This is a reprise of a recent post on my other site “Pen and Psychiatrist.” I apologize to the the reader if you have already read this topic at the other site which deals in more cultural and social issues. But after I posted that entry not too long ago, I realized it more properly belonged on this site, since it deals with one aspect of the mental health reform puzzle in this country.
In my previous life some two decades ago as a young Turk clinical teaching and supervising faculty of psychiatric and child psychiatric residents and fellows in training at Duke Medical Center, I became interested in “manpower” (the vernacular then) or more properly speaking practitioner distribution and training issues of psychiatrists. This was in the so called Golden Age of mental health practice, even though the service delivery system in all disciplines, had serious issues, I and many many others could see the troublesome issue of maldistribution of mental health care professionals that was emerging three decades ago and worsening year by year. Basically what was evolving was a situation in which desirable places to live, urban areas with urban amenities such as the symphonies, ballet and performing arts companies, university centers, and above all many colleagues around for support and lively continuing education meetings of regional psychology, social work and psychiatry societies, kept graduates of advanced training programs in the regions in which they trained. So over time, it evolved that areas like Boston/Cambridge MA, Raleigh-Durham-Chapel Hill NC (the Triangle Area), Ann Arbor MI, Dartmouth, New York City especially Manhattan, Stony Brooke, Long Island, Houston, Los Angeles, San Francisco, Seattle, Eugene OR, San Diego, Davis CA, Charleston SC, Atlanta GA, Birmingham AL, Albuquerque, Tucson AZ, and many other urban areas became the landing places where psychiatrists trained and often stayed to practice, in the university medical center cities. A good friend and colleague, now passed on Bruce Neeley MD of Duke and Emery, used to give lectures to residents nearing the penultimate stages of their training careers and were a year away from the decision of where to settle to practice. By then the 1980’s the trend had become set in concrete, only a minority of graduating psychiatrists left the training centers and set up practice in under-served areas.
Bruce Neeley and I separately in turn would give almost off the records seminars to the ‘senior residents,’ telling them in so many words, almost like the famous newspaper editor of the 1800’s, “Go West Young Psychiatrist,” In North Carolina we first meant go literally to western North Carolina which I knew very well because of my wife’s origin from Cherokee NC. But we also meant “get out of the urban centers, there are too many of us here already.”
WNC then and sadly still is vastly under-served by psychiatry with a chronic shortage that is almost criminal. I can count on the fingers of one hand the number of child psychiatrists in practice west of Asheville and that is a lot of territory. I used to tell senior residents to “Get out of the RTP [Research Triangle Park, another term used to denote the entire Raleigh-Durham-Chapel Hill area since each of those cities incredibly are only 8 to 15 miles from each other!
I also would preach economics, telling the future graduates and practitioners to go to areas that had few or no psychiatrist, and they would be assured of a full schedule in no time and thereafter would likely have no trouble attracting future partners, because the needs in so many medium sized cities for mental health coverage was enormous. Communities commonly were being served well, though with only a fraction of the psychiatrist time and presence they needed by residents in the four area training programs coming to then county mental health centers on usually only a monthly or so basis. Some of those residents would indeed “bond” to those towns and decided to practice there after their training. But not enough. I used to exaggerate, but not by much, hectoring the residents in these “What You Need to know After Residency,” seminars, that they needed to get the Hell out of the medical center cities, as way too many {myself included to do advanced training and to teach] stayed after residency in the towns of the medical school they trained in. I would say things like, “There is another psychiatrist and two therapists under EVERY ROCK in Chapel Hill and Durham! You will have wash windows to make it initially here. There are too many of us here already which really was pretty close to the truth. Competition for patients in those kinds of medical school-residency training cities was fierce all over the country. But still too many chose to stay whey they ‘grew up’ in training. Some stayed because they elected to stay for a few years and wisely round out the depth of their training by practicing in Durham or Chapel Hill or Raleigh and pay for continuing intensive private supervision till they felt really ready to strike out on their own away from the home nest of the training centers. Some did because they were frankly very urban creatures and the prospect of moving to a small city with far fewer of the artsy and intellectual amenities frankly was not consonant with their lifestyles or needs. So over the decades of the rapid expansion of training of psychiatrists until the 1980’s that started with the federal government supporting with training funds through the newly formed National Institute of Mental Health (NIMH) after World War II when the need for psychiatrists for veterans became finally glaringly clear, evolved into a system that fed urban, sophisticated areas the psychiatrists and left the majority of the country quite under-served.
Then the worst thing of all happened. During the Reagan years the philosophy and view that diverting medical teaching hospitals [read: medical school hospital training centers with all kinds of residency programs including psychiatry) were doing something ethically wrong by diverting federal healthcare dollars earned through Medicaid and Medicare to help fund training programs. This was outlawed in legislation in those and the predictions that the medical educators of all specialties screamed to high Heaven about came to pass.
