Community Ment Health J DOI 10.1007/s10597-014-9752-5
ORIGINAL PAPER
‘‘I Always Viewed this as the Real Psychiatry’’: Provider Perspectives on Community Psychiatry as a Career of First Choice Elizabeth Carpenter-Song • William C. Torrey
Received: 8 January 2014 / Accepted: 18 June 2014 Springer Science+Business Media New York 2014
Abstract The US needs engaged and skilled psychiatrists to support the recovery of people with severe mental illnesses and we are currently facing a shortage. This paper examines what attracts providers to community psychiatry and what sustains them in their work. Focus groups and interviews were used to elicit the perspectives of prescribing clinicians in three community mental health clinics in the US. Community psychiatry has inherent challenges, including facing high-risk decisions, encountering intense affects, and occasionally witnessing bad outcomes. Psychiatrists are motivated and sustained in this work by (1) cultivating relationships with patients and colleagues, (2) focusing on the mission of promoting recovery, and (3) engaging with clinical practice as intellectually stimulating work. Administrators support the engagement and morale of psychiatrists by creating workflows that allow psychiatrists to meaningfully apply their expertise to support patients’ recovery. These findings hold implications for recruiting and retaining a new generation of physicians. Keywords Community mental health Workforce challenges Provider perspectives Qualitative research
E. Carpenter-Song (&) Dartmouth Psychiatric Research Center, Rivermill Commercial Center, Geisel School of Medicine at Dartmouth, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766, USA e-mail: [email protected] W. C. Torrey Department of Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive., Lebanon, NH 03766, USA e-mail: [email protected]
Introduction Millions of Americans live with severe mental illnesses. How their lives turn out is dependent, in part, on the availability and quality of community-based psychiatric care. Engaged, skilled psychiatrists can help suffering individuals and their families understand the nature of the illnesses, promote hope, and offer life-enhancing tools and supports, including targeted medications. Major reports on mental health services have raised concerns about the adequacy of the workforce. There are widespread shortages of psychiatric prescribers throughout the United States (Thomas et al. 2009). Recent estimates state that the United States is down about 45,000 psychiatrists (DeMello and Deshpande 2011). The situation is likely to worsen due to increased demand for mental health services and the aging demographics of psychiatrists (DeMello and Deshpande 2011). The number of psychiatric nurse practitioners is also in decline (Staten et al. 2005). A recent estimate of the shortfall found that three quarters of the counties in the United States have a severe shortage in the number of psychiatric prescribers, which leaves at least half the need unmet (Thomas et al. 2009). Recruiting and retaining the psychiatric workforce for community care of people with severe mental illness is not easy. Psychiatry residency training slots do not draw well. In 2013, only 50.1 % of psychiatry categorical residency slots were filled by graduating US medical student seniors, down from 55.1 % in 2012; this was the lowest since 1998 (National Resident Matching Program 2013). Fewer physicians are graduating from psychiatry residency programs: 1,025 in 2012 (Brotherton and Etzel 2013), which is down from 1,142 in 2001 (Brotherton et al. 2005). Concern that psychiatry is stressful is a factor that dissuades medical students from choosing psychiatry as a specialty (Garfinkel
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et al. 2005). Medical students who consider psychiatry but choose other paths cite concerns about getting too emotionally attached to patients and disillusionment with the medical model and management of psychiatric illness (Lambert et al. 2003). Psychiatric nurse practitioners are well positioned to fill a critical access gap in community mental health services as a ‘‘logical alternative’’ to psychiatrists (Muxworthy and Bowllan 2011). Yet psychiatric nurse practitioners are underutilized and face many barriers to providing treatment, which may discourage them from entering community practice (Feldman et al. 2003). Psychiatrist job satisfaction is important (DeMello and Deshpande 2011). Medical students cite the importance of satisfied, inspiring faculty role models when choosing a specialty (Campos-Outcalt et al. 1995). In addition, dissatisfied psychiatrists are more likely to leave their jobs (Ranz et al. 2001) and medicine altogether (Landon et al. 2006). Physician job dissatisfaction has also been associated with poor ratings on quality measures such as patient satisfaction, adherence, and prescribing behavior (Bovier and Perneger 2003). Community psychiatric care of people with severe mental illnesses is challenging (Pollack and Cutler 1992). Psychiatric outpatient visits are complex, agenda-packed, interpersonal interactions in which time constraints, communication barriers, and lack of access to necessary information create obstacles to optimal care (Torrey and Drake 2010). The work has been made harder by the drastic reductions in funding for community care in recent decades (Drake and Latimer 2012). Psychiatrists working in public sector settings often face tremendous time and productivity pressures and high turnover in the workforce. With cuts to other supportive resources for mental healthcare, outpatient community mental health centers are often caring for acutely ill people, with ensuing pressures from emergency rooms, family members, and concerns for public safety. Within this context, why would someone go into community psychiatry? What motivates certain providers to work with people with severe mental illnesses in community settings? What sustains them in this challenging work? These questions are the point of departure for this article. When we set out to solicit the perspectives of community psychiatrists and prescribing clinicians, our goal was to obtain a better understanding of the on-the-ground attitudes and experiences of providers providing routine care in community mental health settings. In our initial conception of the project, we expected that providers’ motivations for entering the field and their thoughts on providing care would be a useful frame for understanding how to facilitate the use of evidence-based practice and shared decision making in community settings. While we certainly gained insight into these issues, we also obtained rich information about the day-to-day realities of providing care, what community psychiatrists value about
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their work, and why they have chosen to spend their professional lives in community mental health settings. We also learned about the frustrations and difficulties faced by community psychiatrists as they strive to provide compassionate, effective care for their patients. These issues, with their workforce implications, warrant examination on their own and are the focus of this article.
