Carolyn B. Robinowitz

State-university collaboration in psychiatry: The pew memorial trust program

This contribution summarizes the background leading up to the goals of and the experience gained from a major national initiative to expand and improve collaborative activities between state departments of mental health and university departments of psychiatry through regional conferences, national workshops, ongoing consultations, and awards. It details the problems of the public system and how successful collaborative efforts have improved the situation, cites the role of one such a program (in Maryland), recounts the process of holding a national invitational conference and the subsequent “Call to Action,” and summarizes what the Pew Project is intended to do and how the project is progressing.

Health Care Reform and Postgraduate Psychiatric Education

Psychiatric educators must prepare to teach in an era in which funding for education is more difficult to obtain, all forms of treatment are shorter, patients are discharged from the hospital while they are still acutely ill, the burden of paperwork and other administrative tasks is greater, psychiatrists provide less psychotherapy, and residents are no longer able to play a primary role in the treatment of patients covered by third-party payment schemes. A surcharge on a national insurance plan could make up for funding deficits, but this is not likely to occur in the near future. A more realistic model involves billing for services of faculty who integrate direct participation in patient care with teaching and better definitions of the role that residents can play in modern patient care. Overage from clinical activities driven by faculty may provide sufficient funding for resident services that provide an opportunity for longitudinal patient experiences. Strategies for political action and for better collaborations with primary care faculty are discussed.

The Physician as a Patient

One of the most pervasive medical myths involves doctors as patients. Traditionally there have been aphorisms and injunctions from biblical times until the present: “Physician heal thyself!” “The doctor who treats himself has a fool for a patient!” The standard hospital stock statement is that doctors and nurses make the worst patients, possibly because there are no surprises left for them in hospitals.

Gender Differences in Faculty Retention and Rank Attainment in Academic Departments of Psychiatry

Using 1989 data from the Faculty Roster System of the Association of American Medical Colleges, the authors examined gender differences in retention and rank attainment of psychiatry faculty who had received their first full-time medical school appointments in 1978. Retention differences between men and women were not significant in either the M.D. or the Ph.D. subgroup. Women M.D.’s in the sample had advanced through the academic ranks to a significantly lesser extent than had men M.D.’s; the rank attainment differences among Ph.D.’s, however, were not significant. These results underscore the need for more study of gender differences in the career paths of faculty in academic psychiatry departments.

Administrative relationships between departments of mental health and academic psychiatry departments: The commissioners' perspectives

This article summarizes survey data gathered from state commissioners of mental health regarding current affiliations between academic psychiatry departments and state psychiatric hospitals. The paper explores the prevalence of state-university relationships, the nature and main objectives of the affiliations, and how they are perceived by state commissioners. Significant trends in design, residency education and leadership style are noted. The authors present this work as a 10-year follow-up to similar survey data published in 1983.

The Impaired Physician and Organized Medicine

It has been estimated that 5%–12% of the physicians in the United States are impaired sufficiently that their condition affects their work and practice. The most common diagnoses are alcohol and drug abuse, emotional disorders, illness related to aging and loss, or physical conditions.1 While traditionally recognition and care of these physicians has been seen as the responsibility of the profession, the lack of success of voluntary treatment, and the inability of many medical groups to initiate effective limiting and/or disciplinary action has led to the increasing concern and involvement of the public, governmental groups (e.g., licensing bodies), as well as organized groups of physicians. A study performed by the American Medical Association stressed that ignorance, apathy, and a lack of feelings of responsibility by physicians generally existed in regard to the impaired and incompetent physician, with intervention coming late in the course of events, or even after the fact (as in physician suicide).2 There are numerous and complex reasons for such delay or inaction.3,4

Is there a shortage of psychiatrists? A psychiatrist's response

Conservative estimates place 15% of the population, or more than 32 million people, in need of mental health services in any given year. These conditions include the most serious mental disorders such as schizophrenia (approximately two million persons), affective disorders (two million), organic brain disorders (at least one million), the serious complications of drug and alcohol abuse and many other disabling problems. Several groups, including the Presidents Commission on Mental Health (1978), the Alcohol, Drug Abuse and Mental Health Administration (1978), the Graduate Medical Education National Advisory Committee, Congress, and the Rand Corporation have described a shortage of some 1020 thousand general and child psychiatrists (GMENAC, HHS, 1981; Langsley & Robinowitz, 1979; Liptzin, 1978; Knesper, 1978; Koran, 1979; Pardes, 1979). While the methodologies for these conclusions varied, each group noted these shortages were based on need for the unique services of psychiatrists (as measured by prevalence and incidence of disease, and the minimum and not necessarily optimum nonsubstitutable care provided by a psychiatrist). These conclusions took into account the role of primary care physicians in the recognition and management of mental illness, as well as the role of nonphysician mental health care providers (e.g., social workers and psychologists) in the care of patients with mental disorders. Informal reports of unfilled positions and referral practices (Robinowitz, 1982b) indicate that there is more work for psychiatrists than psychiatrists are able to provide. In his article in this journal, Dr. Frank raises the possibility that there may not be a shortage of psychiatrists using data based on economic indicators and theory. He notes that the economicmarket place theory directly links rewards

Dilip V. Jeste, M.D., 139th President, 2012-2013.

