October-November 2019
Vol. 10, Issue 3
In This Issue



Gurjot Marwah, MD
Newsletter Guest Editor
Past President, 
Arizona Psychiatric Society
Founder Healing Minds, LLC
Private Practice Psychiatrist

Dear Colleagues:

Recently, I watched the controversially divided new movie "The Joker," the title played effortlessly and hauntingly by Joaquin Phoenix telling the dark and sad life story of a supervillain of many a Batman movies, Arthur Fleck aka The Joker. As I stayed glued to my chair in the multi-storied massive IMAX screen mesmerized by Mr Phoenix's intense acting skills - there are two things that stood out - Arthur, is a compliant, and for the most part insightful patient with a severe mental illness who is barely keeping it together, yet he shows up for his scheduled psychiatrist and therapy appointments. Until the system fails him. Secondly, it makes a case for how guns in the hands of sometimes innocent people with mental illness can lead to mayhem, potentially a case for better gun control.   

In the opening scene, Arthur goes to his monthly appointment with his social worker and begs her to advocate on his behalf to his psychiatrist to increase his medications for "I have never felt this sadness ever leave me a single day of my life."  To which his therapist informs: ". . . you are already taking seven different medications," and does not fulfill his request to collaborate. To add agony to his dilemma, on the  same appointment, the social worker  goes on to inform him that the clinic's funding has been cut and it is closing, hence that would be his last appointment there. He would have to figure out his mental health treatment on his own from that point on. Arthur (the Joker) panics and despondently questions - who am I supposed to go to when life gets rough and where will I get my medications filled. Joaquin Phoenix poignantly portrays his pain and hurt of being abruptly dropped off like a hot cake. That day he writes in his diary:  "why are people with mental illness expected to pretend that they don't have it." 
As we discuss mental health parity on a national level and with state legislators and APA's advocacy efforts - and as members of Arizona Psychiatric Society, we are all too familiar with the many Arthurs aka Jokers who fall through the cracks of the system and succumb to their mental illnesses to the point of no return. Like Arthur, they panic when they run out of their medications and fear the return of their psychosis. These persons are too mentally frail to advocate for themselves, and just like the Joker, often have family members who are entrenched in their own mental health challenges - hence have no one to advocate for them either. So this is an important time, whether it is the 1980s Gotham City or 2019 present day Arizona, where we as psychiatrists can be the fate and gatekeepers of our patients' mental health, as sometimes their one and only hope. Under the leadership of our current APS President Dr. Don Fowls and his strong passion for mental health parity and advocacy, this is an important time for us to recognize the role each one of us can play in aligning conversations with other mental health agencies in the state, including faith-based religious organizations, families, and communities that can provide support to persons with mental illness.

On that note, I wish you all a very Happy Thanksgiving.

Gurjot Marwah, MD, Guest Editor
Premium Corporate Sponsor 2019-2020

Don J. Fowls, MD
President, Arizona Psychiatric Society

As psychiatric physicians, individually, and collectively, as a Society, we see the opportunity ahead of us to engage with our partners and our community on important issues that impact access to care by our patients and the impact to improved mental health that we can make as psychiatrists.  If you missed our special September Newsletter, with information on parity efforts, how you can become engaged, including a Call for Stories being compiled by the Arizona Council of Human Service Providers, CLICK HERE for that important information.   We have also engaged with a broad array of associations and stakeholders in our community in a collaborative effort to make parity more real than it is today, who have shown great interest. It also includes providing data that demonstrates the value of good behavioral health care. 
As we finalize planning for the 2020 Annual Meeting, I am excited to share that National Council for Behavioral Health Medical Director, Joe Parks, MD , has accepted an invitation to be a featured speaker at the Annual Meeting. I hope you have saved the date of May 9, 2020 and are planning to join us at the Wild Horse Pass Conference Center in Chandler, Arizona for a day of noted national speakers.
In addition to joining the advocacy efforts on the local and national stages, you are invited to submit your self-nomination to serve in leadership of the Society or to join key Committees contributing to the success of our mission by completing the survey form included in this edition. Everyone is busy with their work and careers, and this is great. You also have an opportunity to bring psychiatry out of the shadows and into the forefront of our community. Ours is not the only voice, but it is an important one that needs to be heard more vocally.
I hope you enjoy the contributions of several of our members in this edition. They are well-worth reading. Two I wanted to highlight. Dr. Gurjot Murwah makes important points about how we as psychiatrists can be a constructive voice in the community when it comes to issues like gun violence. This is so important and reminds and encourages us to get off the sidelines and out into the open community to help and communicate what we can. And the interview with Dr. Ed Gentile and his wife is very wonderful! Ed is someone who has been both a provider and managed care medical director and by example has done so much to represent the goodness of many people on both sides of the fence. There are many issues to address for sure, but it's always nice to hear about someone who has risen above the fray and been a constructive force through it all.  
Premium Corporate Sponsor 2019-2020  