Methods The study used qualitative methods to examine the perspectives of psychiatrists and other prescribing clinicians working in community mental health settings. An advisory group consisting of psychiatrists, researchers, administrators, and service consumers advised the research team on the development of our goals, focus group and interview guides, and sampling strategies. The investigators for the study were an academic community psychiatrist and a medical anthropologist; a research assistant in public health assisted with data collection at one site. The multidisciplinary research team provided a unique combination of skills and experience to accomplish the objectives of the study. The psychiatrist brought the perspective of academic medicine and the lived experience of working as a community psychiatrist and a community mental health Medical Director to the project. The anthropologist brought expertise in qualitative methodology and experience examining the culture of American psychiatry. Study participants were recruited from three community mental health centers in Vermont, Connecticut, and Colorado. Our goal in selecting sites was to examine routine community-based settings that were not tied to academic medical centers and we also sought to have some geographic diversity. By selecting sites in different parts of the country, we aimed to diminish bias associated with recruiting participants from a single region or site. One of the authors used his network of professional contacts to identify potential sites and contacted the Medical Director at each site to explain the study and gauge interest in participating. One to two day site visits were then scheduled at each location. All study procedures were approved by our institutional review board and participants gave informed consent to participate. We used multiple qualitative methods, including focus groups and interviews, to achieve our objectives of learning about the routine provision of care in community mental health settings. We conducted a focus group at each site using a topic guide. All psychiatrists and prescribing mental health clinicians at each site were invited to participate in the focus group. Focus groups ranged in size from four to twenty1 participants. Two of the participants 1
Given the large number of prescribing clinicians at this site, we conducted two separate focus groups at this site.
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were prescribing nurse practitioners and the rest were psychiatrists. Questions in the topic guide were designed to elicit an understanding of the day-to-day flow of work in a community mental health setting, providers’ perspectives on the key rewards and challenges of clinical practice in community settings, and broad reflections on evidencebased medicine and shared decision making. The topic guide followed the ‘funnel structure’ suggested by Krueger (1994) in which the opening questions are intentionally broad and the questions gradually become more specific as the focus group progresses. The focus groups were approximately an hour in duration at each site and were audio recorded. Following the focus group, we conducted qualitative interviews with individual providers to inquire in greater depth about providers’ experiences of clinical practice; their attitudes toward, and experiences with, evidencebased medicine and shared decision making; and their reflections on how community psychiatric care could be improved. These individual interviews were conducted onsite and in-person whenever possible and, when this was not possible due to providers’ schedules, the interviews were conducted via telephone. Individual interviews were completed with 13 participants (12 psychiatrists, 1 nurse practitioner). Participation in the individual interviews depended upon the interest and availability of providers. Interviews were audio recorded. Audio recordings of focus groups and interviews were transcribed. In the initial phases of analysis, three members of the research team read all transcripts to identify prominent themes that emerged from the data. The researchers held regular meetings to discuss the emergent themes. These discussions led to the creation of a code book to perform more systematic analysis using qualitative coding software. Data were uploaded into Atlas.ti and the two authors of this article coded the transcripts. We held regular meetings to update and revise the code book according to nuances emerging from the data. Three principal domains emerged from the analysis: (1) rewards and challenges of community psychiatry; (2) perspectives on evidence-based medicine; and (3) perspectives on shared decision making. For the present analysis, we focus on content from the first of these domains, rewards and challenges of community psychiatry. The other analytic domains will be addressed in future publications. The two authors met regularly to discuss the narrative ‘output’ from codes relevant to the domain of rewards and challenges of community psychiatry. These discussions led to more nuanced categorization of the data. Through an iterative process of discussing emergent codes and re-reviewing transcripts, we reached consensus on the main findings presented herein. Our analyses did not discern substantial differences between the views of psychiatrists and the
nurse practitioners. For this reason, we use the term ‘‘psychiatrist’’ to refer to prescribers throughout the paper.
Results Before presenting the key findings regarding what attracts and sustains community psychiatrists, we first offer a brief distillation of their perspectives on the challenges they face in their day-to-day work. Insight into challenges provides a broader context for understanding the lived experience of community psychiatry and points to areas for improvement. Challenges of Community Psychiatry Psychiatrists report that some pain and stress is inherent in the work. Psychiatrists must make high-risk decisions and live with ‘‘the anxiety of feeling responsible’’ for patients. Workdays can include being subjected to intensely negative affects: ‘‘I don’t know what the person became angry with me about … I honestly don’t and they won’t say.’’ And psychiatrists can be close to patients who experience bad outcomes, including death by suicide: ‘‘I would have done anything to save this kid—why couldn’t he have called?’’ But what makes psychiatrists express dissatisfaction is not the work’s inherent challenges but workflows that waste their time or create obstacles to offering high-quality care. One participant recounted a past experience working at an agency ‘‘where I had fifteen minutes with clients or less.’’ This psychiatrist felt that such time constraints jeopardized the therapeutic alliance, stating, ‘‘people need to feel heard. They need to not be rushed.’’ Other providers expressed frustration with a lack of support for the psychiatrist’s function by the organization. Community mental health practice is strongly team-oriented, a philosophy that is valued by psychiatrists (as will be discussed below). This egalitarian ethos means that in some settings psychiatrists are asked to ‘‘do what everyone else has to do’’ despite the fact that agencies ‘‘are spending so much money on us.’’ One psychiatrist expressed incredulity at experiences in which ‘‘I am paid by the hour and I am standing at the fax machine doing my own faxing… it just feels like such an amazing waste of time.’’ Also aggravating are dealing with inefficient electronic medical records and insurance preauthorization work: ‘‘interacting with insurance policies are, by far, the most frustrating thing for me … it is because it seems like such a wasted effort.’’ Finally, psychiatrists expressed challenges related to the broader healthcare system. A common complaint was not being able to access necessary information about patients across different providers. Basic information about ‘‘what medicine someone has been on before, what their history has been’’ was often difficult or impossible to access.
