March-April 2019, Vol. 10, Issue 1
In This Issue


Jasleen Chhatwal, MBBS, MD, FAPA
Jason Curry, DO, FAPA
Newsletter Feature Editors

Greetings and welcome Spring! 

It's a great time to be outdoors for Arizonans. Speaking of getting outdoors, did you know that Arizona's very first psychiatrists were the mountains? It's true! Google it.
Sure, we may be known for our canyon, but let us give our mountains their due.  Unwaveringly  the Arizona mountain shadows stretch in the sun and dance in the moonlight. To be the mountain: the thing that always stands firm while it reaches beyond the horizon. The mountain is the keeper of stories and the teller of dreams - and really, is there anything more psychiatric than that?
The spring is not only a fabulous time for outdoors but also a vital time for building-community, and with many important upcoming events, such as our APS Annual Meeting this month (details below - register today) and the May APA Annual meeting in San Francisco, this is more than possible. This Spring Newsletter edition features the stories of many of your fellow psychiatrists venturing out and building-community; be it past APS President, Dr. Gurjot Marwah, and her health advocacy work in Cuba, or Dr. William Offenkrantz and his storied career, or Dr. Sneha Venkatraman and her experience of performing forensic psychological evaluations for asylum. 
We hope these stories are aspirational reminders to, "Get outside!" Join us. Meet your colleagues [be they mountains or otherwise] and let's do the work that brings communities together.
Premium Corporate Sponsor 2018-2019
From the APS ECP Risk Management Events
Thanks to members who contributed to the planning and joined in Phoenix and Tucson for the risk management education, "Minimizing Risk When Treating Suicidal and Violent Patients."  Photos in collage above (Clockwise from upper left): Phoenix City Grille attendees engaging; Lodge on the Desert; Tucson Drs. Jasleen Chhatwal and Jason Curry with Arizona health care attorney Christopher Smith, Esq. and featured faculty, Moira Wertheimer, RN, Esq., Allied World; Dr. Mona Amini, J. Arthur Eaves, Esq., Sanders and Parks, Arizona health care attorney, Ms. Moira Wertheimer, and Dr. Felicitas Koster; Tucson Lodge on the Desert attendees engaging.  

Mona Amini, MD, MBA, FAPA
Arizona Psychiatric Society, President

Dear Colleagues:

We all know well the importance of physician involvement in advocating for our practice and our patients. I recently participated in the APA Advocacy Conference in Washington, D.C. and in meeting with APA leadership and the health staffers from our elected Arizona Senators and Congressmen, I was profoundly impacted. I was able to witness, firsthand, the dedication of APA staff in carrying forward the aspirations of our membership in respect of physician wellness, patient safety, and practice protections, and the receptiveness and eagerness to hear the perspective of psychiatric physicians from our Arizona leadership. It was exciting to be joined by three Arizona residents, Drs. Heck, Kim, and Mecham, and to see their early career interest and commitment to advocacy.  I encourage you to read the perspective from Dr. Heck included in this Newsletter, and will be following up in the next issue with more from Drs. Kim and Mecham.  The Newsletter also includes links for you to become involved as a grassroot advocate by subscribing to the APA Congressional Advocacy Network, through which you will receive action alerts and be encouraged to develop personal relationships with our Arizona Senators and Representatives.

I look forward to an exciting Annual Meeting at the Hilton Scottsdale on April 27-28, 2019, and hope that if you have not already done so that you will register to join us (and share the meeting information with a peer or colleague as well).  It has been a goal of our Planning Committee, and a personal wish of mine, to have the Annual Meeting be accommodating to the lives and schedules of our members.  As a result, you will note that this year there are some changes to the structure of the Annual Meeting that we hope you will find to be an improvement:
  • First, the Friday social has moved to the end of the educational day on Saturday, and you are welcome to have a guest join you for the same.  
  • Second, the education on Saturday will start at 8:50 am (from 7:50 am), and will conclude early enough for the social hour to begin just after 5:00 pm. 
  • Third, an additional Sunday session is available, made possible through a grant partnership, that will provide 3.0 hours live opioid prescriber education (helping our members satisfy the State of Arizona opioid education licensure requirement).  
Further to our goals, the Saturday scientific session includes topics of a variety of interest, including physician safety, learning disabilities over the lifetime, work-life balance improvements possible through the use of technology, the change in work culture, telepsychiatry, and current update on psychopharmacology, presented by a variety of Arizona and national speakers who are experts in their fields.

