The "Rapid Onset Gender Dysphoria" Controversy at AACAP's Annual Meeting

Last month, when I saw the program for the Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), my professional society, there was one session that caught my eye. It featured a presentation by Lisa Littman, MD, MPH titled “Peer Group and Social Media Influences in Adolescent and Young-Adult Rapid-Onset Gender Dysphoria.” In case you’re not familiar with the term “rapid-onset gender dysphoria” (ROGD), it exploded into prominence and controversy in August following the publication of a paper by Dr. Littman reporting data from parents who claim their children started to identify as transgender after being exposed to some form of online influence, social trend amongst their friend group, and/or acute stressor.

This story has been covered extensively in publications like Science and Slate, but in short, the response to this paper was rapid and highly polarized, with the transgender community generally condemning it as flawed and transphobic, while others rushed to defend Dr. Littman from “ideologically-based attempts to squelch controversial research evidence.”

I’ve attended several previous AACAP meetings, where educational sessions tend to have a staid consistency: An academic child psychiatrist or psychologist presents a topic related to their research or clinical area of expertise, there is polite applause at the end, followed by a fairly mundane Q&A in which audience members either praise the speaker and/or talk about how the presentation relates to their own clinical experiences. You may not be surprised to learn that what happened following Dr. Littman’s presentation was very different.

For her presentation, Dr. Littman started by summarizing research from the past decade showing that the age of those presenting to gender clinics as transgender have become older (i.e. adolescents as opposed to pre-pubescent children), with a higher proportion being female-at-birth than male-at-birth, which is the opposite of the previous historical pattern. Dr. Littman noted that around 2015, parents of some transgender teens started reporting on online forums that their teens’ transgender identification seemed to arise in the context of belonging to a peer group in which multiple members came out as transgender around the same time, as well as adopting other behaviors like binge watching of transition videos online.

According to Dr. Littman, this raised the concern that there many be social contagion occurring, and she specifically cited the example of online websites with “pro-ana” or “thinspiration” themes that encourage anorexic behavior. Her study started in 2016 with a Surveymonkey survey that was shared with parents who frequented forums where they shared their experiences of their teens’ “rapid-onset gender dysphoria.” Although Dr. Littman noted that ROGD is a term used by some parents and clinicians but is not an official diagnosis, she did not show much skepticism about the concept, basically accepting it as valid and deserving of research.

Her study, based on the responses of 256 parents who claimed their teens had ROGD, found that in 2/3 of these cases, those teens were part of a social group in which at least one other friend came out as transgender, and in an astounding 36.8% of the cases, the majority of the friend group came to identify as transgender. Also, 80% of the cases reportedly had zero symptoms of DSM-5 Gender Dysphoria before identifying as transgender, 62% had a prior psychiatric diagnosis, 45% had non-suicidal self-injurious behavior, and 58% were described as being easily overwhelmed by strong emotions. Dr. Littman put forth the hypothesis that the youths described in her study are adopting a transgender identity as a maladaptive way of coping, and she provided some example cases that parents shared, such as teens who began to identify as transgender after experiencing sexual assault, school failure, or bullying based on their appearance. In conclusion, Dr. Littman stated that more research is needed on ROGD, and that in future studies, she hopes to involve the transgender youth themselves rather than just their parents.

Following Dr. Littman’s presentation, there was no applause before several audience members launched into questions. Some were more civil than others, but pretty much all were critical. One audience member pointedly asked Dr. Littman what she had previously studied in her research (OB-Gyn public health issues), and whether she has worked with any transgender patients in the past (she has not), before concluding by telling Dr. Littman that she was not qualified to do this kind of research. Another questioner at the end repeatedly asked her “why did you do this study” and “what’s wrong with taking on a different gender identity,” to which she would only say that we should keep open the possibility that there may be social contagion occurring, as with her anorexia example earlier. The questioner then pointed out that unlike anorexia, a transgender identity is not by itself harmful.

