Advocacy: A Maturing Profession

Over the years, the annual Practice Directorate State Leadership Conference has, without question, been the highlight of my involvement within the APA governance. This year’s conference, Strategic Resilience For The Profession – Getting A Jump On Change, was equally outstanding. Mike Sullivan announced that with 580 attendees it was the largest ever. 2004 is a Presidential election year and the stellar presentations by Paul Begala, James Carville, and Tucker Carlson of CNN’s “Crossfire” left no doubt in anyone’s mind that we will have an “interesting” Fall. APA President-Elect Ron Levant and I kept reflecting upon how far Russ has taken professional psychology. The substantive presentations, for example – Evidence-Based Practice [standing room only]; Mobility Update: How Are The Mobility Mechanisms Working?; and Where Is The Health System Headed -- provided an insightful practice-oriented appreciation for the magnitude of change forthcoming in the 21st Century. For those interested in the prescriptive authority (RxP-) agenda, the first hand accounts by four Department of Defense (DoD) graduates regarding How Prescribing Has Changed Our Clinical Practice was refreshing and highly reassuring. Former APA and Division 42 President Stan Graham received the APA Practice Organization Special Citation for his decades of service to the profession. Ron and I were also impressed by the extent to which individual psychologists have become increasingly involved in the public policy process, being elected to state and federal legislative office; not to mention being appointed to cabinet-level positions. Three Members of Congress attended Monday night’s dinner event at the request of their own state’s psychological association. Chester Copemann promised to bring the Virgin Islands’ Representative next year. We truly have come a very long way in a relatively short period of time. Psychology is a maturing and bonafide health care profession. For those who have never had the opportunity to participate in this exciting conference, I would urge you to become more actively involved in your own State Psychological Association governance. It is truly a rewarding experience.

Over the years, Russ and Mike have consistently stressed: the importance of personal involvement in the public policy/political process, the importance of persistence, and the absolute necessity of possessing a long term vision for what is to be accomplished. During the conference, we were informed that significant progress has been made in implementing New Mexico’s 2002 landmark RxP- legislation. Earlier Mario Marquez provided an update for this column:

“When the New Mexico Legislature passed HB-170 in February, 2002 and the Governor signed it into law in March, the statute was turned over to the Psychology and Medical Examining Boards for implementation and regulation. A joint committee was appointed to make recommendations to the Boards regarding rules and regulations. The joint committee began work in March, 2002 and concluded its work in August, 2003. During the 17 months of the committees’ existence, its composition changed several times.

“At the outset, we expressed concern over the make-up of the joint committee. Our major complaints were that the committee was not balanced and over-represented with psychiatrists from the University of New Mexico Health Sciences Center, professionals from the University of New Mexico, and residents of Albuquerque. In particular, it was difficult for us to comprehend how our primary opponents managed to get so many members on the joint committee (three psychiatrists from UNM-HSC); whereas, there was not a single psychologist proponent trained in psychopharmacology, or involved in the legislative process on the committee.

“When we did not obtain a satisfactory response from the Boards, we appealed to the Legislature. In September, 2002 we testified before the Health and Human Services Legislative Interim Committee. The Committee expressed astonishment, disappointment, and regret regarding the constitution of the joint committee. Ultimately, however, this did not matter very much due to the outcome of the joint committees’ work which resulted in three different proposals: a majority report, a minority report, and a report submitted as an addendum to the minutes from the New Mexico Psychological Association.

“In October, 2003 the Chair of the Psychology Board appointed an ad hoc committee to review the work of the joint committee and make recommendations. The ad hoc committee used the majority report of the joint committee and modified it where appropriate to bring it more in line with the statute. In November, the document was submitted to the Psychology Board, adopted, and forwarded to the Medical Board for its approval. Instead the Medical Board proposed a conference committee.

“In January, 2004 we once again appealed to the New Mexico Legislature. Our Representative sponsor and Chair of the Health and Human Services Interim Committee submitted a stern letter to the Medical Board insisting that the prescribing psychologists law be implemented. Within a couple of weeks the conference committee reached an agreement. On February 20, 2004 the Medical Board unanimously approved the draft set of rules and regulations. The Psychology Board will be meeting in March, 2004 and it is anticipated they will also approve the draft. [At State Leadership, we learned that they did.] Following approval by both Boards and the New Mexico Attorney General’s Office, public hearing will be scheduled. Assuredly, we will continue to battle to the very end to ensure fair and objective rules and regulations for the implementation and regulation of the Prescribing Psychologists’ Act in New Mexico.”