Happy Spring, and hope to greet you soon in our Annual Meeting!


great turn-out and an afternoon of collegial exchange and connection was enjoyed at the Women's Group in Psychiatry 3rd Annual Afternoon Tea at Arcadia Farms on March 3, 2019.  Thanks to event sponsors, American Professional Agency, Inc. and Meadows Behavioral Healthcare, for making this favorite traditional event possible.  For more information about the Women's Group and future events, please contact teri@azmed.org or Dr. Mona Amini, Women's Group Chair and APS President.  
REGISTER TODAY for the Arizona Psychiatric Society Annual Meeting, "Psychiatric Update 2019," to be held April 27-28, 2019 at the Hilton Scottsdale, 6333 North Scottsdale Road, Scottsdale, Arizona.  Join us for the great updates planned for the Saturday session, which will start with breakfast at 8 am and Welcome at 8:50 am; join in the business meeting and celebrate Society awards recognizing excellence in psychiatry (see the profile below from Dr. William Offenkrantz, 2019 Career Achievement in Psychiatry Award recipient); stay for the social reception at the conclusion of Saturday; and come back on Sunday for a grant-sponsored opioid education session.  The Sunday session is included in the Annual Meeting registration.  APS Members attend for FREE; AACAP and ArMA members receive a substantial courtesy discount.  CLICK HERE for a printable brochure to review and register online or for a paper registration form.  If you would like assistance with registering, please e-mail or call Teri (teri@azmed.org, 602-347-6903).

The Annual Meeting includes a "best of" poster presentation opportunity for Resident-Fellow Members and Medical Students that is juried for scholarship prizes and a physician peer poster presentation opportunity that is peer evaluated for gift card recognition.  The Invitation, Guidelines for RFM and Medical Students, and Guidelines for Physician Peer Posters are available here.  
Visit  https://www.surveymonkey.com/r/APSPosters2019 to submit your a bstract of 3000 characters or less on or before April 15, 2019.    
Dr. William Offenkrantz

2019 Recipient of the Arizona Psychiatric Society Career Achievement in Psychiatry Award

The Society thanks Dr. Offenkrantz for sharing this personal profile.  We look forward to honoring his contributions to psychiatry in our community at the 2019 Annual Meeting.
I have been actively involved in trying to solve my own problems since my father died when I was 13, as a result of botched surgery for his nephrolithiasis. From personal experience, I subscribe to the psychoanalytic literature by Joan Fleming and her colleagues about the syndrome of parent loss. My 14-year older brother was a physician and a graduate of Columbia U. College of P & S. He helped me to matriculate there for my MD., but my choice of psychiatry was a consequence of my problems in daily living.

I had residency training in Psychiatry at the Veterans Administration Hospital, Lyons, NJ 1947-1950 and New York State Psychiatric Institute/Columbia University 1950-1951. In 1951, I started full time private practice. I was appointed Director of Psychiatric Residency Training at the U. of Chicago from 1957 to 1970, and tenured Professor until 1979, when I moved to Milwaukee.

I completed my first psychoanalytic training program at the William Alanson White Institute in New York City in 1957. I subsequently completed a 2nd full course of Psan. Training at the Chicago Psan. Institute in 1966. With my 2 diplomas, I have been a member of the American Psychoanalytic Association since 1968. My psychoanalytic practice has been strongly influenced by Heinz Kohut and my analyst, Maxwell Gitelson.
A valuable experience that occurred at the U. of Chicago was the result of my research collaboration with Arnold Tobin. We required our private patients to spend 3 nights a year in the U of C Sleep Laboratory. Their REM (Rapid Eye Movement) sleep was recorded all night and a technician awakened them at the end of each dream episode to recount their dream. Dr. Tobin and I worked with the patient's Sleep Lab dreams just as we did with dreams reported spontaneously in our regular therapy sessions. At that time, a prominent theory was that childhood mental disorders could be caused by "Primal Scenes," as the traumatic result of the child observing parental sexual intercourse.

As a result of our work together, Dr. Tobin and I came to believe that primal scenes, instead of resulting from external trauma, are (in the form of fantasies) a regular, inevitable part of every child's cognitive and emotional development. In other words, every child tries to soothe his/her pain at feeling left out of the parents ordinary, daily interactions by unconsciously projecting the fantasy that the parents' minds are as primitive as the child's own. Then the child can identify with one or the other parent and no longer feels left out. Subsequently, the child responds to parental caresses and punishments by fantasying them to have been seductions and assaults. This is both because such perceptions are an inevitable result of the child's primitive emotionality, and also because it increases the intensity of the fantasy of the parent's involvement with the child. We believe those who share the external viewpoint need to take these ideas into account when drawing conclusions about "traumatic external events" as the primary cause of neurosis. That viewpoint contrasts with ours, which emphasizes what the child does in an age-appropriate way, even with their perceptions of parents who interact with each other and with the child in average expectable non-neurotic ways.
Dr. Tobin's and my work together resulted in several publications in the psan. Literature.

In 1979, I left the University of Chicago to become Professor of Psychoanalysis at the Medical College of Wisconsin in Milwaukee. I also helped start a Psychoanalytic Institute there that is still functioning and healthy.

In 1987, Dr. Gustavo Lage lured me to Scottsdale where I was keen to have more opportunity to play tennis outdoors, to start a private practice in Arizona, and to teach psychotherapy to Psychiatry residents. I had been recruited by Dr. Robert St. John, the Psychiatry Residency Director at Maricopa County Medical Center, to become the supervisor for psychotherapy training in that program.

A person who enters psychotherapy with me must be willing to embark on a voyage of discovery. Namely: of the conflict of forces within their mind, either or both of which are yet to be discovered. If a Resident doctor is the patient's therapist, he/she must learn to use empathy instead of sympathy. That is: become a therapist who can taste the patient's emotions and talk about them without swallowing them whole and identifying with them.

