Academic Psychiatry 23:157-159, September 1999
© 1999 Academic Psychiatry
Gone With the Wind
Surviving the Closing of a Psychiatry Residency
Jeff Q. Bostic, M.D., Ed.D.,
Barry K. Knezek, M.D.,
Howard Smith, M.D.,
Lorenzo Triana, M.D. and
Carl Young, M.D.
Dr. Bostic is Director of School Psychiatry, Massachusetts General Hospital (MGH), and clinical instructor, Harvard Medical School, Boston, Massachusetts. Dr. Knezek is Inpatient Medical Director, Green Oaks Hospital, Dallas, Texas. Dr. Smith is Outpatient Medical Director, Dr. Triana is Chief of Medical Staff, and Dr. Young is Inpatient Medical Director, Timberlawn Psychiatric Hospital, Dallas, Texas. Address correspondence and reprint requests to Dr. Bostic, MGH, Harvard Medical School, 15 Parkman Street, WAC 725, Boston, MA 02114–3139.
Key Words: Commentary • Residency • Training
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INTRODUCTION
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Timberlawn was our "Tara," a Dallas plantation turned training site for 24 young psychiatrists enamored with psychodynamic psychiatry. But on July 28, 1993, the psychiatry residents and fellows were notified that Timberlawn was terminating all training programs. Diminishing patient pools, shortened inpatient stays, managed care restrictions on who could see patients, and further downsizing made us expendable. As predicted by our mentor, when these enemies invaded, training would be among the earliest casualties (1). (Jerry M. Lewis, M.D., former psychiatrist-in-chief and residency training director, was not affiliated with Timberlawn Psychiatric Hospital when the residency program was terminated.) In 1 day, Timberlawn's residency program was "gone with the wind." We had no recourse: the decision had already been made, banks were appeased by this cost-cutting effort, and Timberlawn had bought itself a few more months of life. We were encouraged to scavenge leftover residency positions elsewhere for a new home.
Meeting service needs while adorning the facility when psychiatric dignitaries visited, we had deluded ourselves with our importance, oblivious to what our Timberlawn parents witnessed. Like children, we expected our mentors to protect us from any harm. We believed they would sacrifice themselves before allowing anything bad to befall us. But we were not their children. Our mentors had mortgage payments and real children needing college tuition. Some residents threatened legal action, and were encouraged to "get in line behind the banks," chillingly proclaiming Timberlawn's economic commitment to us. Most residents simply began scrambling to find a new home.
Because our cohort of five postgradaute year (PGY)-3s were deep into training and still 2 years from finishing residency, we felt a different camaraderie and commitment than the other residency classes. We were far enough along to have been connected by a shared history of call coverage, rotations, classes, and social outings together. In addition, we had each developed relationships with supervisors over years that still left us feeling more attached than rejected. While PGY-4s were already mentally preparing to leave Tara to begin their professional careers, we were at a different developmental juncture. The five PGY-3s concluded that we had much more to lose than gain if we relocated. For us, moving from an adolescent to an adult relationship with Timberlawn seemed critical in converting a painful rejection into an opportunity to negotiate our own futures.
Realizing the training we had anticipated was lost, our PGY-3 cohort reassessed what remained of Timberlawn to determine if we could survive there. The impending departure of about 20 psychiatrists left Timberlawn in need of inexpensive staff for its remaining outpatient satellite clinics, in-house call needs, and commitments to community health centers and hospitals. Attending staff were not eager to provide these services. We were less costly than replacement psychiatrists, and we were already familiar with Timberlawn's procedures. We also realized if we functioned as a small group, we could better protect ourselves as Timberlawn sought other clinicians/groups to provide services. We agreed to negotiate collectively so that we could not be pitted against each other. Bankruptcy was still only being delayed rather than prevented, so we tried to address the new owners' immediate needs as well as our own training needs. While we would independently staff the satellite clinics, we obtained more supervision hours from preferred on-site supervisors. We negotiated fees for extra services, such as in-house call, beyond those included in the residency requirements. Malpractice insurance would be provided so that we would maintain malpractice coverage even if Timberlawn reorganized as another health care facility. We arranged other economic support from facilities having contracts with Timberlawn. Since the Timberlawn program would officially "close" at the end of that academic year (June 1994), we agreed to provide service through that interval, but with travel time and funds allotted so that placement could be arranged for our 4th year. In addition, we negotiated funds to support relocation (about $5,000 for each resident relocating out of the area).
