Address to APA Board of Trustees by Nyapati R.Rao, MD, MS
New York, Institute of Psychiatric Services
October 11, 2006

President Pedro Ruiz, President-Elect Carolyn Robinowitz, Medical Director Jay Sculley and members of the Board of the APA; I thank you for extending this invitation to me to present a report on Brooklyn District Branch activities. By inviting me to meet with you, you are honoring every member of the Brooklyn DB. In this day and age, when every politically active psychiatrist dreams of running for the national office of the APA, the installation of a mere president of a district branch might be seen as a tame affair. However, our district branch is not just any district branch; it is larger than the state psychiatric societies of Alabama, Alaska, Idaho, Hawaii, Kansas, Kentucky, etc.. Our society represents the Borough of Brooklyn, which is home to 2.5 million individuals of various ethnicities, Brooklyn has extensive psychiatric facilities, with approximately 14 large general hospitals providing extensive and wide ranging psychiatric care. In addition, we have a large state facility in Kingsborough Psychiatric Center. Our society has a total of 313 members, 185 of whom, myself included, were born outside the United States. Brooklyn is also the home for a large public medical school, as well as three general psychiatry residency training programs, two child fellowship programs, one geriatric psychiatry training program, in addition to countless educational programs in other disciplines. It is not uncommon for many nationally prominent psychiatrists to trace their origins to Brooklyn and to fondly reminisce of their childhood here.

The story of Brooklyn is a story of immigrants and acculturation.. In my presentation today, I am going to focus on this issue and how it affects education and career of our society’s members..

Brooklyn’s history dates back far before Christopher Columbus sailed to the New World, and it was inhabited by a group of Native Americans who called themselves Lenape, or, “the people.” They included the Nayak and the Canarsie, who planted corn and tobacco, and fished in the rivers. The Dutch took over Brooklyn in 1643 and founded five villages, Bushwick, Brooklyn, Flatbush, Flatlands, and New Utrecht. The British captured these Dutch territories in 1674 and consolidated them into Kings County. Since then, Brooklyn has been the favorite destination, initially for settlers of European origin, and later for settlers from all over the world.

The Brooklyn Bridge was built in 1883, opening up Brooklyn to New York City, which in turn annexed it in 1898. In more recent years, new waves of immigrants have come from the Caribbean, Latin America, the former Soviet Union, the Middle East, and East Asia. With the result 37.8% of all individuals living in Brooklyn are foreign-born in contrast to 20.4% for the rest of New York. In the above contexts, what are some of the issues unique to Brooklyn and the Brooklyn Psychiatric Society?

In the area of mental healthcare delivery, our members face a daunting task. Except for a few neighborhoods, Brooklyn is an underserved area caused by shortage of psychiatrists as well as increasing demands. One such underserved area is central Brooklyn, whose population is 317,296 80% of whom are African-American. 29@ of the population are foreign born with a below average access to medical care. Other statistics about this are are unsettling: For example, death by homicide in this population is 2.5 times that of New York city, and the rate of hospitalization due to mental illness is 45% more than that for New York City. Finally, 29,000 individuals report no current health coverage, 30,000 did not get medical care in the past year, and 58,000 do not have a personal doctor and nearly one third of them live in poverty. in

In the area of psychiatric education, the ethnic heterogeneity of the trainees engenders many challenges. The first among them is how to properly train residents from all over the world in a specialty which is heavily influenced by American cultural values, and oftentimes in a foreign language. This challenge is not unique to Brooklyn and is shared by any training program that trains IMGs. However, it assumes special relevance in Brooklyn where 95% of all residents are IMGs. Yet another challenge is brought on by lack of cultural and other educational resources to handle complex cultural situations in training. The common and universally accepted term, “cultural competence,” and various strategies to enforce it, are silent on such issues as I described before. The Brooklyn Psychiatric Society and the American Psychiatric Association must encourage the development of training and treatment models. It must encourage its senior members to volunteer to supervise residents from the local training programs.

The second issue is that of a shortage of psychiatrists in Brooklyn and the problem of the underserved. In this regard, the positive role of the international medical graduate in providing care to the underserved is receiving increasing recognition by healthcare researchers. In Brooklyn there are several institutions that are unable to recruit psychiatrists due to absence of employable candidates. On the other hand there are several graduating psych residents on temporary visas who can not choose to work in Brooklyn due to immigration requirements. One must undertake studies to further delineate the problem and demand immigration and educational reforms.

Simultaneously, the competence of psychiatrists who are unable to obtain Board certification must become a national priority for the APA. The board certification performance of younger members of our society who are mostly IMGs is not on par with that of their more senior colleagues in the society. After examining the demographics of the members of Brooklyn District Branch, Linda Majowka wrote to me :”One thing really struck me .Most of the USA and Canadian members went on to become board certified. Only a few foreign born members went on to become board certified, that too several years ago- very few IMGs have been certified in the last several years”. I believe this is a very serious issue and the causes of failure are multiple-such as poor training, anxiety, and language issues. Not being board certified has several ramifications for the candidates as well as the system. The initial success of the pilot project to help ABPN recidivists is a welcome step. We found that when candidates are given an honest appraisal of their deficits, they tend to pass the Boards more easily as described in a recent article in Psych News. I believe our society has a responsibility to identify its members who need assistance to pass the boards and develop strategies with the APA’s office of Education.

As I turn to my next two years as President of the Brooklyn Psychiatric Society, I would like to keep the Society’s focus on these issues of cultural and technical competence of its members. Perhaps there is an opportunity for an APA sponsored national conference on these twin issues at Brooklyn Psychiatric Society. On a more concrete level, the society needs to develop a public presence through the launching of a website to better connect with its members. I’m looking forward to working with the executive council and the executive director of Brooklyn Psychiatric Society, Ms. Linda Majowka.