Thursday, February 08, 2007

Discover Your Inner Hero

I have to admit I've never seen the television show Heroes. I understand the idea behind the show is that ordinary people discover they have extraordinary powers. That got me thinking about medical heroes. Usually when I hear that term I think about people like Dr. Edward Jenner who discovered the vaccination for small pox, or Walter Reed and his colleagues who voluntarily infected themselves with yellow fever to see if their vaccines worked. Medical heroes are people who do big, great things and cure diseases.

I dunno, I'm more fond of the television Heroes' common-man definition. I like the ordinary anonymous docs who go out every day and do extraordinary things. I like the public psychiatrists.

I wish there were more of them. Of the six remaining state hospitals in Maryland, three have psychiatrist positions that have been standing vacant for months. I won't even mention how tough it is to find public psychiatrists to work in corrections.

It's not for lack of trying. In the 1970's our state created the Maryland Plan, a program sponsored jointly by the University of Maryland and the Maryland Department of Mental Hygiene to train and recruit psychiatry residents for employment in the public sector. The Maryland Plan was supposed to be a model program that would fill the physician recruitment needs of our state facilities. It hasn't, not even after closing one hospital.

So where are the doctors? There are 180 psychiatry residency programs in the country; Charm City has two of them and they turn out a dozen or so psychiatrists a year. One of the programs is within walking distance of my prison. They're not walking in my direction.

According to the U.S. Department of Health and Human Services health workforce analysis for Maryland:
"There were 1,093 psychiatrists, 5,390 psychologists and 8,000 social workers in Maryland in 2000. This was equal to 21.3 psychiatrists, 101.5 psychologists, and 150.6 social workers per 100,000 population. Maryland ranked 5th among states in psychiatrists per capita (emphasis mine), 1st among states in psychologists per capita, and 31st among states in social workers per capita."
A search of the Maryland Psychiatric Society's directory will turn up 24 doctors under the category "public mental health system" but you'll get 192 if you search for "psychotherapy".

To add insult to injury, we can't even get public health service docs to work here because the Federal government has decided our need isn't great enough. To qualify for the loan repayment program psychiatrists have to work in a designated Health Professional Shortage Area (HPSA) with a need score of 19 or higher (on a scale of 0 to 100). The HPSA score is based on a convoluted algorithm involving poverty levels, demographic data and the number of mental health professionals in a given population. With a psychiatrist-to-resident ratio of 5000 to 1, Maryland doesn't even come close to the required 20,000 to 1 ratio needed to be a HPSA. There are no sites in Maryland with a need score this high. Correctional facilties get their own scoring system based on annual intakes and average length of stay, but again none of our facilities meet HPSA criteria even though we have longstanding open vacancies.

We're missing a few heroes. And they don't know what they're missing.


Dinah said...

You sound mad. Actually, more than that, you sound mad at the psychiatrists who don't want to serve your population. You post on the wonders of prison psychiatry: no heat, no computer, no cell phone access, you've gone years at a time insisting you "can't take a vacation" because there is no coverage, and you implied that you saw roughly 3000 patients last year (patient contacts or patients? or does it even matter).

Maybe the system should acknowledge that this is a competitive market, even with 2 residency training programs cranking out over TWO dozen new shrinks/yr, and work to make the job desirable enough that someone will want it. That, I believe, is how most of the rest of the world works.

DrivingMissMolly said...

Wow, Dinah, Wow.

The field I work in has to do with education and attorneys.

A few years ago, the law school implemented required pro bono hours in order to graduate. There was some debate about making people do unpaid volunteer work, but it is a requirement now.

I think it was/is a good idea because there are probably people that end up unexpectedly enjoying public interest law that otherwise would possibly have never found this out!

A medical education, I am sure, as well as a legal education, costs a lot of money. Medical and law students get out of school owing 100+K in loans so they cannot afford to work low-paying jobs and have any kind of lifestyle. I know that there are people that want to, lets say, work at the women's shelter getting women restraining orders and divorces, but they cannot afford to live AND pay student loans on less than 35K a year.

If I remember correctly, Clink, you said that these positions are well paying, right?

I know that there are altruistic people in law school and medical school, how are they being reached? Recruited? Retained?

Dinah, I hope that you are not mad at Clink. I think that you have the best of both worlds in your practice, but not everyone has that option. Maybe if there were more clinkshrinks she wouldn't have so many PTs "passing through."

You use residents, I assume, correct?

I think that throwing more money at the problem is the first response, but that isn't necessarily the case.

How about FMGs? Maybe it will come to recruiting them for public interest psychiatry.


BTW, Where are Carrie? Sara? Has anyone heard from Foo?

Asside for Clink:

Yesterday we had two men come and speak about being falsely imprisoned as part of the local "Innocence Project." I have a lot of admiration for you. You must be one fearless nun!

DrivingMissMolly said...

Oops, sorry. I meant to say that throwing money at a problem all though the first thought that comes to mind, may not be the solution. Sometimes a solution demands some creativity and thinking out of the proverbial "box."


Dinah said...

I'm not mad at Clink!!
This is simply the reality of life in our capitalist society: there are lots of jobs for shrinks. If one offers reasonable temperature control and vacation, and another doesn't then the job that doesn't, needs to offer something to offset the fact that the shrink has to work in 90 degree heat with a patient load that exceeds most psychiatrist's idea of reasonable.
Perhaps that other thing is simply Love-of-the-Prisoner, and that is worth the trade off (who needs vacation or A/C when they can have prison nurses calling in the middle of the night?)