APS Meet Your Member Profile of Edward Gentile, DO, DFAPA
By Jason Curry, DO, Guest Interviewer

Doctor Ed Gentile is a remarkably bright and sanguine figure. It was Jasleen's and my fortune to spend an evening with him and his wife, Deborah, walking amongst the massive murals in downtown Tucson, while interviewing Ed about his career and thoughts on the medical complex.

The walk amongst the murals was befitting. There has been a growing movement in the world of murals known as "Environmental Graphics" - a movement represented in many Tucsonan murals. Environmental graphics is a step beyond painting a beautiful piece of art directly on a wall. It is executing that beautiful work in a fashion that enhances the natural aesthetic quality of its surrounding environment: buildings, landscape, plants, road/walkways, etc.

Is the mural then made beautiful by its connection to the space? Or, is the cityscape made beautiful by the mural? The answer to both is "YES." Such is the career of Arizona's latest APA Distinguished Life Fellow, Ed Gentile, DO. His career is artistry in its own right, yet it too has honored and enhanced the medical landscape to the betterment of countless patients.

In his career, which took a turn very early on from pathology to psychiatry, Ed has been a stalwart promotor of patient advocacy, understanding and curiosity. This interplay of caring and curiosity was evident immediately upon our arrival at the first mural.

Epic Rides Mural; Joe Pagac
534 N Stone T/A

This mega mural "spoke" to Ed. He was reminded of his journey from PA out to AZ, which would become his home for 30+ years. A graduate of Philadelphia College of Osteopathic Medicine (1978) and completing residency at the Medical College of Pennsylvania (1985) Ed had to overcome a lot of barriers to become a psychiatrist, especially as a DO in the 70's & 80's, at a time when conceivably stigma against mental illness was worse and notable discrepancies in reimbursement existed between the disciplines in medicine.

Before the venture out to AZ became permanent, Ed spent time working as a general practitioner in WV as part of his National Health Service Corps scholarship payback and later learned the inner workings of a new technology in his academic faculty position in the mid-1980s in Philadelphia - that new "technology" - "managed care."

In 1976 Ed met Deborah. As he gazed up at the mural featuring two wild-hearted bicycle riders cocreating a story through the desert landscape, Ed shared how for the couple "moving out here was an adventure: it felt like landing on Mars." The Sonoran terrain was like an alien planet to Ed, who grew up in Rhode Island and had acclimated to all rich and beautiful vegetation typical of the East Coast. "I had never seen the desert in my life...but as I got to know the desert - it's changing appearance with changes in season, in light - it's changing smell after a rain - it began to feel like HOME."

Ed is grateful to have taken this journey with his beautiful wife and starting their family. His daughter Hilary was 7 at the time the couple moved, and his younger daughter, Brooke, was born in Arizona. Now, his daughters are fully grown. At the foot of the mural, Ed remarks on how these two have their own unique blending of methodical and adventurous natures.

Initially, Ed started working in Tucson in his own blended outpatient and inpatient practice. Later, when he began work with Community Partners of Southern Arizona, he was one of the rare medical providers who held Saturday and afterhours clinics to see his private practice outpatients. The transition to CPSA was an opportunity to continue impacting patient wellbeing while nurturing his own enthusiasm, "I trained in the public sector. I missed that interdisciplinary approach."

In our walk over to the next mural Ed explains how overtime he slowly closed his private practice, while returning to public sector work in what became a 22 yearlong clinical and administrative job with CPSA.

Goddess of Agave; Rock "CyFi" Martinez
440 N 7th Ave T/A

In his own words: "It's exotic - beautiful. It evokes a sense of passion. I'm not a tequila drinker," Ed says pointing to the agave crown atop the head of the ethereal feminine figure, "but I have a passion for what I do."

This mural reminds Ed of the thousands of patients he has encountered at his work in our local community. "What do they want, and how do we help them met their needs?" The confident gaze of the goddess reminds Ed of his appreciation to these many patients who have entrusted him with their "stories, their secret longings and their lives." With these thoughts it is a short but solemn procession to our next mural.

