Fall 2013Vol 4, Issue 3
Navajo Bridge View
Arizona Psychiatric Society Newsletter
Greetings from the Newsletter Committee
APS Logo Refreshed
Robin Reesal, MD, 
Newsletter Chair
September 2013
Welcome to the ethics focused Fall Edition of the APS Newsletter. 
We begin with our Dr. Kowalik, the Society President, succinctly highlighting the important events of this last quarter and telling us about future plans. We then make special mention of Dr. Cleary for achieving his Distinguished Fellow Status and Dr. Thienhaus and Dr. McLoone for their excellent presentations of the DSM-5 Workshops. 

The ethics features begin with an article authored by 
Dr. Matthew Barret DeLiere. This fourth year Chief Resident with the University of Arizona College Of Medicine, South Campus in Tucson does an outstanding job of conceptualizing the ethical issues in his Correctional Psychiatry training.

Dr. Jack Games, one of our Life Members, writes a reflection about his experiences from 1955 to 1961 during the years of his psychiatric training. This insightful article captures the essence of an era and the relevant ethical issues.

Through a series of questions, Dr. Taylor-Desir, in the Early Career Psychiatrist (ECP) perspective, nicely completes our triad of ethics articles. She brings together the medical responsibilities stated in the Hippocratic Oath, the Principles of Medical Ethics of the American Medical Association and the APA Ethics Committee on the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.

Our next section centers on quarterly reports. Joseph Abate, our APS Lobbyist, has wisely selected the important health legislation issues from the Arizona Legislature. His selection includes information on the Governor's expansion and restoration of AHCCCS. Dr. Bastani and Dr. Sadr have spent much time to coalesce the significant psychiatric events in the western United States and Canada as reported from their attendance at the Area VII August Assembly. Their report contains facts on Oregon's Scope of Practice bill that will pay Nurse Practitioners and PAs the same as physicians. Our Members-in-Training complete this section with details of their upcoming Fall Mixer.

The Newsletter concludes by nicely rounding up information on a host of upcoming interesting educational events, including a DSM-5 session in northern Arizona, an APA webinar on the Physician Payment Sunshine Act (free to APA members), the Eli W. Lane Memorial Master Workshop and primer sessions in Tucson, legal competency training, and the Sandra Day O'Connor College of Law Conference, "Before the Shooting Starts."   

The Newsletter Committee hopes you enjoy this edition. 
President's Message
By Joanna Kowalik, MD, MPH, President
Arizona Psychiatric Society

Dear APS Member,

With the Sunrise Application deadline of August 31st, the APS Fall Newsletters for the last two years have brought with them the news on the efforts of psychologists in favor of prescriptive authority.  As confirmed by the APS Lobbyist, Joe Abate, I am glad to inform you that a Sunrise Application has not been filed for the upcoming legislative session.  This does not mean those lobbying efforts have gone away, but it is good news that there will not be a Sunrise hearing on the issue in this session.  

It was a pleasure to see so many Society members at the DSM-5 Workshop in Phoenix, and I understand that the Workshop in Tucson also brought together a full house of members of the behavioral health community.  I would like to extend thanks to Drs. Ole Thienhaus and James McLoone for their personal contributions, both as members of the Society and as educators, in bringing this important education to our community.  Thanks go out, as well, to Dr. Edward Gentile in working collaboratively with the Society to schedule the Tucson Workshop at Community Partnership of Southern Arizona, and to the members of the Executive Council and the Events and Education Committees whose efforts supported these events.  

In conjunction with the Flagstaff Medical Center, another DSM-5 Workshop has been added for Saturday, October 5, 2013 in Flagstaff, Arizona, and the spots are filling up fast.  

We are at work planning a Fall meeting and social, a Winter social and malpractice education session, and, of course, the 2014 Annual Meeting.  Stay in touch and on the look-out for more information on these events, and I hope to see you there!  
In This Issue
President's Message
DSM-5 Flagstaff Workshop
Ethical Considerations and Exposure to Correctional Psychiatry in Training
Meet Dr. Games: Reflection from 1955 to 1961
ECP Perspective on Ethics
Physician Payment Sunshine Act
APS Lobbyist Report
Report from Area VII
Disaster Psychiatry
MIT Fall Mixer Set
Upcoming CME
Fall and Winter Member Events
Before the Shooting Starts
APA Resources for You
Society Highlights 

Michael F. Cleary MD
Michael F. Cleary, MD, DLF APA, attended the APA Annual Meeting in San Francisco in May and received his Distinguished Fellow medallion in the Convocation of Fellows.
Dr. McLoone Phx DSM-5
Dr. McLoone presented the DSM-5 Workshop in Phoenix on August 14th to a full house of APS members and behavioral health professionals.
DSM-5 Dr Thienhaus Tucson
Dr. Ole Thienhaus served as faculty for the DSM-5 Workshop held in Tucson on July 27th.
DSM-5 Tucson Full Room View
With thanks to Dr. Edward Gentile and his supporting staff from Community Partnership of Southern Arizona (CPSA), the Tucson DSM-5 Workshop provided outreach to a full complement of members of the behavioral health community from the region.  

