Delinquency
At the local level:
Held a two-day DevelopMental Leaders Retreat for 24 members on physician leadership and mentoring
Worked closely with local chapters on resident recruitment/retention efforts, including in advocating for the 100% Club
Held another successful Patient Safety/Risk Management scientific educational meeting simulcast to the Pittsburgh area and numerous local chapter educational meetings
Member representation on PAMED’s Board of Trustees, Specialty Leadership Cabinet, House of Delegates and various committees/advisory groups/task forces
As you can see, the Society is working hard for our members and on behalf of all individuals living in the commonwealth. Please contact me at 1.800.422.2900 or via email at firstname.lastname@example.org to get involved or for more information.
Welcome New Members
We welcome the following new PaPS members and congratulate those Members-In-Training who have recently achieved General Member status (effective 9/25/17-12/31/17)
Members in Training
Needa Khan, MD Shehzad H. Siddique, MD
Gregory J. Bredow, MD
Zahid Islam, MD
Members in Training
Hema Vanigalla, MD
Member in Training
Jessica L. Grimes, DO
Abhishek Rai, MD
Members in Training
Dimal D. Shah, MD Elyse Smolcic, MD Jessica Wang, DO Margaret J. Yesalavage, DO Matthew C. Parker, DO
Dimas J. Tirado-Morales, MD Jennifer A. Annon, DO
Life Distinguished Fellow Paul E. Ruskin, MD
Carola A. Kieve, MD
Anil K. Bachu, MD