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Part 2 of 2
For part 1 click here
A STATE HOSPITAL UNIT (cont)
(On becoming a bad fit 3)
A most amazing accidental discovery 1: Human souls can be revived unexpectedly. Like in Dr. Oliver Sack’s Awakenings. After about three weeks, we saw a renewed spirit sprouting. Patients lifted their heads to look with sparkling eyes at a more hopeful world and solidified their community and nourished each other. The world was opening up for them. They were opening up for the world. Knowledgeable people noticed and nodded and quietly smiled when I repeatedly checked with them if we were on the right track.
What was happening?
The men got good doctoring, and enough good staff joined a healing fest. I made ongoing, careful assessments of each patient’s individual psychological and medical needs during my daily on-site real-time psychiatric presence: I got to know them as people who are now my patients, as their doctor. Sensitive, courteous, thoughtful conversation and careful listening, casual interactions, impromptu meetings on the unit and in my office, checking on how a man is doing after we changed a medication. Just sitting together.
Each man had his own, colorful, consistent narrative about himself, his past, and future that deserved a serious respectful hearing, no matter how illogical or delusional he managed to survive with an impaired brain over the years. We used language…Just checking on the progress of a project or physical complaint. Focusing on the here and now. I decided to wear my doctor coat after a couple of weeks to legitimize my reality. A doctor’s uniform.
Then, they needed working doses of the right medications based on the right diagnoses refined in real time for current symptoms, and they needed a voice about their fate. The state required this, and it was done routinely but perfunctorily. I engaged them to their limits in this conversation early, establishing a connection that served as the basis for what came next:
“What medication worked best for you?…How?” They do know which, and they do know how. And they do know that trust has to go both ways. For example, one man’s request (btw, he dressed impeccably, had a gracious manner about him, and loved singing hymns for the group) for ibuprofen to help him stay calm and relieve his chronic headache was repeatedly rejected because it is not standard and can cause rare GI bleeding. The internist also believed the man’s request was delusional. Well, it turns out that current research shows that such anti inflammatory meds can be helpful in schizophrenia and they did calm him down and relieve his headache. Competent about this matter, the patient made that discovery for himself, and the internist approved after a small change in medical management.
Medications today are often really better, and there are more of them to carefully weave together with language-based doctoring and existing social work/supportive activities by competent, genuinely caring staff. We started them off gently as healing sprouted, and stayed present and in the moment with them as they took their first steps, safely refined their medication and tweaked their social environment, focused them on daily personal and community goals, and began to collaborate with some on long term discharge plans.
There was plenty of testing of limits, too — it was definitely not a rose garden. And they each watched closely as I treated others and what happened, and they liked how I encouraged their own little community and mentored their leaders to succeed.
But the secret sauce — what largely made this possible — was language as a powerful neuropsychiatric tool. It turned out that they could thrive. They needed strong, well-timed sparks to restart their engines, and then basic navigating guidance and a safe, fenced road.
Up real close, smell-to-smell. Ready to fist bump. Visible. Approachable. Meticulous about small requests and symptom follow up. Respectful of boundaries. Fair. Patient. Firm. Insisting on some behaviors and punishing others, not intimidated, and always following through: “You are men. This is a hospital, not the street. You live here. I am your doctor. I look out for you. You deserve to have a caring doctor who treats you like a person. Manage your self and relationships with self respect and kindness, or we’ll do it for you.”
Most of our patients’ brains — in various conditions of gross and fine repair, development, and/or functionality, are apparently still well wired enough to welcome proper stimulation. And the spark is wired into our mammalian brains. The spark was simply the thing that excites all humans from birth. That spark electrified mirror neurons and their neural social networks and the many other circuits that feed off them to make our brains miraculous social organs.
This spark is well known, and our brains are prepared to accept it from the first day of life — a human face. A vigorous, safe, interactive human presence that affirms. Stimulation from a full, close, eye-to-eye, face-to-face smiling and nodding. Like the painful knuckle rub on the chest that initiates CPR. A multidimensional sensory human engagement, especially amplified when coming safely from a trusted doctor. Our patients were ready to react with healing, hope, and a natural reaching out.
After about five weeks, the men engaged in more vigorous self-governing, emerged from their rooms, showered more, showed kindnesses to each other, and clamored in community meetings to sing and rap. People were further away from their verge of rage or panic. Those who spoke about it did reveal a personal faith they do not abandon. Singing for most and rapping for some is their celebration as a community. Amazingly, one reclusive aggressive man revealed such creative intelligence in his rapping and conversation that knowing staff exchanged surprised and approving nods. No more slurred speech, no more drooling, more smiles, straighter smoother walking. Less bed wetting. Less smelly rooms. Cleaner clothes. Less tremor. Less ADHD, less depression.
Several more men started their long ways towards discharge. One reticent man diligently sought his daily quota of fist bumps and started showing me his shiny basketball card collection. Another sat next to me in meetings and often invited me to prompt more appropriate behavior. Most dramatically, one reclusive man surprised and delighted everyone and actually had the barber shave off his hairy thicket and started to attend meetings. (And yes, the changes seemed entirely lost on some of our nurses. It would be interesting to compare their daily charting notes with technician notes, mine, and those of the language-based psychologist and social worker.)
Patients, doctor, and most staff joined together to form scaffolds for growth, embodied in an invigorated daily or impromptu community meeting. Once primed, impulses to health cascaded exponentially, recruiting existing neural and social networks, and even entraining otherwise aloof staff to participate. Wow. That’s the best of modern neuroscience at work! That’s psychiatry how it can be! That’s exactly what I signed up for in medical school.
