The APA annual meeting: a photo essay

As posted previously, last month I attended the American Psychiatric Association's (APA's) annual conference.  Straying from my usual format, I thought I'd post pictures from the meeting and, of course, offer comments. The meeting took place in Moscone Center, a conference center complex located just south of Market Street in downtown San Francisco.  Depicted here are anti-psychiatry protesters who held a rally in front of the main entrance at noon on the first day.  There was also an exhibit of psychiatry's cruelties (psychosurgery, shock treatment, inhumane conditions in asylums, etc) running all five days in a tent across the street from the conference.   The conference was also a block from Yerba Buena Gardens, where I caught a very pleasant Balinese gamelan concert at the same time as the protest rally. This simultaneity — two events scheduled to coincide, forcing a choice — was a constant in the conference as well. The "scientific program" consisted of  numerous overlapping talks, such that attending any presentation meant missing five or more other good ones.  I'm not sure why the APA opted for such frustrating redundancy.  Nor can I explain why predictably popular talks were scheduled into small rooms, with the result that dozens of registrants were turned away once the room filled.  For instance, the crowd for Otto Kernberg's psychoanalytic talk on love and aggression was several times larger than the assigned room.  In this unusual case we were all moved to a cavernous hall at the last moment, where Dr. Kernberg gave a warm and very engaging presentation on the necessity and creative consequences of aggression in romantic love.  (I like how this photo depicts the renowned psychoanalyst Kernberg representing the APA in an era of biological ascendancy.)

The same huge auditorium was to hold the keynote address by Bill Clinton.  However, Mr. Clinton was ill and could not be there in person.  Several hundred (a couple thousand?) conference-goers nonetheless waited over an hour to see him on video.  Mr. Clinton was pleasant, thoughtful, and charismatic, but didn't offer much specifically about psychiatry or mental health.  Mostly he spoke about public health needs in general.

I didn't take many photos in the talks themselves.  Officially it was forbidden, although this rule was routinely ignored by attendees.  The quality of the presentations was high — I mostly chose "mainstream" ones this time, not the many off-beat and generally smaller meetings.  I attended presentations on suicide, personality disorders, PTSD, sexual compulsions, DSM-5 and mood disorders, the controversy over antidepressant efficacy, psychiatrists writing and blogging for the general public, teaching psychotherapy to residents, and assessing the capacity of demented patients to make medical decisions for themselves.  There were dozens of others I would have liked to attend, had they not coincided with the ones I chose.

I skipped the industry-sponsored, free lunch or dinner, non-CME presentations.  But I did wander through the exhibit hall, both to see the "new investigator" scientific posters, and to peruse the brand-new DSM-5. In contrast to the last time I went to this conference, the industry booths seemed less garish and "over the top."  Of course, there were still a lot of them.  Several had raffles where valuable prizes such as an iPad Mini could be won by those who gave the company their contact information.  One booth offered a pocket digest of the new DSM-5, MSRP about $60, to everyone who watched a 12 minute presentation and coughed up a mailing address.  I was tempted... but no.  (It's interesting to ponder how much a single psychiatrist contact is worth to a drug company.  Much more than $60, I'd venture.)

The DSM-5 itself is $200 in hardcover, $150 in paperback — an unabashed moneymaker for the APA.  Despite the incredible controversy it stirred up, my impression is that the changes from DSM-IV-TR are relatively minor.  In particular, the personality disorder section hasn't changed much, although the new edition is no longer multi-axial, i.e., there is no "Axis 2".  Some language has been made more precise, as well as more "biological" in some passages, and some disorders have been expanded to include more that would previously have been considered normal.  Whether this is good or bad depends on one's perspective in several respects; mostly I find it unfortunate.  DSM classifications often matter more to insurers and disability officers than to practicing psychiatrists, who in David Brooks' words are "heroes of uncertainty" (echoing an earlier post of mine, but I'll forgive him for not quoting me).  We deal with individuals, not disease categories.

I will end with a slide from the talk on antidepressant efficacy that summarizes this tension in my field.  As I've discussed previously, randomized controlled trials (RCTs) are the gold standard for scientific rigor in psychiatry; however, a lot of psychiatry is not scientific in this sense.  DSM categories help define the "average" patient with a particular disorder, leaving a lot of wiggle room since the categories are not based on etiology.  RCTs say which treatments best help this "average" patient, represented by the computer composite in the center of this slide.  However, I don't see "average" patients,  I see one of the 12 individuals who contributed to the composite.  Thus, for me, the new DSM was a sideshow at the conference.  The most insightful presentations, whether on PTSD, suicide, or capacity assessment, combined science and the nuanced human communication of meaning.  They recognized that our work is informed by science but goes well beyond it.  Anti-psychiatrists don't like this, insurers don't like this, neuroscientists don't like this, even many psychiatrists don't like this.  But it's true and inevitable for the foreseeable future.  I like it.  As for the APA annual meeting, I'm glad I went, and equally glad I won't feel the need to go back for several years at least.