Borderlands Brewery Mural; Joe Pagac
119 E Toole Ave T/A

We cannot linger at this one long. It is next to the train tracks and an iron horse is barreling upon us. Though, we have time enough to see how Ed is called to the significance of this expansive painting. He highlights two central figures: one a hybrid aged man/saguaro cactus and the second a hybrid cherub/hummingbird.

Ed feels honored to be recognized as a Distinguished Life Fellow. He admits, "It wouldn't have happened without Teri. She's a gem." He likens the figures in the mural to the duty bestowed upon all of us to pass down the tradition and share it with the next generation.

Much of his work at CPSA was not only to improve the care delivery systems for patients, such as by collaborating development of assertive community treatment teams, but to learn from and teach other providers how to perform more "nurturing" care. There is no hesitation in his praise for his former teams and coworkers. Ed instructed me that if you are working with young trainees/physicians, "you have to help sustain them." We had to leave: the train is here.

Tucson is graced with many murals downtown, so the walk from Borderlands to the next selected mural was littered with scores of interceding works. However, the next mural brings Ed palpable joy. He says, "It reminded me of the Saturday Evening Post."

Running of the Pinatas; Ignacio Garcia Gonzales
Alley, 6th Ave (Congress & Pennington) T/A

This surreal play on running from bulls features a young boy both delighted and terrified by the fantasy creatures stampeding towards him. It looks to Ed like the boy is "having the greatest time."

In medicine Ed explains, "I feel very conscious of not wanting to make a mistake." This has long been a governing ethos in his work. In recent years it has taken on new light after Ed left CPSA to briefly work as the regional medical director for Southern AZ at Community Bridges and then presently as a Behavioral Health Medical Director for UnitedHealthcare Community Plan. His work here is heavily involved with the care management and care advocacy of individual persons as well as larger populations.

At the same time that Ed craves the carefree exuberance of childlike pursuits, like running from snorting papier-mâché figures, ostensibly filled with delicious candies, he is mindful of the ultimate responsibility his work holds. His reflections are both micro- and macroscopic. "Am I doing the right thing? Are other doctors doing the right thing? Did I add to the administrative burden of the work? Have we done ourselves any favors [with EMRs]?"

He dreams of a future opportunity to see medicine "using data in a real-time and beneficial way...I'd love to come back in a few hundred years and see the state of psychiatry or whatever they call it at that time. Will they think we were barbaric? Will they think [our] new learning brought the needed promise?"

Like Ed I am sure we all hope the answer to his last question is again: "Yes!" It's a short journey to our last mural. Ed takes a brief detour to offer a warm meal and kind words to a homeless gentleman laying on a park bench. 

"Vergiss" (Girl With Mask); Fin Dac
178 E Broadway Blvd T/A

When Ed is conversing at this mural, I cannot tell if he is speaking about the mural or about life. "What's your secret? Did you see something? Why the mask?" The mural itself is a feminine figure whose knowing eyes are played opposite a face made expressionless by a bright red mask and hands held steady in tranquil repose before the mouth and nose.

He echoes back to his gratitude for his patients, and in this appreciation, he expresses great intrigue and awe at the capacity for human healing; "how resilient and really just extraordinary our patients are."

In front of this masked woman and her turquoise stare, Ed also expresses gratitude for his family: an elemental part of his being that he clearly loves beyond his vocation. He remarks of how they all sacrificed for one another, and how he was so lucky to go back to school to receive his MBA at the UofA - at a time when his eldest was also enrolled in her own undergraduate studies.

Our evening with the Gentiles ends with joyful exchanges and the hope to meet and share again. In the future Ed is looking forward to more "carefree adventures", perhaps in transitioning toward retirement, and hoping to see more involvement in the APS and APA, especially by other Tucsonan psychiatrists.

Thank you for the adventure Ed. Thank you for your artistic dedication to the craft of patient care. Congratulations on a distinction well deserved - our newest Distinguished Life Fellow. 

Private practice opportunity in Tucson, Arizona in an overhead sharing arrangement with two other psychiatrists, a DNP, and a master's level therapist.   Contact Shari at 520-795-0309 

The Nominating Committee invites members to submit their interest in serving as an executive officer of the Society (Secretary, Treasurer, Vice President) (one-year terms with opportunity to advance on the leadership ladder to President-Elect and then President), as a Co-RFM Representative (representing your psychiatric residency program), or as an Arizona APA Assembly Representative (two-year term of service with quarterly meeting travel required).  In addition, all Committees or Work Groups are open to members to join.  

