Ensuring That Forensic Psychiatry Thrives as a Medical Specialty in the 21st Century

Larry R. Faulkner, MD
 

SPECIAL ARTICLE based on the Presidential Address given at the 30th Annual Meeting of the American Academy of Psychiatry and the Law, Baltimore, MD, October 14, 1999

The author contends that forensic psychiatry will thrive as a legitimate medical specialty in the 21st century only if it helps to fulfill the crucial requirement of medical systems in the new health care era. The article presents six basic requirements of future medical systems: effective, efficient, and responsible organizations; quality educational programs of the appropriate type and size; linkage to health care networks; primary care capacity and services; restructured systems for research; and effective leadership. Specific opportunities for forensic psychiatry to help meet these requirements are outlined. The author presents major implications of these opportunities for forensic academicians and practitioners as well as for the American Academy of Psychiatry and the Law.

J Am Acad Psychiatry Law 28(1): 14-20, 2000

If we could first know where we are, and whither we are tending, we could then better judge what to do, and how to do it.-Abraham Lincoln¹

As the 21st century dawns, dramatic changes are taking place in medicine, and predictions of gloom and doom are commonplace.^{2, 3} The uncertainties of the time have underscored the need for careful strategic planning and a critical reassessment of educational, research, and service programs.^{4, 5} There is a growing awareness that we are indeed in an era of fiscal restraint that calls for an increased emphasis on the effectiveness, efficiency, and relevance of all programs.^6-9

If forensic psychiatry is to thrive as a legitimate specialty of medicine in the new health care era, I believe it must step boldly into the 21st century with clear strategic processes that demonstrate its value and relevance. My basic premise is that forensic psychiatry will be regarded as a valuable medical specialty to the extent that it helps to fulfill the crucial requirements of all of medicine. If forensic psychiatry is perceived by medical systems as helpful, its stature will grow, and it may even prosper in the new era. However, if forensic psychiatry is perceived as not helpful, it will either be eliminated as an unnecessary expense or ignored as an unimportant "hobby" at the fringe of legitimate medicine. If my premise is true, then it also follows that for forensic psychiatry to be most helpful to the rest of medicine it must move aggressively to meet basic requirements of future medical systems.

The major goals of this article, therefore, are to identify what I believe will be the specific requirements of medical systems in the new health care era, to suggest opportunities for forensic psychiatry to fulfill those requirements, and to outline selected implications of these opportunities for forensic academicians and practitioners as well as for the American Academy of Psychiatry and the Law.

It is important for me to state several personal assumptions and underlying perspectives that will surely influence this discussion. First, I believe strongly that forensic psychiatry should remain a specialty of psychiatry and of medicine. Forensic psychiatrists are physicians first, psychiatrists second, and only then forensic psychiatrists. Second, my opinions about the issues in this article are drawn from the admittedly biased perspective of academic administration. Individuals in other positions might well have different opinions about the issues I discuss. Third, certain aspects of forensic psychiatry, such as private forensic practice, will surely not be emphasized adequately. I must leave those issues to others with greater expertise. Finally, this discussion will focus mainly on the activities of forensic psychiatry within the medical system and not the legal system. Again, I must let others with more expertise consider what the future activities of forensic psychiatrists in the legal arena should be.

Six Requirements of Medical Systems: Opportunities for Forensic Psychiatry

As first outlined by Bloom and me¹⁰ elsewhere, I believe that future medical systems will need to fulfill the following six basic requirements to respond adequately to the forces at work in the new health care era. I do not mean to imply that these requirements are all that will be necessary. There are most certainly other crucial elements that are either not apparent to me at this time or that will arise in the future. The six requirements I describe below are merely those that currently seem most pertinent to me. There is some overlap among several of these requirements, and I have divided them to facilitate discussion. They are not presented in any particular order of priority.

