Third Quarter - 2012 - Missouri Psychiatric Association

Vol 3 No 2 3rd Quarter 2012
Missouri
Psychiatry
Newsletter of the Missouri Psychiatric Association (MPA)
A District Branch of the American Psychiatric Association
We are one, SOS Approves MPA Merger
By Jo-Ellyn M. Ryall MD
F
inally..., on July 25, 2012, the Missouri
Secretary of State approved articles of
merger to combine Central Missouri
Psychiatric Society, Eastern Missouri
Psychiatric Society and Western Missouri
Psychiatric Society into the Missouri
Psychiatric Association (MPA). The
paperwork now is complete. Remaining
tasks are to merge our funds into a single
statewide bank account, which has been
established at Commerce Bank, and
develop an operating budget for 2013.
The new account will allow APA to remit
our membership dues to one organization
instead of three.
The MPA Executive Council worked
hard with our former executive director,
Rebecca DeFilippo, to accomplish the
merger process. In mid-August, MPA
President Bob Batterson named Jill
Watson interim executive director through
Dec. 31. The Executive Council will seek
a new executive director for MPA to start
Jan. 1, 2013. The three regional offices
will be responsible for their own local
membership needs, such as CME and
networking programs.
For the first time, MPA sponsored a
conference September 22 at the Holiday
Inn Executive Center in Columbia.
“Psychiatric Practice in 2012 and Beyond”
offered information about mental health
services in corrections, ABPN certification
and licensure, and DSM 5. The conference,
planned and moderated by Jim Fleming
from Kansas City, provided up to 5.0
Missouri Psychiatry Welcomes
New Editorial Staff
By Rebecca DeFilippo MS, MBA
T
he MPA Executive Council appointed
Moses Tabe Ambilichu MD as editor-in-
chief and Balkozar Adam MD as assistant
editor of Missouri Psychiatry in March.
Tabe Ambilichu succeeds Daniel T.
Mamah MD, MPE, who retired as editor
in January from the volunteer position
he’d held since 2007. The assistant
editor position is new. Tabe Ambilichu
will oversee editorial policy and content
for the state’s only publication devoted
exclusively to psychiatric physicians and
the profession of psychiatry.
Born in Cameroon, Africa, Tabe
Ambilichu completed his medical
education at the University of Perugia
(Italy) and Louis Pasteur University
(France). He trained in general psychiatry
at St. Louis University School of Medicine
and, in July 2011, joined the fellowship
program in child and adolescent
psychiatry at the University of MissouriColumbia. He serves as MPA secretary/
treasurer, chair of the Members-inTraining Committee, and MIT rep to the
Area 4 Council.
Continued on page 11
CME hours. The annual spring meeting
in conjunction with the Missouri State
Medical Association will be held Saturday
April 6, 2013, in Kansas City. So, mark
your calendars and plan to attend.
APA will send dues invoices in October
and we encourage MPA members to renew
for 2013. Because of a slight membership
decline, Missouri may lose an Assembly
Representative. We need approximately 25
to 30 new or reinstating members to retain
our two rep positions.
Thank you, again, for your support and
encouragement. We appreciate your
patience during this long process and look
forward to great things for MPA. n
_____
Jo-Ellyn Ryall is a frequent contributor to
Missouri Psychiatry. As MPA presidentelect, she will become president for a oneyear term in May 2013.
Contents
President’s Message...........................2
Medical Politics.................................3
Slaying Dragons.................................4
The Burden They Carry.....................5
Tell Me More About..........................6
From Our Readers.............................7
Legislative Update.............................8
First Person........................................9
Local MPA Branch News..................9
Classifieds........................................11
Upcoming Events............................16
Missouri Psychiatry
3rd Quarter 2012
From The President
Advocacy Matters
By Bob Batterson, MD
T
hank you for your membership in the
American Psychiatric Association and
the Missouri Psychiatric Association. In
these difficult financial times, people make
careful decisions about where they choose
to invest their money. Supporting your
professional organization is obviously
at the top of your list, as it should be.
No one can advocate for the profession
of psychiatry as well as you can. To do
this, however, APA and MPA need you to
remain a part of our organizations, to keep
our voice strong in Jefferson City and in
Washington DC.
In addition to advocacy, we hope to
provide you with some valuable medical
education through both statewide and
local meetings in 2013. Please send your
ideas and suggestions on how to make
MPA stronger, better and more effective
to batterson@cmh.edu or by postal mail
to Bob Batterson MD, Children’s Mercy
Hospitals & Clinics, 2401 Gillham Road,
Kansas City, MO 64108-4619.
As we begin to develop the 2013 operating
budget, we are contemplating changing
the distribution format for Missouri
Psychiatry. Please respond to the quick
survey on the last page (next to Upcoming
Events) and let us know how you would
prefer to receive this newsletter: by hard
copy, blast-fax or electronically.
Doctor of the Day
As a member of the Missouri State
Medical Association (MSMA), I received
a routine email inviting physicians to
volunteer to be Doctor of the Day at the
Missouri State Capitol. Given my interest
in advocating for psychiatrists and our
patients, I signed up for April 17, which,
in January, seemed a long time away.
I thought I really would enjoy the
2
opportunity to stroll the halls of the
Capitol building and, hopefully, get
to testify on a bill that had healthcare
implications. What I received in return
for my day off from work was more
than I could have imagined. I had a busy
day with access to state senators and
representatives that I never would have
met otherwise. As a physician for the
members of both chambers, I glimpsed
the inner workings of state government
and those who make the laws. It was an
experience that I hope to repeat and one
that I would recommend for other MPA
members.
Doctor of the Day is an MSMA service
program to state government that has been
in operation for many years. Physician
members volunteer to provide both
medical service and advocacy to the state
lawmakers and their staff who work at
the Capitol. Members of the House and
the Senate are in Jefferson City five to six
months of the year. Since most people at
the Capitol have doctors in their home
communities, they can’t just pop in and
see their primary care physician when they
have a minor ailment.