Training funds shrank considerably as teaching hospitals all over the country scrambled to raise monies to fill the gaps left by the loss of the federal dollars diverted from Medicare and Medicaid. [Note I am not well informed or schooled on the legal objections to the practice of “diverting” these funds, so bear in mind this may have completely legal, on the correct side of legal dilemmas etc.] In any case there were shortfalls in medical schools funding their training programs. Tufts’ department of psychiatry nearly went bust, and was bought by Harvard University’s medical school to save it. Public hospitals began a long slow descent into financial ruin and closure, Detroit Mercy Hospital and the venerated St. Vincent’s Hospital in Manhattan. These hospitals and many others that closed in the ’80’s and ’90’s served the poorest patients and the loss of the ability to fund training programs with Medicare and Medicaid dollars, treating mostly uninsured patients, sank them. And their teaching and training programs were lost. I, myself, considered going to St. Vincent’s for psychiatric residency training, had friends that did so, and was quite sad when it had to disappear.
Training programs such as neurosurgery, cardiac surgery, orthopedic surgery, and all surgery training programs in general did not suffer so much because these programs were, still area, and always will be moneymakers as the procedures, diagnostic studies, trauma surgery, and surgeries that residents assisted on, later did on their own as the primary surgeon with an attending mentor, made piles of money for their training host university medical center hospitals. So did departments of cardiology, intervention cardiology and radiology and pathology.
But pediatrics and psychiatry shared the same issue, their clinic patients were the poorest, who had either the less “lucrative” insurances, or none and these programs suffered and shrank nationwide. My program at Duke shrank by over half within 10-15 years after I finished training there. It also made the subtle decision to de-emphasize training clinical psychiatrists and to emphasize even more than it had in the past, training researcher psychiatrists. But if as rich an institution whose endowment rivals Harvard, could not afford to sustain its psychiatric residency and child psychiatry fellowship funding at its historical levels, less well off, less affluent state university medical schools had even more trouble doing so nationwide. This began the slide in the numbers of psychiatrists trained and graduated annually. Pediatrics began to develop and rely on regional and national funding campaigns and foundations. It is no accident that the Children’s Miracle Network which raises money on a national basis primarily for pediatric hospitals and training programs has become a big part of American annual philanthropy and you give money at WalMart and in every fast food chain in the country. Other medical schools copied the then early trend in collegiate and professional football athletic departments as they began to sell the naming rights to big corporations for their Bowl games and to their stadiums across the country copying perhaps the original national sport to tap into the coffers of Big Business sponsorships, NASCAR. There are now a number of long extant, premier medical schools who have sold the naming rights to the fabulously wealthy philanthropists of their areas, for instance, medical schools in Los Angeles and Chicago and New York, to name a few locations [I will leave it up to the reader to guess or do a little Google detective work to figure out these schools who have done so in order to survive].
The other trend that rose to a position of perhaps undue importance and influence was the trend of turning to the drug and biomedical companies for funding new research as the federal government began a policy also about the same time frame over 25 years ago of not meeting the monetary funding needs of the national funding dispersing research bodies such as NIH (National Institutes of Health) etc. Only in the late 1980’s did funding really increase by decent multiples that were needed and that in the area of AIDS research, the National Institute of Allergy and Infectious Diseases. Many centers of medical research had to turn to the coffers of the then global and increasingly rich and powerful pharmaceutical companies, better but not flatteringly known as “Big Pharma.” Much of the research monies, used to support the research hours and efforts of medical school faculty so they could afford to continue to teach medical students and residents, had a future corrosive unethical effect on medical schools and medical research, perhaps best exemplified in the entire Vioxx drug scandal of the early 2000’s.
During the 1980’s managed care got its start nationally, taking the approach of utilizing cut throat review procedures that denied coverage of benefits for medical and psychiatric coverage at a level never seen before. Psychiatry was hit hardest as many psychiatric leaders and practitioners inferred based on their income slashing experiences with arbitrary review practices that our profession had been somewhat singled out because we were not a darling of the American Medical Association, i.e., fiercely defended by them, were an organizationally small and politically weak specialty. NO politician at the national level in those early years of the consolidation of power of managed care, defended the mental health professionals including licensed counselors, social workers, psychologists, and psychiatrists and income levels decreased in these profession dramatically. The word spread quickly among prospective trainees, graduates of medical students, college students considering mental health careers, and for over two decades the national production of mental health practitioners decreased year by year, especially in psychiatry. When I finished psychiatric training and fellowships, this nation was producing over 2,000 psychiatrists a year. A few years ago the total national number of psychiatrists graduated was less than 500. Far fewer medical school graduated even applied to psychiatric training programs making the problem worse as they voted with their economic feet.