Going to the APA meeting?

The annual meeting of the American Psychiatric Association (APA) is in San Francisco this May.  I've attended twice before as I recall, both times when it was here.  I enjoyed it, and even felt it was worth the $1000 we non-members pay to get in, although in my opinion it's not worth doubling that for airfare and lodging to attend in another city.  The presentations were generally of high quality, and so plentiful that I always found something worthwhile to attend.  Up to 50 CME (continuing medical education) hours are available over five days, enough to maintain a California medical license for two years.  This year, in addition to the other presentations, the new DSM-5 will be unveiled and discussed, so we can anticipate hearing a lot that is new and essential for clinical practice.  Bill Clinton will give the keynote speech. Yet it's a hard decision for me to attend this meeting.  The APA and its annual meeting reflect aspects of psychiatry that concern me.  In 2006 the drug industry accounted for about 30 percent of APA's $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences, and industry symposia at the annual meeting.  Every year the annual meeting features a huge exhibit hall of lavish booths courtesy of the pharmaceutical industry.  In past years I watched my fellow psychiatrists line up for branded coffee mugs and similar swag; although voluntary restrictions by the Pharmaceutical Research and Manufacturers of America (PhRMA) in recent years have curtailed this, the APA itself welcomes such giveaways according to this year's information sheet for exhibitors.  This year there are industry sponsored "Product Theater" presentations most days around lunchtime (six sessions total, up to 250 attendees per session), and "Therapeutic Update" meetings at dinnertime (three two-hour sessions) — pure marketing vehicles that are not approved for CME, that lack any pretense of scientific balance or neutrality, and that come with a nice free meal to tickle the limbic systems of the recipients.  In fact, there's a surprisingly wide range of promotional and marketing opportunities at the meeting (pdf here) that the APA sells to industry.  We participants may sign up for the scientific presentations and collegiality, but the APA invites us for the millions of dollars we bring in.

Of course, individual attendees aren't forced to take a seat at a "Therapeutic Update" and may never set foot in the exhibit hall.  So what's the problem?  Can't attendees enjoy an educational experience free of commercial influence?  Unfortunately, with APA selling everything from sponsored wi-fi, to plasma-screen billboard space, to branded do-not-disturb signs at the hotel, the industry flavor will be hard to miss.  Registrants are warned that our names, titles, mailing addresses, and email addresses will be "shared" (i.e., sold) to meeting exhibitors.  Perhaps there's an unpublicized opt-out I'm not aware of.

Whatever one thinks of this blizzard of advertising to a highly selected, captive audience of over 10,000 psychiatrists, it hardly needs to be said that the practice of psychotherapy will have no deep-pocketed sponsorship; healthy nutrition, exercise, lifestyle balance, and introspection will enjoy no "Product Theater" or "Therapeutic Update."  If this year's meeting resembles those I attended in the past, many presenters will mention the importance of psychosocial factors in mental health, and, if one seeks them out, there will be talks by some of the luminaries in trauma research and psychological treatments.  But this will be in the context of blaring signs promoting the newest antidepressant, mood stabilizer, and anti-psychotic — which nowadays may all be the same product — and a zeitgeist of DSM diagnoses leading to pharmaceutical remedies.

Speaking of DSM, the unveiling of DSM-5 ought to be interesting.  DSM diagnosis is an integral part of most mental health (not just psychiatric) practice, as treatment authorization and reimbursement by health plans often hinge on the DSM disorder for which the patient "meets criteria."  Both the process of creating the new DSM-5 and its conclusions have come under repeated attack from a range of reputable critics, including the chair of the DSM-IV Task Force Dr. Allen Frances, Division 32 of the American Psychological Association (the "other" APA), the British Psychological Society, the American Counseling Association, and others.  One common criticism is that diagnostic categories are being loosened (or widened), such that more patents will meet criteria for a mental disorder, and in turn more psychiatric medications will be prescribed.  Dr. Frances charges that the APA treats publication of DSM-5 as a "cash cow," citing the hefty cost ($199 hardcover, $149 paperback) of this instant and inevitable best-seller.  My own feelings about the DSM are mixed, and I'm curious to see how the newest edition turned out, particularly the section on personality disorders.