During my day, I saw three legislators
with allergy complaints, some staff with
sinusitis, and one with asthma. I also
performed blood pressure screenings
on four women and referred one to see
her primary care physician immediately.
I made sure everyone I saw knew that
I was a psychiatrist, not an internist or
family doctor. On one case, I called a
friend in primary care for some advice. I
listened to two sets of lungs and checked
for sinus pain in a very nice intern from
Great Britain working in the General
Assembly. I followed up by email with the
lawmakers, who appreciated the medical
consultation I provided.
Missouri Psychiatric Association
315 Nichols Rd, Suite 250
Kansas City, MO 64112
Phone: (816) 531-8432
Fax: (816) 531-8438
jwatson@metromedkc.org
http://missouri.psych.org
Executive Council Officers
(May 2012-May 2013)
President: Bob Batterson MD
Immediate Past-President: Jo-Ellyn M. Ryall MD
Secretary-Treasurer: Moses Tabe Ambilichu MD
President-Elect: Jo-Ellyn M. Ryall MD
APA Assembly Representatives
Syed Arshad Husain MD
Garry M. Vickar MD
Sherman W. Cole MD (Alternate)
MPA Committee Chairs
Bylaws: Sherman W. Cole MD
Disaster Psychiatry: Syed Arshad Husain MD
Early Career Psychiatry: Faheem S. Arain MD
Ethics: Lawrence F. Kuhn MD
Legislative: Bob Batterson MD
Membership: Maarten Nieuwenhuizen MD
Members-in-Training: Moses Tabe Ambilichu MD
MoPPPAC: Paul B. Simon DO (Treasurer)
Newsletter: Moses Tabe Ambilichu MD (Editor)
and Balkozar Adam MD (Assistant Editor)
Program: James L. Fleming MD
Regional Offices
Central Missouri Regional Office
Fatima Naseer MD, President
Hina Syed, Director
2516 Forum Blvd., Suite 102
Columbia, MO 65203
(573) 289-6495
hinasyedcmps@yahoo.com
Eastern Missouri Regional Office
Paul B. Simon DO, President
Rebecca DeFilippo, Director
8448 Saint Andrews Lane
House Springs, MO 63051
(636) 343-8555
RDefilippo@aol.com
Western Missouri Regional Office
Mahmoud M. Wahba MD, President
Jill Watson, Director
315 Nichols Rd, Suite 250
Kansas City, MO 64112
(816) 531-8432
jwatson@metromedkc.org
Continued on page 10
Missouri Psychiatry
3rd Quarter 2012
Medical Politics: Show up and Bring Something
By Jo-Ellyn M. Ryall MD
O
ne of the best parts of my
undergraduate education at a women’s
college was the chance to experience
the birth of the women’s movement. As
a chemistry major at Douglass College
in New Jersey, I didn’t have much time
for extra reading, but I made sure to read
Betty Friedan’s The Feminine Mystique
and Kate Millett’s Sexual Politics. In
1971, Millett was our commencement
speaker. Brave new horizons and women
power infused my brain. I’ve done things
that I only dreamed of in my youth. But
you have to make choices. Find something
you like and say yes to it. Among my own
yeses have been psychiatry, flying a small
plane, and my chief addiction: medical
politics.
As a medical student at Washington
University School of Medicine in St.
Louis, I knew nothing about organized
medicine but, after receiving some
information about the American Medical
Student Association, I joined. This was my
first brush with medical politics.
During residency years, a girlfriend
and I decided to go to Eastern Missouri
Psychiatric Society (EMPS) meetings
because we were curious. Each monthly
meeting featured the same steak dinner
and open bar—but no condiments. The
second month, I brought lime juice in a
plastic container for the gin and tonics,
and my friend brought A-1 Steak Sauce.
Immediately, we were accepted by who
all wanted us to sit at their table. Why?
Because we were interested, and we had
brought condiments. So, the first piece of
advice is: show up, volunteer, and bring
something of use.
In 1979, I joined the American Medical
Women’s Association. I discovered a
whole new world of mentors and women
who were pioneers in medicine. I also
made the important decision to join my
local and state medical societies and the
American Medical Association (AMA). I
was asked to fill in as a delegate to the
state medical meeting, and I’ve been a
delegate ever since. It’s very easy to be
involved: show up, volunteer, get there,
and do a good job…and they’ll ask you
to do another job. In these volunteer
organizations, what one has to worry
about is doing too much, because one can
get totally burned out.
In the mid-1980s, while still a young
psychiatrist, I became EMPS presidentelect and became involved at the state
level, then at the national level as a
member of the APA Section Council at
the AMA. The first AMA meeting I went
to was a very enlightening experience,
and I was hooked. I’ve now been to 46
semiannual AMA meetings.
I’ve seen a number of organizations from
the inside. I’ve been a member of the APA
Assembly since 1993. Later, I was elected
deputy representative and representative
of APA Area 4, the Midwestern states. I
have lost elections or been told “It’s not
your time.” I’ve learned to have a tough
skin and to realize that in a contested
election there is one winner and one or
more losers.
Organized medicine is really important.
It means that you’re not alone. You will
be able to change some policy. You will
be able to influence some legislators. The
AMA and APA can help get background
information so that we can lobby for our
patients and our profession. I’ve learned,
too, that to get your point across to people,
including legislators, it’s important to
speak their language, have a sense of
humor, and smile.
I was married more than once, and now
I am divorced, and footloose and fancy
free. I can get a lot of work done. Yet, at
times I have wanted to clone myself to
get everything done. What I’ve learned is,
start early in your career. Say yes to the
volunteer opportunities that interest you.