American Professional Agency, Inc. (Newsletter Advertisement)
American Professional June 2013
DSM-5 Workshop Added for Flagstaff
APS Members Receive a Discount on APA publications--Order your copy today at appi.org
Thanks to all the Society and community members that attended, and Drs. Thienhaus and McLoone who instructed, the DSM-5 Workshops held on July 27, 2013 at the Training Center of CPSA in Tucson and on August 14, 2013 at the offices of the Arizona Medical Association in Phoenix were successful events.  It was rewarding to see so many APS members and members of the behavioral health community in Arizona gathered together for these educational opportunities.  

We are pleased to inform you that a DSM-5 Workshop has been added to the series, to be held in Flagstaff, Arizona on October 5, 2013.  If you were unable to attend the Tucson or Phoenix Workshops, register today to attend "DSM-5: What you Need to Know to Transition from DSM-IV," Jointly Sponsored by the American Psychiatric Association and the Arizona Psychiatric Society, in Conjunction with the Flagstaff Medical Center, on Saturday, October 5, 2013, from 8:45 a.m. (registration/check-in) to 1:30 p.m..  For the Flagstaff DSM-5 Workshop, Dr. Ole Thienhaus will serve as Faculty. 

Register today! APS Members attend for a low member rate of $30 for the workshop. Space is limited. For the full registration brochure, click here.  

Direct registration link for the October 5, 2013 Flagstaff Workshop is at:

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the Joint Sponsorship of the American Psychiatric Association (APA) and the Arizona Psychiatric Society. The APA is accredited by the ACCME to provide continuing medical education for physicians.

The American Psychiatric Association designates this live activity for a maximum of 4.0 AMA PRA Category 1 Credits ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

DSM-5 cover is reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

Ethical Considerations and Exposure to Correctional Psychiatry in Training

Matthew Barret DeLiere, MD

Chief Resident, PGY-4

University of Arizona College of Medicine - South Campus

Tucson, Arizona


As a fourth year psychiatry resident, the bulk of my schedule is dedicated to elective rotations, meaning that I have been free to tailor the year based on my unique interests and needs.  This is in contrast to the first three years of training, in which residents are required to complete selected rotations in a variety of mandated areas including in-patient psychiatry, consultation-liaison psychiatry, addiction psychiatry, and out-patient psychiatry.  Exposure to correctional psychiatry, though encouraged as an element of forensic psychiatry rotations, is not mandated by the ACGME. This is surprising given that the severely mentally ill make up an increasingly large percentage of incarcerated individuals (1).  In an attempt to round out my training, I elected to rotate at the Pima County Adult Detention Center (PCADC).  PCADC is a rather conspicuous facility, just five short minutes from my office.  However, I had no exposure to it in my first three years of training.  This is remarkable given the frequency and severity of mental illness expected in such a facility.  PCADC houses approximately 2000 inmates.  With estimates that mentally ill inmates comprise about 20% of the jail population (2), the number of individuals at PCADC requiring mental health care far exceeds the number of patients admitted to all psychiatric hospitals in the Tucson area combined.  While not all mentally ill inmates are in need of inpatient psychiatric services, data from the APA has suggested that about 5% of jail inmates are psychotic at any given time (1), which would mean that there are roughly twice as many actively psychotic inmates at PCADC as there are total adult in-patient psychiatric beds at my primary training hospital.  This was an eye-opening realization for me as I am sure it would be for many of my fellow residents across the country, many of whom complete training with little or no exposure to correctional psychiatry.


As I began working at PCADC, I noticed that the medical knowledge required seemed remarkably straightforward when compared to the complex legal, economic, political, and ethical issues at play.  Though I had become adept at addressing many such psychosocial variables through the course of residency training, I felt uninformed when faced with some of the new and unique challenges I confronted in the jail setting. 


In addition to adjusting to the sheer volume of patients, I quickly had to adapt to providing care in an inherently non-therapeutic environment.  I needed to familiarize myself with terms like "deliberate indifference" and "cruel and unusual punishment", and had to be alert to possible malingering and manipulation by inmates.  I also noticed a trend that patients in the jail were more likely to be poor, homeless, and socially isolated when compared to patients in local hospitals.  I worried about these patients being victimized by non-mentally-ill inmates.  Finally, I was forced to assess my own perspective, preconceived ideas, and counter-transference issues that I brought with me into this setting.  Fleshing these out was, for lack of a better term, quite liberating, in that it allowed me to clarify my role as a clinician and focus more clearly on the psychopathology at hand rather than getting distracted by the punitive function of the jail.


One recent patient encounter made me question some of my assumptions about the course of mental illness, the settings where patient contacts are made, and the way treatment is approached in various contexts.  The case involved a young man who was involuntarily admitted at a local hospital's psychiatric unit after a rather lengthy stay at PCADC.  It dawned on me that I could have just as likely seen this patient at PCADC and that this was the same patient with the same pathology regardless of where he was being held.  Any difference in conceptualizing his case would have come from something I had brought to the doctor-patient relationship, rather than a true difference in presentation.  In considering the ways in which my own views had begun to shift, I wondered how other trainees may perceive work in correctional facilities, and what, if any, ethical obligation exists to better prepare clinicians to serve this sector of the population.