Requirement 1: Organizations That Are Effective, Efficient, and Responsible

All of society is under increasing scrutiny by a public that is demanding more accountability and better management of scarce resources.¹¹ For example, although the nation's 125 medical schools have experienced significant public support and tremendous growth in revenues over the last several decades, they too are facing tough questions about the effectiveness and efficiency of their educational, research, and clinical service programs.^12-14 To maintain credibility, future medical systems will need to demonstrate that their programs are not only effective, but also efficient, consistent with existing laws and regulations, and relevant to the needs of the citizens who support them. This has obvious implications for administrative, strategic planning, and financial management systems employed by medical institutions, as well as for the expertise required by deans, department chairs, and other medical administrators.^{2, 9}

To meet this requirement, forensic psychiatry should:

1. Initiate strategic planning processes to delineate how forensic psychiatry can contribute to the overall goals of medicine and specific medical systems.

2. Document the effectiveness of forensic educational, research, and service programs in fulfilling specific community needs.

3. Maintain the fiscal integrity of all forensic programs.

4. Respond to regulatory and legal requirements in a manner that sets an example for other medical programs in the system.

5. Adopt a spirit of flexibility and cooperation as well as a willingness to modify existing programs to respond to new medical system requirements and opportunities.

Requirement 2: Quality Educational Programs of Appropriate Type and Size

In recent years, discussions of medical workforce size and characteristics have assumed center stage in a debate that has been at times strident and acrimonious.^{15, 16} In general, there seems to be a consensus that the United States has too many physicians, too many specialists, too few generalists, a geographic and sociocultural maldistribution of the physician workforce, and significant deficiencies in the training of physicians to practice in modern service-delivery systems.^{17, 18} Academic medicine is under pressure to demonstrate that its trainees are being prepared in appropriate numbers and types and with the knowledge, skills, and attitudes required to serve adequately the public in the new health care era.^{7, 19} This requirement mandates that academic medicine design its educational programs in a manner that is consistent not only with its own needs but also with local, state, and national workforce requirements. It also dictates that emphasis be placed on the quality rather than on the number of graduates, that careful consideration be given to the educational needs of primary care trainees, that multidisciplinary training experiences be developed, and that training be expanded into alternative sites available in new service-delivery systems.

To meet this requirement, forensic psychiatry should:

1. Demonstrate the need for forensic psychiatrists at the local, state, and national levels.

2. Emphasize the quality rather than the number of programs and trainees.

3. Focus attention on the forensic educational needs of medical students and non-psychiatry residents.

4. Expand educational endeavors in the "public sector" (e.g., jails, prisons, juvenile justice programs, and state hospitals).

5. Develop multidisciplinary training experiences with other mental health disciplines.

Requirement 3: Participation in Health Care Networks

In the last several years, medical administrators as well as individual practitioners of all types have been seeking strategies that might help them receive a steady flow of patients.² One of the most common approaches has been the participation in health care networks that develop integrated systems capable of providing a full range of specific services and levels of care.²⁰ Through innovative marketing, aggressive contracting, decentralization of services, referral of patients within the network, increased efficiency, and economies of scale, these networks hope to be able to compete for patients with other integrated systems in the medical marketplace.²¹ In the modern health care era, it is clear that a high premium will be placed on those strategies that are able to expand network services into new areas and to bring additional, funded patients into the system.

To meet this requirement, forensic psychiatry should:

1. Develop special forensic services that increase the value and competitiveness of the overall medical system to potential customers (e.g., legal medicine consultations; ethics programs and consultations).

2. Demonstrate the effectiveness and efficiency of forensic clinical programs in the network (e.g., adherence to practice guidelines, quality assurance and utilization review, practitioner credentialing, and "customer" satisfaction).

3. Implement systems that facilitate linkages with other network components (e.g., cost accounting, financial management, and management information systems).

4. Promote referrals to the network from forensic contacts (e.g., departments of mental health, juvenile justice, and corrections).

5. Facilitate constructive linkages between network and legal systems (e.g., education of clinicians about legal issues; attorney referrals).

Requirement 4: Primary Care Capacity and Services

In the managed care era, primary care has become a key element of the foundation upon which most modern health care networks are built, because control over primary care also exerts significant influence over subspecialty and hospital referrals.⁵ These facts have led medical administrators to adopt aggressive strategies to expand their own primary care capacity and services, form linkages with primary care groups in the community, or both.^{20, 21} A common theme throughout all of these strategies is their significant cost to the system, not just in revenue but also in the time and energy commitment required of administrators to implement them.² Because of the financial risks involved, a health care network must take steps to ensure that its primary care services are efficient and that it obtains the maximum primary care capacity possible for its investment.^{9, 20} Any reasonable strategies for increasing primary care services or capacity within existing resources are likely to be warmly received by network administrators.