Before every presentation at AACAP, the speaker is supposed to disclose any financial conflicts of interest, and I don’t recall Dr. Littman reporting any such conflicts. However, the most relevant conflicts often don’t come from financial interests, but from one’s own biases or personal allegiance to a particular theory, the pressure to publish, the desire for fame and validation, etc. To me, the most frustrating aspect of Dr. Littman’s presentation was that she remained opaque regarding her own views and why she undertook this study. Is she some sort of right-wing anti-trans ideologue? Is she an anti-PC academic who lacks a filter and doesn’t mind controversy, like a mild Jordan Peterson? Could she just be a guileless public health researcher who unwittingly stumbled into a hornet’s nest? Or is Dr. Littman herself a parent (or a friend of a parent) who had frequented the ROGD forums looking for support and answers? I don’t know if Dr. Littman discussing her own experiences and opinions would have made her study any less controversial, but at least it would have felt more honest and transparent.

The discussant (a.k.a. summarizer and moderator) of the session was Dr. Scott Leibowitz, director of the gender program at Nationwide (Is On Your Side) Children’s Hospital in Columbus, OH. I did not envy the task before him, but Dr. Leibowitz admirably pointed out that child psychiatrists are often caught in the gray zone between opposing sides who view gender issues as black-and-white, whereas we've tended to recognize that a person’s gender identity is formed from biological, psychological, and social factors. He gently but persistently critiqued Dr. Littman’s study as far from neutral in how it presented the concept of ROGD to parents taking its survey. He pointed out that in a political climate where transgender people remain a marginalized minority under constant attack, any research that may affect their well-being has to be done with great sensitivity and consideration of the potential consequences, which this study was not. But he also pushed back against those audience members who thought Dr. Littman should not have gotten involved in an area in which she had no prior experience or expertise.

Dr. Leibowitz’s summation reminded me of the following quote, taken from the previously linked article on Jordan Peterson:

We are living through a time of pervasive rhetorical overkill and genuine fear. In times of extremism, moderation itself can come to seem the greater enemy to those ideologically possessed, in part because it is the true danger: The public will tend to move toward it by default, and thus the instinctive recourse by those who sense the fragility of their extreme doctrines resort to coercive means to prevail in arguments they would not otherwise win.

I hope that moderation can ultimately prevail, and I greatly appreciated Dr. Leibowitz’s approach. But I don’t think there was any applause either at the end of Dr. Leibowitz’s summation. Was the audience fearful of showing where they stood? Also, Dr. Leibowitz did not tweet about this session afterwards, even though he tweeted about many other LGBTQ-related sessions at AACAP. I hope this wasn’t because he was wary of the immoderates of the Internet. In today’s political climate, I really wish the “silent majority” of those in the middle would not be so silent.

Protests, Then and Now

Lately, I’ve been hearing and reading a lot about how America is the most divided it’s been since the 1960’s. But given all of the social progress made over the course of that tumultuous decade, maybe that’s not such a bad thing. I was not around during the 60’s, but my mental image of that era is filled with vivid images of people protesting: at Selma and the March on Washington, on campuses all over the country, even at the Pentagon.

Which got me thinking, how are today’s mass protestors doing? (My thoughts on the NFL’s anthem protestors—and celebrity protests in general—are somewhat separate and not covered here.)

Last month, I was somewhat taken aback when I read about some anti-fascist rallies:

The explicit goal of the November 4 protests, which have been warped into a number of increasingly bizarre, "antifa"-related conspiracy theories by right-wing media, is to remove Trump and his administration from office. In order to achieve that end, millions of people will have to take to the streets of cities like New York, Austin and San Francisco, demanding that the administration step down, organizers tell Newsweek. It’s something that will not be achieved with the actions of only a few left-wing radicals, they say.

WTF?!? Am I the only one who thinks that holding an antifascist protest in SF is like Martin Luther King and other civil rights leaders marching down the streets of Harlem instead of down Hwy 80 from Selma to Montgomery? If you’re protesting fascism, why in the world are you holding your protests in the most diverse places with the fewest white nationalists and their sympathizers? Why not go to where the Trump voters actually live, like the Deep South or Kansas? If that’s too far for city people to travel, how about taking a bus from Pittsburgh to Johnstown, PA or from Detroit to one of those Michigan counties that went for Trump? Or is that still too inconvenient for people?

