Ariana Nesbit, MD

Is organized medicine really on the decline? As more nursing and other allied organizations are growing and becoming more politically active, what is happening to membership in physician organizations? Given the increasing stressors of the COVID-19 pandemic, gun violence, physician wellbeing, rising health care costs, the scope of practice issues, and government intrusion on medical decision making, this is a time when physicians, the field, and our patients need help more than ever. Is there still strength in numbers?

According to the 2018 Survey of America’s Physicians: Practice Patterns and Perspectives, 80% of physicians were at full capacity or overextended, and 78% sometimes or always experienced burnout.

 The COVID-19 pandemic has only worsened these statistics. One 2021 study reported that rates of US physician burnout during the first year of the pandemic increased over time among 4 of 5 frontline specialties, with the greatest increases among hospitalist and primary care respondents.

 Organized medicine and specialty organizations are key pillars of support for individual physicians that provide opportunities to advocate for more funding and resources for our medical system and education.

In the 1950s, about 75% of all practicing physicians in the United States were members of the American Medical Association (AMA).

 According to a December 2016 article by 

 online, AMA membership was representative of about one-sixth of the nation’s physicians.

 Subsequently, the AMA has intentionally worked on representing its members and patients through strategic work on 3 core pillars of advocacy, innovation, and equity, which has helped fuel 10 consecutive years of membership growth with a 35% cumulative increase in members from 2011 to 2021.

Each year when the American Psychiatric Association (APA) membership dues come into members’ inboxes, there are always complaints about the ever-increasing price of membership. With practice expenses and conference fees, along with membership dues, we again ask ourselves, 

“Why are we APA members? What are we paying for?” 

The question comes up year after year. APA membership showed a 14% growth from 2013 to 2018,

 but most recently membership count through year-end 2020 declined 3.6% from the previous year, from 38,799 to 37,420 (

Of note, involvement of members has been an additional issue, as only 19.39% of eligible APA members voted in the 2021 APA election.

APA’s recent decrease in membership is thought to be primarily due to the impact of the COVID-19 pandemic. In the busy world of psychiatric practice, especially with increased patient and staffing demands due to the pandemic-induced mental health crisis, psychiatrists can feel isolated and may find it hard to recognize how organized medicine and the APA can be helpful to the average psychiatrist. With the rise of other mental health disciplines, some psychiatrists additionally feel that organized psychiatry is not helping psychiatric physicians and the field. They instead just want to get their paperwork completed, patients seen, and research statistics completed.

It is important to remember that the APA contributes to education and growth of not only individual psychiatrists, but also the profession as a whole. It provides individual psychiatrists robust educational opportunities through free and discounted subscriptions, journals, and online newsletters, free online CME learning modules, and discounted registration to the APA Annual Meeting and Mental Health Services Conference, among others. Additionally, the APA provides practice tools such as free participation in PsychPRO, the APA’s national mental health registry, access to practice management tools, along with networking and professional development, leadership opportunities, and career search databases. There are additional member benefits for resident-fellow members including discounted membership, online forums, and specific educational opportunities.

Like any organization, the APA is not perfect; it is working on improving diversity and health equity, but we need to be part of the change we want to see. The board of trustees has hired independent consultants to continue to address these issues.

Elie Aoun, MD, MRO, current APA early career psychiatrist trustee at large, describes the organization as his professional home and a place that has provided support and growth as he has moved through his career.

“I consider myself a child of the APA. I joined the organization soon after I moved to the United States and was fascinated by its structure. I joined the assembly as the representative for residents and fellows, then applied and got selected for the APA Leadership Fellowship.That afforded me the most exciting professional opportunity of my career. I got a seat on the Council on Addiction Psychiatry… a seat at the table with the most brilliant minds in addiction psychiatry—leaders whose books I had learned from.”

Even more important is the APA’s role to advocate and lobby on behalf of the psychiatric profession and national mental health issues. Some may say that the APA is not doing enough and has been slow on specific practice issues, but there is no other organization advocating on behalf of general psychiatry. The APA is built on its members and needs our support to direct its efforts. The APA continues to lead the fight for mental health parity, telehealth, collaborative care, GME funding, and fighting against nonphysician scope of practice legislation. APA dues may seem expensive compared to the fees of other organizations, but the annual fee includes not only national and local district branch dues, but also support for local and national lobbying efforts.