I am glad that the field of Psychiatry is more integrated with Medicine then it was when Psychoanalysis formed a major conceptual framework, and the neurobiological advances in our field are very exciting. However, it is worth remembering the up-to-date importance of empathy in successful clinical work and important to learn how to respond skillfully to inevitable empathic failures. Even if we know the diagnosis, the correct medication or procedure, the CBT or mindfulness approach, none of this makes a difference if we don't know the difference between understanding patients empathically versus what happens when we inadvertently fail to do so.

I am still actively practicing, and every day that I go to work I'm anticipating learning something new from a patient or a colleague.... or being reminded of something I should have remembered from long ago, like the therapeutic use of the countertransference.

Or of something new in the field, like the recent discovery of "anxiety cells" in the ventral portion of the hippocampus and their axonal connections to regulatory nuclei in the midbrain. The exciting possibility is a familiar one: a precise pharmacotherapy to help patients cope with disabling anxiety, while their psychoanalytically oriented psychotherapy helps them learn how the past is still alive in the present.
And how a sense of humor is indispensable in achieving a healthy integration of both worlds.

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A Resident Perspective

Sneha Venkatraman, MD, PGY-III
The University of Arizona College of Medicine, Tucson
Noshene E. Ranjbar, MD,
Assistant Professor, Psychiatry
Director, Division of Child and Adolescent Psychiatry
Director, Child and Adolescent Psychiatry Fellowship Training Program
The University of Arizona College of Medicine - Tucson
I had the opportunity to travel to Eloy Detention Center to complete a psychological evaluation for asylum on January 17, 2019. Our team consisted of Dr. Noshene Ranjbar, the Child and Adolescent Psychiatry Fellowship director and my Integrative Psychiatry Clinic supervisor at the University of Arizona, Dr. Kiran Chaudhary from Lake Erie College of Medicine Psychiatry Residency, and myself.

Prior to our trip, we prepared by creating a shared Dropbox including files on assessment templates and helpful information for conducting forensic psychological evaluations. On the one-hour car ride from Tucson to Eloy, we discussed ways to approach the evaluation and reviewed a sample psychological evaluation.  As a third-year psychiatry resident at the University of Arizona, I noted some differences from a standard psychiatric evaluation in the hospital/outpatient setting. The level of detail required in the forensic psychological evaluation reports, often exceeding ten pages, was much more extensive than assessments I had done in the past. We also processed the importance of holding space for the individual and the implementation of relaxation techniques during the interview as needed.
As we took an exit off the highway, miles of bright green farmland and not much else greeted us before we turned into the Eloy Detention Center, a light gray building not too formidable in the morning light. A TSA-like security process allowed us to enter the detention center. The staff were friendly and accommodating throughout the process, asking if we wanted a quieter room for the psychological assessment even prior to our arrival.
The strength with which our client told her difficult story pervaded the two-hour interview. A compassionate interpreter and our own broken Spanish skills allowed for us to hear her story in her own mother tongue. Her practice of weaving baskets from straw to help pass time, even while in detention, helped connect her to her cultural roots. Perhaps it also symbolized hope of one day gifting them to her young grandchildren if she were to be granted asylum. Wearing our hats as psychiatrists evaluating her mental health condition, we were given a glimpse into her profound resilience throughout the detaining process and her life. Visualizing the patient's life in her home country - the day to day happenings, the difficulties, and the personal relationships-was incredibly pertinent to the evaluation as we could begin to form a picture of the client's way of life prior to entering the United States.  Observing the nuances of the patient's speech and the way she described her former life allowed for a higher level of learning from a single case. The amount of time spent with our client, and the richness of the mental status exam stood out to me.
Helping to lead a forensic evaluation training workshop sponsored by the Arizona Asylum Network in September 2018 had prepared me for some aspects of the experience. It had included training on utilization of a trauma-informed approach, discussion of cultural considerations, as well as an introduction to the team dynamic of working closely with the public defense lawyer. However, meeting with our client in person and hearing her powerful story added a whole new dimension to what a forensic evaluation can entail.
Completing a psychological evaluation for asylum allowed me to participate in our rich Arizona community for a well-rounded training experience during psychiatry residency. Our team noted a healing and energizing effect of this journey after returning to our day-to-day work responsibilities in Tucson. This experience was inspirational and humbling with a sense of meaningful connectedness to the Arizona community we live in. I hope to continue learning about and working with the local issues of Arizona and am grateful for the opportunities to do so during my psychiatry residency.
Washington, D.C., March 11-12, 2019

APS President, Dr. Mona Amini, together with RFM members and fellow physician advocates, Drs. Maya Heck, Edwin Kim, and Stephen (Larry) Mecham attended the APA Advocacy Conference in Washington, DC, which event included physician training, exercises in grassroots advocacy, and visits with the Health Care staff for Senators Kyrsten Sinema, Martha McSally, and Representative Greg Stanton, and a visit with Representative David Schweikert.  You can also make a difference in advocating for issues relating to psychiatry and access to care by joining the APA Congressional Advocacy Network (subscribing for APA advocacy action alerts and committing to becoming engaged with the Senator or Representative from your legislative district) and by contributing to the APAPAC.  In this and upcoming Newsletters, we will share feedback from these members on their experience at the Advocacy Conference.  