Given all this #Resist talk, what are people actually doing to resist our president? During the 50’s and 60’s, the protestors organized very effective sit-ins which not only highlighted the racism and oppression of “separate but equal,” but just as importantly, disrupted lots of segregated businesses. And who can forget the cries of “Hey hey LBJ, how many kids did you kill today?” causing Lyndon B. Johnson to not have a moment’s peace:

The president and his principal spokesmen were finding it harder each week to avoid the chanting protesters, who seemed to be everywhere. For the first time in history, a president was unwelcome in public in most parts of the country, making him a veritable prisoner in the White House, "hunkered down" there, to use one of his favorite expressions.

Fast forward to today, when we have a grossly narcissistic guy who cares most about his image, his money, and his opulent properties, so how is the fight being taken to that guy? Certainly lots of people are being blocked by him on Twitter, but what is most noticeable to me is how much he still gets to enjoy playing golf almost every week. So why aren’t people protesting every single weekend at Mar-a-Lago or Trump National Golf Club? Why aren’t they blocking off traffic, as protestors have done in Oakland and St. Louis? Why aren’t protestors shaming everyone who goes to those Trump properties with shouts of “Hey hey DJT, all your lies won’t set you free!”? Is this asking too much, if indeed this man is as dangerous as we think he is?

Speaking of which, one of the most infuriating things I read this year is this account of what actually happened when anti-Trump protestors came face-to-face with Trump supporters at a Trump rally in Arizona:

Elsewhere in the city, the police had done a masterful job of ensuring that large groups of pro-Trump Americans were separated from groups of anti-Trump Americans. The two groups were usually placed on either side of wide barricaded streets, but on this corner, there were no barricades, no police nearby, and access between the two groups was unobstructed.

Which made it all the more surreal and tragic how genial and almost embarrassed the interactions were. 

[…]

The Trump supporters looked up and down at their sudden audience, and, if they could get over their astonishment, smiled and held up their phones to take pictures.

And when the protesters saw just how unarmed and unassuming most of the Trump supporters were, and how free they were of signs, weapons, anything — they were left speechless.

That was a strange thing. There were a hundred or so protesters standing on the high steps, and at any given time a few dozen Trump attendees passing them on the sidewalk, but for much of the time they were in close proximity, and no one said anything.

Something was happening there, in that close confrontation between the two groups. There was recognition. There was the uncomfortable knowledge that they were in many ways very similar people. The rally attendees were not frothing at the mouth and were not spouting racial epithets. They were moms, dads, teenagers, and families who for whatever reason have an exceedingly high tolerance for wretched behavior and the absence of moral leadership from their chief executive.

Thus the protesters were flummoxed. It seemed cruel and strange to yell “Nazi” to a pair of grandparents in yellow polo shirts, or at a trio of Eagle Scouts, and so given the chance to say something directly to Trump supporters passing by them, mere inches away, much of the time they said nothing.

How about “Shame, shame, shame!” or “Your emperor has no clothes!” or “We want a president, not a wannabe dictator!” Am I just being unrealistic? Are my expectations too high? I think that on some level, this lack of basic effectiveness at protesting is one reason why the man is still in office.

Has our consumerist culture (see my last blog post on this), smartphones, and the internet made everyone so complacent that they don’t know how to break out of their own little bubbles to stage an effective protest anymore? Do we really think that some hashtags, clever signs, and funny hats are enough?

How Making Consumers Happy Got Us Here

If you’ve never seen Malcolm Gladwell’s 2004 TED Talk: “Choice, happiness and spaghetti sauce,” please take a moment to check it out:

In the talk, Gladwell focuses on the work of “someone who, I think, has done as much to make Americans happy, as perhaps anyone over the last 20 years, a man who is a great personal hero of mine, someone by the name of Howard Moskowitz, who is most famous for reinventing spaghetti sauce.”