Now as an attending, Aoun constantly encourages trainees to not only join the organization, but also participate as actively as they can in the opportunities the APA has to offer, stating that, “what a missed opportunity it is to not take part of the incredible action the APA leads.”

The American Academy of Psychiatry and the Law

Specialty organizations have also been struggling to keep members active during these changing times. The American Academy of Psychiatry and the Law (AAPL) is an organization of psychiatrists dedicated to excellence in practice, teaching, and research in forensic psychiatry. Although AAPL membership peaked in 2019 at 1890 members, membership dropped by 20% to a nadir of 1505 by May 2021 before increasing just slightly to 1519 members by January 2022. Most concerningly, the drop in membership over the pandemic has been primarily due to the loss of resident and fellow members.

AAPL members are required to be members of either the APA, the American Academy of Child and Adolescent Psychiatry, or the Canadian Psychiatric Association. Therefore, the challenges the APA faces in getting psychiatrists to recognize the benefits of joining their organization are even more pronounced for forensic subspecialists who are considering joining 2 separate organizations, each with their own membership dues. However, there are a number of benefits to AAPL membership (

Ten Reasons to Join the American Academy of Psychiatry and the Law

One of the benefits most frequently cited by AAPL members is the opportunity that AAPL provides to connect and collaborate with forensic colleagues worldwide. Give that it is a small subspecialty field, forensic psychiatrists benefit from networking for academic and job opportunities. Networking is especially valuable for rural and private practice forensic psychiatrists, whose daily work of solo forensic evaluations, followed by seemingly endless report writing, can be especially isolating yet paradoxically reliant on strong networks for case referrals. Networking opportunities within AAPL include not only informal ones, but also formal mentoring programs including the Rappeport Fellowship for third-year psychiatry residents interested in forensic psychiatry and the Women’s Committee’s newly developed small group mentoring program.

Like the APA, AAPL also provides members with educational opportunities including a MOC self-assessment, free virtual AAPL CME presentations, mailed copies of 

The Journal of the American Academy of Psychiatry and

, and discounted registration rates for the annual AAPL meeting and forensic psychiatry board review course. Reduced membership rates are also available for trainees and students.

AAPL members have opportunities to seek leadership positions by joining AAPL committees and pursuing positions on AAPL’s executive council. Members are also able to apply for a members-only educational or research grant from the AAPL Institute for Education and Research.

Finally, and perhaps most importantly, both academic journals and the popular press have focused on the intersection of mental health and the criminal justice system as structural inequities are increasingly exposed. Forensic psychiatry is not only a practice of independent court evaluators, but a field of public and correctional psychiatrists addressing mental health treatment and disparities in care in the criminal justice system. As the national organization of forensic psychiatrists, AAPL is situated at the heart of these issues and AAPL membership provides forensic psychiatrists with an opportunity to shape and influence the field of forensic psychiatry.

According to Susan Hatters-Friedman, MD, AAPL president (2021 to 2022):

“AAPL is a professional home for many forensic psychiatrists. Though we are so much looking forward to the in-person meeting in New Orleans in October, AAPL has remained vital to members during the pandemic, shifting to online annual meetings but also to online live programming—including workshops, lectures by senior leaders, committee meetings, and town hall meetings… AAPL is a leader in the world within forensic psychiatry… AAPL’s ethical guidelines and AAPL’s practice resources ranging from conducting the forensic assessment to correctional prescribing are invaluable to the practice of forensic psychiatry. This is not just within ourselves, but has importance within the justice system and outside of North America, too. As AAPL members, we have the opportunity to comment on and help contribute to these guidelines. At AAPL, we can have a voice in the future of our field.”

Early-career psychiatrists and psychiatrists-in-training should not underestimate the opportunities that organized psychiatry can provide as they develop their career trajectory. For psychiatrists in mid-career and beyond, becoming more involved in local and national organizations provides opportunities to look beyond day-to-day practice and challenge themselves to continue to learn and give back to the field.

