Rearview (eBook)

Introduction:

After departing from Saint Joseph’s Medical Center on the day of my retirement, my wife, Lois, and I drove to our country home for the weekend. It snowed throughout that night. Awakening that Saturday morning and looking out over the small lake seen from our windows, I quietly observed to myself how beautiful the scene was. For the first time in decades I could relish the snow-covered landscape without the attendant worry about whether the “moonlighter,” the off-hours psychiatrist, would be able to get to the hospital, and if they could not what arrangements I could make to assure that the psychiatric service was covered. During subsequent weeks I would receive calls from my successor recounting problematic situations which arose. During those calls I would listen sympathetically and might offer advice. After one such conversation that my wife overheard, she smiled and said: “It must be nice to commiserate but no longer be responsible.” She had gotten it exactly right. Those were the first tangible experiences I had of a weight having been lifted.

While I remained in touch with former colleagues and coworkers, Saint Joseph’s gradually receded in my rearview mirror. Despite those loosening bonds, I found myself thinking back on my professional life. Two years later the idea of writing a memoir began to percolate. I had always found writing about a subject, whether a term paper, opinion piece, research paper or other work, a way to pull together my thinking on a topic. Perhaps a memoir might serve that purpose, helping me gain a concluding perspective on my career and be of interest to a wider audience curious about the facets of a psychiatric physician’s life. The project launched months later when the idea of using the Fragment format flashed into my mind. Ever so gradually, as the Fragments were written one after the other, the book began to feel as though it would actually come to pass. And now it’s done.

I present select experiences, some revealing and others hopefully entertaining, to illuminate how the fields of medicine and psychiatry have been transformed during the five decades since I entered medical school in 1967. Each concludes with My Afterthought on the Fragment’s theme. It was a period during which, incongruously, health-care stories were as likely to be found in the business as in the health section of newspapers. That is to say, health care had become big business. While I make no claim to speak for others who have practiced during the same epoch, I know that many share, at least in part, my experiences and perspectives. Over the span of my years of practice I have been awed by the strides made in understanding the basic science underlying clinical medicine and, in some fields such as oncology, dazzled by its translation into improved outcomes for patients. Disappointingly, the promise of applying newly acquired basic knowledge about the brain to radically improve the lives of those with serious mental illness has proven more elusive. Nevertheless, given the brilliance of many investigators and the continuing growth of knowledge, I continue to harbor a sense of excited anticipation.

Ironically, the possibility of creating a more user- and provider-accessible and responsive health-care system in our country seems less within reach than that of gaining and applying new scientific research to patient care. The barriers to the latter lie within the domain of creative human intelligence and the appropriation of funds for research, whereas the former is contingent on society’s finding the will to overcome the currently entrenched, piecemeal structure that places primacy on corporate profits over the person served. Patients quickly grasp that the insurance system in which they find themselves immersed was not designed primarily for their medical benefit or ease of use despite what spokespersons for the corporations that make up the medical-industrial complex — insurers, drug and device manufacturers, large medical provider systems, etc. — may assert. Too often patients find themselves virtually engaged in mortal combat to get critically needed treatment or exorbitantly priced medications. The truth is that a system that provides quality health care equitably for all would be the right thing to do, in our country it is not a fundamental right. I have watched with dismay as the significant progress made with the passage of the Affordable Care Act, or Obamacare, has been substantially gutted by President Trump and his minions. Achieving the goal of universal access to quality health care has proven tortuous and its final outcome remains uncertain.

For me, and I expect for most doctors, a unique space exists within which I worked with my patients. During sessions with patients or their families, I experienced a degree of insulation from the external forces that encroached on my practice. Consequently, while engaged as a psychiatrist with patients, despite being aware of clinical limitations and cognizant of the hurdles imposed by the health-care system, I felt abundantly psychologically rewarded for my effort. I suspect that many surgeons feel similar satisfaction when operating while resenting the increasingly heavy hand of insurers. Across decades of practice my global sense of satisfaction was buffeted by external change. The introduction of a new medication, such as clozapine, which offered better, more stable lives for persons with schizophrenia uplifted me. But the imposition of ever tighter rules by behavioral managed care organizations – rules seemingly meant to harass and limit access to no more than minimally adequate treatment – infuriated me.

When I entered medical school and embarked on my specialty, I had no real sense of what actual practice would entail nor had I any inkling of what scientific advances or systemic changes would evolve to influence practice during my professional lifetime. How could I have? Few anticipate the future with any degree of certainty. Now retired, I look back and ask myself, might there have been another career or profession I might have preferred? Not having an entrepreneurial bone in my body, I don’t think business would have been suitable for my temperament. What of journalism? The thought of working as a foreign correspondent had a bit of romantic appeal but an itinerant life ultimately had little allure for one who enjoys rootedness. Music? I love it but given my lack of ability to keep a beat or carry a tune, the best I could do was play the stereo. Law only came to have personal import and draw later when I found myself enmeshed in the regulatory processes that increasingly governed my practice and the running of my department. In retrospect I can’t think of another medical specialty that would have better suited me. As it has worked out, I was fortunate in my choice; it permitted me to overlay many stimulating activities onto my core clinical work. I was challenged administratively as a department chair and hospital medical director, fought to mitigate the negative impact of governmental and corporate forces on the practice of psychiatry and the mental health system through collaborative advocacy, published research papers, wrote opinion columns, and briefly hosted a radio program addressing mental health issues. Each of these endeavors served to diversify and enrich my days. That’s the big picture.

From day to day it often felt like a slog due to the long days and unrelenting demands of each involvement. Like many of my colleagues and, it now seems like most Americans, I was sleep deprived and stressed much of the time. The specter of malpractice litigation hung like a Sword of Damocles over my head as it does over all physicians. The ascendancy of behavioral managed care organizations made psychiatric practice increasingly onerous and decision making in emergency situations especially fraught because their approval was required if hospital admissions were to be approved, a necessary step needed for reimbursement. The game was stacked such that no matter what decision they rendered, the liability for the outcome lay with the onsite psychiatrist. Over the years, dealing with behavioral managed care left me feeling as though I were playing TEGWAR, The Exciting Game Without Any Rules, a card game described in Mark Harris’s famous baseball novel Bang the Drum Slowly. In the game of TEGWAR the rube, in our case the clinician, nearly always loses to the players, the companies that set and revise the rules.

I think it was because of what I experienced being imposed on the health-care system and psychiatry in particular that I did not push my children toward careers in medicine, although neither did I discourage them. They may have stepped back from choosing medicine after witnessing the prodigious hours I worked – because of the late hour of my arrival home, it was not until the advent of the microwave oven that I began to enjoy hot dinners during the work week — and hearing my ongoing commentary on the changes that were making my work day more trying. Perhaps, in retrospect, letting the day-to-day outweigh the bigger picture was a mistake. I noted similar ambivalence among many of my colleagues. Certainly, I would have been proud to participate in the hooding of either of my children at a medical school graduation and therefore occasionally ponder whether I should have encouraged them more firmly in that direction. Ultimately, they chose other paths, hopefully more suitable to their temperaments.

Careers in medicine follow a path through premedical and general medical education, specialty training, and practice. By the time I completed of my specialty training I had spent...