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Community Ment Health J Table 1 Provider perspectives on community psychiatry as meaningful practice Themes
Selected quotes
Relationship-centered work Cultivating relationships with patients
‘‘they almost feel like family members’’
Working as part of a team
‘‘I couldn’t keep doing it without the team’’
Mission-driven work Caring for marginalized people
‘‘I have been interested in the outsiders’’
Providing care that ‘‘this is a population where I am really contributes to recovery making a difference’’ Complex and stimulating work Being intellectually challenged
‘‘I don’t get bored. It is always challenging’’
Playing a range of professional roles
‘‘I see what I do there as much more than medication management’’
Community Psychiatry as Meaningful Practice The psychiatrists in the study found community psychiatry to be profoundly meaningful in spite of the many difficulties of this work. Psychiatrists in the study were motivated and sustained by three aspects of their work. As they reflected on what had drawn them into their careers and what they found meaningful in their work, the psychiatrists spoke of community psychiatric practice as (1) relationship-centered, (2) mission-driven, and (3) complex, stimulating work (Table 1). Community Psychiatry as Relationship-Centered Work Relationships with patients and with fellow clinicians were highly valued by the psychiatrists in the study. Cultivating Relationships with Patients The psychiatrists emphasized the importance of cultivating therapeutic relationships with patients. They valued the relationship in itself and spoke of the privilege of being able to work with individual patients over long periods of time. One psychiatrist stated that his patients ‘‘almost feel like family members.’’ Another noted that a ‘‘gratifying’’ aspect of this work is ‘‘being a part of [patients’] lives and a witness to their lives.’’ Furthermore, as the quote below illustrates, strong therapeutic relationships were not limited to those patients with more ‘‘successful’’ outcomes: I am not sure that my most satisfying cases were my successes, where somebody got well and the problems were done. The most satisfying, in a way, were where they stayed with me and I stayed with them.
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Over the years we had each other. And we worked with each other. And it didn’t always go well. Sometimes it is better. And sometimes it is worse. But we muddled our way through a chunk of years. It was just—where we were just at it for a long time with each other, hanging in there together that way. It was not always my most successful in terms of some outcome. Strong therapeutic relationships were understood to be partnerships between patients and providers. Many participants emphasized the importance of patients playing an active, informed role in their own recovery process: And just to emphasize that alliance is very important. But if you can honestly look at them and say, ‘We will not go away. We are here to walk beside you side by side on this pathway. And we will go the way that is your best and highest good,’ it really—it is remarkable what that stance is. You are not doing it for them, but they know that you are there if they need you. And then if you are able to get that across, that is a partnership. The doctor is not dictating how this goes. This is your life. And you need to walk it. And we will be here walking it hand in hand until you need to go on. I think that is really powerful. Time was a crucial aspect of cultivating strong relationships with patients. From the providers’ perspectives, having enough time to interact with patients strengthened therapeutic relationships and provided opportunities to learn from patients: I think that if you really sit down with someone and give them a chance to actually talk, rather than having it be question, answer, question, answer, you learn a whole lot more. Similarly, having time to review patients’ medical histories helped to build strong relationships: And then when I do see someone, I try to take the time. And in this business time is everything at times. We really review their chart and their med history. And when I can convey to the person, ‘I know what you have been on,’ they really like you and are invested. I think it really helps. Strong therapeutic relationships were seen as the foundation for effective practice in community psychiatry. My relationship with the patient, I think that is really key. Do they feel I am listening to them? And do I care about them? I think that, more than anything, shapes what the outcome is going to be. I would say mutual trust that leads also into motivation for the person to make changes.