No one, including me, had expected the amazing inspiring awakenings that happened. Language-based staff were openly thrilled. Administrators with mental health backgrounds recalled them proudly to me so that I would know they too are colleagues. There was a buzz. Word spread beyond the hospital. Something in this contagious flare up of life touched every man and deserves further attention. At least, it was a powerful placebo that kicked brains into gear beyond decades of dormant hospital “care” (and, not infrequently, beyond the around 15 lbs. of brain medication a decade poured into each man, or about 450 lbs. into all the men in this group to date while under state care — correct me if I am wrong, based on an my estimated averages: 2000 mg daily, 20 yrs. LOS. That’s industrial strength neuroscience, possibly harmful).
Anyway, IMHO, the power of placebos and healing relationships are still understudied in neuroscience (Louis Lasagne, M.D. and Jerome Frank, M.D., Ph.D., were among my most memorable and wisest teachers). Placebos were always powerful medicines. Great physicians from antiquity recognized the power of hope in healing. Hope works wonders, as does great advertising and great leadership. And that too is probably wired into our brains (as are trust and faith and love). But you must access hope through language and mind. And there seems to be a lot more room for more on this unit.
On the unit, I began to speak with staff about slowly reducing my active pace to prepare patients for my departure when my contract ended. But I was abruptly and quickly removed (some staff actually gasped when I announced my departure) exactly halfway through. So what happened next to the men on this unit? I won’t know. Sadly. That’s the contract.
Most amazing discovery 2: A human spirit can blossom in most folks who work in a state hospital, too. A majority of seemingly competent and caring administrators and staff, much as in the private sector, “go with the flow”. In hushed sincerity they bemoan and attempt to disown the “jaded system,” shaking their heads and gazing down at their feet, almost like apologizing. They are hanging on, too, I guess, to avoid falling down cracks in the system. But they also are devoted.
Many employees do clearly and even cynically grasp the charade, yet can patiently stay on anyway to steadfastly, quietly care for and connect and give to our thrown-away neighbors — and that’s awesome. Even some housekeepers make their peace with this hell and join the singing. That’s love. These precious people are truly our best healers, our humane, gentle, saintly fixers of the world.
Even as a powerful few dehumanize, these steadfast folks manage to steadily rehumanize to keep patient hope alive. Each has a story about how many times they almost quit. They do resist the flow selectively, I guess, and they also like their state benefits and overtime pay and pensions; nothing wrong with that. Those who give so much deserve it. You know who you are. Thank you. I wish I could have your strength!
This is what also happened, from my POV: Patients in all hospitals depend on productive collaborations between physicians and nursing leadership, and a new doctor especially needs clear communication with the head nurse. But unlike most of their colleagues, a few nurses — the ruling clique — openly and stubbornly made a show of their refusal to communicate and collaborate with me.
I was tipped off early by several clandestine self-appointed “allies” that, should I have any friction with one particularly hostile nurse, I will be the one who ends up leaving. It was a no brainer for them. Near the end, another self-appointed ally tipped me off to a “setup” that will be coming soon and to how it might happen.
Indeed, the ruling clique and their allies seemingly mounted its offensive more openly when it became clear that I was succeeding. They apparently had critical words with the nursing staffers that did work well with me. They apparently spread stories that made their replacement in the unit difficult by transferring other nurses. They also apparently stonewalled for weeks administration efforts to respond to my urgent demands for a simple nursing protocol for quickly evacuating to an ER a severely medically ill uncooperative man in a manner that could save his life. (I learned later, to my relief, that my persistence did indeed finally lead to life-saving abdominal surgery soon after I left.)
And the ambushes did come, wrapped in plausible deniability, always in front of witnesses. In one meeting, during a discussion of transitioning a soon-to-be-discharged man back to his family, a social worker employee, non-language oriented and mostly functioning as a case worker and psychoeducational group and activities leader, suddenly burst into tears, complaining that I did not like her but liked another (female on another unit) social worker better, and that I did not like women in general (a first for me). Crossfire quickly followed, even as I made a stunned strategic retreat for the door while tactfully trying to calm her. This time the attack came from another employee, known by others for such behaviors, who goaded me maliciously with something like, “You are the psychiatrist. Don’t go. Please keep talking with her.” This setup happened just around the time and in the manner predicted.
Another ambush followed quickly during morning rounds when the hostile nurse, in the presence of her supervisor, refused to report blood pressures of a patient who had fallen during the night. It is routine nursing practice to check BP sitting / lying and standing in such events and inform the doctor, but only one measurement was done, it turned out. The nurse told me to check the chart myself.
Had the supervisor not been there to give tacit approval, I’d have merely faced yet another bit of familiar nastiness by the same nurse. Instead, I now saw a flagrant abuse of medical protocol and clearly and shamelessly arranged by the entire nursing hierarchy to scuttle me. So I asked the supervisor to contact her boss, the head of nursing. It was all very calm. Soon, head of nursing arrived with my own boss in tow, grumbling sadly something like, “We just can’t have more fracturing in this unit. In a few days, they will miss having a doctor here. Today is your last day, so do what you need to leave.”
Alas, as an experienced administrator and clinician, careful to prevent new conflicts or splits that could harm morale and patient care, in the end, I did eventually succumb to profound system failures and deep splits. And good people counseled me repeatedly to compromise more and stay away from the edge of splits, to sugarcoat my approach more, and to put away my “sledge hammer.” I pushed a tired status quo too hard, seemingly well beyond its willingness to respond, and it pushed back. Fortunately, I had the advantage of naïvité, relative administrative insularity as a non-employee, an irreverent sense of humor, and speed and surprise that all bought me the time to invest myself fully and enthusiastically. All things move slowly in this system, as did my undoing.