Reflection on the Advocacy Conference: 
RFM Co-Representative, Dr. Maya Heck  

This trip to the Capitol was my first experience in advocacy, and I truly enjoyed every minute of it! I was surprised and also encouraged by the in-depth knowledge that the legislators and staffers already had on significant mental health issues. It was clear to me that mental health topics are finally getting the attention they deserve. I came away feeling inspired that our presence and discussions with the legislators could truly make a difference in the lives of many patients.


Joseph F. Abate, Esq.
APS Lobbyist

Gretchen Alexander, MD
APS Legislative Chair

The 2019 session brought new challenges for the health care industry, including the new voluntary Sunrise process for scope of practice and an onslaught of health care related legislation brought on by changes in the world around us. The 2019 session saw more healthcare-related bills drop than in preceding years by far.

Helping physicians manage a successful timeline towards compliance with the ePrescribing requirements of the Governor's 2018 Opioid Act, the session began with HB2075, signed into law to allow extension of the e-prescribing mandate through next year. Representative Regina Cobb and Senator Heather Carter advanced identical bills on this issue on an expedited basis.

Early in the session, legislation was introduced to protect and preserve KidsCare funding, which had widespread support from within and outside of the physician community.
The Sunrise deadline moved to November 1st under the new guidelines, and those applications relevant to psychiatric physicians included:
  • HB2548 (later Striker HB 2494) seeking expanded prescribing authority for pharmacists - After prolonged oppositional efforts led by the Arizona Medical Association and Arizona Osteopathic Medical Association, the pharmacists agreed to kill this bill and negotiated a compromise on HB2060 that allows pharmacists to provide 7-day emergency refills if certain criteria are met.
  • HB2068 sought prescribing authority for Clinical Nurse Specialists, within a defined health care facility and within the protocols prescribed by the facility. The Society stood opposed to this legislation. CLICK HERE to read the letter from the APA on our behalf of our members on this issue. The Nurses Association foundation argument was a cross-walk of equivalency between CNS education and APRN education. This legislation has moved forward out of both the House and Senate Health Committees. It is expected to be adopted, but final vote in the Senate has yet to occur.
  • HB2519 sought to change from physician supervision to physician collaboration by physician assistants. After negotiations with physician organizations, lead by ArMA and AOMA, the physician assistants agreed to leave the supervision relation intact in exchange for an agreement to allow a physician to supervise up to six physician assistants (up from four previously).  
With thanks to Dr. Gretchen Alexander, Chair of the Legislative Committee, and Dr. Jack Potts, past Chair of the Legislative Committee, for testifying in support of the same, three Bills introduced to provide expanded housing and support to homeless, families, youth, and the seriously mental ill made it out during the last full week of Committee hearings of the House Ways & Means Committee (SB1471) and the House Health & Human Services Committee (SB1098 and SB1336). CLICK HERE to read the testimony prepared by Dr. Alexander with contributions from Dr. Carol Olson.

The Society signed on to a stakeholder letter in support of retaining the current protections of vaccination. Three version of legislation introduced in this session found Arizona in the national spotlight over the introduced anti-vaccination legislation. APS and ArMA member, Dr. Stephen Herman, a forensic child psychiatrist, was among the physicians who testified to ask to protect vaccinations and oppose the legislations. Although the three Bills advanced out of the House Health and Human Services Committee, the Senate Health and Human Services Chair Senator Brophy McGee stated that the Committee would not hear any vaccination bills this session, and Governor Ducey announced his intention to veto any anti-vaccination legislation that advanced to his office.

The Society also joined fellow stakeholder organizations in support of HB2148 (replaced by striker amendment HB2718) for safe syringe exchange programs. Currently, it looks like the Bill is not advancing to a vote.

The Society supported SB1354 which would provide additional graduate medical education funding in the State of Arizona from AHCCCS.

There were many different forms of marijuana legislation introduced that concerned the Society; however, the current law requires adoption of any legislation regarding marijuana to be approved by a three-quarters majority, so these legislative efforts will not advance.

The legislative session is wrapping up now and the only bills remaining to be heard in Committee will be striker amendments and bills from budget or appropriations. One such bill, striker Amendment to HB2550 on the regulation of Kratom products, passed out of the Senate Appropriations Committee this week, 9-0. The bill establishes requirements and prohibitions related to the preparation, distribution, and sale of kratom products, and authorizes the Director of ADHS to impose a civil penalty against a kratom product dealer who violates prescribed regulations.

If you would like any additional information regarding the legislative session, please contact the APS Lobbyist, Joe Abate, at 602-380-8337. If you are interested in being a part of the Legislative Committee of APS, chaired by Dr. Gretchen Alexander, please contact teri@azmed.org.

