Presidents Column

Psychiatric Practice in 21 st century – Challenges and Opportunities for IAPP
11th Annual National Conference of IAGMH, GERON 2015, Presidential Address

Changing scientific, technological, social, and financial pressures are likely to significantly alter psychiatric practice in the 21st century. Significant effort will be required to keep pace with contemporary trends. The silver lining is substantial professional rewards.

Psychiatric Services : Peep into the Future

Although some psychiatric practices will retain the status of small scale enterprise, individual office, independent-practice model, public, nonprofit, and private systems of care, as well as larger individual and group practices, will align practice patterns with affordability, affability, accessibility and accountability. Under oppressive financial, social, technological and scientific pressures, systems of care and practice that optimize these core values are likely to taste success.

Individual patients are becoming more informed and selective consumers. Contemporary media, the Internet, and direct-to-consumer advertising by pharmaceutical companies and healthcare systems have educated the general public's demands. The advertisements of Revital and zero addiction are example of such trends. Many Indians now routinely research health information online. Patients atleast in metros routinely google disorders, treatments, and clinicians.

Academic Tertiary Service Providers : The Future?

Academic centres like NIMHANS feature complicated organizational structures, complex political agendas, individuals working at cross purpose and rocked by internal and external pressures. Once audits are performed on costs and returns, unrestricted funding will be a thing of the past and academic tertiary centres will require self sustainability models like in US today.

Are Our Institutions Training Psychiatrists For The 21st Century?

Residency training does not accommodate to practice patterns shaped by multiple external and internal challenges. The average practitioner learns on the job combining intuition and pragmatism into a heady cocktail.

The New Age Competition

So, who might compete with tomorrow's academic psychiatric departments? Consider how the following missions might potentially be conducted efficiently and cost-effectively:

Clinical services:

The evolving National Mental Health Policy and the National Mental Health Program envisages programs designed to manage psychiatric and medical comorbidities in primary care health centres. Primary care doctors or doctors as rural health practitioners with mental health professionals located in the vicinity might provide both psychiatric and medical care.

Disorder-centric models of care, including disease-management programs conducted by large pharmaceutical companies which have played a major role in development of atleast some guidelines, may well enlarge if market economic rules are met. Telephone and web-based monitoring and intervention programs for depression and anxiety have been shown to be viable and effective. Measurement-based disease-management care will progress as even chronically ill psychiatric patients increasingly use computer-based tools in waiting rooms to rate their clinical status before office appointments.

Further affecting clinical services, consider the potential impacts of remote site consultation and treatment using telephone, videophone, e-mail, and Internet; that is, instantaneous global communication: “anyone, anywhere, 24/7.” Consultants can help every remote-dwelling practitioner diagnose and treat local patients. SKPE like interactions have already begun across the world.

Training: Almost anything that can be taught in a classroom can now be taught through web-based, distance-learning, permitting great latitude regarding where teaching programs originate and are transacted. Medical students routinely use you tube videos to download neuroanatomical slides, pathological specimens are captured by smart phones and what sapped. Tele psychiatry is practical and feasible.

“24/7”environments offer students educational programming to custom fit their temporal needs: evenings, nights, weekends, summers, part-time. Yesterday a past president of IAPP asked me to conduct online CMEs 24/7 through the web portal of IAPP.

Clinical research: Effectiveness studies or real world studies conducted outside the portals of hallowed universities are fast competing with revered efficacy studies. Pharmaceutical companies increasingly prefer time-efficient private IECs over Institutional Review Boards.

Increasing distrust in academic centres regarding Pharma might become counter productive with the brighter clinical researcher-teacher preferring the private sector in both practice and corporate position.

Exciting New Ways Scientific Advancements Might Shape Practice

A private practitioner from Punjab churns out one you tube lesson on mental health every week. One among us here has his own studio for media training.

Virtual reality technologies combined with game simulations would lead to standardized CBT being administered to large number of clients simultaneously, brief psychotherapies with virtual therapist packaged with nicotine gum/ patch offered as an option to those seeking freedom from nicotine.

Electronic compliance of drug delivery with 100% adherence, robotics in handling violent patients, 24/ 7 survelliance of substance abuser, relapse signature sensing electronic monitors might change disease outcomes in unrecognizable ways.

Role Definition of the Psychiatrist

There is no single role definition for tomorrow's psychiatrist. Future senior resident psychiatrists are likely to diversify increasingly into a proliferating array of subspecialty positions via formal fellowships leading to added qualifications/board certifications.