While I did want to continue serving the men on this unit in some capacity beyond the term of my contract, I eventually understood that I could not fit for very much longer. I even joked about that to those I trusted. I had neither the time nor temperament to slow down, hang my head down and navigate around land mines hidden by entrenched, well-practiced experts. Keeping my vision focused on patients took all of my energy. I felt helpless and mostly alone, without effective administrative interest, guidance, or protection (or interference), even after my repeated threats to leave, which were “getting old”, as one top administrator semi-warmly quipped. In retrospect, I now want to believe that the administrators helped more than I know.
Reader: You really have to see this jaded culture of devotion, incompetence, grace, competence, courage, dignity, love, moral corruption, and fear to believe it. It is tucked right into our midst and is also part of who we truly are. (Anyway, BTW, I may have also discovered a new treatment method. Let’s give it a name — GPP, for Good Psychiatric Practice. That’s sarcastic.)
CHILDREN'S SERVICES IN A WELL-REGARDED FAMILY SERVICE AGENCY
Still hoping to work in a facility serving poor people in a setting that respects them and their caregivers by striving for good care, I continued my journey, returning to a private outpatient community agency that had employed me for eight great years at the beginning of my professional career, when a team of social work colleagues and I had set up and ran a large aftercare clinic for over 250 state hospital adult dischargees. We had worked energetically and collaboratively in the tradition of the community service team model I learned from family therapy educator and pioneer Charles Kramer, M.D. (who got me the job) and child / adolescent psychiatry innovator Sherman Feinstein, M.D. I thought it a hopeful sign that the term "behavioral health" was not mentioned even once in my return to this agency.
American-trained M.A.- level social workers and psychologist therapists varied widely in competence. I worked only with staff members having children patients on medication, but it would be reasonable to assume that they represented at least minimal agency standards. Hoping to manage expectations, and as a way of introducing myself, I asked that administration and staff read an earlier version of this article before I was hired, and some supposedly did, adding to my optimism that I would fit into this agency's enlightened culture.
So, for five hours every two weeks my duties now were to evaluate and treat high risk children and adolescents with a variety of disorders. In addition, these children are growing up under the stressors, physical and psychological risks, and the challenges of poverty, sometimes extreme. Often, parents may be mentally ill, substance users or criminals, and poor parenting, displacements, moves, violence, and early parent loss are frequent.
My predecessor had practiced like a "queen bee", without bothering to talk with patients or parents in very brief and infrequent visits. One child on medication was actually seen twice or three times a year for a total annual time of less then an hour. So I began to get to know the kids and parents with increased time spent with each.
One dedicated staff member worked closely with me, and we sometimes met with kids and parents together. This beginning paid off quickly. The dramatic changes began. For example, a bright teen girl who had chronically avoided school because of long undiagnosed ADD was now successfully back in the classroom, an anxious boy with severe PTSD was finally engaged in treatment and was getting traction in a job, and most parents were relieved and word was getting around that a doctor was finally spending time with them and their children. My goal was to upgrade the care of each child to the best level possible within the six months of my contract, and then possibly stay on.
To accomplish this, I needed information about the whole child and family, apparently for some reason not routinely collected at this well-regarded agency. To provide essential actionable credible information for basic evaluation and treatment of children and families, I requested that pediatric and family information be obtained via the parent questionnaires, and school functioning data via the teacher questionnaires I introduced. We were beginning to implement this and important predictive information began to flow, but some professional staff were surprisingly suspicious and resistant.
To increase time with each patient, I proposed steps to streamline receptionist management of patient flow, chart preparation, and scheduling. In spite of passive grumbling, the first two were starting to improve. But the scheduling issue quickly became a deal breaker because this was where this well-regarded agency's broken core became exposed.
(On becoming a bad fit 4)
An anemic culture of mediocrity and poor communication dominated. I had insufficient meetings with staff to discuss cases, and encounters I initiated with the clinician-administrator were rushed, procedural, and uncollaborative. He never seemed to be around for curbside consultations, often leaving me isolated with a new load of his clients and setting a tone for the rest of his staff.
What's worse, teamwork was relegated to mostly useless occasional one-paragraph notes left for me. Agency practice apparently no longer included the modern, decades old, multidisciplinary collegial integrative team approach, developed almost a century ago in the child guidance movement. This crucial innovation enabled work with complex childhood disorders in their family, school, and community contexts. An ongoing formal and informal conversation among staff in real time is needed to understand and effectively treat multi-system childhood disorders, and has been standard practice. This movement also spawned a proud, enlightened, and humane social work profession, and additionally pioneered the now pervasive practice of using multidisciplinary collaborative teams in many progressive workplaces.
Instead of energy and teamwork, this is what I found: inadequate, naive, and superficial diagnostic conceptualizations and treatment planning; seeming ignorance or distrust of the biopsychosocial model ("I don't believe in medication for children"); insufficient history, paltry developmental information, and poor communication with schools; reactive rather than proactive therapy with unclear treatment goals; and rigid isolation of the psychiatrist as merely a pill dispenser, with staff mostly resistant to open collaboration ("The psychiatrist should just prescribe and not talk too much or do therapy"). I have spent a lifetime working in many capacities with agencies serving children, even some with poor leaderships, but this one really took the cake.
We are back to the dark ages of services for children, to an era even before the child guidance movement many decades ago. The basic minimal underpinnings of good practice at this well-regarded agency too have deteriorated, much as at the hospital units I describe above. I was now witnessing how young voiceless children and their parents are shafted as outpatients too.