For more information on health care legislation relevant to psychiatry included in the 2019 legislative session, see the Bill Summaries provided in the full Report.
March 9-10, 2019, Boise, Idaho

Payam Sadr, MD, DFAPA, Arizona Assembly Representative
Jason Curry, DO, FAPA, Arizona Assembly Representative (Alternate)
Jasleen Chhatwal, MD, MBBS, FAPA, Area VII ECP Deputy Representative

APA Area 7 Representatives met in Boise, Idaho on March 9-10, 2019.  Arizona members in attendance included Dr. Payam Sadr and Dr. Jason Curry, as Arizona Assembly Representatives, and Dr. Chhatwal, as Area 7 ECP Deputy Representative.  READ THE FULL MINUTES here, including important updates from the APA including a discussion of moving the 2021 APA Annual Meeting site to Los Angeles, California to make it more accessible and affordable to the membership.  To support outreach to the Hawaii District Branch, the Area 7 applied for funding to hold the Area 7 August 2019 meeting in Honolulu.  Scope of practice, parity, access to care, and maintenance of certification continue to be key issues for Area 7.  Tim Miller, Regional Director, reported on APA participation in group stakeholder letter asking federal government to fund research into firearm injury; Senate request for more residency positions funding; 42 CFR issues, among other matters.  
The First in a Series of Three Articles

Gurjot J. Marwah, MD, FAPA
Past President, Arizona Psychiatric Society
Founder of Healing Minds, PLC
Tempe, Arizona

Nothing prepared me for what to expect as I arrived in Cuba's capital Havana on a mostly empty Southwest Airlines (Yes! Southwest) flight on a warm October day recently-a flight that landed way too soon after it took off from Fort Lauterdale . The weather was warm, as was the welcome by our English- speaking driver who drove us past large roundabouts with large statues of military heroes (conspicuously missing were any statues of Fidel Castro) lined with lush palm trees. The bus drove us past the famed US embassy in Havana, a large forbidding concrete structure with a lone guard outside, to a hotel next to it. 
The place was indeed stuck in a time capsule where old American cars in hot pink color zoomed past you with eagerly waving tourists as I strolled leisurely on the wall that Cuba built by the ocean. A group of 7-10- year old boys were discussing the neighborhood politics--no cell phones, no fancy playing gadgets, while leaning over someone's prized possession, a bright green American 1950s Ford, the paint touched up on the doors, clearly evident to a careful eye. Two of the boys were ignoring the loud shouts of their mothers over a balcony as several were being summoned that it was time to come home. 

My  visit to Cuba was organized by Gail Reed, the American executive editor of the health journal  Medicc  Review , which focuses on Cuban health care. "So, there is something to be said for Cuba's building of a national primary-care network that posts health professionals in neighborhoods nationwide."
On our first day - along with five other US physicians, we visited the neighborhood clinic, which was called Policlinico Docente Vedado, a family medicine clinic that serves about 900 people. There are 450 such clinics in all of Cuba to serve its 12 million population. Anybody can walk to the clinic whether they have a sore throat, chest pain, or need to set up for knee surgery. The clinic had multiple side-by-side rooms for referrals. The patient waiting room was decorated with large modern paintings interspersed with photos, and a photo of a heavily armed Fidel Castro loomed over a meeting room in the clinic. Talking about guns, that was the ONLY gun that I saw on my entire trip, in photos of Castro and Chavez and other Cuban revolutionaries (even the police did not carry any weapons).
The major strength of the Cuban healthcare system is that it assures universal access for all AND is completely free. Cuba has the Medicare for All that many Americans dream about. The focus is on prevention and management of noncommunicable diseases like Diabetes, Hypertension, and Obesity. Doctors make frequent housecalls. Home visits are also a chance to reach elderly and disabled people, to coach families about lifestyle changes, and to work on  prevention

With infant mortality at 4 deaths per 1000 live births, it is significantly lower than US at 5.1. Doctor-to-patient ratio in Cuba is among the world's highest at 127 inhabitants per physician; the most heartening fact was that 61% of all physicians are women.
In Cuba, a nation of 11 million people with a universal health system, the consultorios, or family doctor-and-nurse offices, located in every neighborhood across the country, form the backbone of primary care. Each office is staffed by a family doctor-and-nurse team responsible for a catchment area of up to 1500 people. These family physicians, under the country's universal education system, graduate debt-free and are required to complete a two-year residency in comprehensive general medicine 
(family medicine) before pursuing a second specialty. the Family Doctor-and-Nurse Program was piloted in Havana in 1983.  I was pleasantly surprised to know that these physicians lived above the consultorios -  to better provide integrated, comprehensive primary care based on easy access and an annual neighborhood health assessment. 
The family doctor-and-nurse model was then extended throughout Cuba, reaching the most remote areas, until finally reaching the whole population. As the program grew, it became impractical to locate every doctor's residence in the same building as the consultorio. Although this model is still found in many neighborhoods, today some physicians, live within a block or two of their consultorio instead of directly above it. 
Each consultorio refers patients to and is supervised by a multispecialty, multiservice clinic called a polyclinic. Also based in the community, polyclinics offer diagnostic procedures, laboratory testing, dentistry, physical therapy, natural and traditional medicine consultations and primary care specialties such as internal medicine, pediatrics, psychiatry and ob-gyn. Each of Cuba's 451 polyclinics supervises a maximum of 30 consultorios and provides services for between 20,000 and 60,000 patients. Evaluating Community Health to Improve Health, The CARE process, which is dynamic and ongoing, and an annual neighborhood analysis together provide a snapshot of the health of each community and the individuals within it. These tools serve as the evidence base for family doctors (and inform the health analyses of their corresponding polyclinics) to tailor services to the specific needs of their catchment area. 
Although national health priorities, programs, and guidelines are established and implemented by Cuba's Ministry of Public Health (MINSAP), regular analyses of disease burden, risk factors and social determinants of health at the local level empower primary care providers to prioritize and tailor health 
promotion messages and disease prevention, diagnosis and treatment, and rehabilitation services.
These assessments categorize individuals in four groups:
Group I:    Apparently healthy individuals
Group II:  At-risk individuals who may develop health problems due to risk exposure at home or work
Group III:  Sick individuals, including those with chronic, communicable or non-communicable diseases
Group IV:  Disabled or otherwise incapacitated (temporarily or permanently) individuals suffering from disruption of their motor, functional, sensory or mental capacities
Categorizing individuals thus enables their providers to design follow-up and treatment plans. 

