AMA Eliminates Department of Mental Health Abrupt Firing of Director Raises Questions, Concerns

Only one month after the American Medical Association unveiled a major reorganization of its science and technology departments-one that included the dismantling of its department of mental health-the former director, psychiatrist Larry Goldman, M.D., was fired after he criticized the changes. This incident set the stage for an all-out effort at damage control by AMA officials, as they sought to allay fears that the organization was lessening its commitment to mental health issues.

Goldman's firing on Jan. 14-a day before the controversial dismissal of George Lundgren, M.D., editor in chief of The Journal of the American Medical Association-drew no national media attention. Nevertheless, it caused consternation among officials at the American Psychiatric Association and other psychiatric professional associations who were not consulted prior to the AMA's action. Both the departmental reorganization and Goldman's termination are symbolic of an ongoing effort by the AMA to realign administrative functions in the wake of the furor that erupted over its failed agreement to endorse Sunbeam Corp. medical appliances in 1997.

In February 1998, the AMA announced a major effort to "strengthen and reposition its senior management" in order to "more aggressively advance the organization's objectives of professionalism in medical practice, service to its members and advocacy of the patient-physician relationship."

Three months later, the AMA hired its current executive vice president and chief executive officer, E. Ratcliffe Anderson Jr., M.D., the former surgeon general of the Air Force who most recently was CEO at a Kansas City health center, to lead the charge toward putting into place "the core management team necessary to intelligently and quickly transform the AMA's organizational culture so that it more closely reflects the vision and values of the AMA."

It didn't take long for new management to leave its imprint. On Dec. 17, 1998, the AMA's senior vice president of professional standards, Reed Tuckson, M.D., announced a reorganization that eliminated two divisions and nine departments, substituting in their stead a science and technology unit, an integrated public health unit and a clinical medicine unit. In addition to mental health, departments handling areas such as alcohol and other drugs, adolescent health, HIV, and geriatric health were also disbanded. Most of the former department heads were reassigned as program directors, which are nonmanagerial staff positions.

When former mental health director Goldman circulated an e-mail to colleagues within the AMA on Jan. 12 challenging the merits of the reorganization, officials were quick to respond. Two days later, Goldman was summarily dismissed. His supervisor called the e-mail "inciting and demoralizing" and charged Goldman with insubordinate conduct, inappropriate or unprofessional behavior, and inappropriate conduct to the "detriment of the AMA."

In his e-mail, a copy of which was obtained by Psychiatric Times, Goldman described the reorganization to a number of fellow employees and chronicled his efforts to discuss concerns over the manner, timing and propriety of the changes. "Many staff will doubtless remain with weakened enthusiasm for the AMA mission and trust of its staff leaders," Goldman wrote. "In any case, I fear that AMA Science will be damaged for some time to come."

Although AMA officials denied that the restructuring signaled a lessening commitment to mental health and called Goldman's firing a personnel issue, thus far few details have emerged regarding how the changes will affect psychiatrists and their patients. Despite a number of meetings and ongoing contact between AMA officials and leaders of several psychiatric professional associations, there has not been much specific information, according to participants. The AMA has, however, promised to fill the new position of mental health program director with a psychiatrist.

"We had struggled for a long time to get Dr. Goldman there, since that position was previously not in the hands of a psychiatrist," APA president Rodrigo A. Muoz, M.D., told Psychiatric Times. "We were distressed to be informed of the events after they had happened. We had been advocating for a very open and meaningful interaction with the AMA, and we suddenly felt as if psychiatry was no longer represented."

A meeting between high-level officials at the AMA and APA in March, however, was productive, according to Muoz, who added that "we are now discussing how the reorganization is not going to diminish the presence of psychiatry in the AMA." Muoz noted that psychiatrists have increased their presence in the AMA house of delegates over time, and that in his interactions with board of trustees president Nancy W. Dickey, M.D., he has come away believing they share similar goals, despite their occasional disagreements over tactics.

Meanwhile, Muoz said that during the meeting, attended by both Anderson and Tuckson, the APA leadership clarified its position regarding any future steps. "We have been building an interaction [with the AMA] in which we saw eye to eye on matters related to psychiatry," Muoz said, "so we would expect that if anything of importance would happen, we would participate in understanding the steps the AMA would take."

Muoz said that they would have to watch as events unfolded to see whether the restructuring had a negative effect. "On this I was very clear. We are going to be proactive. We are going to help [recruit] this new psychiatrist and we will [work with the AMA] so that we are satisfied psychiatry doesn't have a diminished role or the office is less important than it was before."

David Fassler, M.D., a child and adolescent psychiatrist in Burlington, Vt., and a member of the AMA's house of delegates representing the American Academy of Child and Adolescent Psychiatry, mirrored Muoz's cautious approach. "From the outside, and without having all the information, it looked like the reorganization happened in an abrupt manner without a full plan in place," said Fassler. In a vague reference to the Goldman termination, he added, "without knowing all the details, it would be my hope that people working at the AMA feel free to express their opinions and views about issues affecting the work that they do."

Nevertheless, Fassler pointed to an increasing level of cooperation between psychiatry and AMA staff. "We've made tremendous strides in educating fellow delegates about the concerns of psychiatry, and as a delegation we are very well accepted by our colleagues and our input is actively sought on a wide range of issues," he said. As for the changes unfolding at the AMA, Fassler added, "we are watching the situation closely and we are closely monitoring the reorganization. We have been reassured that mental health will continue to receive appropriate attention and AMA resources."

In an interview with Psychiatric Times, Goldman said that his dismissal would have a chilling effect on existing and newly hired staff, comparing the treatment he received to physicians under managed care who are "deselected" without a hearing or due process. He has filed a complaint with the National Labor Relations Board, alleging that the AMA broke the law when it terminated him for communicating with fellow employees in the workplace over issues of common importance. He also said the dilution of the position from a department head to a program director may not bode well for psychiatry.

"One of the reasons I went to the AMA in the first place was because I thought it would be a place to work on integrating mental health into general medicine on a larger stage and to interact with more people on this," Goldman said. "There's not enough psychiatric presence in the AMA leadership, so there wasn't anyone pushing for something to happen from within. There needs to be someone with an interest powerful enough to carry it forward."

The AMA's Tuckson said that the reorganization would actually enhance integration of mental health into the goals and objectives of the association. He refuted charges that diminishing the position to a program director status from a department head would have any effect on the way the AMA viewed psychiatry or mental health.

"We had an organization structure that consisted of a large number of extremely small departments that operated in isolation from the overall strategic direction of the association," Tuckson told Psychiatric Times. "As such, programs like mental health were not integrated into the fabric of the normal conduct of the business of the association. They were more segregated and, because of that, we were not getting maximum value from the program. My desire and intent is to elevate not only mental health issues, but the psychological issues associated with human behavior that lead to a predisposition toward diseases. I'm also interested in the issues of the psychiatric and psychological components of behavior that exacerbate the natural history of diseases."

The restructuring effort, according to Tuckson, will actually address a longtime complaint that psychiatrists and mental health issues were pushed to the periphery of medicine. "We don't want to ghettoize the mental health issues any further, we want to integrate them more into the lifeblood of the association."