So I struggled from the beginning with, "Should I stay and work slowly to improve things for these underserved children? Who will serve these voiceless high risk kids and broken families?" So I hung in. A colleague friend pointed out that, clearly, I was simply not hired to make changes. She was right. I eventually realized that there was no support forthcoming from the top for actual collaborative work, just increasing grumbling, apathy, hostility, and resentment.
The final irony and deal breaker was this: despite -- or because of -- my efforts to spend more time with each child, as many as five or even six ended up regularly squeezed by the receptionist into my last hour on site. The locum tenens arrangement dictates strict adherence to contracted hours, so staying late repeatedly was not an option. That basically shortchanges five children to ten or less minutes per child that hour, if you count coming in and out and settling down.
Obvious solutions would have been to redistribute these appointments over the five hours to allow at least twenty minutes, or to shift my working hours to later to better accommodate after-school needs. But for weeks, administration just would not respond to my repeated written requests to redistribute my time, nor have a dialogue, nor itself suggest a strategy to solve this problem.
Things came to a head early one cold afternoon, about three months into my contract, when I arrived at the office. A stunning unequivocalIy clear answer did come in the form of my schedule for that afternoon: not only were five children with parents yet again squeezed into the last hour, but, additionally, in the first ninety minutes, not one patient was scheduled. Not a one in the ninety earlier minutes, yet five in a later hour.
Wow. Stonewalling. That was the agency's clear answer to my requests for more reasonable scheduling. The administrator did not comment when I found him, but when I asked him on the spot to reschedule some right then, he firmly refused: "Agency policy". Unbelievable. So agency policy is to curtail and withhold adequate care. Unnecessary, arbitrary, bad practice, shameful.
So what's the big deal here? Why make a fuss?
First, complexity. These high risk children suffered from poverty, behavior disorders, depression, anxiety, ADD/HD, PTSD, LD, OCD, bipolar disorder, eating disorders, and usually a hard-to-sort-out mixture of several of these together to tease apart and treat, and the always-accompanying impaired home, school, and community functioning to track. They deserve adequate time with a doctor.
Second, urgency. I have known first hand the special urgency here, having just worked immersively inside the hellish futures some of these kids will most definitely have, described above. It is especially important to get it right the first time now, when we can still make a difference.These kids have the same histories as hundreds of adults I had just treated in hospitals. These kids are very high risk and deserve the best possible care now, their mind / brain maturation still sensitive, when we can still push their developmental trajectories towards healthier futures.
Third, thoroughness. With collaborative teamwork and administrative support lacking, a child psychiatrist wanting to practice good medicine at this agency has one hand tied behind his back. No matter the setting, patients deserve his professional best. So he needs even more time to do his work: greet and connect with a child and parent, separately or together, sometimes using a translator; break the ice; catch up; engage; interact (assessing kids must include flexible pacing and careful tuning into the child and cannot be rushed -- it takes more time, but kids trust people who respect that); sometimes measure HR and BP and assess physical complaints (I auscultated one athletic teen boy's heart when he reported chest pain and referred him to his pediatrician for the murmur is heard); review questionnaires; complete an entry in the medication log; write a progress note; code the visit by figuring out how many minutes I spent on medication-related and how many speaking with the child and mom to further our relationship, while assessing functioning and stressors; and hand-write multiple prescriptions in carbon paper triplicate (the old kind, where a cardboard flap prevents ruining the next set if you press too hard. Well, you can guess how that goes when you're in a hurry.)
Fourth, cruelty. This administrative shortcut amounts to unnecessary callousness and cruelty. At this well-regarded agency, they had no problem nor professional shame about administratively arm-twisting a doctor so crassly, expecting him to agree, with full knowledge ahead of time, to routinely unethically withhold good care. What was the big necessity here? Why schedule hurried, insufficient, bad care? In essence why be cruel, yes, cruel, the opposite of kind and healing?
Fifth, callousness. Having stonewalled discussion, this agency seemingly actually planned to resolve the issue unilaterally with an arbitrary administrative maneuver. No explanation to me or the patients. And do the parents and kids have a choice? Maybe the administrator-clinician and his superiors got away with such outrageous callousness in the past with the "queen bees" they had hired for their several offices. Maybe it was a sign of poor leadership, bad standards, inadequate internal communication, ignorance, or just indifference. Whatever the reason, that's how far standards have fallen for serving poor people.
I do understand well the uphill pursuit of excellence against the constraints of shrinking funding as a recent board member of another well-regarded large multi-site family agency serving children and teens. I had a view from my high perch near management, working closely with site directors and the executive director for over ten years. But in this agency it was not about that. It was mainly about shamefully low professional standards, callousness, and poor leadership.
Bottom line: Even here, in the midst of a nice suburb of a major metro area, in a nice office located on a nice street among houses with nice lawns and neat businesses, mostly poor high risk kids as young as five and their parents routinely and intentionally receive sloppy dregs of mental health care, the ultimate of professional cruelty, disrespect, and irresponsibility, from a well-regarded agency with a prominent blue-ribbon board of directors.
My heart sank at this clumsy Kafkaesque brutality. This well-regarded family agency is pathetically failing its mission, and it is too broken inside for me to function there. This confrontation clearly signaled that there was no hope of continuing my work at this awful place and maintain my standards.
So I immediately resigned on the spot, and I walked out. I could no longer participate in this charade. I did trust that parents and kids scheduled for that afternoon would be given a copy of the apologetic note I insisted on hurriedly drafting. I had some difficulty endorsing how the facility would now use family practitioners in the community for filling in psychiatric care that only a specialist could deliver well. But people needed continuity of some care -- another compromise. One staff member asked why I hadn't contacted a board member, but no one from the agency ever followed up with me.
