As I enter my office on a typical Monday morning, I inevitably have to pass the Oath of Hippocrates. It is hung on the wall above the chair on which patients or students usually sit, as if I might need to be reminded about something ethical. These days it seems I need more and more reminders about how to address my daily challenges.
Then, when I get to my desk, if I am not immediately interrupted, I read the so-called Maimonides' Physician's Prayer. This medical oath also contains ethical standards that a doctor should follow.
It's not that ethics weren't relevant to me 25 years ago when I first started my academic career. In fact, ethical considerations was one of the prime reasons that I decided to specialize in community psychiatry at Baylor College of Medicine. I was concerned with trying to help the underserved in psychiatry, and an academic setting seemed to be a place where I not only could serve this populatiod but also teach others to do so and find out why such disparities existed. While what I do now can still be called community psychiatry, it now takes place at the Medical College of Wisconsin in a public sector, managed care system imbued with ethical challenges and dilemmas.
But this day starts with a seemingly more pedestrian and traditional activity. I see a couple of "private patients." Like most academics nowadays, clinical work helps to meet the obligation to support one's salary. But it is more than that. These private patients and I have mutually decided to work together, allowing me to do some traditional psychotherapy. It does provide some ethical pause as I wonder if they are receiving better care than patients I see in our managed care system. But I reconcile that question with the perspective that I try to provide the best that finances allow and advocate for a better mental health system in my spare time.
Next up is our Department's biweekly Executive Committee meeting. My role here is Vice-Chair for Managed Care. Besides discussing other major departmental issues—a move to a new building, trying to find a new Director of Child Psychiatry, and developments in our fledging biological research—I need to discuss the uncertainties of the future of our major capitated, full-at-risk, carve-out managed care contract.
The parent Health Maintenance Organization has now become a private for-profit company traded on Wall Street, and they may want to do the behavioral healthcare themselves in an integrated system with the rest of medical care. This contract, which I have managed for 13 years, has supplied yearly profits to keep the department solvent, provided managed care education to numerous students, produced scores of articles, held presentations, and employed a full-time staff of more than 50. We were the first department in the country to do such a contract and now it could end. For me, it has been an area of expertise, but surrounded by all the volatile controversy about managed care.
Today, I have to help decide whether we can afford to continue at lower capitation, with all the stress that may put on quality of care and our reputation (including mine). Many questions float through my mind as we discuss the issue. Do I buy stock in the company? How much do I tell the staff at this time, with the risk they will leave prematurely, but not have a job if they wait too long? What will I do if this ends? As is often the case, this meeting ends by planning more meetings to work on this problem.
Then there's a little time to catch up on messages and mail, especially e-mail. Most of the e-mails this day relate to a national think tank group of which I am a member. Our purpose is to prepare psychiatrists for possible future terrorist attacks. This is another occasional, unexpected offshoot of being a community psychiatrist. This time the community is a future trauma victim.
Next is a pharmaceutical company sponsored lunch for my County Mental Health Clinic staff, which involves a different managed care contract. This has always seemed so ethically complicated. Why have a "drug rep" speak about medication to an academic audience, some of whom do drug trials? Academically speaking, I know the literature says we can be influenced by such presentations, no matter what we consciously believe. But if all the companies rotate, maybe they'll cancel each other out. Besides, we desperately need their samples and assistance programs for our poor, uninsured patients. This lunch is good, better than anything I'll eat the rest of the week!
We follow lunch with a staff meeting. My role is to make final decisions on administrative matters or clinical case presentations. Today, a resident presented a threatening new patient who refused to leave the clinic until he received Valium for sleep. I thought I should be a role model, so I interviewed the patient with the resident, discussing the differential diagnosis and building an alliance. The resident wants to give Neurontin. But despite the drug rep's information, there is nothing substantial to support its use in this hypomanic patient. I give it a try anyway.
Then I see my share of the clinic's seriously ill patients of various cultural backgrounds for the infamous 15-minute "med checks." Over time and through medication trials, the 15 minutes often seem satisfactory. But, as I tell the residents, I wish someone had done a study comparing 15-, 30-, or 45-minute med checks. We have so many gaps in our knowledge of how to provide treatment.
I then close the scheduled day with the traditional supervisory hour with a resident. If I look closer at the Hippocratic oath, it says "… to teach them this art if they shall wish to learn it, without fee …" Without fee means uncompensated time. And the art of medicine can't ignore what is evidence-based. But the time is also valuable because this is really where I see what I know.
Before I leave, I try to quickly work on some academic projects. Right now, it not only includes this paper, but a presentation on "Ethical Guidelines for Psychiatrist Administrators" and processing nominations for the Moffic Award for Ethical Practice in Public Sector Managed Behavioral Healthcare.
So as I muse on the way out, after 25 years what does this typical academic day seem to signify? To keep my focus on the underserved and related ethical issues, when funding to do so is more and more limited, takes flexibility. However, the variety and unexpected demands have their own reward. Seeing patients in different systems, teaching, performing various administrative tasks, and writing allows one to see all aspects of an issue. Having limited time forces me to focus on what is essential. As I leave the office, I could almost swear that it seems like the picture of Hippocrates is winking.