President Jeste, President-Elect Lieberman, past presidents, Board of Trustees, honored guests, ladies and gentlemen, “Chance favors the preparedmind.” That saying is particularly apt in considering the challenges and opportunities that have marked Dr. Jeste’s tenure as APA president. Each APA president has been confronted by issues particular to our profession, such as stigma, antipsychiatry groups, insufficient access to care, funding for research and education. None have complained of having too few challenges during their tenure. But this year has been extraordinary. Dr. Jeste has taken on several major tasks, any one of which could occupy a presidential year, and all have considerable impact on our Association, not only for a year, but for decades. Recognizing the potential impact of Jay Scully’s retirement at the end of this year, Dr. Jeste appointed a search committee composed of a diverse group of members, chaired by Past President Paul Appelbaum and charged to conduct a wide search to identify potential candidates. Dilip set a timeline that allowed the identification of an excellent successor who could work collaboratively for somemonths with our Medical Director/CEO to ensure a seamless and successful transition. The DSMprocess provides another example. It has been almost two decades since the publication of the previous edition, and the process for the development of DSM-5 was extensive, involving hundreds of researchers and clinicians. (In fact, Dilip himself participated in the study of the research agenda for DSM-5 published in 2007.) The work involved online review and comments from thousands of scientists, as well as interested lay people from around the world. As the final report was being completed, Dilip became the conductor of this great symphony (resembling Mahler’s 9th?), ensuring that the process would not lag while also ensuring that each recommendationwas carefully reviewed by leaders in the Association, and that there would be appropriate educational materials and programs for its use so that this transition too would be seamless. When the implementation of the AMA’s new CPT code resulted in particularly bad behavior on the part of insurance companies denying patients and clinicians appropriate access to and reimbursement for care, Dilip led the Board beyond outraged rhetoric to aggressive action, filing suit demonstrating that we will not tolerate such discrimination. What was the background and experience that prepared our president for these and other challenges? Dilip grew up in a small town in India and was the first physician in his family. A bookworm, as a teenager he read voraciously and was particularly taken by Freud’s Interpretation of Dreams, as well as books for lay readers on human behavior. He was fascinated by mystery fiction, especially Agatha Christie, detection, and problem solving. He entered medical school in Pune when he was 17 and studied the mysteries of the body—and then the mysteries of themind as a psychiatry resident inMumbai. He viewed the United States, through books and movies, as a mecca, but this vision was tempered by the reality of his first assignment in Newark, New Jersey, a challenging and stressful environment in a less than welcoming culture, clearly a different and less romantic picture than West Side Story. He went on to residency at Cornell, training in neurology at George Washington, and a neuroscience research fellowship at NIH. His New York and NIH mentors and colleagues were a “who’s who” of psychiatric leaders. His wife Sonali completed training and work in child psychiatry at Johns Hopkins, while Dilip drove between Rockville and St. Elizabeth’s Hospital, taking their daughters (Shafali and Neelum) to school and activities. But Washington could not compete with the research opportunities offered by Lew Judd at UCSD. There, Dilip has multiple leadership roles: an endowed chair, Distinguished Professor, Director of Geriatric Psychiatry, director of an institute for research on aging, and director of an innovation center. His scientific accomplishments are outstanding and world class—broad and deep, almost 600 articles, books, and chapters integrating neurobiological discoveries with psychosocial aspects of adaptation and coping—from psychosis in the elderly to successful aging. His publications are important. He has been listed by the Institute for Scientific Information as one of the world’s most cited authors, an elite group comprising less than one-half of 1% of all publishing researchers of the past two decades, andwas elected to the Institute ofMedicine of theNational Academy of Sciences. Just listing his national and international accolades and awards would take more than my allotted time. And in addition to being a continuously funded NIH distinguished scientist, he has been a generative mentor ensuring the development of young scientists. Work is doing what he loves—a different kind of detective work, trying to understand the interesting, exciting, and most complicated computer in the world.