Gladwell goes on to describe Moskowitz’s key insight in coming up with chunky pasta sauce for Prego, which is that there is no single sauce that is perfect for everyone, but there is a perfect sauce for each individual consumer. As the saying goes: “The customer is always right.” Thus, the explosion from just Prego vs Ragu to different varies of Prego and Ragu to the cornucopia of choices we have for pasta sauce today.

But as the sauce went, so went everything else. We no longer have to suffer through the primitive days of ABC’s Wide World of Sports or just one cable sports channel. There’s ESPN 2 (and 3 and Classic), FS1, NBCSN, CBSSN, even channels devoted to motorsports or golf. Long gone are the days of everyone tuning in to Walter Cronkite for the day's news. Instead, everyone can find the talking head who agrees most with their personal views and never have to be inconvenienced by a dissenting view.

Online, we no longer have to be exposed to the same reality or set of facts. Facebook, YouTube, Google News, et al. make it so we don’t even have to go out of our way to search out those with similar views; these behemoths feed us stuff based on all the data they have gathered from tracking our online behavior. Of course, they’re doing this to make us happy, but what price are we paying for this sort of happiness?

Which brings us, inevitably, to the present political situation. I think it’s obvious that our current president would not be in office if not for this drive to feed consumers only what they want to see, hear, and experience. Much has been made about how the Russians took advantage of people’s news feeds to try to drive Americans further apart. However, even without foreign interference, I believe that modern America’s brand of consumerism is damaging to all Americans, young and old, left and right. It tells the consumer, “only you and what you want matters.” This kind of implicit message inevitably leads to inflated egos all around, self-selection into smaller and smaller interest groups, and less of a willingness to see things from another perspective. Not surprisingly, frustration, anger, and inability to compromise are the result when people who are used to shaping their own reality are confronted by realities determined by others with different beliefs, such as when a black president gets elected or a controversial speaker gets invited to speak at a college campus.

Is fixing our system (which I believe involves fixing our culture) even possible at this point? Once the Pandora’s Box of unlimited choice for the consumer has been opened, is there any going back to the spirit of “ask not what your country can do for you—ask what you can do for your country”? In my less hopeful moments, I think that it would take some sort of unimaginable catastrophe—like the Great Depression bringing an end to the Roaring 20’s—to drive people to put sufficient effort into overcoming the centrifugal forces that are splitting us apart. Yet, as Tom Hanks said, “If you’re concerned about what’s going on today, read history and figure out what to do because it’s all right there.” I'm not sure if he was thinking about a specific historical era, but what came to my mind was what happened during the Renaissance Papacy, when the Popes became so focused on worldly riches, pleasure, and power that they lost their religious legitimacy, leading directly to the Protestant Reformation.

From the Wikipedia entry:

The popes of this period used the papal military not only to enrich themselves and their families, but also to enforce and expand upon the longstanding territorial and property claims of the papacy as an institution. […] With ambitious expenditures on war and construction projects, popes turned to new sources of revenue from the sale of indulgences and of bureaucratic and ecclesiastical offices. […] The popes of this period became absolute monarchs, but unlike their European peers, they were not hereditary, so they could only promote their family interests through nepotism.

That period of the papacy lasted roughly a century before the Reformation forced Catholicism to reform itself. Yes, there were bloody religious wars as a result of the split in Western Christianity, and peace between Catholics and Protestants took centuries to achieve in some places. And some pundits argue that the Reformation created as many horrors as it addressed. But the overall (admittedly simple) lesson I get from this history is that there are many potential Martin Luthers out there, waiting to change the world, even if inadvertently. I just hope we don’t have to wait a hundred years for that to happen.

Assimilation vs. Independence

Last week, I got the chance to have dinner with a friend who is a businessman and one of his acquaintances, a cardiologist. My friend asked the two of us what we thought of the state of medicine, and what it was like being a doctor these days. It was interesting to hear what the cardiologist had to say. He had been part of an independent medical group, which was recently bought out by a large hospital system. He talked about all the additional rules and regulations that he had to follow and how burdensome they were. Then he had this to say:

"Basically, the problem is that doctors have no power or control over our own profession. The reimbursements rates and policies are determined by the government and private insurers. The doctors who are older can tell themselves they only have to stick with it a few more years before retiring, while younger doctors are too busy trying to establish themselves and pay down medical school debt. Doctors can't unionize or go on strike. It's hard to organize them because it's like herding cats. Therefore, we just have to accept the system and work within it."