Other medical fields are growing and uniting to advocate for their professions. Psychiatrists need to wake up and work together to support each other and the field. Specifically, we need to advocate for our patients and our profession and to protect our scope of practice. The time is now!

is senior psychiatrist and director of psychiatric education at NYC/Health + Hospitals Correctional Health Services and clinical assistant professor in the Department of Psychiatry at the NYU Grossman School of Medicine in New York, NY. 

 is the deputy chief medical officer of Central Regional Hospital and an adjunct assistant professor in the Department of Psychiatry at the University of North Carolina at Chapel Hill. 

 is an adult and forensic psychiatrist in private practice in Draper, Utah. He is an adjunct assistant professor of psychiatry in the University of Utah Department of Psychiatry and medical director of Strive Psychiatry in Draper, Utah. 

 is professor and chairman, the Paul and Ruth Jonas Chair in Mental Health, and chief of psychiatry for OU Health at the University of Oklahoma College of Medicine.

The American Academy of Psychiatry and the Law 53rd Annual Meeting will take place in New Orleans, Louisiana, from October 27 to 30, 2022. To register or to learn more, visit 

1. 2018 survey of America’s physicians: practice patterns and perspectives. The Physicians Foundation. 2018. Accessed September 5, 2022. 

https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf

Frontline physician burnout during the COVID-19 pandemic: national survey findings

3. Quiller LM. Organized medicine: why physician membership is more important now than ever before. Medical Association of the State of Alabama. December 11, 2017. Accessed September 5, 2022. 

https://alabamamedicine.org/organized-medicine-physician-membership-important-now-ever/

4. Drum K. The AMA represents only about one-sixth of all doctors. 

. December 27, 2016. Accessed September 5, 2022. 

https://www.motherjones.com/kevin-drum/2016/12/ama-represents-only-about-one-sixth-all-doctors/

5. AMA fact sheet on its decade of membership growth. American Medical Association. 2021. Accessed September 5, 2022. 

https://www.ama-assn.org/system/files/2021-06/ama-10-years-2021-fact-sheet.pdf

8. American Academy of Psychiatry and the Law. 10 reasons to join AAPL. American Academy of Psychiatry and the Law. 2022. Accessed September 5, 2022. 

https://aapl.org/docs/pdf/AAPL%20Member%20Benefits.pdf

Articles

Here’s how the American Psychiatric Association and the American Academy of Psychiatry and the Law provide valuable opportunities for psychiatrists and the psychiatric field.

The Strength and Value of Organized Psychiatry

“If it takes a village to raise a child, it takes a village to abuse one.”

 emphasizes the sad fact that when something horrible happens, most people don’t want to know about it. And-as psychiatrists-we know too well that those closest to the victim can “turn a blind eye.”

The 2016 Oscar winner for Best Picture does an excellent job of portraying the brave and thorough work of the 

’s investigative journalism team known as “Spotlight.” The 

 would later go on to win the 2003 Pulitzer Prize for the exposÃ© that was the result of the investigation dramatized in this film.

Sometimes silence is loud. The film sheds light on the important issue of sexual abuse and illustrates the most damaging part of abuse-the failure of those who were supposed to protect the victim.

Our experience living and training in Boston made 

 particularly disturbing to watch. We have savored the hot dogs at Fenway Park. We recognized the South End Buttery. We know the steeples rising amidst the rundown triple-deckers. How could its inhabitants have been blind to such a devastating problem for so long?

As a psychiatrist who specializes in paraphilic disorders in the Boston area and as a student of Ed Messner, MD-a psychiatrist whose patient was the notorious Father Geoghan, who sexually abused children while assigned to various parishes in the Boston Archdiocese-I (Dr. Sorrentino) was heartened to see the attention 

 brought to the subject of child sexual abuse. The CDC estimates that approximately 1 in 6 boys and 1 in 4 girls are sexually abused before age 18.

 Estimated average lifetime expenses per victim of child abuse are $210,012, costing the US billions annually.

 However, the financial expense of child sexual abuse is secondary to the emotional trauma and psychological damage to both the victim and society at large.

Public awareness of and concern about childhood sexual abuse have advanced scientific knowledge in this field. Sexual abuse research has identified both typologies of offenders and risk factors associated with sexual offender recidivism. About 90% of child victims of sexual abuse know their abuser.