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Working as Part of a Team Psychiatrists also highly valued their relationships with fellow clinicians in the community mental health center. Participating as part of a multidisciplinary team was felt to be ‘‘one of the glories of working here [in community mental health].’’ The clinical team was understood to be a ‘‘system that backs you up’’ and providers looked to fellow colleagues as a source of support: I like the team approach as well. I couldn’t keep doing it without the team. It is fantastic. But I also like being able to talk to people—and have colleagues and the support. Study participants preferred the collaborative culture of community mental health over the perceived isolation of private practice: I would have hated not having people that I could go and talk to when we have something difficult that has been going on. Working as part of a team was viewed as essential to facilitating recovery for people with severe mental illnesses: For me, [what I find meaningful] is that people can and do recover. And I think that having a system of care around people really facilitates that. It is great to see. It is very gratifying. And you are not isolated, you know. You do have people that are around you and pulling together. It is good. Community Psychiatry as Mission-Driven Work Providers’ genuine interest in, and passion for, working in community mental health settings were palpable throughout the site visits. Caring for Marginalized People Whereas working with predominantly low-income, often severely ill and disenfranchised patients might deter some from entering this field, for the providers with whom we spoke, these were some of the very characteristics that drew them into this work and continue to motivate them in their clinical practices. One participant said simply, ‘‘I think it is really important for me to serve an underserved population.’’ Many spoke of a deep commitment to vulnerable populations and a strong orientation to social justice: And, the community psychiatry piece, I would say from the early on, I have been interested in the outsiders. I have been interested in the ones who are invisible, or who stand out in a negative way. I am interested in people, who might have a hard time. I
am interested in seeing that their lives have value, or have much meaning. And, you know, who more than the chronically mentally ill on the fringes of society, fit that bill? And, those are the people that I have felt more of an urge to help. And, so, that was a big draw to coming here to work in community psychiatry. Providing Care that Contributes to Recovery Participants valued the opportunity to play a role in people’s recovery through effective care. In discussing effective care, they emphasized the importance of functional goals and milestones rather than a narrow focus on reducing symptoms: I also feel like this is a population where I am really making a difference… because of my work with them was able to—continue working, or get a job, or stay out of the hospital. The context of community psychiatry created opportunities to witness—and celebrate—healing, growth, and achievements among their patients: And working with people long term is very different from inpatient. And people get stabilized and strong. So, just actually being there to celebrate their recovery with them—and being [there] just long term is just a huge piece of it. Community Psychiatry as Complex and Stimulating Work Psychiatrists were also motivated by the intellectual challenge of caring for people with severe mental illnesses and the ability to play a range of professional roles in their clinical practice. Being Intellectually Challenged Providing care for people with severe mental illnesses is inherently complex and challenging work. As discussed above, some of these inherent challenges are experienced negatively. But mostly, participants viewed the difficulty and complexity of the work in a positive light: The most interesting thing is the intellectual challenge. The complexity is fascinating. Sorting through all of the different dimensions of thinking about human beings and, you know, strengths and challenges that we all face and the folks that I am trying to help. Participants felt stimulated by their work: And, it is sort of fun in a way because it is intellectually stimulating to be pulled in a lot of directions.
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Participants noted that they ‘‘don’t get bored’’ and that they ‘‘never have a dull day.’’ In this context, ‘‘There is always something new. Playing a Range of Professional Roles Although managing psychotropic medications constitutes a primary responsibility in psychiatric care, psychiatrists in the study viewed themselves as more than ‘‘just prescribers.’’ The leader of one organization spoke put it bluntly: So, you will hear a big bias of mine, which is that I have told the psychiatrists here. It was when I was the medical director. If you are here just to prescribe medicines and you are not doing psychotherapy…in the time…that you meet with people, then I don’t need you here. You need to do something that is therapeutic with folks and that is besides prescribing medications when you see them. The psychiatrists with whom we spoke downplayed the medication management activities they conduct; indeed, on the whole, we heard very little about prescribing practices and medication decision-making. Instead, they emphasized their roles as ‘‘educators,’’ ‘‘advisers,’’ and ‘‘consultants’’ in relation to patients and families: I do view doctoring as, fundamentally, as being like a teacher. It is, you know, educating people about things… and how to make good choices about their own health care. Participants in the study spoke about how medication management entails much more than ‘‘just their symptoms and their side effects’’: I don’t like the whole business…that it is called medication management. That is because I see what I do there as much more than medication management. I think the whole key to working with any patient is the relationship. And you really get to know them. And it is not just their symptoms and their side effects. So, you know, although, it is supposed to be a medication visit….certainly from the initial interview, though, I want to know who they are as people. I want to know what their hopes and dreams are. I want to know what their fears are, and what their challenges in life are. It is because with a purely symptom-based approach, you really can’t even understand the symptoms out of context. You just don’t know what they mean, without really having a psychological understanding, you know. You have to have some kind of existential understanding…of the patient. Similarly, this participant explains how scientific knowledge coupled with patient-centered education is
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equally important to empowering consumers and facilitating recovery: I possess expertise in—I possess psychiatric expertise and med management. It is related to my understanding a biological functioning organ and I want to understand how somebody’s brain can be helped by biological interventions and then, I also want to educate my patients, whom we call consumers. I want to educate my consumers, how to understand their illnesses and their strengths in understanding an illness and empower them to make informed and good choices about how to live happily with everything that they are dealing with. So, I sort of see those as being co-equally important and in terms of my role as a psychiatrist doing med management. Creating a Culture to Support Meaningful Community Psychiatric Practice: The Role of Senior Administrators The ability of psychiatrists to experience the benefits of their work depends in large part on the organizational culture in which they work. Many of the psychiatrists with whom we spoke had worked in organizations in the past in which they lacked time with patients and where they were not supported and valued by administrators: And so, it varies—the treatment setting, very much… the worst places [are] where the administration sort of takes you for granted. And you are expected to sign everything and not have much input on any of it or how it might get done or whether you think it is done well. You will see as many patients as you can possibly see in a day. You have programmatic decisions being made without any medical input. And so those are the most discouraging places. Senior administrators play a lead role in setting the tone for the organization and structuring the flow of clinical work. The psychiatrists in the study indicated that they need the support of agency leaders to remove obstacles to effective and efficient work in order to apply their skill and energy to the mission. Participants looked to the standard flow in primary care offices, in which patients are ‘‘roomed’’ by support staff and initial evaluations and vital signs are completed by a nurse, as a model for how community psychiatry could be improved. One participant noted that, ‘‘just clerical support alone… can save an hour a day.’’ Another participant articulated his vision for restructuring care delivery: [What I want is to] Have the charts on my desk when I walk in. You know, and have a nurse or some other clinician available to have blood pressures and weights and things that I might be interested in. To