Help us learn more about your interest and vision in contributing to the Society by completing the interest form on or before January 6, 2020.  
Dr. Noshene Ranjbar - Integrative Psychiatry
Dr. Gretchen Alexander - Psychiatry

It is our pleasure to share, with the authors' consent, links to articles recently authored by Arizona members.  We welcome members to provide updates to us on publications and accomplishments that we may share on your behalf.  

" What can we as physicians do to advocate for effective practice management?" Read more about the impact you can help make by promoting best business practices in  The Missing Key to Physician Wellness: Effective Practice Management, Gretchen Alexander, MD, The Arizona Pulse, September 27, 2019
The Final Installment in a Three-Part Series

Gurjot Marwah, MD, FAPA
Past President, Arizona Psychiatric Society
Private Practice Psychiatrist
Founder of Healing Minds, PLC
Tempe, Arizona

In a country with a burgeoning population that is being diagnosed with Type 2 Diabetes, like the rest of the developing countries in Latin America, one thing that sets Cuba apart is a passionate focus on using primary care setting as a vehicle for imparting diabetes prevention education and care to the population, whether as regular monitoring of their blood glucose levels in the consultorios (the free local clinic assigned to all Cubans), and also with frequent in-home visits by the primary care team to assess life style and give dietary recommendations, a pop-in visit during dinner time by their PCP who usually lives in the neighborhood and knows the family well is fairly common. This model's success with its people is being repeated in other Latin American countries. Doctor-to-patient ratio in Cuba is among the world's highest at 127 persons per  physician; surprisingly 61% of all physicians in Cuba are women. There are 150 hospitals; 450 community polyclinics; and an astounding  13,131 neighborhood family doctor-and-nurse offices which provides primary care including  diabetes education.  

Dr. Garcia Herrera, senior Researcher and expert in Cuba in Angiology, talks about the Cuban invention, Heberprot-P, a unique therapy that lowers the risk of amputation in Diabetics by 70%.
In October 2018, I got to witness this unique model first hand in Havana - as a member of the "unofficial " US delegation to Cuba, which included two podiatrists, two cardiovascular surgeons, a nephrologist and a psychiatrist, along with a US congressman - all there to learn how healthcare is imparted in our neighboring country, isolated politically and emotionally, not culturally, with a strict trade embargo since the 1950s Cuban missile crisis. A country only a 45-minute flight from Miami, Florida where time seemed to be in no rush, like stepping into another era, where there are no fast food joints; no malls; where kids don't know what Coke and Pepsi are; where internet access is extremely limited to the general public and mobile phones are a rarity.  Yet among the beautifully restored colorful Spanish colonial and baroque style buildings of old Havana, it was a heartening sight to see kids playing and running around in the narrow streets, as their mothers chatted from across their fourth floor small balconies, casually keeping an eye on the kids and each other, the men aggregated in their own groups sitting on rundown plastic chairs in the street in front of their small apartments, their loud spirited laughter and conversations oblivious to any discomfort from the hot humid air, as much an audience, from the Atlantic Ocean close by. The old city of Havana was getting ready to celebrate its 500th year birthday in 2019 with welcoming tourists from all over the world.  Including us.  
Our team got to see how Cuban government is implementing a healthcare initiative to manage the complications of Diabetes with new drugs. Foot ulcers are a serious complication of diabetes. In diabetes, there is decreased production of epidermal growth factor, hence decreased oxygenation and impaired blood flow to the peripheral organs slows wound healing on feet. Cuban researchers have developed a medication called Heberprot-P which when applied topically or injected directly into a foot ulcer has been successful in patients with diabetes to reduce the risk of foot amputations by 70%. With 73,000 foot amputation's occurring in the US alone each year, mostly in patients with diabetes, the Cubans were making a case for improved US - Cuba relations, to loosen the strict diplomatic embargo in place since the 1950s, to open access to the US patient population with Diabetes to Heberprot-P.  Heberprot is an innovative product developed in Cuba and now available in 23 other countries containing recombinant Human epidermal growth factor for peri- and intra-lesional infiltration; evidence reveals it accelerates healing of deep and complex ulcers, both 
ischemic and neuropathic, and reduces diabetes-related amputations.  Heberprot-P is a unique therapy for the most complicated and recal citrant chronic wounds usually associated with high amputation risk.  