I wonder, do agency leaders and staff even know how bad the fundamental flaws really are in their culture, basic integrity, and professionalism? How did they view and react to this incident? Would they care? Would they minimize or cover up? Would they even get it?
I did feel a deep sadness, this time close to home, that high risk savable children needing the best care in the worst way are not getting anything close, and nobody seems to know or care. Looking back at my four failures to fit, I am most upset about this one because of needlessly lost precious opportunities to reformat the futures of these high risk kids. So innocent, so voiceless, many so savable.
WHAT I THINK HAPPENED, AND PSYCHIATRY’S ROLE
Something really bad has been happening in the past few decades that few speak openly about. Of course, it is all about priorities, values, money, governance, ethics, morality, taxes, etc., and there is plenty of blame to go around for anyone who wants to sling it or accept it. (One urgent matter I know little about is that too many poor Americans who are mentally ill end up in overcrowded jails receiving even worse services I have described here.)
But let’s be real — the buck has to stop somewhere, and more than a few cents stop with psychiatrists, individually and as a profession. If you are poor and mentally ill, no matter anything else, you will get relatively little relevant personal attention, spotty psychiatric expertise, and it is rare that anyone really knows you or speaks with you seriously about your past and future in a Behavioral Health system.
Our public and private psychiatry delivery systems right now are dangerously broken (much as the entire medical care system) and not bringing even a small fraction of the promises of neuroscience to people who are poor because its current psychopharmacology application is too often incompetent. And because largely “mindless” queen bees can barely reach people. (Click here for a fuller discussion of these concepts).
The tragedy is that a patient is lucky to get a fraction of the value taxpayers buy. Except that these days, facilities are mostly decent physically, subject to modern hospital standards, medications can work pretty well when used correctly, and there are probably some very fine programs, staffed by psychiatrists and others, struggling to give the best possible care in an abysmal climate.
IMHO the reality has become a national disgrace and crisis infecting all of medicine. People still believe that they can trust care based on professional medical standards based on the accumulated scientific and professional wisdom of American medicine as a special patient-centered calling that takes years of sound training to master. No more. Patient-centered medical standards have become largely defunct over the past few decades. Instead, rich and poor folks alike and their hospitals and doctors are now harnessed to mostly money-centered insurers who pay the bills.
While we psychiatrists are celebrating the wonders of the human genome and neuroscience, we are also justifiably losing our credibility as physicians because too many of our colleagues practice extremely poorly in some Behavioral Health hospital units and outpatient settings serving poor chronically ill people, and too many have delegated their best skills to others who serve folks who are not poor.
The profession that trained me — modern psychiatry — was first built on the careful and caring art of listening to speech and language in all their nuances and responding in kind as a central element of psychiatric practice. Medical and non-medical psychology pioneers have worked brilliantly and diligently for over a century to free the mentally ill from stigma and to understand and treat them humanely. These pioneers tried to base their practices on systematic notions of the brain/mind that made sense. They tried to infer brain function and structure from mental processes and behavior in the most humane ways — talking with and intensely and actively listening to patients. By “language-based” psychiatry and related professions I mean practice conceptually rooted in solid understandings of the human mind with all its richness as the function of the brain with all its blessings.
Paradoxically, at the very same time that neuroscience is confirming the biological bases of much of what we have learned clinically about the human mind in language-based therapies in the past century, actual American psychiatric practice in most areas away from rare metropolitan pockets is rapidly drifting too far away from its intelligent, disciplined, language-based roots that bridge the mind, brain, behavior, consciousness, and healthy living. A huge and increasing number of practices apparently neither utilize language nor correctly deploy medication. This disastrous trend is especially true of inpatient and outpatient care reimbursed by Medicaid and Medicare on behalf of poor people who are mentally ill.
As the use of language declines and “mind”lessness becomes the psychiatric norm, are we breaking our already broken neuroscience delivery system even more by starving poor people of humane language-based healing? Are we giving up our relevance as doctors? Are we abandoning our unique skills in integrating mind, brain, behavior, and healthy daily living for the whole patient? Are pill mills the new standard of care? Is this good for people?
Yes. Yes. Yes. Maybe! No!! Furthermore, IMHO in many ways psychiatry has been the “canary in the coal mine” of American medicine. So — all doctors and patients beware!
Medicaid- and Medicare-funded systems are a main funnel of today’s neuroscience applications, and these are badly broken. A few medical businesses, much like in other specialties, eventually became known as Medicare or Medicaid Mills or pill mills: Non-language based production lines for poor people — high volume / less quality control / lower profit margin / more errors. Some doctors — and I hate using that word for them — at first mostly western-trained in all specialties — innovated the earliest, Medicaid and Medicare mills a few decades ago. These providers were sometimes investigated and even indicted and jailed for fraud and other illegal practices that sometimes even caused hospitals and nursing homes to close. The problem of how to deal with bottom-feeding colleagues flirting with ethical boundaries is not unique to psychiatry nor to any profession, while the absence of language as a treatment tool is absolutely crucial to psychiatry.
Too many fellow Americans, especially poor folks and their children, are tragically not receiving the care they need simply because they are receiving the wrong care. The system is seriously and dangerously broken, even as everyone seems to choose words carefully to comply to the letter with reimbursement.
This is also part of major social problems in our country. But as citizens and individuals, each professional must search their own conscience to decide where they stand on this issue and how much, by deed done or silence, they are perpetuating or enabling this travesty. That’s the least we can do. Many who work in the system have become dulled to its egregious norms and incompetence. But that is not an excuse. Neither is economic hardship.