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have it in some ways be sort of more of a medical clinic model. Anything that would give me more time to sit with the client and talk to them. One Medical Director saw his role as removing obstacles to the work: I was thinking about if I had a meter…that somehow measured frustration. I have been in community mental health now for like 10 years. And I am very interested in systems and making them work better. But, if I had like a system meter…a very simple meter that had a dial: is the system at any given moment working for me or working against me? Do you know what I mean? Is it making my job easier? Or is it, actually, making it harder to do my job? By ‘the system’, I mean everything from electronic medical records to the ten different forms filled out on any different patient on any given day. …And, so, I am pretty attuned to that. And I would definitely have a bad day if that meter was like that ninety-five percent of the day. I mean that is bad day. I would be pretty pissed off. And if it was…maybe only fifty percent of the time, then… it is a good day. Discussion The mental health providers in our study came from three unrelated sites but spoke with one voice about the challenges and satisfactions of community psychiatric care of adults with severe mental illnesses. Overall, the study participants felt that they had found a professional home in community psychiatry—they were glad to have a way to put their values into action in the world. They were gratified in the work to the extent that they could meaningfully contribute to a service-oriented mission, team up with patients, co-workers, and senior administrators to accomplish the mission, and continue to learn and grow professionally over time. The psychiatrists we spoke to find the work to be very important: they want to use their talents and training to support the recovery of people who experience severe mental illnesses. They are guided and sustained by a strong sense of mission. The narratives elicited in this study augment the finding of Garfinkel et al. (2005) that belief in the intrinsic value of psychiatry was the strongest predictor of satisfaction for psychiatrists. The psychiatrists in the study are in tune with what ‘‘really matters’’ in the lives of their patients in the moral sense discussed by psychiatristanthropologist, Arthur Kleinman (2006). Working in community settings, there is an emphasis on promoting functional recovery—work, housing, family—over and above symptom reduction (Torrey et al. 2005). In fact, they tended to downplay the importance of ‘‘medication
management’’ as a stand-alone activity, seeing it as an integrated aspect of an overall therapeutic engagement. They spoke at length about developing and sustaining meaningful therapeutic alliances. This aligns with previous findings of the satisfaction derived from psychotherapeutic work among psychiatrists (Garfinkel et al. 2005) and the positive impact of interacting with patients on career satisfaction for psychiatrists (DeMello and Deshpande 2011). The findings have workforce implications. Many students enter medical school wanting to serve others who really need the help (Good 1994). The views expressed by the psychiatrists in this study underscore the moral motivations of clinical care (Good 1994). At a time when medical students are ‘‘flocking’’ to opportunities that resonate with their values of social justice (Kleinman 2012), community care of adults with severe mental illnesses needs to be promoted as a context for engaging with complex emotional and social issues. Exposing medical students to the human satisfactions of this work could draw more students into psychiatry in general and community psychiatry in particular. Psychiatry residents, too, are more likely to choose community care of adults with severe mental illness if some of their training is provided in community sites that do the work well and where they encounter inspiring role models (Torrey et al. 2005). Sustaining psychiatrists in the work appears to be largely related to workplace administrative leadership. Although money must play some role in recruiting and retaining psychiatrists it was not mentioned once in the focus groups or individual interviews. What mattered was having the senior administrators actively and visibly engaged in articulating and moving the mission forward. Psychiatrists felt valued and supported when senior administrators structured the work to give psychiatrists time to connect humanly with the patients, fostered teambased care, and dedicated supports and energy to removing spirit-draining hassles such as insurance preauthorizations and FAXing. These findings are consistent with the literature on burnout in psychiatry. Exposure to emotionally difficult situations and suffering such as one sees in this work can lead to burnout (Maslach 1982 cited in Lasalvia et al. 2009). Behavioral health workers have been found to be at high risk. Psychiatrists experience more work-related emotional exhaustion and severe depression than other physicians (Fischer et al. 2007). Interacting with patients puts people at risk for burnout but is also a source of reward. Team cohesion appears to mitigate workplace stress and a perception of lack of fairness is associated with burnout (Lasalvia et al. 2009). There is some evidence that an engaging leadership style can improve work performance, attitudes towards work, and well-being at work (Alimo-Metcalfe et al. 2008).
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Limitations This study is limited by its small sample size of three community mental health agencies. Sampling additional sites with a range of characteristics (e.g., urban/rural, size, client demographics) would be advisable in future studies. Furthermore, our aim was to examine perspectives on work in non-academic, routine community mental health settings. The three sites that agreed to participate may have diverged from the spirit of ‘‘routine’’ settings in their strong recovery orientation and the supportive and insightful nature of the agency leaders. The agencies had psychiatrist team meetings and were willing to devote this valuable time to this project, both of which may make them non-representative. Perhaps for this reason we did not hear frustrations with leadership from participating psychiatrists, which other studies suggest is a source of dissatisfaction in community mental health providers (Lasalvia et al. 2009).
Concluding Remarks Recovering from a severe mental illness involves developing hope, reclaiming power, and getting on with life beyond illness (Torrey and Wyzik 2000). Understandably, people who live with severe mental illnesses want their psychiatrists to support this kind of process of recovery. They generally want a human connection with a hopepromoting doctor who is able to communicate to them that how their life turns out really matters; they usually want the opportunity to meaningfully participate in the health decisions that will deeply affect their lives; and they typically want treatments (including medications) to functionally improve their lives, not just suppress symptoms (Deegan and Drake 2006). The good news from this study is that what motivates and sustains community psychiatrists is being able to offer just such recovery-supporting services. The challenge is creating the administrative infrastructure that supports engaged and meaningful therapeutic interactions, allowing them to take place sustainably over time. Our study illustrates the tenacity and creative agency of a group of psychiatrists and senior administrators as they strive to cultivate a recovery-oriented culture in their agencies and to structure the workflow to facilitate meaningful engagement with patients.