I thought it was a very good summary of the present situation facing most medical specialties. It was a nice coincidence that the following day, 1 Boring Old Man wrote wrote this post highlighting some of his reactions to recent articles on psychiatrists & insurance panels, as well as whether psychiatrists who do psychopharmacology vs. psychotherapy will eventually split into different professions. He began:

I went into practice around 1986. If patients used insurance, that was fine with me, but for two simple reasons, it never occurred to me to take insurance. First, I would’ve had to have a staff to file it and keep up with it and I didn’t want to pass on those costs. Second, that would’ve required me to be on insurance panels that would’ve prescribed how I practiced, meaning becoming a psychiatrist who primarily prescribed medications – the kind of psychiatrist people rave about in the blog comments, on Mad in America, or on the steps of the APA Meeting in New York.

Dr. Dawson wrote the following in response to 1BOM's post:

We will all remain in the limbo of politicians telling us we need increased access and insurance companies decreasing access in order to increase their profitability.  And that has nothing to do with the fact that psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy.  Not accepting insurance is the ultimate affirmation that business does not define medicine or psychiatry.

In a comment on 1BOM's post, Dr. Reidbord had this to say:

It appears many of us psychiatrists simply got the memo a little earlier. Psychiatry, like primary care medicine, is fast becoming two-tier: practiced at the level of professional excellence when business does not define it, and something tragically less when it does.

What I wonder is, why don't more psychiatrists speak out about the state of things? The difficulty in spurring practicing clinicians to action is vexing, since I believe that the majority of psychiatrists enjoy spending time with patients and did not go into the profession to become 15-minute med checkers or care team consultants who do not directly see patients.

Of course, I think the cardiologist's explanation above is a good one, but additionally, I believe that ideology and zeal are two primary factors that give psychiatrists of the key opinion leader (KOL) variety a disproportionate amount of power. 1BOM has written before about the dangers of therapeutic zeal, while I've written about the NIMH's techno-utopian vision. The problem here is that ideology and zeal are unifying forces that rally people to a cause, allowing them to dictate the course of events even when they are in the minority. It is much harder to get people to rally around the banner of multi-disciplinary thought ("psychiatrists need to be trained in neurology, neuroscience, medicine, and psychotherapy") or the biopsychosocial model. As David Brooks wrote in a recent column on threats to the international system of liberal pluralism:

It was barely possible [to defend the system] when we were facing an obviously menacing foe like the Soviet Union. But it’s harder when the system is being gouged by a hundred sub-threshold threats. […]

Moreover, people will die for Mother Russia or Allah. But it is harder to get people to die for a set of pluralistic procedures to protect faraway places. It’s been pulling teeth to get people to accept commercial pain and impose sanctions.

Can there possibly be a solution? Well, it is fortuitous that at least for psychiatrists, independence is still an option. Unlike many other medical specialities, we don't have to buy expensive equipment or hire an extensive support staff. Solo office-based practice is still possible. In certain parts of the country, people are willing to pay $250 per hour for a psychiatrist who is good with both medications and therapy, though if you're like 1BOM and don't care about income maximization, you can probably work anywhere.

And perhaps some day, enough doctors will tire of the "long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism," and declare independence en masse. That'll be an interesting day.

On Integrated Mental Health Care

The American Psychiatric Association sure seems to be pushing hard for integrated (a.k.a. "collaborative") care these days. They even commissioned a report on how integrated care would save the system billions, which the Psych Practice blog recently dissected. APA president Dr. Jeffrey Lieberman, who is nearing the end of his term, recently published this piece in Psychiatric News. The attitude is one of "change is coming, so we'd best prepare." In this post, I'd like to take a critical look at various aspects of integrated care, based on my own (admittedly limited) experience.