Say no to those that don’t. If you appear at
meetings and are interested, you’ll get a
job. If you do a good job, you’ll get
another job. Choose wisely, but choose to
join and support with your money, if not
your time and talent, because organized
medicine provides a framework in which
we can help ourselves and help our
patients.
My dad used to take my brother and
me on Sunday drives, and we would sit
and watch private planes land at a small
airport. In 1983, I obtained my private
pilot’s license. I enjoyed flying, all the
way from my first lesson in 1983 until
2004, when I piloted a plane out of
Anchorage, Alaska, while my friend and
the flight instructor looked for moose,
sheep, goats, and bears in the mountains.
I considered Amelia Earhart my heroine.
I was glad not to have to fly over vast
expanses of water though, because I
knew it was easy enough to get lost over
land. Yet, I found out that I do well in
emergencies. For instance, in 1999, I
was flying with a friend to the Lake of
the Ozarks in Missouri for lunch. About
100 miles from St. Louis, I heard engine
trouble and knew I would have to land
at the small airport we had just passed or
else end up in a tree. I managed a perfect
landing on the runway and turned off
onto the taxiway—and then the engine
died. I felt angels’ wings under my plane.
Fortunately, some people were at the
airport and were able to use their SUV to
tow the plane out of harm’s way. It was
not my day to die. I had posttraumatic
stress disorder symptoms flying in that
plane afterward, but I did fly in it again.
So, don’t let adversity keep you from your
goals. Try to think things through and do
them anyway. n
_____
Jo-Ellyn Ryall is an associate professor of
clinical psychiatry at Washington University
School of Medicine in St. Louis, Mo. She
served as the first president of the Missouri
Psychiatric Association, for the 2011-2012
term. This article first appeared in Psychiatric
News Update (June 20, 2012, Vol. 2 No 27).
3
Missouri Psychiatry
3rd Quarter 2012
Slaying Dragons Helps Fight Stigma
By Rebecca DeFilippo MS, MBA
F
our APA/MPA member psychiatrists in
St. Louis discussed depression at a series
of staged readings presented by Slaying
Dragons, a local nonprofit organization
whose mission is to eradicate the stigma of
mental illness in our communities.
Collins Lewis MD, Department of
Psychiatry at Washington University in
St. Louis; Adelita Segovia MD, Clayton
Behavioral Center; Jo-Ellyn M. Ryall
MD, Psych Care Consultants; and
Jaron Asher MD, Family Health Care
Center and Places for People, led postperformance dialogues on Jerome Kilty’s
“Look Away,” a play about Mary Todd
Lincoln on the eve of her insanity hearing
in 1875. Slaying Dragons presented
four performances in August during the
Missouri History Museum’s exhibit, The
Civil War in Missouri.
“Look Away” featured Slaying Dragons’
founder and director Helene Meyer as
Mary Todd Lincoln and Andrea Purnell
as Elizbath Keckly (sometimes spelled
Elizabeth Keckly/Keckley). Born into
slavery, Keckly served as dressmaker and
confidante to Mrs. Lincoln, and eventually
wrote Behind the Scenes, 30 years a slave
and four years in the White House about
her time with the Abraham Lincoln family.
Meyer, who has depression, said she
founded Slaying Dragons to fight stigma.
The organization’s continuing goal is
to “slay the dragons” of stigma -- to
help others and their families cope with
depression and anxiety, and educate the
public. Slaying Dragons fulfills its mission
through theatrical productions to educate
and challenge its audiences and to begin a
conversation about depression and anxiety,
she said.
4
Lewis, a psychiatrist and professional
actor, performs frequently in the
company’s productions, most recently in
“The Tragedy of Mary Todd Lincoln.”
That play looks at the stigma associated
with depression and anxiety by comparing
and contrasting Mrs. Lincoln’s experience
with depression and social stigma in 1875
to today’s treatment and the continuing
stigma associated with mental illness.
At Lewis’s urging, Jo-Ellyn Ryall attended
a recent performance of “Mary Todd
Lincoln” moderated by Jaron Asher. She
said she left the play determined to do
more to help in the fight against stigma.
“I had no idea what to expect, but was
very much impressed with the play, the
dialogue, the actors, with everything this
small group of local players is doing for
those with mental illness,” Ryall said.
“So much so, that I volunteered on the
spot to lead audience discussions at future
productions.”
Elizbath Keckly
Meyer points out that depression is one
of the most treatable illnesses: 80% to
90% of those suffering from depressive
disorders find relief. “Let’s begin
impacting the lives of the 29.3 million
Americans suffering from depression and
anxiety,” she added.
For more information, visit http://www.
slayingdragons.org. n
_____
Rebecca DeFilippo is managing editor of
Missouri Psychiatry and director of the MPAEastern Missouri Regional Office.
Media Benefits for MPA
Members
Your membership in the Missouri
Psychiatric Association entitles you
to several key media benefits:
1. Free ad listings on the MPA
website. MPA members can post their
research studies, job listings, events
or books for 6 months on the MPA
website at http://missouri.psych.org.
The listing can repost again after that
period.
2. Reduced newsletter ad rates.
MPA members may place any
size ad in Missouri Psychiatry,
MPA’s quarterly newsletter, for
50% off the regular rate. Missouri
Psychiatry reaches nearly 600 MPA
members and associated healthcare
professionals in the state and appears
online at the MPA website. It is
the only publication dedicated to
psychiatrists in the state of Missouri.
3. Free “Upcoming Events” listings.
There is no charge for members to
post upcoming meetings and special
events of interest to the behavioral
health community.
All ads must be camera ready in an
electronic format and should include
a link to the advertiser’s e-mail
address or website. Web ads may be
submitted in color or black & white.
Newsletter ads will print in black
and PMS 294 Blue inks regardless of
submission format. To take advantage
of these media benefits for MPA
members, please contact Victoria
“Tori” Braswell at vbraswell21@
gmail.com.