References Alimo-Metcalfe, B., Alban-Metcalfe, J., Bradley, M., Mariathasan, J., & Samele, C. (2008). The impact of engaging leadership on performance, attitudes toward work and wellbeing at work: A
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longitudinal study. Journal of Health Organization and Management, 22(6), 586–598. Bovier, P. A., & Perneger, T. V. (2003). Predictors of work satisfaction among physicians. The European Journal of Public Health, 13(4), 299–305. Brotherton, S. E., & Etzel, S. I. (2013). Graduate medical education, 2012–2013. JAMA, 310(21), 2328–2346. Brotherton, S. E., Rockey, P. H., & Etzel, S. I. (2005). US graduate medical education, 2004–2005. JAMA, the Journal of the American Medical Association, 294(9), 1075–1082. Campos-Outcalt, D., Senf, J., Watkins, A. J., & Bastacky, S. (1995). The effects of medical school curricula, faculty role models, and biomedical research support on choice of generalist physician careers: A review and quality assessment of the literature. Academic Medicine, 70(7), 611–619. Deegan, P., & Drake, R. E. (2006). Shared decision making and medication management in the recovery process. Psychiatric Services, 57(11), 1636–1639. DeMello, J. P., & Deshpande, S. P. (2011). Career satisfaction of psychiatrists. Psychiatric Services, 62(9), 1013–1018. Drake, R. E., & Latimer, E. (2012). Lessons learned in developing community mental health care in North America. World Psychiatry, 11, 47–51. Feldman, S., Bachman, J., Cuffel, B., Friesen, B., & McCabe, J. (2003). Advanced practice psychiatric nurses as a treatment resource: Survey and analysis. Administration and Policy in Mental Health, 30(6), 470–494. Fischer, J., Kumar, S., & Hatcher, S. (2007). What makes psychiatry such a stressful profession? A qualitative study. Australasian Psychiatry, 15(5), 417–421. Garfinkel, P. E., Bagby, R. M., Schuller, D. R., Dickens, S. E., & Schulte, F. S. (2005). Predictors of professional and personal satisfaction with a career in psychiatry. Canadian Journal of Psychiatry, 50(6), 333–341. Good, B. J. (1994). Medicine, rationality, and experience: An anthropological perspective. New York: Cambridge University Press. Kleinman, A. (2006). What really matters: Living a moral life amidst uncertainty and danger. New York: Oxford University Press. Kleinman, A. (2012). Rebalancing academic psychiatry: Why it needs to happen–and soon. The British Journal of Psychiatry, 201(6), 421–422. Krueger, R. A. (1994). Focus groups: A practical guide for applied research (2nd ed.). Thousand Oaks, CA: Sage Publications. Lambert, T. W., Davidson, J. M., Evans, J., & Goldacre, M. J. (2003). Doctors’ reasons for rejecting initial choices of specialties as long-term careers. Medical Education, 37(4), 312–318. Landon, B. E., Reschovsky, J. D., Pham, H. H., & Blumenthal, D. (2006). Leaving medicine: The consequences of physician dissatisfaction. Medical Care, 44(3), 234–242. Lasalvia, A., Bonetto, C., Bertani, et al. (2009). Influence of perceived organisational factors on job burnout: Survey of community mental health staff. The British Journal of Psychiatry, 195(6), 537–544. Muxworthy, H., & Bowllan, N. (2011). Barriers to practice and impact on care: An analysis of the psychiatric mental health nurse practitioner role. Journal of the New York State Nurses Association, 42(1&2), 8–14. Pollack, D. A., & Cutler, D. L. (1992). Psychiatry in community mental health centers: Everyone can win. Community Mental Health Journal, 28(3), 259–267. National Resident Matching Program. (2013). Results and Data: 2013 Main Residency MatchÒ. Washington, DC: National Resident Matching Program. Ranz, J., Stueve, A., & McQuistion, H. L. (2001). The role of the psychiatrist: Job satisfaction of medical directors and staff
Community Ment Health J psychiatrists. Community Mental Health Journal, 37(6), 525–539. Staten, R., Hamera, E., Hanrahan, N., Hillyer, D., Limandri, B., Phoenix, B., et al. (2005). Advanced practice psychiatric nurses: 2005 legislative update. Journal of the American Psychiatric Nurses Association, 11(6), 371–380. Thomas, K., Ellis, A., Konrad, T., Holzer, C., & Morrissey, J. (2009). County-level estimates of mental health professional shortage in the united states. Psychiatric Services, 60(10), 1323–1328. Torrey, W. C., & Drake, R. E. (2010). Practicing shared decision making in the outpatient psychiatric care of adults with severe
mental illnesses: Redesigning care for the future. Community Mental Health Journal, 46(5), 433–440. Torrey, W. C., Green, R. L., & Drake, R. E. (2005). Psychiatrists and psychiatric rehabilitation. Journal of Psychiatric Practice, 11(3), 155–160. Torrey, W. C., & Wyzik, P. (2000). Recovery vision as a service improvement guide for community mental health center providers. Community Mental Health Journal, 36(2), 209–216.