All family doctors and nurses in Cuba, are required to conduct assessments of individuals in Group I once a year, in Groups II and IV twice annually, and in Group III three times.[2] "One of the  reasons I love family medicine is that it allows you to customize care for each person," said Dr Díaz, who serves the polyclinic our group visited.   The Cuban healthcare system, borne out of its revolutionary socialist ideology, regards accessibility to healthcare as a fundamental right of its citizens. It focuses heavily on a preventative approach to medicine and offering the simplest check-up to the most complex surgery, free of charge. Dental care, medicines and even home visits from doctors are all covered by the system. 

Cuba is poor, has no fancy restaurants or malls, but in healthcare it does an impressive job. The Cuban healthcare system is often stated as one of Fidel Castro's greatest achievements. Borne out of its revolutionary socialist ideology, regarding accessibility to healthcare as a fundamental right of its citizens. It focuses heavily on a preventative approach to medicine and offering the simplest check-up to the most complex surgery, free of charge. Dental care, medicines and even home visits from doctors are all covered by the system. 

Cuba regularly screens all women for breast and cervical cancer, so it is excellent at finding cancers - but then it lacks enough machines for radiation treatment. On the contrary, in the United States, many women don't get regular screenings, as they do not have a PCP or a gynecologist, or don't get reminders to make their annual appointment. Some may have personal and religious reasons not to see doctors, so cancers may be discovered late in the US, but then there are advanced treatment options.

Gail shared a story about her nurse, who last year, upon recognizing that Gail had missed her annual pap exam, walked all the way to the end of the neighborhood where they both live, climbed several flights of stairs to her third-story apartment in old Havana and knocked fiercely. "Gail - now this is not what I expected of you--to miss your exam appointment," she reprimanded her, and then, over a cup of Cuban coffee, they shared stories about their sons, and then walked together back to the clinic, on the way making short stopovers to greet other neighbors. Back at the clinic, not only did Gail got her exam, but also picked up her refill (free) from the pharmacy located in the polyclinic.  Something to be said about a missed appointment and make a non-compliant patient compliant.

Talk about making a non-compliant patient compliant for life.


https://www.bbc.com/news/health-35073966 "Prevention Better than Cure in Cuban Healthcare System," Fiona Hill, Health Check, BBC World Service, 13 December 2015.

(The Arizona Psychiatric Society thanks Dr. Marwah for sharing her experiences and insights in to the health care system, the culture, and the people of Cuba. This is the first of three installments she is writing for our members in this series, and we look forward to the next!)

Announcement of Arizona Psychiatric Society  Newest Life Members:

The following members of the Arizona Psychiatric Society were recognized by the APA for reaching the following Life membership status (at the May 2019 APA Annual Meeting):

Mohammad Bhatti, MD, LFAPA
Karnail Dhillon, MD, LFAPA
Patricia Fangohr, MD, LAPA
Richard Gottlieb, MD, DLFAPA
Linda Kalivas, MD, LFAPA
Dheerendranath Raikhelkar, MD, LAPA
Randall Ricardi, DO, DLFAPA
Robin Ross, MD, DLFAPA
Douglas Stockwell, MD, LFAPA

50-Year Members:
Of special note, we recognize the following members who achieved the
pinnacle of 50-Year Members in the APA as of January 2019:

James M. Campbell, MD, LAPA
James Ernest Campbell, MD, LAPA
Bruce R. Holzman, MD, LAPA

These members will be acknowledged in the Convocation at the 2019 APA
Annual Meeting.

We recognize these Society members for their years of dedicated service to
the APA and the Society and to their contributions to the field of
psychiatry and the enrichment of our mental health community.