As Clink has pointed out, that "something" could be satisfaction of a debt obligation, and our MD prisons don't qualify (I think this was the point of the article).

Or, the job might have perks not seen in private practice: low overhead, a fixed definative salary, often public sector outpatient jobs have no call, paid vacation, or higher salaries then can be gotten elsewhere to snag the hungry and in-debt.

I don't work in jails, but a portion of my career has always entailed working in the public sector, for a variety of reasons.

Midwife with a Knife said...

The lack of ancillary staff, phones, office, and climate control is more of a disincentive to me serving the underserved than sub-market monetary compensation. I would be willing to work for less than market value to serve the public, but I'm not willing to work without heat or air conditioning or appropriate ancillary staff. I don't know if I'm representative of shrinks, but I may be.

ClinkShrink said...

Wow, I didn't think my post came across as angry--I actually rewrote it because I thought the original one was too dry and "fact-based". Regardless, I don't have any problem admitting that correctional work is a mission of mine and I get rather passionate about it. That's probably what's kept me slogging at it for this whole time, although the downside is I have trouble understanding sometimes when people don't share my intensity.

I know Dinah isn't mad at me, and my post (or this comment) isn't directed at her because I'd be preaching to the converted. Dinah does a lot of humanitarian professional stuff without making a big deal about it, not the least of which is being a Katrina psychiatrist. I know she gets where I'm coming from and she doesn't view the work as all being medical economics or professional comfort.

When I see numbers like what I put in my post, I get concerned because on the face of it it looks like psychiatry as a profession is abandoning our public institutions and I think that is a topic worth getting stirred up about. When physicians back away from a problem it ends up getting handed to people with no health care training, no mental health training or both. That's not good for the system or the patients.

If you frame the problem solely in terms of workplace comfort and economics you end up in a logical conundrum: You can't get doctors until you improve the system, but the system won't improve until you get doctors.

So short of cloning Dinah, what do you do? I was kind of hoping that by putting up the post and posing the question there might be a 1% chance of stirring a mental health worker somewhere out of professional apathy. One percent out of a world-wide readership is a lot of people.

Lily I think you summed it up well---how do you reach, recruit and retain psychiatrists? That's exactly what the public institutions are struggling with. Forensic fellowships require correctional experience now and that is helping but it doesn't do much for state hospitals. We do use a lot of foreign medical grads, but it's a bit embarrassing to admit that it's easier to bring someone overseas than it is to get them to walk down the street.

In conclusion, thank you everybody for talking cogently about something that matters to me.

DrivingMissMolly said...

I assume this has been brought up at your annual meetings for the American Psychiatric Association or the AMA, right? If not, well, maybe some of you can spotlight the issue that way? Set up a roundtable discussion or something?

Dinah, my intention was not to offend. I KNOW that you've done a lot of comunity work, including work with the survivors of Katrina. I meant that you have the ability to spend time with your private patients as well as dealing with the time constraints of the clinic.

OK, well, I wish I could help. I just hated to see the lack of comments on what I think is a good post by Clink.

Take care and have a good weekend.


NeoNurseChic said...

Lily - Thanks for wondering where I was... I've been reading posts and comments here and there, but this has been a bad few weeks for me. First I had a blog crisis of sorts, and then was in the car accident a week and a half ago. Then my mom's best friend died on Saturday. She was 53 and had 3 children - all boys - the youngest of which had just graduated from college. Her middle son is my brother's absolute best friend, and our friend who died is a 2nd mother to my brother. We've been friends with them for years. So early in the week, I was spending a lot of time with my family or at our friend's house when I had down time. Then the viewing was Tuesday and the funeral was Wednesday. Then I worked 12 hours today and yesterday. I had to commute in from my parents' house (where I am now) because I have no car and I wanted to spend this difficult time with my family, so that means very long commutes. Just been exhausted.

So that's why I haven't been commenting as much. But thanks for asking.

And Clink - it was a good post - maybe I'll make a "real" comment sometime tomorrow if I get a moment. My couch is being delivered tomorrow and my aunt is coming down from NYC.

Take care all,

alwaysthegoodgirl said...

It's me, the 3rd year med student interested in psych. I changed my Blogger Display name for anonymity a while back.
This question is really going to show my ignorance but are there public sector outpatient clinics?
Does public sector just mean that you are being paid by the state?

ClinkShrink said...

Thanks for the compliments on the post. Peanut Gallery, it is a bit tricky to define what constitutes a public health clinic in free society. Dinah and Roy and I talked about that on our last podcast and finally concluded that any clinic that treats Medicaid/Medical Assistance patients could be considered a public mental health clinic. Once upon a time (sigh...I'm dating myself and I really miss those days) we actually did have a network of publicly-funded mental health clinics that covered geographical regions (once called "catchment areas") of the state but those clinics have pretty much all been closed or bought out by the private sector.

Within the correctional setting we have outpatient clinics, infirmary services and crisis intervention services. Some facilities have special housing for the mentally ill with additional mental health support for people assigned there.

Hope this answers your question.

Steve & Barb said...

Excellent post! I didn't hear anger, just a tsk-tsk for those who don't "pitch in", but rather cash in.

Dinah is right. Part of the reason for a shortage is that there are so many opportunities. Same as the nursing shortage. There are so many other, non-clinical, opportunities for nurses now (eg, nurse reviewer for a managed care company, etc) that it is hard to find ones who will to bedside care.

Psychologists, too. Maryland has the highest number of psychologists per capita in the country. But, try to get an appointment with one (even find one) on the Eastern Shore or in Western Maryland.