When I was approached about contributing to this themed issue of Academic Psychiatry, my first response was: I'll have to let them know I can't do it because I'm not an academic anymore. In the midst of editing several papers for publication, revising two chapters, planning trips to Sacramento to present psychiatry grand rounds and to New York for the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) Council meeting, my second thought was: I don't know if I'll have enough time. Eventually, the irony penetrated. So, what is an "academic" anyway?
After a reassuring e-mail exchange with Drs. Roberts and Muskin, I consulted the 10th edition of Webster's Collegiate Dictionary, where I found the following definitions of academic: "1. a member of an institution of learning; 2. one who is academic in background, outlook, or methods." Having left full-time academia about 5 years ago, I no longer meet the first definition, but I may still qualify for the second. Hence, I decided to proceed.
I currently spend about 2 days a week in private practice, where I treat a broad spectrum of patients. I generally employ both psychotherapy and pharmacotherapy, although I do "medicate" some patients, generally for therapists I know personally. I find treating patients challenging, frequently rewarding, often exhausting and difficult, and always a confirmation of my choice of psychiatry as a profession that promised continued emotional and intellectual growth. Practicing also keeps me up to date with the field and gives me the security of knowing that I can make a living on my own. I dislike the business aspects of practice, but I'm learning to manage them somewhat better as I go along.
Today I see a young woman with a primary diagnosis of body dysmorphic disorder, who continues to challenge me to define what is actually a delusion. She often startles me with her sudden shifts in presentation. I tend to focus on her tremendous social anxiety, and suddenly she will come up with something so odd, magical, or paranoid I wonder if she might actually be schizophrenic. She's definitely better, but she's chafing to be cured. I try to be patient, but I am worried about her and considering adding another medication. She is followed by a traumatic brain injury patient who is struggling with depression, emotional lability, anxiety, cognitive deficits, and major losses: marriage, executive job, self-esteem. I need to get some specific health history for a report that his attorney needs, but right now he needs me to listen to how awful he's feeling.
In the other half of my work week, I am the medical director of a "behavioral health service" (in quotes because I loathe that designation!). As far as I know, this service is unique in residing in three (soon to be four) nurse practitioner (NP) run primary health centers located in housing projects in Philadelphia. In part because of the sense of mission and enthusiasm of the people who work there, and in part because of their designation as a federal demonstration project (and the resources that come with that), these clinics are able to deliver high quality care to people who wouldn't ordinarily have access to it. The excellent mental health staff is composed of psychiatrists, psychologists, and trainees, along with crucially important administrators and outreach workers, some of whom come from the communities we serve.
In addition to evaluating and treating patients, a quarter of my time here is set aside for teaching, supervision, and administration. I consult with the NPs via pager, or they grab me in the hallway, and I "circuit ride" to a different site each week for more formal consultations with both staffs. The NPs do routine depression screening on all adult and child patients who come for primary care. It is in some ways more difficult, but also more rewarding, to teach experienced mental health and primary care professionals than medical students and residents. They tend to be more skeptical and practical, but also more appreciative and interested in what I have to say. I likewise learn a lot from my colleagues, and I enjoy the continued exposure to developments in medicine. I feel well situated at the juncture of mental health and medicine and very lucky to be working with this organization.
Today I will see patients in the morning and the afternoon, broken by a midday staff meeting and case conference. A particularly heart-rending patient, a young man in his early twenties who has a rapidly progressive neurologic disorder, was discharged from a local psychiatric inpatient unit last week without our being aware of it. In the ensuing confusion, he has been without medication and has become psychotic again. Can he be managed at home? His NP, therapist, and I consult on what to do. Another patient with a history of severe sexual and physical abuse and a diagnosis of dissociative identity disorder presents with suicidal and homicidal ideation, which I know to be chronic. I also know she is immeasurably better than she was 5 years ago. At the case conference, the clinical director presents the case of a woman we have been treating for 5 years without much improvement. This woman ratted out her murderer-boyfriend to the police, and she suffers from panic disorder, agoraphobia, and depression. One of our administrators, who lives in her community, is unable to tell us what she was like before this event occurred years ago. The patient writes poetry about relationships, flowers, and loneliness but hardly communicates verbally. Her therapist mentions that she demonstrates fast and jumbled thoughts and advances the possibility of an attention deficit disorder. I express my doubts but admire her courage. We agree to try to get some psychological testing.
As the Car Guys would say, the "third half" of my week is the time I devote to more traditionally academic pursuits. What is nice is that I don't have to work on anything I don't buy into, and I can work at my own pace. This allows me to focus on activities that are meaningful and enjoyable to me. I have excellent and rewarding access to colleagues via e-mail, fax, and phone, so I don't feel isolated. The downside of this independence is that most of this work is not compensated, although I do get paid for speaking and, occasionally, writing. I have no secretary or administrative assistant, and no on-site computer help. I pay my own postage and phone bill. Worst of all, I pay for all of my own insurances! Also, I'm the only one responsible for making sure that I use this time productively. More than people who have ordinary academic jobs, I have to think a little harder about why I'm doing what I do, and if I still want to be doing it.
My activities include: working on sundry projects for and participating in meetings of the councils of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) and ACE (Alliance for Clinical Education), the interdisciplinary association of clerkship directors' organizations; preparing and giving lectures for a variety of audiences on a variety of subjects; and writing and reviewing papers, chapters and editorials. I have also used this time for consulting, for example, to the county office of mental health on medical education programs and local primary care entities on mental health services.
Today I am attempting to put together some pithy and articulate, or at least coherent, comments for two reporters who have requested interviews following the recent publication in Academic Medicine of an ACE-sponsored survey of a national sample of multidisciplinary clerkship directors regarding the effects of managed care on medical student education. The findings of reduced resources for education are consistent with the overall draining of assets away from health care to the private sector, which has occupied much of my work for the past several years, and I want to get the word out. But I'm aware of the need to be careful not to inflate the findings beyond their significance.
At this point in my life, I like to think I'm not doing anything I haven't chosen to do. I don't think I'm a workaholic, but I often feel pressed for time, particularly for time to exercise and to read. I'm lucky to have wonderful friends and family that sustain me through thick and thin and try to keep me from taking myself too seriously!