Studies looking at attitudes towards correctional psychiatry as a career path, even in residents who have completed jail rotations, have generally been neutral; if not slightly negative when compared to other areas, like in-patient psychiatry (2).  While it does not appear to be the case that any exposure in this setting, either mandatory or as an elective, leads residents to pursue it as a career, it is worth noting that only about one half of programs make correctional psychiatry rotations available with only a fraction being mandatory (3).  Though likely not deliberate, there does seem to be a certain indifference towards this demanding and potentially rewarding field of psychiatry.


In my limited time at PCADC, I have found that the underlying ethical dilemmas pertaining to the provision of care to incarcerated patients provide the most compelling argument for training in correctional psychiatry.  I am learning that it is the setting that changes, not the patients.  There were moments at PCADC when I felt as though I was drowning in an endless sea of malingering, manipulation, and cynicism; however, there remained landmasses of undeniable mental illness.  I began to really appreciate the educational value of working at PCADC when I was able to work with patients with long-standing severe mental illness, treatment non-adherence, and comorbid substance use; many of whom likely would have gone untreated had they not been arrested.  At a time when a great deal of emphasis has been placed on community psychiatry, it is hard to believe that correctional psychiatry is not more common in residency training.  After all, there is nothing more community than the county jail.  Having now developed a better appreciation for the movement of and individual experiences of psychiatric patients within our community, I am more confident in my capability of dealing with even the most difficult patients no matter where they are housed.  




1.       http://www.schizophrenia.com/szfacts.htm#

 2.       Fuehrlein, B.S., et al. (2013), "Availability and Attitudes toward correctional psychiatry training: Results of a National Survey of Training Directors," Journal of Behavioral Health Services & Research, 2013. 1-6.

3.       Fuehrlein, B.S. et al. (2012), "Can we address the shortage of psychiatrists in the correctional setting with exposure during residency training?," Community Mental Health Journal 48:756-760.


Author Acknowledgments


With special thanks to the following mentors for their guidance and support:

Aimee Kaempf, MD, Assistant Professor of Psychiatry; Director, Psychiatry Residency Training Program at the University of Arizona College of Medicine at South Campus; and

Steven R. Galper, MD, JD, Clinical Assistant Professor of Psychiatry and Anesthesiology at the University of Arizona College of Medicine, Director of Mental Health for Pima County Adult Detention Complex, and Medical Director of Behavioral Health for Marana Health Center.   

Meet Fellow APS Member:  Jack E. Games, MD, Life Member, APA -
Recollections of Psychiatric Training and Experiences 1955 to 1961
Jack E. Games, MD, Life Member, APA
Dr. Games Residency Photo

After obtaining my MD from the University of Washington School of Medicine in June 1955, the Northern Pacific Railroad took me from Seattle to Washington, DC. At St. Elizabeth' Dr. Games Life Member s Hospital I did my rotating internship primarily at the Medical and Surgical Unit attending to the needs of psychiatric patients. The first year of my psychiatric residency was also spent there. When I was at St. Elizabeth's, it was not a parochial institution, but rather a US Government facility, and a part of the Department of Health, Education, and Welfare. Founded 100 years earlier, as the "Government Hospital for the Insane", there was a campus of over 300 acres, many red brick buildings, 7500 patients, and 2600 employees. Originally soldiers, sailors, and DC residents were served, and it was active during Civil War times. The property overlooks the Anacostia River, which unites nearby with the Potomac.

Segregation was the practice until about 1954, meaning there were separate wards for each group, designated as Black Male and Black Female, White Male and White Female. This rainbow of limited options seemed to fit the demographics at the time. My Internship included outside rotations in pediatrics and OB/GYN, and the psychiatry year consisted of 4 months "Subacute", 2 months Chronic, and 6 months Acute or Admissions.

A tunnel connected the Subacute Service Unit to the M & S, Medical and Surgical Unit. I recall once sending a guerney with an acute MI patient along that tunnel to further aid. I became de facto charge of that 400 bed unit when the Director and Assistant Director were absent for a period. I made rounds in the AM and PM, discussing the patient needs with each Head Nurse, and writing orders as needed, including dilantin, phenobarbital, Insulin, MOM, and Cascara. While assigned to a Chronic Ward, thick records were reviewed, with notes by previous generations of psychiatrists. One patient was described as "the stormiest petrel of the lot".

On the Admissions Service many patients were in acute psychosis, often young schizophrenics in initial episode. The use of major tranquilizers was very new. Thorazine, Stelazine, and Tofranil were available. Ritalin was used to counter sedative effects. I supervised a visiting Japanese psychiatrist, who was eager to learn of these psychotropics. We thought Manic Depression was very rare, and one article illuminated psychodynamic generators in 12 cases. The use of Lithium years latter was to alter this view. ( FDA Approval for Mania 1970 )

The interns and residents were instructed by direct supervision of patient care on the wards, and also via various conferences. A memorable example is a conference involving various levels of trainees with focus on a single patient. I should particularly note that we were lectured on the importance of the Limbic system, an omen indeed! A staff psychiatrist , Dr. L. Konchegul, did group therapy with chronic patients, Dr. Benjamin Karpman studied sexual deviates, and wrote on this topic. There was a chaplaincy program and a dance therapist. A sociologist was embedded and followed me on night rounds sometimes, with my permission, to observe the interaction. He published regarding his observations. ("Asylum" by Erving Goffman. )

Of note is the 3 story structure of many of the buildings, with the lower level holding the most subdued patients, the upper level for the most agitated or biggest patients. The size and strength of the staff increased with altitude also. For sedation there was a mixture of Hyoscine, Morphine, and Scopolamine in strength # 1 or # 2. .