Local injection in complex diabetic wounds has demonstrated a favor able risk-benefit ratio by speeding healing, at the Diabetics speciality clinic, where a team of mostly women physicians demonstrated to us the ease with each they injected the patients at high risk. In a country where medical care is free to all its citizens, even the latest medications like Heberprot-P is easily available with no copay, and no prior authorization. All that is needed is a referral by their primary care doctor. 
Next stop was a visit to the Center For Genetic Engineering and Biotechnology in the heart of Havana. It  was a brief refresher to our US medical team to all the cutting edge therapies, medications being engineered in Cuba and their success, some unheard of in the United States. 
Innovations in Diabetic Care with an 
educational  exchange with various Cuban scientists whose work has been central to the formulation of innovative approaches to diabetes care and its complications, such as medications for diabetic foot ulcers developed at the Genetic Engineering and Biotechnology Center. 
Day 3 of my stay was  Educational Exchange at a Comprehensive Diabetes Care Center in Havana to observe patient education and treatment. We interacted with Cuban health professionals and patients, as the endocrinologist injected Heberprot-P at the edges of weeping wounds on the feet, talked of care and management.

Our US team had a working  lunch at a private in home restaurant called Paladares with the director of the  National Endocrinology Institute of Cuba, where we exchanged about the epidemiology of diabetes and related conditions in Cuba and the USA, as well as population health approaches to management and patient education.
Each year the number of people diagnosed with diabetes type two are increasing worldwide. The years of life "lost" by virtue of living with sub-optimal quality of life (years lived with disability, or YLD).   Between 1990 and 2010, DM's all-age DALY rate increased by  30% worldwide.
Art adorns the streets of Havana.
This information is relevant to our field of psychiatry as patients with mental illness are more likely to be overweight, partly as a side effect of SSRIs, atypical antipsychotics, poor self care, that can not only increase the risk of diabetes, and the weight gain becomes a stubborn reality. Seriously mentally ill patients have frequent complications related to this serious disease- including foot ulcers and amputations. A more engaged primary care team as well a psychiatrist who regularly checks BMI and weight can advocate on their patients' behalf for better care.
Improved relations between Cuba and USA  can also open doors allowing exchange of newest medical inventions bettering possible health care for patients of both countries.
The team's five day trip ended with a idyllic exploration of the art scene of old Havana - amongst its many road side heavy weight steel modern art installations, that beckons passers by to pause in awe - to be in the moment, to engage. A gentle invitation to come back.

Milliman Report Shows Disparities Continue; Arizona Parity Efforts Ongoing; Engage Campaign on National Parity; Advocacy Update; Call for APA PAC Support and How to Support Advocacy in Arizona

The new  Milliman report, an update and expansion upon the 2017 report, has just been released. The out-of-network and reimbursement disparities continued to grow in 2016 and 2017 (the previous report data covered 2013-15).  CLICK HERE to access the 2019 Milliman Report and other reference documents to assist in efforts to establish parity and insured's access to care.
Here is the national press release.  In addition, you may find useful the Talking Points developed by The Bowman Family Foundation for advocates containing useful suggestions for how to talk about the report and background on the report itself, as well as the State Data Fact Sheet (compiled by Arizona Coalition Founders, the JEM Foundation (see more about the Coalition below), from the Milliman Report data).  

Arizona Coalition for Insurance Parity Continues Its Efforts; Call for Stories

The Arizona Coalition for Insurance Parity, a collaboration between the  Arizona Council of Human Service Providers JEM Foundation Mental Health America of Arizona MIKID , and the  Neighbors Council, with support from the Arizona Psychiatric Society and the Arizona Chapter of the American Society for Suicide Prevention, is continuing their Call for Mental Health Stories.  If you, or someone you know, has  been unable to access needed behavioral health services or had a claim denied for mental health and/or substance use disorder treatment, the Coalition would like to hear from you. The information you provide will help to shape public policy and influence legislation in order to move us towards full parity implementation and mental health equity.

The link to complete the survey electronically is:

By completing this survey you are acknowledging that your information is being collected to help understand the current trends and circumstances surrounding mental health and substance use disorder treatment claim denials in Arizona. All information you provide will be kept confidential, and any identifiable information you choose to provide will not be shared without your permission.
Please share this  Call for Stories widely with your friends, family members, colleagues, neighbors, and others.  For more information on the Call for Stories, reference information available to you and your patients on mental health parity and enforcement, CLICK HERE for our special Parity Newsletter distributed in September.  

If you would like to join the Parity Work Group or the Legislative Committee and be part of these efforts ongoing, please contact teri@azmed.org.  Together we can and do make a difference. 