Missouri Psychiatry
3rd Quarter 2012
The Burden They Carry: Mental Illness, Stigma,
and the Role of Media
By Balkozar Adam MD
Istruggle
ndividuals with mental illness who
with both their diagnosis and
treatment also must overcome what
research has shown to be the greatest
barrier to quality of life—not the illness
itself, but the stigma they often encounter.
Stigma, a mark of disgrace or shame
manifested in the negative stereotypes and
beliefs held by society, is due partly to
misunderstandings and inaccuracies found
in the media. The more the mentally ill
are stigmatized, the more the public fears,
rejects and discriminates against them.
A number of myths and misconceptions
surround the mentally ill, beginning with
the false notion that they all are violent,
unpredictable and dangerous. In fact,
studies point to the opposite. The mentally
ill are statistically less likely to commit a
crime and are, in fact, more likely to be
victims than perpetrators. Other accepted
beliefs are that the mentally ill are lazy
and lack willpower and are unintelligent
and uneducated. However, some of our
greatest leaders, artists and intellectuals
are believed to have had a mental illness.
For example, Abraham Lincoln, Ernest
Hemingway and Isaac Newton are all said
to have had mental illness. Where would
we be if slavery had not been outlawed?
If we had not been able to read “The Old
Man and the Sea”? Or if the world never
learned about the laws of motion?
What’s more, only a fraction of mental
illnesses are accepted by society.
Although a person with mental illness is
no more to blame for his or her condition
than a person with cancer or diabetes,
for instance, society often blames the
mentally ill and expects them to “shake
it off.” People are more willing to share
with friends and neighbors that a family
member has been diagnosed with a
medical disease than a mental illness.
The effects of this stigma are far-reaching.
People with mental illness tend to stay
silent because they fear that if they
disclose their illness, their friends
and community will reject them and
discriminate against them. They can
be fired from a job, evicted or denied
housing, even suffer verbal or physical
abuse; it’s not infrequent that law
enforcement gets involved. In addition,
stigma can lead to negative self-image,
isolation and poor family relations.
The media, whether it is news reports,
movies, TV, radio or social media, shapes
public opinion and perception and,
therefore, can play a vital role in ending
the stigma. Media can influence political
views and affect health and social policies.
As such, a positive media portrayal of
the mentally ill can promote help-seeking
behavior, medication adherence and aid
in treatment. Moreover, it can foster
positive relations and involvement in the
community.
Media often depict individuals with mental
illness negatively as being violent, isolated
or homeless.
Photo by Jack Newton
http://www.flickr.com/photos/jdn/
Conversely, a negative portrayal can
have the opposite effect. Unfortunately,
some media depict mental illness as
interchangeable with violence, isolation,
loss, misery, homelessness and the result
of personal failure. When evaluating a
news story, it’s important to keep an eye
out for how the mentally ill are portrayed.
Is the story about a man who has
schizophrenia or about a “schizophrenic”?
The distinction is subtle but essential. The
first, a man with schizophrenia, alludes
to the fact that schizophrenia is just one
aspect of who he is but he also may have
a fulfilling job, be in a relationship and
enjoy spending time with friends. To
describe him solely as a schizophrenic
is to fall into the trap of describing him
solely as a mental illness, nothing more.
When a negative story appears in the
media, don’t respond when angry. Write
down what was offensive in the story,
whether you believed the information
to be reliable and even the relevance of
including the person’s mental illness in
the story. Use those points when crafting a
letter to the editor, an email or phone call
to the reporter.
Your organization should have a media
policy in place. If you don’t, make sure
to develop one in the near future. Be
available to respond quickly to a media
request. Journalists are often on tight
deadlines and, if you or someone from
your organization doesn’t call back
in time, you’ll lose the opportunity
to comment. If you’re uncomfortable
with being quoted, offer to speak on
background or refer the reporter to the
designated spokesperson (as outlined in
your media policy).
Journalists want to tell the whole story and
do not want to stigmatize. In between their
time constraints and your expertise, this is
possible. Develop a rapport with reporters
and pitch them positive story ideas. Use
your relationship with the reporter to take
a proactive role in eliminating the stigma
of mental illness in the media. n
_____
Dr. Adam is a clinical assistant professor
of psychiatry at the University of MissouriColumbia. She has worked with children,
adolescent and adults for over 20 years.
5
Missouri Psychiatry
3rd Quarter 2012
Tell Me More About...
Risk Issues with Split Treatment1
By Kristen Lambert, JD, MSW, LICSW, CPHRM
T
he demand for psychiatric care is on
the rise and, as a result, psychiatrists and
non-physician clinicians may be involved
in “split treatment.” There are a variety
of reasons why non-physicians may be
involved in care and treatment of the
patient. First, although the demand for
care is increasing, the number of available
psychiatrists is limited. As such, patients
may need to wait an extended period
of time for an initial appointment with
the physician. Non-physician clinicians
may be more readily available to begin
treatment sooner than the psychiatrist.
Additionally, some insurers may
not pay for a psychiatrist to provide
psychotherapy. Given these circumstances,
the model of medication management
being provided by the psychiatrist,
while a non-physician clinician provides
psychotherapy, is typical and increasing.
Split treatment is not without risks,
however.
Psychiatrists who practice split treatment
should decide how potential conflicts in
this type of treatment apply to the mental
health care of a specific patient. The
psychiatrist should then determine whether
split treatment is a viable clinical option
for the patient.