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ORIGINAL PAPER
‘‘I Always Viewed this as the Real Psychiatry’’: Provider Perspectives on Community Psychiatry as a Career of First Choice Elizabeth Carpenter-Song • William C. Torrey
Received: 8 January 2014 / Accepted: 18 June 2014 Springer Science+Business Media New York 2014
Abstract The US needs engaged and skilled psychiatrists to support the recovery of people with severe mental illnesses and we are currently facing a shortage. This paper examines what attracts providers to community psychiatry and what sustains them in their work. Focus groups and interviews were used to elicit the perspectives of prescribing clinicians in three community mental health clinics in the US. Community psychiatry has inherent challenges, including facing high-risk decisions, encountering intense affects, and occasionally witnessing bad outcomes. Psychiatrists are motivated and sustained in this work by (1) cultivating relationships with patients and colleagues, (2) focusing on the mission of promoting recovery, and (3) engaging with clinical practice as intellectually stimulating work. Administrators support the engagement and morale of psychiatrists by creating workflows that allow psychiatrists to meaningfully apply their expertise to support patients’ recovery. These findings hold implications for recruiting and retaining a new generation of physicians. Keywords Community mental health Workforce challenges Provider perspectives Qualitative research
E. Carpenter-Song (&) Dartmouth Psychiatric Research Center, Rivermill Commercial Center, Geisel School of Medicine at Dartmouth, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766, USA e-mail: [email protected] W. C. Torrey Department of Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive., Lebanon, NH 03766, USA e-mail: [email protected]
Introduction Millions of Americans live with severe mental illnesses. How their lives turn out is dependent, in part, on the availability and quality of community-based psychiatric care. Engaged, skilled psychiatrists can help suffering individuals and their families understand the nature of the illnesses, promote hope, and offer life-enhancing tools and supports, including targeted medications. Major reports on mental health services have raised concerns about the adequacy of the workforce. There are widespread shortages of psychiatric prescribers throughout the United States (Thomas et al. 2009). Recent estimates state that the United States is down about 45,000 psychiatrists (DeMello and Deshpande 2011). The situation is likely to worsen due to increased demand for mental health services and the aging demographics of psychiatrists (DeMello and Deshpande 2011). The number of psychiatric nurse practitioners is also in decline (Staten et al. 2005). A recent estimate of the shortfall found that three quarters of the counties in the United States have a severe shortage in the number of psychiatric prescribers, which leaves at least half the need unmet (Thomas et al. 2009). Recruiting and retaining the psychiatric workforce for community care of people with severe mental illness is not easy. Psychiatry residency training slots do not draw well. In 2013, only 50.1 % of psychiatry categorical residency slots were filled by graduating US medical student seniors, down from 55.1 % in 2012; this was the lowest since 1998 (National Resident Matching Program 2013). Fewer physicians are graduating from psychiatry residency programs: 1,025 in 2012 (Brotherton and Etzel 2013), which is down from 1,142 in 2001 (Brotherton et al. 2005). Concern that psychiatry is stressful is a factor that dissuades medical students from choosing psychiatry as a specialty (Garfinkel
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et al. 2005). Medical students who consider psychiatry but choose other paths cite concerns about getting too emotionally attached to patients and disillusionment with the medical model and management of psychiatric illness (Lambert et al. 2003). Psychiatric nurse practitioners are well positioned to fill a critical access gap in community mental health services as a ‘‘logical alternative’’ to psychiatrists (Muxworthy and Bowllan 2011). Yet psychiatric nurse practitioners are underutilized and face many barriers to providing treatment, which may discourage them from entering community practice (Feldman et al. 2003). Psychiatrist job satisfaction is important (DeMello and Deshpande 2011). Medical students cite the importance of satisfied, inspiring faculty role models when choosing a specialty (Campos-Outcalt et al. 1995). In addition, dissatisfied psychiatrists are more likely to leave their jobs (Ranz et al. 2001) and medicine altogether (Landon et al. 2006). Physician job dissatisfaction has also been associated with poor ratings on quality measures such as patient satisfaction, adherence, and prescribing behavior (Bovier and Perneger 2003). Community psychiatric care of people with severe mental illnesses is challenging (Pollack and Cutler 1992). Psychiatric outpatient visits are complex, agenda-packed, interpersonal interactions in which time constraints, communication barriers, and lack of access to necessary information create obstacles to optimal care (Torrey and Drake 2010). The work has been made harder by the drastic reductions in funding for community care in recent decades (Drake and Latimer 2012). Psychiatrists working in public sector settings often face tremendous time and productivity pressures and high turnover in the workforce. With cuts to other supportive resources for mental healthcare, outpatient community mental health centers are often caring for acutely ill people, with ensuing pressures from emergency rooms, family members, and concerns for public safety. Within this context, why would someone go into community psychiatry? What motivates certain providers to work with people with severe mental illnesses in community settings? What sustains them in this challenging work? These questions are the point of departure for this article. When we set out to solicit the perspectives of community psychiatrists and prescribing clinicians, our goal was to obtain a better understanding of the on-the-ground attitudes and experiences of providers providing routine care in community mental health settings. In our initial conception of the project, we expected that providers’ motivations for entering the field and their thoughts on providing care would be a useful frame for understanding how to facilitate the use of evidence-based practice and shared decision making in community settings. While we certainly gained insight into these issues, we also obtained rich information about the day-to-day realities of providing care, what community psychiatrists value about
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their work, and why they have chosen to spend their professional lives in community mental health settings. We also learned about the frustrations and difficulties faced by community psychiatrists as they strive to provide compassionate, effective care for their patients. These issues, with their workforce implications, warrant examination on their own and are the focus of this article.