In child psychiatry things were far worse. In virtually every psychiatric residency adult training program at every training medical center, only a fraction of residents finishing adult psychiatric training went into the extra two or three years of child psychiatric training. At Duke “in my day,” we trained 16 or so adult psychiatric residents a year in the three year program. In child psychiatry we trained two a year in the additional two year child psychiatric fellowship. Years later, Duke merged its child program with a nearby state psychiatric teaching hospital with which it had had historical integrated shared teaching rotations since the late 1960’s. At that time Duke then at its lowest point trained only two child psychiatrist every two years. And it had to have financial help from the training funds of that state hospital to buoy up its own child psychiatry training funds almost to survive.
Training a child psychiatrist is extremely expensive. Good programs offer didactic (lecture) teaching series that average almost half the fellows’ training time to cover the vast territory of child psychiatry which is a “whole nuther world” on top of adult psychiatry. Child development, the different child psychiatric conditions, learning to do play therapy, parent and child therapy, parent therapy, and family therapy, skills unknown to an adult psychiatrist, all took more faculty and more specialized, scarce faculty skilled in those truly sub-specialty areas. And then there was the issue of clinical supervision. Good, high quality training programs would provide up to an hour clinical processing supervision by an experienced child faculty member for every 1-2 hours spent in seeing a child and/or family. That is very expensive and few other medical training programs offer that level of intimate, frequent, almost hour for hour supervision by senior faculty. That takes money, lots of money. And coupled with psychiatry programs being the equivalent of the grocery stores’ “loss leaders,” a product that loses money at every instance of rendering of service, because child psychiatry typical serves the poor and uninsured, makes for economics that in this day and time, does not curry favor with the financial heads of medical schools. So, by the early 2000’s many national figures in the profession and enlightened mental health advocates began to realize that child psychiatrists were working into their late 70’s and even into their 80’s [I have many an older colleague and even some of mentors in their 80’s who still teach!] because of the then looming and growing shortage of child psychiatrists, possibly first nationally reported on and highlighted by the conservative Wall Street Journal nearly a decade ago. Also the national level health care planners from many circles in healthcare, realized we were not only graduating too few child psychiatrists, that we were developing shortages in large urban areas that had never seen child psychiatrist shortages before and that we may not have been replacing the psychiatrists that died or retired each year.
Several years ago, in his next to last term in the House of Representative, the former Congressman Patrick Kennedy of the Kennedy family introduced an enlightened bill to dramatically increase the training funds, loan funds and economic loan forgiveness programs in the national Congress, to all the mental health training disciplines. His was the right approach. We needed not just more child psychiatrists, we needed more of all the mental health care specialist practtioners and by a factor of four to five times as many as being produced. His bill went nowhere and likely suffered political neglect from his open and public drug abuse relapse several years ago which caused him to resign from Congress, get himself back together in thorough going treatment and devote himself to national advocacy on this issue. But he still had limited effect until the national mental health crisis, brewing in this country since the 1980’s and due to even more factors than I have alluded to here, brroke wide open in this country on multiple fronts, social, public safety, school safety, return of rise in violent crime, filling up of all levels of jails and detention facilities with the mentally ill and the sort of sudden lack of inpatient and outpatient mental health treatment in a timely available manner. Media began covering stories of suicidal kids stuck in community hospitals for weeks while they waited the opening of a bed in any psychiatric child unit whether private or public. Young mentally ill adults who could access or be proactively retained in psychiatric treatment for severe psychotic illnesses began having tragedies on a weekly basis all over the country, suiciding, taking hostages for delusional reasons, randomly killing persons, attacking and/or killing their parents while in active neglected psychotic episodes. The state senator from Virginia Craige Deeds and the tragedy of his son Gus whose schizophrenic son Gus, tried to stab his father, the state senator to death and then killed himself was perhaps the turning point in this country’s realizing “maybe we have a problem here….”
And as usual in this country we neglect a problem until it becomes such a dangerous crisis that we can no longer hope it will go away and rage at it for ‘costing public monies,’ and forgetting we are all in this together and again forgetting the concept of the “commonweal,” the good and benefit for the many that enriches us all.
There is some good news. Enrollment in mental health disciplines’ training programs is up and perhaps ‘back in vogue,’ and not every kid wants to be a CSI anymore…The recent “Match” program in American medical school programs and choice of training programs by graduating medical students, saw psychiatry’s applicants for psychiatry residencies rise to 1300 or so this year, which is good news. So we are finally making progress, but the national funding “push” programs like former Rep. Patrick Kennedy’s are still needed as is the new bill in Congress, the Helping Families in Mental Health Crisis Act sponsored by Congressman Tim Murphy is urgently needed and a good piece of legislation.
So progress if finally here, and very much needed and welcome, but it has taken far too long and at too great a price. Hopefully the political class will begin to learn the we cannot neglect national problems for so long out of ideological rigidity and begin to fashion workable solutions and compromises that have long been available and known to us.
The Mental Health Reform Blog 