Thunderstorms sometimes came at night, and I remember the eerie sensation going past the collection of specimens in jars in Blackburn Lab, lightning flashing, while on my way to an area where we typed and cross matched blood to use in emergency surgery. I met at least one patient who had a lobotomy. 

Most of the time I lived on campus. I have copy of an etching from 1855 with horse drawn carriages in the courtyard. We did have some well known patients whose confidentiality I continue to protect. The overall Director, since 1937, was Winfred Overholser, MD. 

Harry Stack Sullivan, passed away in 1949, but very much an influence in the DC area. His Interpersonal School of Psychiatry stimulated interest, and his book on the Clinical Interview was helpful. A Basic Books subscription sent books of psychiatric relevance on a monthly basis, e.g. Alfred Adler, Karen Horney, and Freud. The Ernest Jones biography volumes were read.

Ruth Monroe's "Schools of Psychoanalysis" was an overall view of concepts in this area. Carl Jung as presented by Ira Progoff, Oedipus per Patrick Mullahy, David Riesman's "The Lonely Crowd", Anna Freud, and Otto Fenichel, were part of a long list of the literary explorations that supplemented the intense and extensive daily patient contacts. My feeling at that time was more that I was studying mental illness, and the ideas regarding psychotherapy were at that point quite embryonic. The DSM-I was read in 1954 and did not have many pages compared to recent versions!

The two years of Active Duty as Captain in the US Army Medical Corps came next in my career, and my assignment was as neuropsychiatrist at Valley Forge Army Hospital in Pennsylvania. Our patients were flown in from places wherever US Forces were deployed. Evaluation and treatment were dual missions, and ECT was used for some depressions. At times a course of 20 ECT was used for schizophrenia. There was also insulin treatment for the latter, but deep coma insulin was discontinued about 1958. Psychotropics were prescribed, listening and talking done. Dr A. Noyes and Dr. E. A. Strecker visited to lecture or consult.

After the Army, Year 2 of residency was spent at Shepard and Enoch Pratt Hospital near Baltimore. There was green campus with castle-like old brick buildings, and here the private patients lived in comfort and treatment was multimodal, including comprehensive individual assessment, medications as indicated, and psychotherapy by residents with supervision. Involvement in arts and crafts work was also available. With lithium still not available, manic episodes were treated with cold wet sheetpacks (CWSP), in a room with several bathtubs, monitored by nursing staff. There were many conferences and visiting notables. The training Director was a psychoanalyst from New York City.

Year 3 was spent back in Seattle, since I planned to practice there, so in 1960 I was in the combined University of Washington / VA program. Here Dr. Herbert Ripley led us through "The Interpretation of Dreams" by S. Freud. Dr. Thomas Holmes continued an influence on my particular viewpoint due to his emphasis on the effects of stress and the psychophysiologic aspects of all illness. At The VA Hospital on Beacon Hill, I especially remember WW II vets, including one with nightmares associated with Solomon Islands memories. Also I had benefit of supervision by a psychiatrist who drove up from Olympia each week.

Ethical issues are plentiful in a review of these years. The racial segregation in a hospital seems surprising now. In November and December of 1956, I was assigned to a "chronic black female" ward and helped reintegrate these patients into the general ward.
Patients in the mid 1950's were minimally empowered and subjects of an authoritarian but beneficient regime. A distrust of the caregivers developed over the next 15 years and the mega-psychiatric institutions were closed. , Patients found themselves homeless or in prison, while others received care in community mental health clinics, or with private psychiatrists.

In summary, medical ethics were more implicit than explicit in those years, and without formal rules and expectations, there was, e.g., less attention supplied to informed consent, risks/benefits explanations, and restraint monitoring.

This look back to 1955-1961 is presented so that those of you in psychiatric training in 2013 or thereabout can compare these times and ponder about change and the evolution of how mental illness has been treated.
ECP Perspective on Ethics:  "What Is Your Code of Ethics?"
Taylor-Desir photo Monica Taylor-Desir, MD, MPH
Co-Chair, Early Career Psychiatrists Committee
When is the last time you actually pondered your code of ethics? Is it the same as your code of behavior? Does it determine what is right or wrong in your professional environment? Now that you've had a few seconds to think about the above question, what is your response? The Hippocratic Oath? First Do No Harm? Did anyone say The Principles of Medical Ethics of the American Medical Association? Some of you may say, "Wait.... Why would I operate by the AMA's code of ethics? I'm not even a member." Yet, there is a statement on the APA website that says, "All members of the [American Psychiatric] Association shall be bound by the ethical code of the medical profession specifically defined in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry" (http://www.psychiatry.org/practice/ethics).
It is good to know that there are specific annotations for psychiatry. What are the daily ethical issues you face?