Supporting Federal Advocacy Efforts

Congressional support for APA's Mental Health Parity Compliance Act (H.R. 3165/S. 1737) continues to grow, due in large part to APA members' advocacy efforts. In the past few months, APA members have called, met with, or written letters to their federal lawmakers in support of this important piece of legislation. As a result, 31 members of the House of Representatives are cosponsoring H.R. 3165.  Recently, a member of Congress joined the Mental Health Parity Compliance Act after receiving just one letter from a local psychiatrist. Have you sent your letter yet? Use APA's online tool to write your lawmakers in support of mental health parity today .  

When you renew your APA membership, you can strengthen your advocacy impact by contributing to the Fund for Safe Prescribing (helping the APA protect patient safety by ensuring that only appropriate medical professionals can prescribe medications) and/or to the APAPAC (ensuring that psychiatry has a seat at the table when decisions are being made in Washington, DC).  

The last few months have seen a broad array of movement on a number of issues.  Learn more about the work of the APA Policy and Government Relations team by viewing the full October Advocacy Update .   
Honolulu, Oahu, Hawaii, August 2019

Payam Sadr, MD, FAPA
Jason Curry, DO, FAPA
Arizona Assembly Representatives

Dr. Payam Sadr and Dr. Jason Curry attended the APA Area VII Meeting in Honolulu, Oahu, Hawaii, on August 9-10, 2019, joined by Dr. Jasleen Chhatwal, as the Area 7 ECP Deputy Representative.   

Area 7 leadership actively collaborates to strengthen the Area 7 District Branches membership, advocacy, and voice in the APA Assembly.  CLICK HERE for Minutes from the August meeting.  
Janssen Announces U.S. FDA Approval of SPRAVATO™ (esketamine) CIII Nasal Spray for Adults with Treatment-Resistant Depression (TRD) Who Have Cycled Through Multiple Treatments Without Relief.  CLICK HERE for the full Press Release.   

* SPRAVATO™ uses the first new mechanism of action in decades to treat major depressive disorder.
* In short- and long-term clinical trials, those who received SPRAVATO™ and a newly initiated oral antidepressant achieved superior improvement in depression symptoms, and sustained improvement in their symptoms over time compared to adults who received a placebo and an oral antidepressant.
* To support responsible use of the medication while ensuring patient access, SPRAVATO™ will launch with a controlled distribution model, including a comprehensive Risk Evaluation and Mitigation Strategy.

Paid Advertisement - Premium Corporate Sponsor 2019-2020

APA FREE MEMBER CME:  November Course of the Month is:  Culture, Family Caregiving, and Geriatric Psychiatry.   The population of the United States is aging and growing increasingly diverse, creating a demographic imperative to address diversity among older adults. Diversity encompasses ethnicity, cultural background, gender, sexual orientation, sexual identity, and immigration status. Currently, 13% of the population is over the age of 65. This course considers the role of family in geriatric healthcare, and discusses innovative and culturally sensitive approaches incorporating families and caregivers. Presented by Ladson W. Hinton, M.D., University of California, Davis.

SMI ADVISER  is an initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and implemented by the American Psychiatric Association.  Its mission is to advance the use of person-centered approaches to care that ensure treatment and support for people with serious mental illness (SMI).  Through the SMI Adviser website and smartphone app, clinicians can access education, data, and consultations to help them make evidence-based treatment decisions, and individuals affected by SMI can access resources and answers from a national network of experts.  

Grand Rounds for the Department of Psychiatry, Banner-University Medical Center Phoenix are held on Fridays from 12 to 1 pm in the Medical Education Ampitheatre, Banner-University Medical Center Phoenix.  In November, no Grand Rounds will be held on November 29, 2019.  December Grand Rounds resume starting December 6, 2019; no Grand Rounds will be held on December 20 or 27, 2019.  

Next event in the Friends of C. G. Jung calendar:  "Synchronicity, Complexity, and the Psychoid Imagination: Examples from Ecology and Artistic Intuition,"  Joseph Cambroy, Ph.D., Jungian Analyst, Saturday, January 11, 2020, 9:30 am to 3:30 pm, The Casa Franciscan Renewal Center, Sarah Room, Piper Hall, 5801 East Lincoln Drive, Scottsdale, Arizona  85253.  CLICK HERE for more information, to sign-up for future event notifications, or to register.  