Despite my concern about undue commercial influence, misplaced priorities, and its controversial diagnostic manual, I plan to go to the APA meeting this year.  There's too much of value to me in all those presentations.  But when I pass the anti-psychiatry protesters at the entrance, I know I will wish for some way to declare myself neither anti-psychiatry nor, despite appearances, in full agreement with the spectacle within.

CME in California

Last weekend I attended the annual one-day conference for providers of continuing medical education (CME) in California. Presented in Sacramento this year by the Institute for Medical Quality (IMQ), a division of the California Medical Association, there were talks on documentation requirements and updated accreditation criteria. There was praise and support for the majority of those attending, the office staff who organize much of the CME offered in the state.

I was there as chair of my hospital's CME Committee, a position I've held since January. While my primary concern is commercial bias in CME, the conference highlighted two other areas of potential controversy I thought I'd share here as well.

Regarding industry bias, there is good news and bad news. The good is that overt bias is explicitly and increasingly monitored. There are regulations at both state and national levels to maintain a wall of separation between industry funding sources and the content of CME presentations. Physician audiences evaluate each CME offering and are asked whether any bias was present. Thanks to media attention and official pronouncements, the issue is now on everyone's mind. At last it seems reasonable to hope that bald-faced marketing pitches in the guise of balanced CME are on their way out, at least in academic settings.

The bad news is that CME is not provided only in academic settings. "Medical education communication companies" (MECCs) are private entities that host about 40% of all CME accredited by ACCME, using funds mostly from drug companies. As described in the PharmaLive blog, "Most MECCs were simply spun off from advertising and marketing agencies doing business with pharmaceutical companies." Psychiatrist-blogger Daniel Carlat calls this arrangement "money laundering"; the fairness of this characterization hinges on whether the MECC itself allows its funding to influence its message. While I imagine MECCs run the gamut from earnest educators to crass money launderers, I confess to some cynicism after having experienced first-hand a public relations firm showcasing a Wyeth drug pitch in the guise of a public education event.

More subtle biases continue to slip under the radar as well. New products are welcome topics for CME, while older products, perhaps equally effective, are not. Prescription medications heavily advertised to the public — all new, relatively expensive, and not available generically — require CME introductions, so that doctors have an intelligent response when patients obey the advertising pitch and "ask their doctor" about them. Since physicians themselves seek education about new products, truly unbiased CME at this level seems an ideal not easily reached in real life.

Another topic discussed at the IMQ conference was a 2006 California law that requires all CME in the state to include "cultural and linguistic competency" (CLC) as part of the presentation. This CLC requirement aims to incorporate information regarding "health disparities" in all ongoing medical education. The basic idea is that language, economic, and cultural barriers have health consequences, and that it ought to be part of every California doctor's training to know about them, and how they apply in every clinical situation. I'm sure the legislation was well-intended, and I agree CLC warrants special focus in medical education.

The problem is force-fitting CLC into every CME presentation. Many CME speakers have an area of research or clinical expertise, which is why they were chosen to speak in the first place. Most are not experts on CLC issues, but in deference to state law they need to cover (or pay lip-service to) this anyway. Instead of making speakers talk about something they lack expertise in, a better alternative would be to require a certain number of CME hours specifically devoted to CLC for annual re-licensing. Then CLC could be presented by CLC experts, and be given the attention and focus it deserves.

Perhaps the most interesting thing I experienced at the IMQ conference was the way "improving patient care" constituted the unquestionable goal of CME. Certainly it is a hard rationale to argue with. After all, medical practice as a whole is aimed toward patient care. It also lends itself to empirical validation: Did physician practices change, and ideally did patient outcomes improve, as a result of a given educational experience? I do agree that the goal of the great majority of CME should be to improve patient care.

However, physicians are not mere technicians. I have attended CME talks on psychiatric practices in other countries. I would be hard pressed to say how this changes my care of patients here, but it still seems valuable for me to know. I have attended CME on standards of care in medical areas other than psychiatry, areas I will never practice myself. I can easily imagine valuable CME that reviews public perceptions of controversial area of medicine both psychiatric and non-psychiatric, cosmetic surgery for instance, that would have no effect on patient care per se. Each of these examples rounds out the education of physician-learners in important but intangible ways. Unless the profession and the public are content with medical "training" as opposed to education, the focus of CME should in my opinion span a somewhat wider domain.

Ironically, the IMQ conference itself awarded me 5.5 hours of CME credit for attending, and yet nothing presented will "improve patient care" in any direct sense. It was still valuable, and I am glad I attended.