My patient just sent me a friend request on Facebook, what do I do?
My patient tells me she is suicidal via e-mail in the middle of the night. What are the rules of e-mail communication with my patient?
Can I accept handmade gifts from my patient?
I practice in a small town, how do avoid dual relationships and what do I do if I am already in one?
Can I practice acupuncture along with my psychiatric practice? 
(Really, It IS in the code of ethics.)

The APA's Ethics Committee is responsible for drafting annotations to update the current Principles of Medical Ethics. The Ethics Committee also responds to members inquiries about ethical issues and provides each District Branch (such as the Arizona Psychiatric Society) ethics committee with educational activities related to ethical issues. The Ethics Committee also monitors the processing of complaints against APA members in accordance with the APA's Procedure for Handling Complaints of Unethical Conduct.  At the District Branch level, the current Arizona Psychiatric Society Ethics Committee members are Dr. Kowalik, as Chair, together with Drs. Potts, Kohlhepp, Reesal, Blum, Carrera, and Victor.  

If you are interested in learning more about the ethical principles that govern our members you can obtain a copy of Opinions of the Ethics Committee on the Principle of Medical Ethics, 2010 available on the Ethics Resources and Standards Page on the APA website. (http://www.psychiatry.org/practice/ethics/resources-standards). You may also purchase the Ethics Primer geared for residents and those teaching ethics or wishing to generate ethical discussions among colleagues. You can purchase this through APPI (www.appi.org).  APA members receive discounted pricing.
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PRMS Updated
Understanding the Physician Payment Sunshine Act - APA Webinars and More
Sunshine Act

Do you partake of the meals or beverages provided by pharmaceutical or medical device manufacturers at medical conferences or CME events? Have manufacturers offered you a "free" medical textbook or dropped off lunches at your medical office? 

While these transactions are not illegal, the Physician Payment Sunshine Act (PPSA) now requires pharmaceutical and medical device manufacturers to report physicians who receive textbooks and most meals, beverages, or other items of value from them to CMS, so that CMS can make the physicians' names and mention of the items they accept public on a CMS website. Regulations implementing the "Sunshine Act" are complex, and the APA encourages members to learn more about the PPSA by participating in one of two PPSA webinars being provided for APA members, as follows:


Upcoming Webinar: APA Physician Payment Sunshine Act

September 12, 2013 

First Webinar: 12 p.m. EDT

Second Webinar: 12 p.m. PDT


During the one hour PPSA webinar, the APA's General Counsel and Deputy Director of Regulatory Affairs will explain the PPSA, including the law's reporting requirements and exclusions, as well as how physicians can monitor the transactions in which they are reported.  There will be an opportunity for Questions and Answers. For more information on how you may be impacted by the Sunshine Act, visit the APA's PPSA webpage at www.psychiatry.org/sunshineact


To Register, please email advocacy@psych.org. Provide your name and APA Member ID.  For a helpful reference, click here to view the APA Brochure on Understanding the PPSA.  

APS Lobbyist Report from the 2012-2013 Legislative Session
RestoreArizona Joseph F. Abate, Esq., APS Lobbyist

For the 2013 Legislative Session, the legislation with the largest impact to health care providers was the Governor's Arizona Health Care Cost Containment System (AHCCCS) expansion proposal.  Following is a summary of HB 2010, adopted in Special Session, relating to Restoring Arizona, together with highlights of other relevant health care legislation adopted in the 2013 Legislative Session.  If you would like any additional information, please contact the APS Lobbyist, Joe Abate, at 602-393-1700.  If you are interested in being a part of the Legislative Committee of APS, co-chaired by Dr. Jack Potts and Dr. Carol Olson, please contact teri@azmed.org.


The legislation with greatest impact to psychiatry are summarized and provided for your information, and include the following:  H2010 Budget; BRB; Health; Welfare; FY2013-2014; H2045: Health Care; Direct Pay; AHCCCS Rates (AHCCCS; Hospital Reimbursement Methodology); H2064: Training Permits; Military Health Professionals; H2065: Community Based Residential Treatment; Placement; H2310: Courts; Evaluation; Mental Health; Report (Escheated Property; Proceeds; Claim); H2327: Dangerous Drugs; Definition; H2393: State Agencies; Licensure; Time Frames; H2409: Medical BD Licensure; Dental BD Exams (Dental Hygienists; Examinations); H2550: Health Insurance; Policies; Rating Areas; H2593: Campaign Finance; Contribution Limit (Tech Correction; Veterans); S1175: Vulnerable Adult; Duty; S1188: Pharmacy Board; S1235: Psychiatric Security Review Board; Continuation; S1341: Vulnerable Adults; Financial Exploitation; S1346: Class Action; Reform (Dangerous Drugs; Analogues; Penalties); S1353: Health Insurance; Telemedicine; S1374: Behavioral Health Examiners Board; S1375: Behavioral Health Services; Dependent Children; and S1443: Marijuana; Postsecondary Education; Medical Research.  
CLICK HERE to read the 2013 Health Care Legislative Report including the summaries of these issues.  