Exciting new areas of specialization

Contemporary market needs, galloping scientific and technological advances are likely to generate new niche areas of specialization. Informatics psychiatrists might emerge dealing with web disease management programs through EMRs.

Some among us trained in gaming might generate web based programs on PTSD, OCD and phobias.

At the World Biological Conference we are showcasing next year, there is a complete half day session on neuro imaging. Two years ago we flew in the pioneers for Deep Brain Stimulation. Neuro radiology and nuclear medicine fellowships for psychiatrists might be the new frontier. Intervention psychiatrists for DBS, gene therapy might be modern labels some will choose to aspire to.

Yesterday the chief guest called some among us (rightfully so), drug pushers, fashionable derogatory terms from the internet highway. Add up epigenetics, personalized medicine, cognitive enhancers, designer customized drug pellets with novel delivery applications and hey presto, the new age aesthetic psychopharmacologist is born.

We are familiar with fusion music and fusion food. Welcome to fusion psychiatrist who will purport to carry law and management degrees to combat increasingly assertive and irrational pressures of the regulatory bodies.

Ambulance chasers and commodities trading are dirty words in our lexicon. The sexily named tornados, cyclones earthquakes which continue to overwhelm our shorelines will see govt outsourcing disaster management to private sector with psychiatrists bringing corporate order to psychological interventions in disaster.

Psychiatric beds will become hi tech and expensive. These beds quite like hotel rooms will require decent occupancy standards to maintain. Our blessed land celebrates throughout the year albeit in different pockets. Onam in Kerala with low occupancy might see patients being shifted from expensive Varanasi with attractive discounted packages. Beds pricing like airline fares, might be the new trading area.

The Challenge, the Risk and the Opportunity for IAPP:

The shiny new exciting 21st century psychiatrist striding across modern India hides an ugly reality. It is quite akin to the spotless, futuristic designed city of Shanghai and the tenements outside city limits or the charming heritage structures around the river Nile for tourist consumption and the dirty, dusty bazaars of Egypt. Cut practice, drug pushing, non evidence based treatments, wanton flouting of minimalistic guidelines continue to pockmark our psychiatric landscape. Neurologists, gastroenterologists, endocrinologists, paediatricians carry out attrition marked territorial battles, constantly.

This psychiatrist in private purports to carry 70% of the service burden of mental health delivery in our country. Our constitutional fathers in clause 3.1 d and 3.10 seek to empower the psychiatrist in private practice to rise up to the modern day challenges.

One strategy or niti is to go global.

Benchmark ourselves with the best and see our standards rise as we force ourselves up. Large charitable hospitals armed with NHAI accreditation painfully follow industry standards of electronic record keeping, human resource management, new age informatics shedding large amounts of human and material deadwood.

Why IAPP?

When we google for association of private psychiatry throughout the world, we learn that in America and Japan there is some activity but no organized effort. Only IAPP figures very prominently.The WPA has a Section on Private Practice established in 1997 and permanent status approval in 1999. The link to the website of this section is under development. Nominated positions. Nothing happening.

The mission statement worthy of emulation is ‘Organize a global network of practitioners dedicated to the daily care of the mentally ill and promote and preserve the essential values that characterize the spirit and ethics of private practice.

The section goals are:

The National Advisory Board has now empowered us to go truly global. We have bought the URL www.globepsych.com,net,info,org . We intend to encourage organization of mental health practitioners in private practice in all countries throughout the world. This global federation of societies led by the IAPP with prime mover advantage will help shape the practice in private space.

We have many firsts to our credit. Our soon to be patented ‘Art Of Psychiatry’ is an innovative, one of its kind program which we intend to showcase. Our open house session, interface with pharma, workshop peppered initiatives are aligned to become global initiatives. Akin to the large charitable hospital transforming itself to a lean , mean corporate hospital with deadwood being discarded, we need to carry out this leap of faith.

We at IAPP intend to metamorphose into a lean, mean structure by intelligent delegation, evolution of contemporary vision and mission statements, more nuanced approach to contemporary realities and evolve into global leaders.

We are dreaming big. But these are exciting times.

Young psychiatrists from large govt hospitals are exiting and using sharp marketing skills honed by the collective wisdom of families to innovative systems of mental health delivery. Our elderly colleagues with tons of collective wisdom need to be tapped by open enquiring minds.

Darwinian realities confront us today. We need to survive. For survival we need to evolve. For evolution we need to consolidate inner strength by benchmarking IAPP to global standards and stare deep and hard outward, go global. Empower the practitioner in private practice who stands befuddled with regulatory pressures, new laws each year, label of being mercenary to the status of service providers with consolidation of our core values of honesty and compassionate care to our patients.