December 12 - 13, 2019
Pre-Conference sessions will be held December 11, 2019
Scott Resort and Spa in Scottsdale, Arizona
Register Here!   You will receive a complimentary textbook on behavioral emergencies when you register for the full conference. All providers of emergency care to psychiatric patients are invited to this year's conference, which includes hot topic presentations on mass shootings and the opioid epidemic, rapid fire sessions, lectures and workshop presentations by renowned speakers, and a scientific session on state of the art care.
In addition to the two-day conference (December 12-13, 2019), there will be 2 full-day pre-conference sessions on Wednesday, December 11 that focus on:
Critical Topics in Behavioral Emergencies for Emergency Physicians
Critical Topics in Emergency Medicine for Psychiatrists
IBHI will continue to offer its one day seminar in improving Emergency Department Flow for people with behavioral health problems on Wednesday Dec 11. E-mail Peter@IMHI.net for information.

Plan now to attend the 2020 APA Annual Meeting, concluding the celebration of the 175th anniversary of the APA

Registration for the 2020 Annual Meeting Opens January 7, 2020
April 25 - 29, 2020 | Philadelphia,  Advancing Quality: Challenges and Opportunities


The Arizona Opioid Prescriber Education program is a free online continuing medical education (CME) program for health care professionals that provides the latest information about Arizona's opioid laws and regulations, prescribing guidelines and treatment options for opioid use disorder. The education modules are accredited for all types of physicians, nurse practitioners, physician assistants and pharmacists and satisfy the license renewal three-hour CME requirements in Arizona law. Visit www.AzRxEd.org.   
Hyatt Regency Union Square
San Francisco, CA
May 19, 2019

Brian Espinoza MD
Interventional Psychiatry

The 29th International Society of ECT & Neurostimulation (ISEN) Annual Meeting was held on May 19, 2019 at the Hyatt Regency Union Square, San Francisco, CA.  This year we had members from 11 different countries in the audience, and was my eleventh year in attendance. The theme for morning presentations was "Contemporary ECT Around the World."  For the full report from the conference, please CLICK HERE.  

Shanghai (Business Center for Mainland China)
Part 3: Finances for the Future

Robin T. Reesal, MD, FAPA, DABPN
Psychiatrist and Educator

Finances for the Future

Today's article is part of a continuing series on Lifestyle management for early career psychiatrists. The topic today is financial wellbeing. Nothing written in this article substitutes for advice from a financial expert.

Context: For most people, medicine is a new world that has its own vocabulary and culture. It is a fulltime job to absorb medical knowledge and learn the healthcare rules. Others, make billions of dollars from the health provider/health recipient relationship. They have a multitude of resources to squeeze all the dollars they can from this relationship. Yet, physicians who provide care to their patients often face challenges and feel inadequate about how to achieve financial security.

Research: Set time aside to do your research about taking care of your finances.We are back to the theme of putting time aside for yourself. Talk to senior colleagues about financial ideas. Seek out advice from financial advisors. Use the resources of the APA and the AMA. There are numerous books on personal financial management.
Financial planners: The relationship between you and a financial advisor is based on similar factors that a psychiatrist has with patients. The "fit" or relationship with the advisor is paramount. Transparency is important. It is your money, your life and you have the final say. If you do not understand a financial plan or investment, ask questions until you do. Be cautious about time pressured decisions. Understand the short term, long-term and tax consequences of your decisions. Please remember that there is a significant difference between a broker and a certified financial advisor. Does your financial advisor have a fiduciary responsibility to you? Good to know the answer to this. Ask about fees. They can diminish a portfolio significantly over time.

Debt: Debt is more than a burden. It steals personal time and family time because it demands that you work long hours. Debt reduces your freedom by limiting your options. You know that when you are personally indebted to someone, sooner or later you are obligated to pay that debt. Finances are no different. Interest rates on credit card debt can wilt a growing income very quickly.

A smaller house may not be as socially impressive but it may mean a smaller debt load. A more conservative lifestyle may mean a smaller debt load. Financial deprivation is hard to do. Find a balance between a comfortable lifestyle and fiscal conservatism.
When discussing the writing of a history of present illness on a consultation, the message to residents is to start at the end of the report. What does this mean? Your diagnoses should be supported by your HPI. If you want to end your career with a certain level of financial security, then plan and live a life that will lead to that outcome. Hoping for the best financial outcome when you retire without a plan is a questionable approach. Decide how much you want for retirement. Check with experts as to how much they think you need. Then try to come up with a plan that you think works for you and your family. These choices are personal in terms of risk tolerance and lifestyle choices.