This is my main point: IMHO, psychiatric care is minimal and substandard in the Behavioral Health units I saw, and as long as that is the case, such units will not be truly competent, humane or optimally efficient. I have come to believe that patients in these facilities depend on too many Behavioral Health provider colleagues, who knowingly, intentionally, or not, are “keeping their heads down” and contributing to profound social injustice, as had doctors in state hospitals fifty years ago.
What we might have now is a failing system, featuring incompetent medical standards, that actually perpetuates social injustices and prejudices against our society’s throwaway peoples. It is a silent blight in our midst. I also fear that wither psychiatry goes, so does the rest of medicine — general decline in professionalism and attendant mediocrity and the gap between rich and poor have now become institutionalized, and we have a multi-tier system.
Nor is this an overnight blight, but decades old. In fact, one of my most senior mentors, actually a pioneer department chair and psychopharmacologist, accurately predicted in the mid or late 1970’s or so, because at that time the National Institutes of Mental Health was stopping subsidies to psychiatry residency training in teaching hospitals, that the profession would sink seriously and move away from its best traditions.
I remember the moment I heard him (on a beach in Miami after a professional meeting), much as people remember what they were doing just before a bomb goes off. It has been in the back of my mind ever since, and now I see what my mentor meant as the trend is really accelerating and has become industrial strength.
We all saw psychiatric services in general hospitals “bleeding money” because of unequal coverage of mental illness by private and public insurers, especially those serving many poor people. Less than 20 years ago, I remember sitting in budget meetings in my doctor coat with growingly impatient, fidgety administrators wearing suits. We always lost money, especially children’s programs, because no insurance scheme paid enough to take care of sick families and children. And we had to account for every pencil and eraser in our programs because the hospital carried us as a goodwill service to the community.
Another piece of reality (not frequently discussed openly, but always a big elephant in the room) is that not all doctors or nurses are alike: Looking back, there has always been a big divide within medicine, especially psychiatry, with mostly US medical school, university hospital-trained graduates serving employed and insured (even if poorly) Americans and their families.
Our practices and settings were language-based, generally lower volume/customized service, higher quality/higher profit margin / fewer errors / commercial insurance and out of pocket fee payment. We continued naturally an identity, relationships, and other educational and practice activities. We worked in public clinics for an hourly pay, usually part-time, consulted, and set the pace and general treatment course of patients of a collaborative team.
My network of similar practitioners usually started off careers treating inpatients in community or university-affiliated hospitals right after our training, but then continued to outpatient practice settings, combining outpatient, teaching, research, consultation, and / or pro bono and other community work. Some colleagues continued in community, public, and academic settings. About half of today’s mental health professionals are now opted out of all insurance so that we can use language in our practices. This trend now continues with nurse practitioners, especially in states where they are able to prescribe medication.
But we all knew about another side, and very few of us engaged with it, or with their private practices. Doctors serving the poor in public institutions were mostly trained elsewhere, almost never the cutting edge West, and are industriously struggling for their place in American life. They tend to be much less expensive and a lot less trouble, much as also seem many RNs in the public settings I worked. Their numbers seem to have grown over the past decades, and they also predominated in some of the hospitals where I worked.
Historically, there wasn’t much mixing among psychiatrists from these systems. However, there were some excellent collegial collaborations between university-based biological psychiatry researchers and non-language based colleagues and scientists, especially in state-run facilities affiliated with teaching hospitals training programs. These were other strata of professionals, that few of us ever cared about or welcomed, to our shame, that were grateful to serve in public hospitals and shortage rural places. Whenever they can, however, these practitioners, including now nurse practitioners, usually later try to leave public psychiatry to start their own private practices, considered more lucrative and prestigious. Only rarely have language-based US-trained practitioners crossed over from their private or academic practices into public psychiatry, and when they try, they are rarely welcomed by administrators and threatened entrenched clinical staff, as I have discovered repeatedly.
The wider context has been a general decline in humaneness in medicine. I have my own personal view of this general decline. Before WWII, most specialists retained strong callings as physicians and continued some general medical practice, while most generalists practiced some specialties. WWII military doctors were often assigned as generalists, no matter their training. In America’s neighborhoods, generalists engaged the whole patient and her family. People kept doctors for lifetimes in relationships of mutual loyalty.
Since about then, several powerful forces started changing that: Exponential knowledge and intensive skill sets, bureaucratization of hospitals and growth of insurers, the greening of medicine, changed American society, and eventually, flagrant corruption as government and large insurers came into medicine.
Fee payment, first embedded in a personal, ethical doctor-patient relationship, became a business transaction between insurers and doctors, and disenfranchised patients. The identity of “doctor” as person with a calling, as an ethical and moral healer in the best tradition of the profession and modern science, moved away, first to “specialist” and then, alas, “provider”, “hospitalist“, etc. Malpractice suit fears and astronomical premiums added a dimension of mistrust in an increasing estrangement between doctors and patients, as lawyers joined insurers and administrators at the bedside.
Private practice, where a doctor owns his own place and is free to be his best (and worst), is on the decline, and many experienced doctors are pulling away from a devoted engagement when they become someone else’s 9 to 5 employees. People left their trusted doctors who did not participate in new networks set up by insurers to control fees. Another factor today is how the economic crisis causes increased stress on the poor and damages safety nets serving them.
Yet another factor is that doctors have lost their sense of neighborliness to patients and to their own professional communities, as hospitals turn away from the local practitioners that gave them quality and professional accountability to become production lines. (Hospitals were centers of professional life. We used to have staff meetings, grand rounds, department meetings and doctor dining rooms. We used to talk to each other. We used to monitor each other formally and learn together from our mistakes, even in small community facilities.)