There are three models of split treatment:
supervisory role, collaborative role, and
consultative role. In the supervisory
role, the psychiatrist is hierarchically
responsible for the overall care of
the patient including decisions of the
actions of the professionals under his/her
direction. This model has the highest level
of risk. As the supervisor, the psychiatrist
has the ability to alter treatment and
clinicians involved in the care of the
patient; is responsible for the actions of
his/her staff and can be held liable for
the acts of those he/she supervises. The
supervising physician may have no direct
involvement with the care at issue but may
6
be held liable for the acts of those he/she
supervises. Some risk considerations in the
supervisory relationship include: 1) state
regulations regarding type and frequency
of supervision required; 2) the level of
experience, training and competence of the
other non-physician clinician to determine
the type of oversight the psychiatrist
provides; and 3) office policies and
procedures regarding supervision. These
issues are important to determine prior to
treatment being provided to the patient.
The collaborative role of split treatment
may be the most complicated of the
three models. There is a mutually shared
responsibility for the patient’s care.
A therapist (non-physician clinician)
who is qualified through training,
experience and independent licensure
is treating the patient. Both clinicians
have a responsibility to ask for and
provide professional information to one
another. Some risk considerations in the
collaborative relationship include: 1)
agreement upon the basis of the patient’s
diagnosis, anticipated treatment, and risks
that derive from the patient’s diagnosis
and treatment; 2) a determination that
each provider has adequate malpractice
insurance in the event of an adverse
outcome; 3) a determination of the
independent and interdependent duties
for ongoing risk assessment; and 4)
responsibility for obtaining sufficient
direct examination of the patient
consistent with his/her clinical status and,
if there is a change, ensuring that there is
communication between providers.
Finally, the consultative role is typically
the role with the least risk of liability.
The psychiatrist offers advice on a
“take it or leave it” basis. He/she is not
directly responsible for the patient, and a
therapist (non-physician clinician), who is
qualified through training, experience and
independent licensure, treats the patient.
The psychiatrist does not have the
authority to hire or terminate the nonphysician clinician and remains outside
the decision-making chain of command.
Both the therapist and the patient need
to understand that the psychiatrist is not
responsible for continued, ongoing care.
This is an important issue in the event
of an adverse outcome. It is important to
make sure that the psychiatrist’s role is
clearly defined and delineated.
The benefits to split treatment
include increased patient access
to psychopharmacology and/or
psychotherapy while allowing the patient
to maximize choices as healthcare
consumers. Some of the risks have been
outlined above. However, in general,
additional risks may involve treatment of
unstable patients and adverse outcomes
that could potentially occur; the need for
communication between providers may
not be practicable and, as such, decreased
communication may result in increased
risk.
Here are some questions psychiatrists
should ask themselves prior to entering
into a split treatment arrangement:
• What is my clinical competency and
what is my duty to the patient in the split
treatment role?
• What is my autonomy concerning
treatment decisions?
• What are my areas of independence
regarding the patient’s treatment?
• Are there state or federal regulations
that impact the treatment offered to the
patient?
• What are the clinical standards?
• What are the professional/ethical
standards?
Continued on page 10
Missouri Psychiatry
3rd Quarter 2012
From our Readers
MPA Seeks Member Input on
ACA
Of all the political issues in this highly
contentious election cycle, few are more
controversial than the Patient Protection
and Affordable Care Act (ACA), referred
to as “Obamacare” by its detractors. After
the U.S. Supreme Court upheld the law
almost in its entirety, the APA released a
statement explaining why the Board of
Trustees decided to join the American
Medical Association in support of the
ACA.
According to the APA statement released
one day after the June 28, 2012, Supreme
Court decision, some of the reasons for
this support include the following:
• The ACA ensures that all Americans
will have access to affordable health
insurance that meets core coverage
standards, including APA-advocated
parity for treatment of mental illness and
substance use disorders.
• Psychiatric patients can’t be denied
coverage because, through no fault of
their own, they have had a psychiatric
illness. And they can’t be dropped by their
insurance for getting treatment, nor will
they have to worry that their insurance
benefits will run out when they are most in
need of treatment.
• These and other provisions in the law
expand access to psychiatric treatment for
millions of Americans.
I encourage members to read the brief
APA press release.* The “bottom line” is
that both organizations support the ACA
because of its positive impact on patients.
The ACA provides coverage of mental
illness and substance use disorders, notes
the APA, as part of the “core benefits”
package. Eventually, coverage of these
disorders must be at parity with other
medical and surgical benefits for all plans
sold in the exchanges. This is “real parity,
with teeth,” the APA states.
Despite these and other benefits to
patients, Missouri, like many other states,
is actively resisting implementation of the
law. Missouri should:
• Set up insurance exchanges online
in which consumers can learn about
what insurance policies are available
and at what price. (Federal money in the
millions is available for this but Missouri
lawmakers say they won’t accept it.
However, if states donʼt create their own
exchanges the feds will design them.
Opposition on this issue is irrational and
self-defeating.)
• Comply with provisions to expand
Medicaid coverage to the level called for
in the ACA, i.e., at 133% of the federal
poverty level. (The federal government
would bear most of the cost and the state
would receive more than enough to cover
the cost, at least in the first five years.
Many more poor Missourians would have
health insurance—most important for
them, but also for hospitals which bear
the economic brunt of emergency care,
which, in turn, drives up insurance costs
for everyone.)
For several weeks in July, the MPA
Executive Council engaged in a lively
online discussion about the ACA. I
proposed that Missouri Psychiatric
Association formally encourage Governor
Jay Nixon and legislative leaders to
implement these provisions of the law.
The motion was tabled pending input from
the membership. The MPA Executive
Council seeks your input. E-mail your
thoughts to MPA President Bob Batterson
at bbatterson@cmh.edu.
_____
Dr. Fleming is a voting member of the MPA
Executive Council by virtue of his position
as CME Program Chair. He works with the
Missouri Department of Corrections via its
behavioral health contractor, MHM Services
Inc., and with North Central Missouri Mental
Health Center. He also has a private practice
in Lee’s Summit, Mo.