APA Assembly Representative Report from Area VII Assembly
Jehengiar "Jay" B. Bastani, MD, DLFAPA, Arizona APA Assembly Representative
Payam Sadr, MD, Arizona Deputy Assembly Representative

The Area VII Council, comprising of Representatives and Deputy Representatives of the District Branches (DB) of southwestern US and western Canada met in Seattle WA for the weekend of Aug 10-11, 2013. Also present were the MIT and ECP Representatives and Deputy Representatives. After introduction of the guests as well as new members to the Council, the meeting proceeded with the various DB presenting their reports. In this, they shared their uniqueness and the commonality of their problems. 

Western Canada: Since April 2013, their DB has added 60 new members bringing their total to 503. The western chapters that are active are Vancouver, Calgary and Edmonton. Saskatoon and Winnipeg have no chapter presidents at present. With increase in membership, DB finances remains good. They plan to do training for DSM-5 in each chapter as a way of encouraging member participation. There is a shortage of psychiatrists in their provinces & territories. Recently a new hospital was opened in Calgary and a few psychiatrists were employed from Ireland, adult and child psychiatrists. Parity is not an issue as each province and territory has its own fee codes with universal health care. The medical system makes it possible for any person, including the mental health patient, to be served. 

Wyoming: Continues to thrive as the smallest DB in the APA; currently having 25 members. Challenges are of having psychiatrists entering and leaving their state. The lack of defined salaried jobs in their state presents the greatest challenges for recruitment. They have a number of qualified ECP members who have not yet formed an ECP group. Their DB is financially stable with the help of a pending Infrastructure Grant (support their administrative needs) and a lean annual expenditures. They collaborate with the Wyoming Medical Society for administrative service. Their annual meeting in Laramie was held in conjunction with the Wyoming Medical Society, the theme was financial cutbacks and Medicaid changes. Concerning advocacy, they are actively involved in revisions to Involuntary Commitment Statute (Title 25). They face no scope of practice issues.


Alaska: Xerox has taken over the administration of State's Medical Administration and they are dealing with its arbitrariness e.g., EHR documentation is cumbersome and is necessary for re-imbursement. Psychiatrist scarcity is an ongoing concern. DSM-5 training will be in September and the trainees in turn will go out to the remote areas to teach others. Aging psychiatrist population increase is disconcerting.

Colorado - No official report.

Hawaii: Active recruitment has resulted in an increase among younger members. State directed EHR for re-imbursement remains poor. The DB is on Facebook, Blog, and Twitter and has a Listserv. They plan a dues increase to $250 annually. They hold social events periodically for members and non-members. The University of Hawaii in Hilo is a Trojan horse for a Master's degree in psychopharmacology prescribing.

Idaho: They are planning to combine DSM-5 training with a membership recruitment effort by offering training at several sites around the state. Although they have 116 licensed psychiatrists in state, only 50 are DB members. Their new Executive Director, Margy Leach, works with Idaho Medical Association. Finances are stable with the APA's Membership recruitment and an Infrastructure grant. Their legislature has amended state commitment law where mid-levels can place psychiatric holds. Idaho Psychiatric Residency Program received increase in funding from 2013 legislative session. OPTUM will administer their Medicaid Behavioral Health Outpatient plan. 

Montana: No report.

Nevada: Membership remains stable and DB will secure the services of a part-time staff person in Las Vegas to give a local presence to their DB. Financially, remain solvent due to income derived from Psychopharmacology course. Nurse practitioners were granted independent prescribing privileges by Legislature. Their DB held two successful DSM-5 trainings together with the psychologists in Nevada. The major problem in public sector mental health is funding and leadership. Concern re: "Greyhound discharge planning" has received wide attention. It is getting hard to find young psychiatrists to go into private practice. State employed physicians feel they have inadequate voices in driving care. A UNLV PhD student will do a project on Branding, trying to make their DB more attractive to young members. Seems this is common problem in all kinds of organizations. One of the ways to help is to enroll members early in careers and demonstrate the benefits of the organization to them. It will be interesting to see if this brings results over the next couple of years.

Oregon: Their DB has a new executive director and lobbyist. DB has formalized fiscal control policy; consolidated funds into one bank, use centralized billing, begun work on a new website, and are considering changing their name to "Oregon Psychiatric Physicians Association." They had an ethics complaint against a member, was resolved via an educational option. Their OPAL K program was funded. It is a child psychiatry access line, details on http://oregonpediatricsociety.org/programs/ops-programs/opalk. Their Scope of Practice bill (HB2902) passed which pays Nurse Practitioners and PA's the same as physicians and sunsets in 2018. There will be a task force to look at better solutions and an advisory panel for this consisting of only psychiatrists, primary care and nurse practitioners. Civil commitment bill (SB 421) passed, allowing district attorneys to use the civil commitment laws to create a preventative detention scheme, which can be used for those, deemed "extremely dangerous." The way designed, it will potentially result in people who are subject to lifelong preventative detention while others who have committed the same crime are not. It has their Psychiatric Security Review Board which manages individual found criminal but insane (a legal process), not civil commitment (a medical process) to manage those who are civilly committed under this new law and requires them to parse out who is "extremely dangerous" versus "substantially dangerous." 