To meet this requirement, forensic psychiatry should:

1. Provide education to primary care clinicians about forensic and ethics problems.

2. Readily accept consultation referrals of patients with forensic issues from primary care clinicians.

3. Provide basic primary care services to forensic patients.

4. Refer forensic patients with more complicated problems to primary care clinicians in the network.

5. Facilitate linkages between forensic systems (e.g., mental health, juvenile justice, and corrections) and primary care clinicians in the network.

Requirement 5: Restructured Systems for Research

Perhaps academic medicine's most striking success over the past half century has been its contribution to our nation's preeminent position in medical research.²² These efforts have been funded through a combination of federal, state, and private resources as well as from revenues generated by clinical services. Threats exist to the integrity of each of these traditional sources of funding in the new era,² and it appears unlikely that academic medicine will be able to maintain current levels of research effort without a serious reconsideration of the structure and function of existing programs.^{8, 20} This requirement might very well lead to a reorganization of medical systems to promote efficiency and to be more consistent with multidisciplinary research requirements.^{2, 3} It almost certainly will entail a much closer collaboration between academic medicine and private industry as well as a willingness to focus on issues pertaining to health service delivery in more nontraditional systems of care.^{5, 20}

To meet this requirement, forensic psychiatry should:

1. Develop multidisciplinary forensic research collaborations.

2. Focus on forensic aspects of health services research relevant to the medical and forensic systems.

3. Establish research linkages with private industry (e.g., pharmaceutical companies, private forensic companies).

4. Initiate research projects in nontraditional systems of care (e.g., health maintenance organizations).

5. Expand research linkages with state and federal institutions (e.g., departments of mental health, juvenile justice, and corrections; the Veterans Administration).

Requirement 6: Effective Leadership

The diverse and complex challenges in the new health care era will require talented and courageous leaders. Medical systems must be organized more like businesses, with streamlined operations and effective methods for financial analysis, cost allocation, and the careful assessment of potential markets for educational, research, and service products.^{12, 13} New models of organizations may be required, as well as modification in the roles and responsibilities of administrators and practitioners.⁹ These changes may well mandate an evolution in the basic culture of medicine, as emphasis is placed on the documentation of performance in market terms rather than more traditional medical measures.² To manage these difficult transitions, medical leaders must be able to develop and implement effective strategic planning processes that identify the major elements of a program's mission. The leaders must also set a realistic yet challenging vision for the future, clarify basic operating principles that will govern the enterprise, and outline specific objectives that capitalize on the unique capabilities of system participants as well as local market conditions.²³ These complex tasks will require that medical leaders possess not only stellar academic credentials, but also the special administrative knowledge and skills required to analyze and manage increasingly complicated health care systems.

To meet this requirement, forensic psychiatry should:

1. Implement innovative administrative processes in forensic programs (e.g., strategic planning, budgeting and financial management, billing compliance, and assessment of faculty productivity).

2. Maintain strict adherence to all legal and regulatory requirements in forensic programs (e.g., billing and research documentation and compliance).

3. Educate and consult with medical leaders about legal and ethics issues in educational, research, and service programs.

4. Actively participate in administrative processes within medical systems (e.g., committees, task forces, and strategic planning).

5. Readily respond to opportunities to assume leadership positions in medical systems.

Implications for Forensic Academicians, Practitioners, and the American Academy of Psychiatry and the Law

I believe the opportunities I have outlined for forensic psychiatry to respond to the basic requirements of medical systems in the 21st century have important implications for forensic academicians and practitioners, as well as for the American Academy of Psychiatry and the Law. Space and knowledge limitations prevent me from listing all of the conceivable implications of the opportunities I have suggested. Instead, I will again outline those that seem most pertinent to me at this time. For ease of presentation, I will organize my recommendations into sections titled Assess, Participate, Provide, Lead, and Educate. As can be seen, the first letters of each section quite appropriately spell "APPLE," the name commonly associated with the American Academy of Psychiatry and the Law (the AAPL).

Implications for Forensic Academicians

Forensic academicians who wish to be productive and valuable members of their academic medical systems in the new health care era must do the following.