Our sincerest congratulations to Mario and Elaine LeVine for their legislative success; and to Julie Lockwood and Tom Sims for their impressive efforts during the implementation process. Mahalo.

The Future Is APAGS: Ron and I were also quite pleased with the visibility of APAGS (the Committee for the American Psychological Association of Graduate Students) at the conference. At the public policy level, it soon becomes evident that the success of any profession relies upon the active involvement of its future generations, often far more than senior practitioners might appreciate. Rebecca Kayo, currently a postdoctoral fellow, provides a first hand glimpse of how lonely or exciting that role can be.

“I was very recently reminded (more like hit over the head) of not only how important our work is but also how special each and every one of you [RxP- advocates] is. Each of you is willing to courageously fight for what you believe in, to have the increasingly rare open mind, and to take the often needed calculated risks. You seek out the future with eagerness while also being aware of the past. There are too many of us who sit on the sidelines and do nothing or who close our mind to what can be or to what is fair. One of the examples I can share is a recent meeting regarding my fellowship. Briefly, during the meeting (which consists of psychologists and psychiatrists) I had asked to be allowed a minor rotation in advocacy. Discussion ensued, although there were other things shared the psychiatrists made it clear that I would never be allowed to fight for a bill such as RxP- for psychologists while any psychiatrist fellow would be allowed to fight against such a bill if it came forth. There was no one in the room who addressed this issue. Given my position, I clearly just stated that while I may have to abide by the fellowship rules under the fellow name, what I did as an individual is separate and mine to do with as I please. The discussion soon ended.

“So needless to say once again I have grown in my warm appreciation for you all. Because of the special qualities that you all possess and the importance of RxP-, it is vitally important that our psychology students be connected to you. As the Division 55 [American Society for the Advancement of Pharmacotherapy] Student Liaison, I would like to begin to create this bridge between students and mentors in RxP-. More specifically, I would like to ask for all those psychologists who are interested in being a student RxP- mentor. A minimum of one is needed in each state. Below is a list of possible mentor duties:

“1. Providing any missing RxP- education to the student (e.g., pros and con arguments, history of RxP-, relevant articles).... 2. Engaging the student in any RxP- legislative activity in your state. At any level that your state is involved, whether it is just currently a discussion or an actual bill is being introduced, the students could benefit from being involved. Similarly, RxP- would benefit from having them involved. The process may also include helping students understand the legislative process and/or the ins and outs of being an advocate. Part of helping the next generation get involved is to acknowledge that we need future advocates. This knowledge and skill is something that they would never learn in school. This will only be taught by hands on training in the real world. [And,] 3. Helping the students educate or engage other students. When and if the student becomes interested in creating a state student RxP- discussion group or reaching out to other students in general, they would benefit from a mentor’s experience in reaching and engaging others....”

Senior members of Division 42 should learn from Rebecca’s vision. It is time to be proactive and as Russ indicated: Get A Jump On Change.

A New Political Agenda – Inclusion In Pediatric GME: Those who specialize in providing care to our nation’s children appreciate the extent to which “kids are not merely little adults.” They have unique needs and strengths which oftentimes, unfortunately, get overlooked in adult-oriented health care initiatives or research projects, notwithstanding the good intentions of those professionals involved. During my tenure on the APA Board Directors, Gerry Koocher was a consistent voice for this oftentimes vulnerable population. On December 1, 1999 then-First Lady Hillary Rodham Clinton stated:

“Ask any young parent whom they turn to first with questions and concerns about their children, and they’re likely to answer, ‘The pediatrician.’ When our children are young, many of us call the pediatrician at the first sign of a sniffle. We rely on them to calm our anxieties about the full range of complaints – from colic to chicken pox, bronchitis to boyfriends.

“Last month, with overwhelming bipartisan support, Congress passed the Children’s Hospitals Education and Research Act. Introduced by Congresswoman Nancy Johnson of Connecticut, and Senator Bob Kerrey of Nebraska, the bill will provide long overdue financial support to the very institutions – the children’s medical centers and teaching hospitals – that are the most important training facilities for our children’s doctors.

“In an increasingly competitive health-care market, dominated by managed care, teaching hospitals struggle to cover the significant costs associated with training and research. While other teaching hospitals receive support for these costs through Medicare [GME], children’s hospitals receive virtually no federal funds, even though they train 30 percent of the nation’s pediatricians and nearly 50 percent of all pediatric specialists. In many cases, they provide the regional safety net for children, regardless of medical or economic need, and they are the major centers of research on children’s health problems.

“Millions of American children each year are treated by physicians affiliated with or trained in one of 60 independent children’s hospitals across the country. As I have traveled around the country over the past 25 years, I have had the opportunity to become acquainted with the valuable services many of them provide....