First, why is integrated care a good idea? Where I work now, many psychiatrists do not accept insurance, and it can take patients months to get in to see a psychiatrist. When they do see a psychiatrist, the psychiatrist and referring physician are often too busy to communicate with one another. In some places, primary care doctors are forced to handle psychiatric patients with severe illnesses like schizophrenia, as highlighted in this post by Dr. Maria Yang. With children, pediatricians with very little psychiatric training often end up counseling parents about behavioral issues and prescribing medications, due partly to the severe shortage of child and adolescent psychiatrists.

Just as the American health care system is not just one system, but a patchwork mostly local systems, integrated/collaborative mental health care is not one thing; it can be done in many different ways. Several years ago, I experienced integrated care first-hand when I worked as a consulting psychiatrist in several primary care clinics that mainly provided care for underserved populations. Not surprisingly, most patients I saw were over 40 and had multiple medical problems. Most were referred to me because of depression or anxiety, though a significant number had a personality disorder, bipolar disorder, or schizophrenia. I got to spend an hour for each new patient visit and 30 minutes for each follow-up. In some of the clinics, I was told I should try to refer the patient back to their primary care physician (PCP) after 6 visits with me, though they were generally flexible about that.

I have to say, it was overall a good experience for me. I got to focus on providing patient care and did not have to deal with insurance companies or pharmacy benefit managers, since the clinics mostly used a generic formulary for medications. I was also glad that I helped not only the patient, but fellow physicians as well. The primary care doctors were uniformly and sincerely appreciative of having a psychiatrist that they could quickly refer patients to, or quickly consult with on a "curbside" basis. The patients tended to show up consistently for their appointments and liked having more time to talk with me compared to their brief PCP appointments. In one of the clinics, where the patients were mostly refugees and immigrants, few of them would have sought out a therapist or psychiatrist on their own, but they were more comfortable going to their doctor's office to meet with me. This all seems to concur with the APA's view of things.

That being said, my experience with integrated care was far from perfect. I thought that the vast majority of patients I saw would have benefitted from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists (usually LCSWs), they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down. To quote Sandra Steingard's comment last month on the 1Boring Old Man blog:

I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like, "So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!"

I also get quite concerned when I read things like Dr. Lieberman's article, which reflects the thinking of the APA leadership. From his closing paragraphs:

The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.

There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.

Is the focus on improving patient care, or something else? I believe that most psychiatrists are secure with their professional identities, and it is the more biologically-oriented psychiatrists who feel that we must claim our rightful place amongst other medical professionals. It's clear that they fear that psychiatrists would just opt out of the system entirely and remain in solo practice or collaborate mostly with independent psychologists and therapists. This would open the door for people like prescribing psychologists or nurse practitioners to fill the unmet need of psychiatric prescribers in medical settings. So on some level, this is a political battle as the APA fights to retain the mantle of mental health leadership. Why else do you think they have prominent politicians like Bill Clinton and Joe Biden opening the APA annual meetings?

In my mind, the biggest unmet need in mental health right now for the insured population is increasing the numbers of providers of effective therapies like CBT, DBT, PCIT, and so on. Of course, the APA does not address this at all. Instead, what the biological psychiatrists tend to emphasize is that primary care doctors don't diagnose enough, don't use the right dosage of medication, and patients do not stay on medications for long enough. Thus, the relentless push for diagnostic inflation, mass screening so cases are not missed, medication algorithms so that doses are optimized, and tracking patients like they're widgets in a factory. If psychiatry changes in accord with this vision, it would profoundly alter who enters this profession (if it continues to exist at all). Most psychiatrists I know went into this field because of a desire to treat the whole person rather than just symptoms, not to "or at least oversee" treatment provided by someone else. This type of system would favor those whose interests lie primarily in numbers, charts, "huddling" with a team. Is this really what anyone other than the APA wants business interests of managed care want the future psychiatrist to be?

This post was edited to more accurately reflect what I meant to say. Thanks, Dr. Dawson!