New Mexico: In June 2013, an independent audit reported over the past three years, $36 million in overpayments to 15 New Mexico Medicaid's behavioral health provider companies. The audit also turned up possible fraud, and the data was turned over to the State Attorney General's office for a criminal investigation. New Mexico Medicaid Mental Health Services are in a Behavioral Health Collaborative managed under a billion-dollar contract to Optum Health (whose parent company is United Health). Some alleged abuses and excesses include $1.5 million paid annually to a CEO and family members of one nonprofit. Another company bought services and rented space from a firm partially owned by its own CEO and COO. The temporary "fix" implemented by the governor involves spending $18 million on consultants from Arizona who will come in to provide training and oversight. Their State is withholding details of the audit, with the justification that they are now part of a criminal investigation. Medicaid funding was abruptly cut off to the 15 nonprofit provider companies, serving 80,000 patients in New Mexico with resultant major disruption in services.

Utah: Optum Healthcare (Medicaid provider) have not paid for services in several months; continue automatic Peer reviews on the Day 3 and 6 of hospital stays; show up on the unit to interview patients who make their own diagnostic decisions; control admission (not allowing currently) and discharge from the Utah State Hospital and will not pay for second generation depot injections for inpatients. Legislative issues are APRN interns being able to prescribe while completing hours in psychiatry; "Applied Behavior Analyst" can make diagnosis and/or treat Autism; HJR38 allows physicians to say "I am sorry" without it being used against them in court and a "Prompt pay" legislation requiring insurance to pay within 30 days of receiving the provider claim.

Member-In-Training: The MIT Center was a pilot project at the 2013 Annual Meeting and well attended. The APA Board of Trustees (BOT) supported the MIT Center for NYC in 2014. In order to facilitate communication, networking, and peer-to-peer recruitment (core elements of the MIT/ECP membership engagement and retention strategy,) the APA BOT is developing and potentially piloting a social networking forum targeted at this group. In addition, they have adopted an MIT/ECP advisory panel to inform APA staff on new initiatives. The BOT also approved additional staff FTE dedicated to work with MIT/ECPs on topical/novel initiatives with a fund of $25K to support such efforts. They continue to have monthly discussion topics on ACOM conferences.

ECP: ECP committee continues to meet monthly via teleconference. The APA MIT/ECP social night at the May 2013 annual meeting in San Francisco was well received. The APA will be sponsoring this evening again, to be held on May 5, 2014 in New York City and encourages ECPs/MITs to save the date. The "ECP transition to Practice" workshop at the 2013 Annual meeting was well attended and will be offered again next year. ECP committee plans to draft an action paper relating to Caregivers for the November 2013 assembly meeting and Josh Sonkiss MD of Alaska will lead this paper. 

Join the Disaster Psychiatry Task Force!
Dr. Jay Bastani has agreed to lead a Task Force in connection with preparing a Disaster Psychiatry Plan for the Arizona District Branch.  If you are interested in contributing to this important and timely effort, please contact Teri (602-347-6903, teri@azmed.org).  
MIT Event:  Fall Mixer Set for September 14, 2013
Thanks to the coordinated efforts from all of the Arizona psychiatric residency programs, as represented by Dr. Felicitas Koster, Member-in-Training Representative, and MIT Committee Members, Drs. Matthew Goldenberg, Suzanne Tariot-Sheard, Jason Curry, and Elisa Gumm, the date for a Fall Mixer has been established.  All psychiatric residents, members and non-members alike, are invited to attend:

Fall Mixer for Members-in-Training
Saturday, September 14, 2013
4:30 to 6:30 pm
The Vig Uptown (North of Bethany Home Road on 16th Street)

If you have questions regarding the event or wish to RSVP, please contact Teri (teri@azmed.org) or your psychiatric program member listed above.  Safe travels to all!
Eli W. Lane Memorial Master Workshop (and Primer), and Legal Competency Training
Eli Lane

Eli W. Lane Memorial Master Workshop 

Neuroscience and Psychoanalysis Converge:  Implications for Treatment


Mark Solms, Ph.D.

Sunday, November 3, 2013,  9:00am-4:00pm

Registration from 8:30-9:00am

at Hacienda del Sol Guest Ranch Resort 

5501 N. Hacienda del Sol Rd., Tucson, Arizona


Back by popular demand following his presentation in November 2012, Dr. Solms will continue the discussion of the integration of psychoanalytic and neurobiological perspectives. In this Master Workshop, Dr. Solms will review advances in affective neuroscience and the neurobiological basis of attachment/separation, fear/anxiety, rage, nurturance/care, and play. He will then demonstrate, using clinical case material, how these advances in neurobiology influence how therapists conduct psychodynamic treatment.  Visit http://swpsychoanalytic.org/web/events/upcoming/ for more information on upcoming events, including the following primer event for the Eli W. Lane Memorial Master Workshop:


A Primer on the Brain, Emotions and Emotional Disorders
Presented by: Ryan Smith, M.S.
Discussant: Richard Lane, M.D., Ph.D.
Thursday, October 24, 2013, 7:00-9:00 pm (Registration from 6:45-7:00 pm)
at the Pima County Medical Society, Tucson, Arizona




The Legal Comp Training AZ Arizona Supreme Court will once again host the Legal Competency and Restoration Conference for Mental Health Professionals on November 18-20, 2013 at the Judicial Education Center located at 541 E. Van Buren, Suite B4 in Phoenix, Arizona (located on the ASU Downtown Mercado campus).