They know us: Institutions outside our profession know medical doctors have a strong work ethic with a sense of obligation to pay off their debt. This is one reason why financial institutions like giving physicians loans. You are a good risk to them and they use your work ethic to their advantage. When you are living a self-sacrificing life, others know you are tired and want relief. The financial sales pitch can include, "You deserve the money doc, you work hard". When tired and overworked, primary process thinking in your personal life is appealing, after all you had to follow the rules all day long. There is a simple rule you can use to limit impulsive debt and purchases. Give yourself time before completing any major purchase, including loans. You can use a minimum of 24 hours to 48 hours as a guide. If a rule for medical consent, when possible, is to give a patient 24 hours or more to think about the advantages and disadvantages of a major medical intervention, why not use the same rule for yourself to consider your options, weigh risks and receive input from others?

Career plan:   Consider how you plan to set up your career. Do you want to work full-time as an employee for a certain number of years then retire? Do you want to work part-time for a long time? Do you want to work part-time while raising children then work full-time? Do you want to work in medicine for a certain number of years then change careers? How do you plan to manage risk adversity as you age? How do you plan to manage the effects of aging on your career? What if you do not like plans and want to take life as it comes? It is worth deciding what style suits you and develop a template for yourself that has built in flexibility for health, couple career planning, family responsibilities and crises. Have a plan for the unexpected. Let's look at some scenarios as a guide towards planning.

One implication of being in private practice is that you are responsible for setting up your own pension plan and securing your financial future. You also need to like being a part time business person. Fee for service allows you the opportunity to earn as much income as you wish by the number of hours you work. An advantage is that you are in charge of your finances. Remember you will not have the same drive and energy at age 60 as you did at 45. If a life event stops you from working for a period of time, your income is limited. Take steps to put money aside, an emergency fund. Is there an insurance plan to cover a work absence?

If you work as an employee, you may have controlled work hours, benefits and a pension plan. Life can be more ordered. However, with a fixed income, you can be cash poor when it comes to covering additional expenses such as children school fees. Pension plans may not be as lucrative as they once were. Your financial future is dependent on whether your employer is still in business when retirement comes. How is your money being invested in your retirement plan? How should it be invested? Be cautious about having all of your financial future in one basket.

Insurance: Insurance is a safety net. You will need multiple types of insurance besides home and car insurance. Remember because of your assets and income you are a target for some in the legal profession. One advice about the legal profession, it is sometimes best to seek their help when you do not need them. They can guide you to avoid later legal messes. Take the time to know what is the safest way to legally protect your assets from legal suits. Ask about insurances for disability and sickness both short term and long-term.

Retirement: Remember my comment about starting with a conclusion and writing a script that supports the conclusion. Have you thought of what kind of health insurance is available for your retirement, if you spend your late years in a nursing home? Prices go up as you get older. What are your options and how much would you pay in midcareer vs at the end of your career?

Taxes: Pay your income tax. Consider it part of your overhead. Be careful about marginal deductions especially if you are going to sit up at night thinking about an audit. Unless you are really good with numbers, the complexity of tax law and yearly changes promote hiring an accountant to do your taxes. Colleagues and financial advisors will know people who have expertise for small businesses and physicians.
Deferring your taxes is just that, deferring your taxes. You need to decide what type of person you are, one who can live with long-term deferred taxes or one who takes a balanced approach or one who wants to pay all taxes upfront as you go. There is no right answer. It is up to you to decide the approach.

Reassess: Take time each year to assess where you are financially and re-assess your financial plan. Again, make the time to do this. If your day job of being a doctor does not give you the time to sit down and do financial contemplation, you are in trouble because while money does not buy happiness having no money can make your life miserable.

Final total: To summarize the approach, managing your finances is very personal between you your family and those who give you financial advice. Do your research. Have qualified people assisting you. Follow the legal rules for finances, including paying your taxes. Given that your financial health plays a significant role in your emotional and physical health please strongly consider reviewing your financial status at least once per year. Try to have a long-term financial plan.

The next article will be on the role loneliness and connectedness and will conclude the ECP lifestyle series.  
Saturday, May 9, 2020 - Wild Horse Pass Conference Center, Chandler, Arizona

The date is set and the Education Committee is finalizing speakers for the 2020 Annual Meeting.  If you have a specific topic that your practice needs met, we would love to have that feedback.  Contact teri@azmed.org with your input.  Save May 9, 2020 on your calendar--you don't want to miss this meeting!