Thank you to each of the Arizona Psychiatric Residency Programs for welcoming the Arizona Psychiatric Society in the fall and at the beginning of the year to their campuses for a chance to discuss the importance of physician advocacy and protecting the profession of psychiatry and supporting mental health parity now and into the future.  We celebrate (photographed above) the University of Arizona College of Medicine - Phoenix Psychiatry Residency Program at Banner - University Medical Center Phoenix for achieving 100% Club status in the American Psychiatric Association/Arizona Psychiatric Society.  

For those who attended the APS 2018 Annual Meeting and were interested in the presentation on evolutionary psychiatry by Randolph Nesse, MD from the Arizona State University Center for Evolution and Medicine, the USA launch for Dr. Nesse's new book, "Good Reasons for Bad Feelings: Insights from the Frontier of Evolutionary Psychiatry," happened on April 2, 2019. The book argues that evolutionary biology provides a missing foundation for psychiatry that can resolve persistent controversies and lead to new research and treatments. At the launch, Dr. Nesse provided a brief overview, then three distinguished panelists (Dr. Nesse, Dr. Douglas Kenrick, Dr. Joan Silk, and Dr. Cynthia Stonnington) addressed the question "Can Evolutionary Thinking Improve Psychiatric Treatment?"  The event was live-streamed and the archived video is available for viewing at https://evmed.asu.edu/video.  

Sign-up today for the 2019 premier integrative mental health conference, April 15-17th in San Francisco! Learn from 35 internationally renowned experts, including best-selling authors, award-winning physicians, researchers and professors.

Integrative methods to enhance mental well-being will be taught by speakers such as: Dr. Jasleen Chhatwal, Dr. Andrew Weil, Dr. Gabor Maté , Dr. Christopher Palmer, Dr. Charles Raison, Michael Pollan, Dr. Richard Davidson, Dr. Dale Bredesen, Dr. Judson Brewer, Dr. Sonja Lyubomirsky, and Dr. Andrew Newberg.   Learn about the latest advances in topics such as:   Mind-body connections, sleep disorders, spirituality, mindfulness, diet and nutritional supplements, integrative practice models, imagery, brain biology, microbiome, the new science of psychedelics and what it means for mental health care, positive psychology, addiction and trauma.

Visit www.imhc2019.com for more details and to register. Follow @AzCIM on Facebook and Twitter for event updates and exciting announcements. Use code AZPSYCHIATRYSOCIETY to save 10% off registration.

REGISTER AHEAD FOR THE MAY 4, 2019 TUCSON CLIMB OUT OF DARKNESS.  Come out on May 4, 2019 to the Brandi Fenton Memorial Park in Tucson to help support  Tucson Postpartum Depression Coalition and raise awareness about perinatal mood and anxiety disorders.  CLICK HERE for a full flyer about the event and post-partum depression resources.  

REGISTER TODAY to join Mental Health America of Arizona (MHA AZ) at its 25th Annual SEEDS conference on May 22, 2019 at Glendale Community College, during National Mental Health Awareness Month. This year's conference theme, #NextGen:B4STAGE4 will build collaborative partnerships that promote the mental health, resilience and self- determination of young adults. There is also an opportunity to register for an optional Mental Health First Aid or Youth Mental Health First Aid Training on May 23, 2019.  

APA free education highlight
APA MEMBER APRIL COURSE OF THE MONTH  - Complementary and Integrative Approaches to Autism Spectrum Disorder
Autism Spectrum Disorders (ASD) are common and complex neurodevelopmental disorders which may present at different stages with different target symptoms. This course discusses how families often utilize complementary and integrative treatments for ASD, the evidence for such use, and risks and benefits of these treatments. Presented by Robert Lee Hendren, D.O., University of California, San Francisco School of Medicine.    Click here to access the Course of the Month and sign up for updates about this free member benefit.

Banner Grand Rounds for the Department of Psychiatry, University of Arizona Colleage of Medicine - Phoenix at Banner-University Medical Center Phoenix:  Every Friday in April, except April 26, 2019, 12:00 Noon to 1:00 pm, Medical Education Amphitheatre (April topics include Trichotillomania and Other Body Focused Repetitive Behaviors, Couples Behavioral Therapy in the Treatment of Substance Abuse, and Emotional Intelligence) (CLICK HERE for April Flyer with more details).  
February 14-16, 2019
Las Vegas, Nevada

Brian Espinoza MD FAPA
Interventional Psychiatry

Dr. Espinoza shares with us his third report from this annual conference and his twelvth year in attendance. Sponsored by the Nevada Psychiatric Association, a District Branch of the APA, this conference remains the largest Psychopharmacology Conference in the country. 

From anxiety disorders and bipolar disorders to medical treatment of ADHD over the lifespan, a session on PTSD (with featured speaker Dr. Murray Stein), neuropsychiatric management of Parkinson's, and other psychopharmacological updates, to review the highlight notes from the workshops attended, please CLICK HERE.

Next Report: Massachusetts General Hospital Psychiatry Academy Child and Adolescent Psychopharmacology 2019, Ko Olin, Hawaii; March 15-17, 2019.  
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Hoi An Vietnam photo by Dr. Robin T. Reesal

Part I:  New Reality

Robin T. Reesal, MD, FAPA, 
Psychiatrist and Educator
A goal of this column is to assist early career psychiatrists with their quest for good health. They face a different work-home reality than their baby boomer colleagues; therefore, new solutions are needed for health and wellness.