Letters to the Editor
We invite readers to submit letters of
not more than 500 words. Missouri
Psychiatry reserves the right to edit
letters and to publish them in all
editions, print, electronic, or other
media. All letters must be signed.
Send letters by postal mail to Missouri
Psychiatry, 315 Nichols Rd, Suite 250,
Kansas City, MO 64112 or by e-mail
to <bbatterson@cmh.edu>. Clinical
opinions are not peer reviewed and
thus should be verified independently.
NOTICE
New MPA
Telephone Numbers
Phone: 816-531-8432
Fax: 816-531-8438
Please update your records.
Thank you.
James L. Fleming MD
* Read about the APA’s position on the
Affordable Care Act at <http://www.
psych.org/advocacy--newsroom/advocacy/
summary-of-the-patient-protection-andaffordable-care-act-and-its-impact-onpsychiatry-and-its-patients>. n
7
Missouri Psychiatry
3rd Quarter 2012
Legislative Update
MPA Legislative Report
By Mo McCullough
T
he 2012 legislative session ended
May 18 at 6 pm with, ahem, … barely a
whimper.
Missouri lawmakers introduced more
than 1,600 bills and resolutions to the
96th General Assembly during its Second
Regular Session. Of those bills, 113
reached the governor’s desk; he vetoed 14.
Not much to show for five months at the
Capitol Building in Jefferson City.
“Legislation is not always vetoed on
policy grounds,” according to a July 2012
Capitol Briefing <http://www.senate.
mo.gov/newsroom>. “Often, the governor
will veto measures that were passed as
language in other bills or are otherwise
duplicative.”
July 14 was the constitutional deadline
for the governor to take executive action
on passed legislation. If the governor took
no action, by either approval or veto, then
the legislation would be automatically
enacted into law on its effective date,
which for the majority of the bills was
Aug. 28. However, those that contained
an emergency clause took effect upon the
governor’s signature.
Members in both chambers may attempt
to override a veto during the annual veto
session in mid-September. Veto overrides
require a two-thirds majority vote in each
chamber.
The best news is that Missouri ended
Fiscal Year 2012 on June 30 with a budget
passed before its constitutional deadline
and economic growth slightly above the
predicted rate. Actual growth clocked in at
around 3.2 percent for FY 2012—one-half
percent higher than forecast, amounting to
an additional $39 million more in general
revenue than what lawmakers anticipated.
The higher revenues mostly came from
8
increased individual income tax, sales tax
and use tax collections. It was welcome
news for the FY2013 budget that began
July 1 and totals more than $24 billion.
The fall elections were another dynamic
this year. A round of term limits and new
House and Senate districts caused by
federal redistricting sent waves of debate
and dissent throughout the Capitol and
touched many aspects of the legislative
process.
One successful bill we followed was
House Bill 1563, to give more children
with autism access to Applied Behavioral
Analysis (ABA), a beneficial form of
therapy. Gov. Jay Nixon signed the bill
into law on July 12.
Many other bills on our Watch List died
because they either were never assigned
to a committee or did not advance beyond
a public hearing. Unfortunately, one bill
that didn’t pass would have provided
coverage for the diagnosis and treatment
of eating disorders. Senate Bill 634
and its companion, HB1509, faced stiff
opposition from health insurance carriers
and health benefit plans. Advocates
promise to try again in 2013.
Other bills that failed sought to expand the
scope of practice for non-physicians into
the medical arena, presenting potential
risks to patients. HB 1082 would have
allowed licensed professional counselors
(LPCs) to diagnosis mental, emotional,
and behavior disorders, and SB 679 would
have modified laws relating to advanced
practice registered nurses (APRNs) and
collaborative practice arrangements.
HB 1372 sought to change the laws
regarding the dispensing of controlled
substances by establishing the Prescription
Drug Monitoring Program Act. The bill
was referred to a House committee, had a
public hearing in January, but later died.
Companion bills HB 1456 and SB 518,
authorizing the Department of Corrections
to establish a mental health assessment
pilot program for certain criminal
offenders, were voted “do pass” by their
respective committees but didn’t cross the
aisle to the other chamber.
A bill (HB 1987) to require parental
consent for mental health screenings
in school and the use of psychotropic
medications with children in the custody
of the Department of Social Services also
died.
For the umpteenth year in a row, the
several bills known as “Helmet Laws”
were dead on arrival. The bills would have
exempted persons over 21 from wearing
protective headgear when operating or
riding as a passenger on any motorcycle or
motortricycle.
The state Mental Health budget took a hit,
but not as bad as it could have been. Core
services and psychiatric beds continue to
suffer cuts.
The 2013 legislative session will offer
its own special set of opportunities and
challenges. Elections both statewide and
nationally will rule the day. There will be
new leadership, new faces, new numbers,
new agendas, and new priorities. We fully
expect psychologist-prescribing (RxP)
and other scope of practice bills to return
because of all the new faces in Jeff City.
2013 will be the year. So, strap on your
seatbelt and hold on to your hat, it’s going
to be a wild ride! Now, let’s get ready! n
_____
Richard “Mo” McCullough has represented the
political interests of Missouri’s psychiatrists
before the General Assembly since 2000. Based
in Jefferson City, he is a frequent contributor to
Missouri Psychiatry.
Missouri Psychiatry
3rd Quarter 2012
First Person: Speaking
Internationally About Stigma
By Balkozar Adam MD
T
his April, for the first time, I attended
and presented at the Eighth International
Conference on Psychiatry, held in Saudi
Arabia. The theme of the conference
was “Comorbidity within Psychiatric
Disorders and Medical Illnesses.” I was
impressed by the calibre of the more
than 1,200 attendees, many of who were
psychiatrists, psychologists and mental
health professionals from hospitals and
universities across the globe.
