on history 4

Posted on Monday 28 January 2013

Following the light of the sun, we left the Old World …       
Christopher Columbus

This is obviously a view of a limited history, from a single person, in one place, at one slice of time – inseparable from my personal history even if I tried. Maybe it’s more a remembrance of things past than history. But it’s what I’ve got, so I’ll continue. I ended by saying that in retrospect, I think I saw a prequel of what was coming up ahead along the way, though I didn’t quite register it at the time. And it wasn’t the part about the coming of the DSM-III and all of the changes that accompanied its arrival – although that was a big part of my own leave taking. It was in these sentences.

    "I finally had to stop rotating residents and students through GMHI or letting them take call there. It was no longer a training facility, but the loss of the placement [and the residency stipends] put a huge strain on our already thinning budget."

The reason I had to stop sending our residents to rotate at GMHI was that the only factor of importance had become the number of beds available. The Catchment Area had outgrown the hospital. Instead of evaluating patients on clinical grounds [dangerousness, symptoms, community resources, diagnosis, response to treatment, etc.], the decisions were largely predetermined by the bed availability. The same with discharge. Patients were being sent out prematurely. The forces to overmedicate were everywhere. I just didn’t want trainees to be forced to practice that way. The State was closing beds that were essential all over the State. It was that simple. It was a huge loss because those rotations paid the salaries of a number of the residents and had been a great clinical experience for years before – including for me. Private hospitals were closing or cutting back too in response to Managed Care, so senior resident rotations were also disappearing. When I first proposed removing the residents, the chairman understandably balked. GMHI was in part his creation. The next afternoon, I took him to a unit where we walked the halls. I showed him some charts and then he met with the residents on that unit. He agreed on the spot and that was that. Some things have to be seen to be believed, and we were already past due. Why was that a prequel? What did it portend? Here’s how I now see that piece of the story.

First, we insisted that the residents and students took a complete history on every patient, including where and how they lived and particularly their treatment history. Things were getting so harried in those days that there was a strong temptation to rapidly medicate chronic patients to free up beds without paying proper attention to their living situation, their clinical course, their medications, and their resources – fiscal, interpersonal, medical, etc. At GMHI, the patients were coming through for such short stays that the pressure of necessity meant we could no longer have those same expectations. And there’s no "quicky" treatment for profound depression, for mania, or for that matter, anything dramatic enough to get someone into a crowded State hospital. The residents couldn’t hold onto the patients long enough to do a decent job of either getting to know them or treating them. "It was no longer a training facility." I now see that situation as a prequel to the coming over-reliance on medication – thinking the medicine "had to work" [which was not guaranteed] and giving in to the temptation to "push" medication.

But more than that, "… the loss of the placement [and the residency stipends] put a huge strain on our already thinning budget." Postgraduate medical training has to pay for itself, at least that’s true every place I’ve ever been. We had a large volunteer faculty from the community. We had an adequate full-time faculty, but they were paid for doing clinical jobs, or from their research budgets – not for teaching. Very few of us were paid by the University. And the residents worked for a living in a wide variety of settings. That’s just the way things work in Medicine. Psychiatry is no exception. Most people don’t realize that doctors train other doctors frequently gratis. With the powerful pinch of Managed Care in the private sector and the dwindling Federal and State funds in public mental health, we were dirt poor and getting poorer. For thirty five years, our chairman had done an amazing job of keeping us in the black, but he  was running out of knobs to turn and things were beginning to look mighty red. I looked forward to the coming of a new chairman who might have more tricks up his sleeve. The retiring chairman shared that sentiment. He was tired.

It worked out differently than I thought. Being part of the old regime is a vulnerable spot to be in I learned. One of the solutions was to trim back the outpatient training, for the residents to spend a lot more time treating inpatients. It was my turn to balk, but there were many other more fundamental irreconcilables. I stayed and helped with the transition, then moved on – a joint decision. In a short time, the new chairman moved too – but he moved up to become Dean of the Medical School not long after I left. His replacement was Dr. Charlie Nemeroff, known to us all. In the years thereafter, the Department thrived. There was an influx of new faculty, primarily in biological research. Famous people came for Grand Rounds. The residents got to travel to meetings. The influx of funding was palpable and the program began to rise in the ratings. I marveled at the rags to riches part of the story, mystified when I thought about it, but I had plenty else on my plate and made a clean break.

So how was "… the loss of the placement [and the residency stipends] put a huge strain on our already thinning budget" a prequel? You already know the answer, but I didn’t for a surprisingly long time. The parched earth I had left grew verdant, bathed by the influx of pharmaceutical industry funding that flowed in through every portal. Besides basic federal grants for biological research, there were "translational" programs, joint NIMH/Industry programs, industry financed research and clinical trials, unrestricted training grants, advisory boards, speaker’s bureaus, etc. – things I never imagined. We had seen the declining paradigms [State Hospitals, the public Mental Health programs, and Private Hospital Treatment] being replaced by the radical shift to biological psychiatry as the stuff of a scientific paradigm shift. It was certainly that, and that’s indeed how the story was told. But there was something else going on that had to do with the immortal line from All the President’s Men, "Follow the money." Academic psychiatry was in dire straits, maybe more so where I was, but it was an abiding problem elsewhere. The rise of the thing we call the Academic·Industrial Complex now seems to me like a perfect storm, an accident waiting to happen, a rescue operation, a bail-out, maybe even a merger, a buy-out, or a takeover.

There are as many theories about the motives and mechanisms by which academic psychiatry and the pharmaceutical industry came together as there are theorists musing on the question. That was a piece of history I wasn’t around to see, so I can’t add anything that would count as data. And thus far, no one who was part of that has come forward with anything but justifying rhetoric. How did these two estates that had previously been conversational but separated by a solid barrier [conflict of interest] become so entwined? This post is about the forces in why, not how it happened. But I guess I see it like those little Scottie refrigerator magnets that repel each other until you alter the alignment – then they’re irresistibly drawn together into a tight bond. But in this case, there were more than two puppies.

Since I seem to be on a quotation and old saying kick, here’s one that I’m going to have to revise a bit: Necessity is the mother of more than just invention. It drives a lot of corruption too…
    Steve Lucas
    January 28, 2013 | 4:20 PM

    I have followed this series with interest. Changing the words medicine to business and a few of the references and you have described my academic experience. I watched the changes during the 70’s as we moved from problem solving in my undergraduate program to how to game the system of my graduate program.

    An undergraduate sales management course dealt with the out of control salesman. Today we see lists of those positions where we most likely will find a psychopath. On a list last week sales people were number four while clergy were number eight, I have dealt with both.

    Business problems are all framed in the question: Is there an app for that? People always claim there will be technology next year that will solve the problem and young managers have monthly car payment sized cell phone and internet access fee bills.

    Reading various blogs I ran across a comment by a young psychiatrist who was lamenting an increase to 40 patients a day. Doing the math you have to ask: How does he have time to say hello, how is your day going, before he is on to his next patient.

    All of medicine today is being performed by the low cost provider. Nurses do physicals and histories. Fresh undergraduate psychology and social work graduates work with those who are most disturbed. All the doctors have time to do is scan a piece of paper and follow the pharma developed prescribing guidelines.

    I see psychiatry as the template for pharma’s takeover of medicine. Control the way medicine is practiced and the prescribing guidelines and you control the industry. Many in the business of medicine like this model and they are personally enriched or have increased power and status.

    The problem is this does not help those with psychological problems or the patient with physical issues. Low cost providers pushing patients out the door may be good for the bottom line, but will not help those patients who are in need.

    Steve Lucas

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