Arizona law restricts the performance of court-ordered competency evaluations in criminal and juvenile cases to mental health experts who are approved by the court under court-developed guidelines. This program is designed for licensed Arizona physicians and licensed Arizona psychologists with forensic experience who seek to become court-approved evaluators in criminal and juvenile cases. Faculty include judges and mental health experts from throughout Arizona. The program provides 17.00 hours of continuing education for adult competency and restoration, and 4.50 hours for juvenile competency matters. Evaluators currently on a court-approved list are encouraged to attend and may be required by a local court to attend as part of the requirements to remain on the approved list. Attendance at this program does not guarantee placement on the court-approved list of evaluators.

To register, visit http://2013legalcompetencyrestoration-es2.eventbrite.com/ 

For more information, go to http://www.azcourts.gov/educationservices/MentalHealth.aspx
to view the conference brochure and agenda.  

Fall Business Meeting and the APA, Winter Social and "What You Do If?" Audience-Interactive Malpractice Program
In October, the Society is finalizing the details for Fall business meetings and member socials, in each of Phoenix and Tucson, featuring a joint presentation on advocacy and healthcare reforms (including the Physician Payment Sunshine Act) by Janice Brannon, Deputy Director, State Affairs, and Julie Clements, Deputy Director, Regulatory Affairs, from the American Psychiatric Association. Look for sign-up information coming to you soon.  Targeted dates are October 21 and 22, 2013.

For the Winter Social, a social and audience-interactive malpractice program, "What Would You Do If," is being targeted for mid-January to early February.  Dates for each of Phoenix and Tucson are being developed, and we will be in touch with the membership as soon as the details are set.  
Sandra Day O'Connor College of Law Conference - November 22, 2013
"Before the Shooting Starts:  Predicting and Preventing Rampage Killings," as the fifth in a series of biennial conferences on brain science and the law, will bring together many of the nation's leading researchers, thinkers, and practitioners from a variety of disciplines and perspectives to discuss the factors (psychological, social, environmental, genetic) that lead to rampage killings, the ability of science to predict such violence, and possible treatment or prevention strategies.  The conference is free (pre-registration requested).  Up to 6 hours of CLE credit is available for a fee.  For more information, visit the ASU College of Law website.  
APA Resources for You:  DSM-5; Keep the Benefits of Membership - Reinstate Today!
DSM-5 banner
Additional information and reference materials on DSM-5 are available to the general public online at http://www.psychiatry.org/practice/dsm/dsm5. On this page, you will find links to articles in Psychiatric News, fact sheets, and videos that explain the new organization and features of the DSM-5 and the diagnostic differences between DSM-IV-TR and DSM-5. From this webpage, you can view the DSM-5 Table of Contents; view and download online assessment measures; learn more about the insurance implications of DSM-5; and watch the DSM-5 Press Briefing at the APA Annual Meeting in San Francisco, May 18, 2013. Please check this webpage frequently for updated information.

Additional CME opportunities on DSM-5 are available at http://www.apaeducation.org, including the online version of the DSM-5: What You Need to Know Master Course from the 2013 APA Annual Meeting in San Francisco. The online version is available at a discounted rate for APA members and comes complete with slide handouts and DSM-5 fact sheets. Earn up to 6 AMA PRA Category 1 CME Credits™ for Physicians or Certificate of Attendance (coming soon, the online course for psychologists, social workers, certified counselors, addiction counselors and registered nurses, offering CE credits). 




The deadline for paying current-year APA membership due passed on June 30. Members whose dues were unpaid on that date have lapsed in membership, but can still be administratively reinstated by bringing dues current.  Contact the Arizona administrative office (teri@azmed.org, 602-347-6903) or the Arizona APA Membership Coordinator, Jovellyn Olivar (jolivar@psych.org, direct line: 703-907-7365).  

If your e-mail or mailing address have recently changed, please contact Teri Harnisch (teri@azmed.org, or 602-347-6903) to update the same.  

If you are interested in contributing an article to the Newsletter or have a topic that you would like addressed, please contact us.  The inset photograph for the Fall Newsletter is the view from Navajo Bridge.  If you have a personal photograph from an Arizona destination, or a photograph from an APS member event, that you are willing to submit for future Newsletters, please e-mail the same to teri@azmed.org.  

We hope to see you at the Fall meeting and social--more details to follow.   

APS Newsletter Committee:  Robin Reesal, MD, Chair; Elizabeth Kohlhepp, MD, DFAPA; and Gretchen Alexander, MD.