These particular arrangements are far less important than the larger training issue forced by circumstances beyond our "parents' control." Unfortunately, mental health systems— like all contemporary health care services—now face considerable pressures. Other onslaughts are likely to occur at other times during our professional lives. While not formally placed in our training curriculum, this "unanticipated renegotiation" has proved among the most important training experiences we received to engage in professional practice. Accepted as an unfortunate but sometimes unavoidable circumstance, Timberlawn's residency closing allowed us to move forward with our own professional growth. Three of us (LT, HS, CY) remain at Timberlawn. While this decision may have reflected an effort to preserve a group who had survived a common disaster and remained loyal to each other, it may also have indicated the importance of recognizing personality matches useful for future practice associations. Perhaps more telling, all five of us now function as medical directors. We were not a unique class of "leaders." Instead, we have realized how negotiating with others' needs in mind has prepared us for such roles, and also we suspect that we attempted to position ourselves where we would never again feel so powerless.
Visible because of the large number of trainees displaced, Timberlawn proved what all training programs continue to fear. Training programs are no longer safe from market forces or downsizing (2). Forces continue marching not just in the South but in all directions. Medicare and the Health Care Financing Administration continue inducements to eliminate training programs, most recently "incentivizing" New York's hospitals to cut residency positions by at least one-fifth (3).
Training programs facing such adversities might consider opportunities not immediately apparent to us. First, the communication pattern frames the roles of system participants. Residents learned of the residency's demise from secretaries. While perhaps shielded from frightening news, we were positioned to respond as children perceived incapable of being able to sit with distress. Perceived as having no allegiance to Timberlawn, we felt "expected" to run away as soon as possible. Addressing us directly, early, would have put us in a more adult role, and empowered us to collaborate with our mentors about solutions beneficial to both parties. Second, development emerged a critical variable: what we needed and configured would not have been appropriate for other residency classes. PGY-4s sought transitions to real practices, while we needed more administrative responsibilities to better see "real-world" medical practice. PGY-2s desired collaboration around how their psychiatric identity was taking shape, and what programs would have been a step up from their Timberlawn experience. PGY-ls had been offsite during their brief association with Timberlawn, and they requested help with basic needs (e.g., relocation) but also needed help with their perceptions of rejection and abandonment. Third, negotiations can be complex. Our female residents described more distress negotiating with the identified (female) administrator, and they perceived receiving "worse deals" than their male counterparts. Collectively defining what we all were willing to accept might have facilitated greater equity, but also participation with more than one administrator (or residency training director) present may have allowed more collegial negotiations.
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CONCLUSION
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Although not its original intention, Timberlawn prepared us well to practice psychiatry in a tumultuous time. We all agreed that if we had it to do over again, even knowing the residency program would burn, we would still train there. This realization not only speaks to Timberlawn's training program, but also to the special bonds we developed with each other before and during Timberlawn' s demise. Where our PGY-3 cohort was in our professional development may have encouraged us to preserve our group, but this also clarified the importance of personality factors for selecting partners for subsequent practice relationships. This early opportunity to negotiate time-limited arrangements beneficial for multiple parties, with collective rather than individual efforts, prepared us to think creatively about "win-win" scenarios when facing other grim circumstances. Residents facing similar circumstances may benefit from adopting professional "adult" roles, allying with trustworthy others, collectively addressing needs of the institution and each resident, and remembering seemingly imposed `decisions" may only reflect initial oversimplified plans that are actually amenable to creative improvements and solutions.
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REFERENCES
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Lewis JM: Systems, stress, and survival: psychiatric hospitals in the 1990s. Psychiatric Hospital 1992; 22:145–151
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Yager J, Burt V, Mohl PC: Downsizing psychiatric residency programs. Academic Psychiatry 1998; 22:127–134[Abstract/Free Full Text]
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Kostreski F: More hospitals to be paid to cut residency slots. Clinical Psychiatry News, October 1997, p. 30
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INTRODUCTION
CONCLUSION