The former president and presidentelect of the World Psychiatric
Association (WPA) attended the
conference, as well as the president of
the Collegium Internationale NeuroPsychopharmacologicum (CINP). The
conference was conducted in both
English and Arabic, and my presentation
was in English. About 60 percent of the
speakers were from outside the Middle
East, prompting conference organizers
to call it one of the most internationally
representative in the region. A number
of international news outlets covered the
conference and broadcast it online.
I was invited to speak on “The Stigma of
Mental Illness and the Role of the Media
in Promoting Positive Public Opinion.” I
reminded the audience that research has
shown that stigma is the greatest barrier
to quality of life for people with mental
illnesses. I described the role of the media,
ways to reduce that stigma and referenced
literature in the Western world. I also
referred to national and international
organizations that work to break down the
stigma of mental illness, such as WPA,
National Alliance on Mental Illness, and
the Substance Abuse and Mental Health
Services Administration (SAMHSA).
unpredictable and dangerous. This
can lead to a fear of rejection and
discrimination. People with mental
illnesses may worry that they will be fired
from a job or evicted from their home, and
may not seek treatment as a result.
I was struck by the way stigma manifested
itself in the Arab world. There is a
tendency to ascribe odd or troubling
behavior to personal faults or weaknesses,
not to mental illness. By extension,
seeking treatment from a mental health
provider also can be viewed with
skepticism. Although the psychiatrists
used similar psychotropic medications
(and the DSM and the ICD systems in
making a diagnosis), the patients tended
to also use other natural remedies and
prayers to help ease their suffering.
The goal of the conference was to
contribute in a concrete way to the
issues surrounding comorbidity within
mental disorders and illness. While much
research and many a conference have been
devoted to the study of mental illnesses,
there is growing awareness that studying
comorbidity within those disorders is
paramount. The numerous presentations
and workshops ranged from comorbidity
with ADHD, depression, schizophrenia,
substance abuse, and countless other
topics that all tackled real issues and led to
intriguing discussions. It was an honor to
be a part of the conversation.n
_____
Dr. Adam is a clinical assistant professor
of psychiatry at the University Of MissouriColumbia. She has worked with children,
adolescent and adults for over 20 years.
News from
Around the
Show-Me-State
Western Missouri
Regional Office
The REACH Healthcare Foundation
Board of Directors elected eight members
to the Board, including WMPS member
J. Stuart Munro MD. The REACH
Foundation is a charitable organization
that provides grants and other support to
improve health care and health access. The
Foundation is governed by a 17-member
volunteer Board of Directors. Dr. Munroe
was elected to serve a three-year term.
Dr. Munro is Chair of Psychiatry at
the University of Missouri-Kansas City
School of Medicine, and Medical Director
and Associate Dean for the Center for
Behavioral Medicine. He is President-elect
of the American Association of Chairs of
Departments of Psychiatry.
Central Missouri
Regional Office
Hina Syed, director of MPA-Central
Missouri Regional Office, reports
that members have elected executive
council officers for one-year terms
for May 2012 through May 2013.
The officers are Fatima Naseer MD,
president; Ganesh Gopalakrishna MD,
secretary/treasurer; Efosa O. Airuehia
MD, MIT Representative; and Maarten
Nieuwenhuizen MD, membership
committee chair. Dr. Nieuwenhuizen
also chairs the MPA Membership
Committee, which oversees the Fellow
and Distinguished Fellow nomination
processes.
Culture often colors the lens in which we
view the world, and mental illness, stigma
and the role of the media is no different.
In the U.S., a common stereotype is that
people with mental illnesses are violent,
9
Missouri Psychiatry
3rd Quarter 2012
Risk Issues with Split Treatment1
Continued from Page 6
These are just a few of the issues to
consider when entering into a split
treatment arrangement. The American
Psychiatric Association document
entitled Guidelines for Psychiatrists
in Consultative, Supervisory or
Collaborative Relationships with
Nonphysician Clinicians (2009) can be
found on the APA website.
This information is not intended to be and
should not be used as a substitute for legal
advice. Rather it is intended to provide
general risk management information
only. Legal advice should be obtained
from qualified counsel to address specific
facts and circumstances and to ensure
compliance with applicable laws and
standards of care.
1
References
American Psychiatric Association Resource
Document. Guidelines for Psychiatrists in
Consultative, Supervisory or Collaborative
Relationships with Nonphysician Clinicians
(2009)
Cohen v State, 51 AD 2d 494, 382 NY 2d 128
(1976)
Falvey, Janet Elizabeth. Managing Clinical
Supervision: Ethical Practice and Legal Risk
Management. Brooks/Cole (2002)
Flach, Frederic, M.D. (Ed.) A Comprehensive
Guide to Malpractice Risk Management in
Psychiatry. Haterleigh Press (1998)
Harris, Gardiner, “Talk Doesn’t Pay, So
Psychiatry Turns Instead to Drug Therapy,”
New York Times, March 5, 2011
Meyer, D., M.D., Split Treatment and
Coordinated Care with Multiple Mental Health
Clinicians: Clinical and Risk Management
Issues. Primary Psychiatry.2002; 9(4) 56-60
<http://www.primarypsychiatry.com/aspx/
articledetail.aspx?articleid=2312>
Tarasoff v. Regents of the University of
California, 188 Cal. Rptr. 14, 551 P 2d 334
(1976) n
10
_____
Kristen Lambert, JD, MSW, LICSW, CPHRM is
Vice President of Healthcare Risk Management
for AWAC Services Company, a member of
Allied World Assurance Company Holdings,
AG, which, through its subsidiaries, is a global
provider of innovative property, casualty and
specialty insurance and reinsurance solutions.
Ms. Lambert leads risk management services
for Allied World’s psychiatrist policyholders
and has a background in litigation and clinical
social work.
Submit questions or topics of interest to
Tell Me More About by email to kristen.
lambert@awacservices.com or by postal
mail to Kristen Lambert, JD, MSW,
LICSW, Healthcare Risk Management,
AWAC Services Company, 1690 New
Britain Avenue, Farmington CT 06032.