 Offenders in positions of authority and to whom children are entrusted, use the relationship to groom and gain access to the victim, as the film depicts.

 follows the investigative team as it does the painstaking work of uncovering a network of abusive priests, the children they abused, and the system that concealed the abuses. There are 4 team members: Walter “Robby” Robinson (Michael Keaton), Michael Rezendes (Mark Ruffalo), Sacha Pfeiffer (Rachel McAdams), and Matty Carroll (Brian d’Arcy James).

 hires a new editor, Marty Baron (Liev Schreiber). Baron asks the 

 staff whether they had followed up on a story they had published about a priest charged with sexually abusing children. No one can explain why there had been no follow-up, and the reporters are clearly uncomfortable when Baron suggests that they do so. This discomfort can be explained by the ties that each journalist has to the Catholic Church. It takes Baron, an outsider from Miami, “an unmarried man of the Jewish faith who hates baseball,” to open their eyes to the horrifying truth. [See: "

The Spotlight team learns how the priests groom and target the most vulnerable: boys, who are thought to be less likely than girls to “talk,” and children from underprivileged families and broken homes. They also learn how the abuse affects the 

-frequently leading to substance use, self-injurious behavior, and even suicide. Although the team views the victimization as a huge story on its own, Marty Baron keeps pushing Spotlight to dig deeper to figure out whether it is just “a few bad apples” or whether the problem is systemic.

As the team discovers the extent of the problem, they wrestle with their own faith. Pfeiffer becomes uncomfortable attending Sunday Mass with her grandmother. Rezendes makes the agonizing realization that he will never return to the Church. Yet the team members are surprised to learn that the psychiatrist, Richard Sipe, who has spent 30 years studying abusive priests, still considers himself Catholic. He explains, “My faith is eternal. I try to separate the two.”

The characters are complicated and believable. Few are simply “good” or “bad.” We learn that some Church insiders tried to address the issue years ago, whereas some of those currently working to uncover the truth failed to take action when they had the opportunity.

We appreciated the transparency of the film; any effort to glamorize the issue of 

 would have been inappropriate. Much of the movie takes place in dingy, poorly lit basements, complete with disorderly stacks of papers, scuffed desks, and even the occasional dead rat. The viewer feels as if he or she were right there, slogging away with the tireless reporters as they discuss the daunting project over leftover pizza.

The few scenes filmed in posh environments-the Catholic Charities Gala, the golf range-all feature Church insiders. In one scene, we flash between a beautifully decorated Church, where children are singing “Silent Night,” and a variety of dreary workspaces where reporters are putting final touches on their work. This contrast exemplifies the privilege awarded the Church up until that time. However, even in the church scene, we see Rezendes standing in the back, clearly worrying about the safety of the children.

In one of the final scenes, Rezendes hand-delivers a copy of the 

 article to lawyer Mitchell Garabedian (Stanley Tucci). As Rezendes leaves the office, he sees 2 small children playing in the waiting room. Garabedian explains that both of them had been abused by a priest 2 weeks earlier. This clearly makes the point that although the Globe’s work is a good first step, there is still much more to be done. What can psychiatrists do to get the conversation going?

A public health response to the Catholic Church sexual abuse crisis should include educating the public about “acquaintance maintenance” and not simply “stranger danger.” Acquaintance maintenance refers to educating children about appropriate and inappropriate behaviors in those individuals with whom they are familiar or acquainted.

The ability to diagnose pedophilia is key to preventing child sexual abuse (

): it makes possible accurate risk assessment and informed decisions regarding who is safe to work with children-and who is not.

 has raised the public consciousness about child sexual abuse. But we as a society need to move from awareness to prevention, lest we become as guilty as those upon whom we cast guilt.

This article was originally posted on 4/13/2016 and has since been updated.

Dr Nesbit is a third year psychiatry resident at Cambridge Hospital in Cambridge, Massachusetts. Dr Sorrentino is a forensic psychiatrist who specializes in the treatment of paraphilic disorders and sexual offenders. Dr Sorrentino is the Medical Director at the Institute for Sexual Wellness and Clinical Assistant in Psychiatry at Massachusetts General Hospital in Boston, Massachusetts.

 Centers for Disease Control and Prevention. 

Adverse Childhood Experiences Study: Data and Statistics

. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2005.

 Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. 

 Finkelhor D, Shattuck A. Characteristics of crimes against juveniles. Durham, NH: Crimes Against Children Research Center; 2012. 

http://www.unh.edu/ccrc/pdf/CV26_Revised%20Characteristics%20of%20Crimes%20against%20Juveniles_5-2-12.pdf

The ability to diagnose pedophilia is key to preventing child sexual abuse: it makes possible accurate risk assessment and informed decisions regarding who is safe to work with children-and who is not.

Ariana Nesbit, MD

Articles

The Strength and Value of Organized Psychiatry

Psychiatric Spotlight on Child Sexual Abuse