Nevertheless, last time I checked, psychiatry was still a fully credentialed medical specialty. So what happened to the American Oslerian ideal of rational medicine applied humanely that so many top medical students in my now retiring generation signed up for as psychiatrists?
What happened to the fundamental medical principles of “do no harm” and to the professional, ethical, and moral obligation to practice at least competently, if not creatively? What happened to following carefully made diagnoses with appropriate, thoughtful and effective treatments? What happened to the term “psychiatric treatment” in a world of “behavioral health”? How did I get to be a “behavioral health medical provider”? Can the promises of neuroscience be delivered by this broken system?
IMHO, You can’t get ever quality anything by rewarding the lowest bidder and “going with the flow”. And in medicine, that is deadly. In vital services, the lowest bidder is not the best healer. You end up getting the worst. Lives are at stake. It is plain wrong. Our taxes at work — I’d estimate we get about five cents, even on your cheap dollar, on a good day in both private and public sectors. Basically, both probably technically legal, is private Behavioral Health seemingly failing us with naked, active greed, and the state system with greed by a few rotten apples manipulating tired, unionized bureaucracies?
We all bear responsibility. Shareholders of corporations own many Behavioral Health facilities, as taxpayers own local and state public clinics. A wild thought: Why not merge the sectors after scooping out their purulent cores? Or, only if “caregivers” doctors and nurses just practiced according to the letter and spirit of their professional standards and refused to compromise, we would have a great start towards decency.
SO, IF NOT NOW, WHEN?
Would the words “Behavioral Health” now signal a new context and redefinition for psychiatry, just as the word “providers” in the 1990’s changed the professional context for all doctors, and most just accepted it? These words now pass for who we are to many people and ourselves, and apparently work as long as you don’t deal with people’s need for healing.
Here we are today, with the ACA here, in the age of the human genome, neuroscience, and technology, still with one foot in the sewer. We are all morally soiled by the muck. Looking forward, I doubt that poor mentally ill people will ever get many resources as they compete in a public service economy also struggling with broken physical infrastructures and educational systems. But they can get more if we stood up for our profession and its standards.
Things have changed in psychiatry and can be re-changed now that we have the brain in our vision: Psychiatrists are supposed to be the experts in accessing the mind / brain through language. Most language-based psychiatrists were trained for years in this craft and created the model now followed by other professionals, and they used to be tested to pass the boards.
But about a decade or two ago, psychiatry board exams stopped employing live patient interviews (paid volunteers) to assess doctors’ language-based interview skills. So now, most board-qualifying psychiatric residencies give only lip service to teaching language-based skills, once an egregious deficit reserved for the least competitive training programs. And now, it appears OK in some settings to interrupt the connection with patients by multitasking with the clinical onscreen computer record. Ironic, how we are doing to our patients what I have taught we must not do to our children and vice versa, as an expert such matters, I view full face to face engagement as necessary to provide the best professional healing care for the buck. That means no distractions, including frequently interrupting eye contact to engage in record keeping via computer, now considered a norm.
Shortsightedly trying to move psychiatry closer to the scientific medical mainstream, actually we have needlessly shamefully abandoned essential medical practices and values that make doctors healers. Instead, our “professional” signatures mainly enable systems very few of us would have our own family members go near.
And maybe there are many more creative solutions possible we have not considered, especially since as US medical school graduates we are supposed to be America’s best and brightest. In the general context of what is happening in medicine: If psychiatry wants to continue its humane leadership as the best hope for the mentally ill, we’d better examine our roles ASAP in this mess. Neuroscience is a basic science and cannot fix it directly (except if we all wake up use our brains), but its applications need our engineering skills.
As the best trained and placed scholars and professionals bridging the mind, the body, the brain and everyday healthy functioning, we must speak out from our credible history of compassionate intelligent care and design worthy systems. We psychiatrists must review our own roles in this shameful destruction of our profession and its humane — that means competent — treatment of poor mentally ill people.
We must shift our attention back to the severely ill in the facilities that treat them. We must advocate for our patients, provide and police better standards, support well-trained professionals of whatever discipline in the best professional and ethical tradition of medicine, and educate our colleagues.
For example, can we innovate and adapt tele psychiatry and IT systems to translate conversation in clinical encounters directly in real time into parsed text and codes, thereby removing the huge current obstacle to humanelanguage-based care (here’s another great entrepreneurial opportunity!)? Detecting deficits and activated by strings of language (e.g. “Has anyone ever hurt you or touched you in private places?”) the software could require minimal language-based competence to yield coded texts and detect clinical omissions and, for trainees, positionof the eyes? It will free clinicians to use language without interfering with creation of a billable record.
Can we welcome, empower, and help better train the new wave of eager, compassionate, talented, and diligent behavioral health RN+ nurse practitioners in the US, who do still practice in the best traditions of the nursing profession and evidence-based medicine, resist corruption, and serve the disenfranchised mentally ill as a “last line of defense” and advocacy. Like psychiatry residents, too few are learning the power of language-based practices today. Careful deployment of such well-trained and supervised Western-trained professionals, including doctorate-level psychologists, might alleviate the shortages that force today’s poorer care. Strong affiliations with university-based teaching programs could only improve professionalism at all levels.
We must try to influence policy makers to shift entrenched basic economic incentives driving this shameful system so that good medical practices dominate. I am not an expert in that, but our civil service and private industry have plenty of credible talent. A shift to greater professionalism should not be that expensive.