President’s Message
Continued from Page 2
All of this could sound a little basic to
some or even stressful to others because it
is “out of the box” of our usual practice.
But, nothing I did was beyond what I had
learned as a medical student or first year
resident; it all came back quite handily.
The experience provided an interesting
change from my daily medical practice
and change is good once in a while!
All too often, I hear people who confuse
psychiatrists with psychologists. As we
know too well, psychologists now want to
prescribe medication. This is one very big
way for us to educate our lawmakers about
the difference in professions. We can say
to them: “Folks, we are physicians and,
while we specialize in mental health, we
are still physicians!” Using a stethoscope
goes a long way to put the exclamation
point behind that sentence. Contact
MSMA for more information at <www.
msma.org>. n
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Missouri Psychiatry
3rd Quarter 2012
New Editorial Staff
Continued from Page 1
Assistant Editor Balkozar Adam MD
is a child and adolescent psychiatrist
and clinical assistant professor at the
University of Missouri-Columbia. She
graduated from Cairo (Egypt) University
School of Medicine and completed her
residency and fellowship at UM-C. She
previously served as medical director at
the University of Arkansas Children’s
Hospital inpatient children’s unit and
as medical director of the child and
adolescent unit at Mid Missouri Mental
Health Center in Columbia.
Dr. Adam is an APA Distinguished Fellow,
a Fellow of the American Academy of
Child and Adolescent Psychiatry, and past
Moses Tabe Ambilichu MD
president of Central Missouri Psychiatric
Society. She also is a member of the
International Center for Psychological
Trauma and International Medical and
Educational Trust. She hopes to bring a
unique perspective to pertinent topics in
Balkozar Adam MD
psychiatry.
Submit ideas or articles to Dr. Tabe
Ambilichu at donmoise@hotmail.com or
Dr. Adam at adamb@health.missouri.
edu. n
Classifieds
11
Missouri Psychiatry
12
3rd Quarter 2012
Missouri Psychiatry
3rd Quarter 2012
Medical Director Opportunity
Missouri
MHM Services, Inc., a progressive leader in the dynamic field of correctional healthcare. MHM
Services provides the opportunity to make a difference to an important and underserved population while being part of an elite organization. If you are a dedicated psychiatrist seeking a
medical director opportunity and embraces progressive treatment methods while being part of
the solution, now is the time to explore a career with MHM Services, Inc. In addition to rewarding work, we offer a work/personal life balance, a highly competitive salary, and an outstanding benefits package which includes the following:
• 28 Paid days off per year, plus 6 company paid holidays
• 401(k) plan with employer match
• Company-sponsored health, dental, life & disability insurance
• Paid malpractice insurance
• CEU reimbursement and 4 additional days off
• Flexible spending accounts for healthcare and dependent.
The following job expectations for an MHM Medical Director will be to provide supervision to an
elite team. Provide clinical direction needed to meet the service delivery requirements specific
to the contract. Ensure that the patient’s care meets compliance. Promote and maintain quality
relationships with the mental health team and
the client. Interfaces with clinical and administrative leadership on issues related to mental
health services.
If you are interested or know someone who might be, please contact
Mark Hyde, 877-861-7993 or email: mark@mhmcareers.com
13
Missouri Psychiatry
3rd Quarter 2012
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Missouri Psychiatry
3rd Quarter 2012
We strive to offer content in Missouri Psychiatry that represents our membership and encourage members to participate in its
creation. For communications regarding the newsletter or to submit articles, letters to the editor or upcoming events, please
contact: Editor, Missouri Psychiatry, c/o Metropolitan Medical Society of Greater Kansas City, 315 Nichols Road, Suite 250,
Kansas City, MO 64112 or donmoise@hotmail.com.
For advertisement information, please contact Victoria Braswell by e-mail at vbraswell21@gmail.com.
Submit items specific to your local office to:
• Central Missouri Regional Office: Hina Syed at hinasyedcmps@yahoo.com
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• Western Missouri Regional Office: Stacy DeMeyer at sdemeyer@metromedkc.org
Newsletter Disclaimer: The opinions expressed herein are those of the authors and do not necessarily state or reflect the views
of Missouri Psychiatric Association. Publication in this newsletter should not be considered an endorsement.
Copyright ©2012 by Missouri Psychiatric Association. All rights reserved. No part of this document may be reproduced or
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Upcoming Events
Saturday, Nov. 17, 2012
NAMI St. Louis 2012 Annual Gala
“Celebrating Beautiful Minds.” Hilton St.
Louis Frontenac Hotel, 1335 S. Lindbergh
Blvd., St. Louis MO 63131. Sponsored by
the Alliance on Mental Illness - NAMI St.
Louis. For information, contact 314-9624670 or dar.walker@namistl.org.
April 5-7, 2013
MSMA’s 155th Annual Convention,
Westin Crown Center, One East Pershing
Road, Kansas City MO 64108. Sponsored
by Missouri State Medical Association
(MSMA). For information, contact MSMA
at 573-636-5151, toll free at 800-869-6762
or bstennis@msma.org.
16
Saturday, April 6, 2013
MPA Psychiatry Program at MSMA’s
155th Annual Convention, Westin Crown
Center, One East Pershing Road, Kansas
City MO 64108. Sponsored by Missouri
Psychiatric Association (MPA). Contact
MPA at 816-531-8432
or jwatson@
metromedkc.org.
April 10-13, 2013
WPA Regional Congress 2013:
“Facilitating Mental Health, Primary
Care and Public Health Integration for
Southeast Europe & Eurasia.” Palace
of the Parliament, Bucharest, Romania.
Sponsored by the World Psychiatric
Association (WPA). Find more details
about this superb scientific program at
http://www.wpa2013bucharest.org.
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