Assess

Evaluate the administrative needs of modern medical systems, and of effective and efficient educational, research, and service programs, and obtain the knowledge and skills necessary to fulfill medical system requirements.

Participate

Collaborate with other medical and mental health professionals in developing multidisciplinary educational, research, and service programs, and establish relationships with other institutions and potential customers that might be of value to the entire academic medical system.

Provide

Establish forensic educational, research, and service programs that emphasize quality rather than quantity, and ensure the administrative, fiscal, and legal integrity of all forensic programs.

Lead

Pursue administrative and leadership roles in academic medical systems, and maintain a spirit of flexibility and cooperation with the efforts of academic medical system leaders.

Educate

Participate in educational programs for medical students and non-psychiatry residents, and establish educational programs in non-academic settings.

Implications for Forensic Practitioners

Forensic practitioners who wish to be productive and valuable members of their medical systems in the new health care era must do the following.

Assess

Evaluate personal readiness to meet the forensic needs of modern medical systems, and correct specific knowledge and skill deficiencies.

Participate

Become involved in the forensic services in medical systems, and embrace new multidisciplinary interactions with other medical and mental health professionals.

Provide

Emphasize quality consultation and service that fulfills the requirements of the medical system, and maintain strict adherence to legal and ethical requirements in all professional activities.

Lead

Become involved and assume leadership roles in medical systems and medical organizations, and support efforts to advocate for an expanded role for forensic psychiatry in medical systems.

Educate

Participate in the educational programs in medical systems, and ensure that personal knowledge and skills are adequate to fulfill current requirements of educational programs.

Implications for the American Academy of Psychiatry and the Law

The American Academy of Psychiatry and the Law must be willing to assist forensic psychiatrists in their efforts to thrive as a medical specialty in the new health care era. The Academy should do the following.

Assess

Evaluate the forensic educational, research, and service needs of modern medical systems, and encourage the increased participation of forensic psychiatrists in fulfilling medical system requirements.

Participate

Increase active liaison with other national medical organizations, and promote forensic psychiatrists as leaders within medical systems and organizations.

Provide

Develop practice guidelines for common forensic psychiatry activities, and establish a Forensic Psychiatry Education and Research Institute to support focused educational and research projects demonstrating the value of forensic psychiatry to medical systems.

Lead

Advocate for a broadening of the scope of practice of forensic psychiatry to include expertise in the administration of medical systems, and promote educational, research, and service collaborations that demonstrate the value of forensic psychiatry to medical systems and their potential customers.

Educate

Develop educational programs that are specifically designed to teach forensic academicians and practitioners the pertinent leadership, administrative, educational, research, and clinical knowledge and skills required in modern medical systems, and encourage the increased participation of forensic psychiatrists in the education of medical students and non-psychiatry residents.

Conclusions

This is an historic time for all of medicine. The basic requirements of medical systems in the 21st century will determine the structure and function of future medical programs and specialties. Although much has been accomplished by physicians over the past several decades, new knowledge, skills, and attitudes will be required to participate effectively in and lead modern medical systems. All of the changes and uncertainties of the new health care era will certainly present many challenges to be overcome, but new opportunities will also surely exist for those physicians and medical organizations ready to confront them in a positive and constructive manner. It is my firm belief that forensic psychiatry can solidify an important role for itself within the mainstream of medicine in the 21st century. This will only be possible, however, if forensic academicians, practitioners, and the American Academy of Psychiatry and the Law prepare themselves now to take advantage of the opportunities that will arise. They must set aside whatever past success they have had and meet future challenges with a spirit akin to that so well articulated by Abraham Lincoln many years ago:

Still the question recurs "can we do better?" The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew, and we must act anew . We must disenthrall ourselves.²⁴

References

Dr. Faulkner is Vice President for Medical Affairs and Dean, School of Medicine, University of South Carolina; he is also the immediate Past President, American Academy of Psychiatry and the Law. This paper is based in part on the Presidential Address given at the 30th Annual Meeting of the American Academy of Psychiatry and the Law, Baltimore, MD, October 14, 1999. Address correspondence to: Larry R. Faulkner, MD, Vice President for Medical Affairs and Dean, School of Medicine, University of South Carolina, Columbia, SC 29208.