“Earlier this year, I invited a group of senior children’s hospital administrators to the White House to discuss the burdensome costs of graduate medical education. A typical independent children’s teaching hospital receives less than 1/200th, or .005 percent, of the Medicare graduate medical education support that other teaching hospitals receive. This inequity is only exacerbated by the fact that these centers face the additional costs of serving the poorest, sickest and most vulnerable children, as well as conducting research that benefits all children.

“That day, I was pleased to announce that, in order to address this issue, the President would earmark $40 million in his FY2000 budget plan to provide federal financing of graduate medical education for freestanding children’s hospitals. On average, hospitals could receive nearly $10,000 per resident, or almost $700,000 for each facility. We worked tirelessly to win these funds, and were extremely pleased that Congress authorized them in the budget agreement.

“When the President signs the Children’s Hospitals Education and Research Act, we will have taken an important first step towards putting children’s teaching hospitals on an even footing with other medical education centers – a critical investment in a healthy future for all our children.”

[It soon became Public Law 106-310].

The Administration’s FY2005 budget justification requested $303,258,000 for the Children’s Hospital Graduate Medical Education (CHGME) program. The initiative:

“(A)ddresses the need for funds beyond patient revenues to support the broad teaching mission of freestanding children’s teaching hospitals, which includes conducting biomedical research, training health professionals, providing rare and highly specialized clinical services, including clinical care, and providing care to the poor and the underserved.... In FY2001, the CHGME PP supported the training of 4,429 medical residents in 59 freestanding children’s teaching hospitals.... This support averaged about $77,000 per resident.... On average, freestanding acute care children’s hospitals report devoting nearly half of their patient care to children who are assisted by public assistance (Medicaid, Medicare, SCHIP) and uninsured patients. In addition, these hospitals are regional and national referral centers for very sick children, often serving as the only source of care for many critical pediatric services.... The CHGME PP support for training of resident physicians represents an investment in the future of the pediatric workforce, because these hospitals train nearly 30 percent of the Nation’s pediatricians, nearly half of the Nation’s pediatric subspecialists, and the majority of selected pediatric specialists. These are the physicians who will care for America’s youngest population – its children.”

As the Congress begins its deliberations on the President’s FY2005 budget request, Senators Bond, Kennedy, DeWine, and Murray have taken the lead in urging the Senate Appropriations Committee to continue to make graduate medical education funding for our nation’s independent children’s teaching hospitals a high priority.

“With your continuing support, Congress once again provided equitable graduate medical education funding for our nation’s independent teaching hospitals for fiscal year 2004. The $303 million appropriated... will assure that these hospitals receive federal funding for their teaching programs similar to that all other teaching hospitals receive through Medicare. This year, for the first time, the President has included full funding for the CHGME program, at the fiscal year 2004 level, in his budget proposal for fiscal year 2005. We are gratified by the Administration’s expression of support for the program and the recognition that this program serves a clear and valuable purpose. We respectfully urge you to continue equitable GME support for our children’s hospitals as you consider appropriations for the coming fiscal year. We recognize the serious challenges that you will face in balancing spending priorities with limited resources.... The CHGME program has been a remarkable success. It has stemmed reductions in the number of pediatric residents, specifically in pediatric subspecialty areas, many of which are experiencing serious shortages.... The need for equitable Children’s Hospital GME funding is as great as ever today.”

And yet, support for psychology is not authorized under this program. Do we not have meaningful services and expertise to offer? We should seek to have pediatric psychology recognized.

The underlying policy question for professional psychology is whether we truly believe that our clinical and scientific expertise can made a difference in the lives of our nation’s children and their families. During my APA Presidency, President-Elect Norine Johnson and then-Board Member Ron Levant participated in a White House conference addressing the use of psychotropic medications with children. There is no question in my mind that our behavioral-psychosocial-cultural expertise should be an integral component of this important clinical debate. Late last year, the Food and Drug Administration issued a public health advisory urging doctors to be especially careful in prescribing antidepressants to children and adolescents, due to a possible association between the drugs and suicide. After an expert advisory committee hearing early this year, the little ApA’s witness reported that: “Hearings like this frighten parents and make it less likely they will bring their kids in for treatment.” Professionally, we do have a different perspective than medicine. At the State Leadership conference the DoD prescribing psychologists definitely did. And, Native Hawaiian psychologist John Myhre reports: “My own data base is now approaching 5000 patient visits seen and/or supervised by me. Two thirds of my patients are on meds, and we are still getting people into remission or recovery in under four visits for most folks.” Aloha.

Pat DeLeon is a former APA President.

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