Here’s a silver lining: We all know that people and institutions in crises are actually more accessible to positive changes. We definitely have a crisis. Another: Behavioral Health and public services today are located nearby, inside cities, not exiled and isolated to the far-away countryside. Here’s another: At least, we are not burning mentally ill people at the stake any longer in our country, as we were doing just a few hundred years ago. We have laws against that now, I think.
My repeated failures to fit have come as a shock (to everybody involved — the nice people who bet on my endurance, valued colleagues who recommended me, and to the cordial places that employed me, and to me. In retrospect, my naivety seems embarrassingly clear. How could I have missed it? Everybody, including me, assumed I knew what I was getting into.
I had not noticed, nor did anyone ever spell it out for me until I worked in several places, that I had been wrong to assume, as usual, that I was hired simply to do my best as a doctor. That meant practicing as competently as possible and advocating for the best medical care of my patients. But I was wrong. I was expected to understand automatically that I was also expected to cover up my own basic medical standards as I was covering these practices.
I see now how, from an administrator’s POV, requiring the most efficient coding to obtain payments, everything I did seemed disruptive: “Imposing” my own diagnoses and treatments, prioritizing, encouraging a collaborative atmosphere of learning, teaching, and largely “interfering.” I suspect that a major unspoken worry was how the contrast with my practice “methods” can place the permanent doctors, who are hard to find and whose daily signatures are desperately essential for the system’s financial viability, in a contrasting light. “Why bother to write about this at all? I could be embarrassing myself. Let it go,” I told myself, “Keep your head down.” The trouble is, no one, especially me, would ever come close to understanding what had happened until I had worked it out, out loud in writing for this chronicle.
“Also, why write this for public view? Isn’t that poor judgment?” Maybe. I hope not. After much careful reflection and many rewritings, I feel obligated to share what I saw. I believe that the details of misfittings by an accomplished psychiatrist with high standards can reveal enough about us and our institutions to accomplish my goal, which is to teach and to provoke discussion in the right circles that would lead to positive actions. I believe that as America experiments with new models of healthcare delivery, all current practices must be considered.
Reader: I beg your forgiveness for any errors of omission and commission and urge you to think critically, keeping in mind my goal. Of course, because I am too close to the subject and have only a small window on it, I cannot expect to be considered fair. But I do keep my biases clear and do try to be honest, balanced and transparent. This is, after all, a unique subjective account of a journey into controversial places. Once I understood what was happening, I found myself in the ethical quandary I pose above that I am now attempting to solve for myself. So far, I have decided to continue working to serve people who are poor and severely mentally ill, teach colleagues, and write. So — reader — please consider this essay a step.
Looking back and making sense of my recent journey, I initially sought locum tenens work because I needed the pay, but immediately became intensely wrapped up in rediscovering my medical and psychiatric roots, and was seduced by the immersive challenge of seeing very ill people actually quickly improving in front of my eyes again! That relit flame is still burning in me. But it blinded me at first. Now, as I pass a certain hospital and glance up at the second floor, I still think, “Folks could be stumbling through nightmarish medico – bureaucratic purgatories, right up there, just beyond those windows”.
I hope my writings here beget positive results. I realize fully — and so should any reader — that generalizing from what I saw in just a few units and drawing major conclusions about a whole industry and the people who man it is simply not valid nor fair. My use of “non language-based” is not intended to describe specifically any folks or colleagues. My intent here is only to create transparency and signal an alert from a professional and patient advocacy POV that would prompt more valid, larger, helpful studies.
In practical personal terms, however, IMHO these observations are reliable enough for me to now know how to find work that fits me. What I saw is extremely alarming and the valid bases for my own personal reactions described herein. And clearly, this is why fitting into the Behavioral Health inpatient and state hospital units I serviced, and going with the flow and keeping my head low to cover these practices, was impossible for me personally during my 44th year of practice and after a lifetime of pursuing professional excellence.
I am now obligated to take responsibility for my own part of the current mess, especially for ignoring the plight of so many neighbors. So this essay is not about bashing anyone, and I don’t even know who the main players behind this scenario are. The taxpayer pays and patients suffer with unacceptable psychiatric services –that much I know. I am grateful and humbled for being among US university-trained psychiatrists, well trained medically and then mind / brain diagnoses and treatments and always striving to excel on behalf of patients.
But, reader, you know who you are, and so do others. If you believe what I wrote, silence would put you too in a moral quandary, if you choose to see it that way. Of course, if this essay is too much of a challenge to some entities and hopefully has sufficient impact, predictably, my credibility could be questioned and conclusions even attacked ad hominem by anyone who disagrees (or the opposite, my opinions used out of context by activists).
My POV might be dismissed as coming from just another fading old dinosaur, longing for good old days that never existed; a self-righteous, self-serving wrinkled relic of the social activism of the turbulent Sixties; or from a disingenuous, effete, condescending elitist, an arrogant self-promoting eccentric, or just an ungrateful, hypocritical, conspiracy theorist and troublemaker. Or all of the above. Or worse. No matter. Even if I am found inaccurate in some of my perceptions or details or faulty in some of my conclusions, or have some personal failings, I did craft the above language carefully to describe what I see and think as a doctor. Please understand that, ethically, I am compelled to speak up for the sake of our present neighbors and to leave a better world for my grandchildren and their generations.
Finally, my fond personal thanks again to the dedicated administrators, nurses, staff, and doctors who accepted me into their workplaces, and additionally to the many patients, for collaborating in some of my most challenging and rewarding professional work in years. You know who you are.
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About the Author
Eitan Schwarz, MD FAACAP DLFAPA
Board-certified general and child and adolescent psychiatry. Education: Cornell, Johns Hopkins, and trained at the U of Chcgo, now Northwe
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