Baby boomer careers tend to revolve around qualities of long work hours with the concept of "first in and last out" having a strong influence on their lives. An early career psychiatrist who discards this approach can foster erroneous thoughts by older colleagues that they are less devoted to our profession. An emphasis on self-sacrifice, with the moto "career first and personal life second", has roamed the halls of teaching hospitals for many years. For boomers, a sense of self and professional identity may be inseparable. Invincibility is a key feature of this culture that is frequently married to shame-based learning. Fear and intimidation are tactics used to "promote excellence" among this generation of physicians. Within this code, working long hours and having high volume caseloads are seen as a rite of passage, "I did it, so why shouldn't you?"
The baby boomer culture and lifestyle patterns are a difficult fit for early career psychiatrist and their families. Here is why. Post boomer work life balance expectations have changed. Spouses are expected to participate and share equally with childrearing and domestic responsibilities. A career is less likely to define an individual as it once did. Early career psychiatrists want to provide the best service possible. Their quest for clinical excellence has not changed from past generations. But, they seek a different path in a rapidly changing social environment to achieve these goals.    

Technology is transforming how people work. Younger professionals are more accepting of technology to work in different settings and at varied hours. Home and work borders are more porous and fluid because of a 24/7 societal approach. Younger generations of workers have grown up with technology as part of their lives versus an imposed necessity. All of this means they work differently from their older peers and the context of their work is different from the past.

Large case volumes and open-ended work hours for face to face services at one physical location are less of a fit for younger psychiatrists and their families. Early career psychiatrists have less workplace autonomy and control than earlier generations. Therefore, early career psychiatrists are faced with the dilemma of lifestyle preservation for themselves and their families versus adherence to a corporate medical culture that emphasizes devotion to the workplace and patients, at all costs. This is not an easy balancing act.  

The daily need to adhere to legal expectations versus medical expectations is higher than it was in the past. Checks and reviews are more frequent and critical. For example, progress notes are written for to fulfill audits and legal expectations with an emphasis on writing all that was done versus writing the relevant positive findings. The work environment and the patients we serve are less understanding of medical errors. Blame seems to be a necessity for negative outcomes. The perception of medicine as an imperfect science is fading. Expectations are higher and "thank you's" seem to be less.

Solutions and ideas

Not alone: Changes to healthcare systems worldwide are having a negative effect on physicians resulting in higher rates of burnout, depression and anxiety. Medical systems are in flux and its professionals are feeling the stress of this chaos.

Peer pressure: Live a life that brings you and your family health and happiness. I cannot count the number of employees that were "used up" by their workplace. Years later they regret the lack of integrating family and a personal life due to career devotion. Doing what is best for you is not selfish or narcissistic. Rather, workplaces can be selfish by making sure their needs are met at any cost.

Not enough time: "I do not have enough time to take care of myself..." Really? Not enough time to take care of your own health? How much can be done for others if you lose your health? When you lose your, health, you lose your income, you cannot fulfill your roles, you mortgage your future and you are less likely to be happy. You can make some time management changes.

Daily: Consider having a quiet family half hour or hour each evening. Again, out of 24 hours it is hard to believe you cannot re-allocate this time for personal use. This contemplative time allows for planning, organizing, prioritizing and reconciling daily conflicts and stressors. You can use relaxation techniques and meditation to enter this mindset which helps slow time down.

Weekly or every few weeks: Take short "time outs" from the daily grind every few weeks. This can be as simple as a few hours at a spa, working on a hobby or playing a sport. Find the amount of time that fits with your schedule that allows for replication of the activity. Establishing a pattern that allows you and others to make this pattern a "normal" part of your life. If you can only spare an hour then take that. Disconnecting from your routine is the key.

Every four to six months: Leave the city for personal time, couple time or family time. Leaving your home environment forces your brain to move out work and time pressure mode. You may have to check emails for a brief part of the day to ease your mind from facing hundreds of emails upon your return. Total disconnection is better, but take what you can get. You can plan these trips for the year, to insure they take place, or you can plan the next trip shortly after your return from your last trip.

That's it for today. Next time, solutions will include managing information overload, financial stress and social connectedness.

If you missed the 2019 Dues Renewal Date of 2019, you can administratively reinstate your membership with minimal interruption by acting today!   If you have not already renewed your APA membership for 2019, you can reinstate by paying your dues.  If you need assistance doing so, please contact Brittany Hipple, the APA Membership Coordinator for Arizona, or Teri for assistance.  
Your membership is important to our efforts.  Thank you for being a member.

Quality Measures Initiative
Join APA in the development of new quality measures with PsychPRO and receive:
  • A small honorarium for your efforts ($500)
  • A tablet computer for easy patient online portal access to complete required assessments
  • For APA non-members, free registration for the registry
  • Acknowledgement in publications and white papers
  • And more
CLICK HERE FOR MORE INFORMATION.  All behavioral health providers across the United States, including those in solo practices, small and large group practices, health care systems, and academic institutions are eligible to participate.