Methods The study used qualitative methods to examine the perspectives of psychiatrists and other prescribing clinicians working in community mental health settings. An advisory group consisting of psychiatrists, researchers, administrators, and service consumers advised the research team on the development of our goals, focus group and interview guides, and sampling strategies. The investigators for the study were an academic community psychiatrist and a medical anthropologist; a research assistant in public health assisted with data collection at one site. The multidisciplinary research team provided a unique combination of skills and experience to accomplish the objectives of the study. The psychiatrist brought the perspective of academic medicine and the lived experience of working as a community psychiatrist and a community mental health Medical Director to the project. The anthropologist brought expertise in qualitative methodology and experience examining the culture of American psychiatry. Study participants were recruited from three community mental health centers in Vermont, Connecticut, and Colorado. Our goal in selecting sites was to examine routine community-based settings that were not tied to academic medical centers and we also sought to have some geographic diversity. By selecting sites in different parts of the country, we aimed to diminish bias associated with recruiting participants from a single region or site. One of the authors used his network of professional contacts to identify potential sites and contacted the Medical Director at each site to explain the study and gauge interest in participating. One to two day site visits were then scheduled at each location. All study procedures were approved by our institutional review board and participants gave informed consent to participate. We used multiple qualitative methods, including focus groups and interviews, to achieve our objectives of learning about the routine provision of care in community mental health settings. We conducted a focus group at each site using a topic guide. All psychiatrists and prescribing mental health clinicians at each site were invited to participate in the focus group. Focus groups ranged in size from four to twenty1 participants. Two of the participants 1
Given the large number of prescribing clinicians at this site, we conducted two separate focus groups at this site.
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were prescribing nurse practitioners and the rest were psychiatrists. Questions in the topic guide were designed to elicit an understanding of the day-to-day flow of work in a community mental health setting, providers’ perspectives on the key rewards and challenges of clinical practice in community settings, and broad reflections on evidencebased medicine and shared decision making. The topic guide followed the ‘funnel structure’ suggested by Krueger (1994) in which the opening questions are intentionally broad and the questions gradually become more specific as the focus group progresses. The focus groups were approximately an hour in duration at each site and were audio recorded. Following the focus group, we conducted qualitative interviews with individual providers to inquire in greater depth about providers’ experiences of clinical practice; their attitudes toward, and experiences with, evidencebased medicine and shared decision making; and their reflections on how community psychiatric care could be improved. These individual interviews were conducted onsite and in-person whenever possible and, when this was not possible due to providers’ schedules, the interviews were conducted via telephone. Individual interviews were completed with 13 participants (12 psychiatrists, 1 nurse practitioner). Participation in the individual interviews depended upon the interest and availability of providers. Interviews were audio recorded. Audio recordings of focus groups and interviews were transcribed. In the initial phases of analysis, three members of the research team read all transcripts to identify prominent themes that emerged from the data. The researchers held regular meetings to discuss the emergent themes. These discussions led to the creation of a code book to perform more systematic analysis using qualitative coding software. Data were uploaded into Atlas.ti and the two authors of this article coded the transcripts. We held regular meetings to update and revise the code book according to nuances emerging from the data. Three principal domains emerged from the analysis: (1) rewards and challenges of community psychiatry; (2) perspectives on evidence-based medicine; and (3) perspectives on shared decision making. For the present analysis, we focus on content from the first of these domains, rewards and challenges of community psychiatry. The other analytic domains will be addressed in future publications. The two authors met regularly to discuss the narrative ‘output’ from codes relevant to the domain of rewards and challenges of community psychiatry. These discussions led to more nuanced categorization of the data. Through an iterative process of discussing emergent codes and re-reviewing transcripts, we reached consensus on the main findings presented herein. Our analyses did not discern substantial differences between the views of psychiatrists and the
nurse practitioners. For this reason, we use the term ‘‘psychiatrist’’ to refer to prescribers throughout the paper.
Results Before presenting the key findings regarding what attracts and sustains community psychiatrists, we first offer a brief distillation of their perspectives on the challenges they face in their day-to-day work. Insight into challenges provides a broader context for understanding the lived experience of community psychiatry and points to areas for improvement. Challenges of Community Psychiatry Psychiatrists report that some pain and stress is inherent in the work. Psychiatrists must make high-risk decisions and live with ‘‘the anxiety of feeling responsible’’ for patients. Workdays can include being subjected to intensely negative affects: ‘‘I don’t know what the person became angry with me about … I honestly don’t and they won’t say.’’ And psychiatrists can be close to patients who experience bad outcomes, including death by suicide: ‘‘I would have done anything to save this kid—why couldn’t he have called?’’ But what makes psychiatrists express dissatisfaction is not the work’s inherent challenges but workflows that waste their time or create obstacles to offering high-quality care. One participant recounted a past experience working at an agency ‘‘where I had fifteen minutes with clients or less.’’ This psychiatrist felt that such time constraints jeopardized the therapeutic alliance, stating, ‘‘people need to feel heard. They need to not be rushed.’’ Other providers expressed frustration with a lack of support for the psychiatrist’s function by the organization. Community mental health practice is strongly team-oriented, a philosophy that is valued by psychiatrists (as will be discussed below). This egalitarian ethos means that in some settings psychiatrists are asked to ‘‘do what everyone else has to do’’ despite the fact that agencies ‘‘are spending so much money on us.’’ One psychiatrist expressed incredulity at experiences in which ‘‘I am paid by the hour and I am standing at the fax machine doing my own faxing… it just feels like such an amazing waste of time.’’ Also aggravating are dealing with inefficient electronic medical records and insurance preauthorization work: ‘‘interacting with insurance policies are, by far, the most frustrating thing for me … it is because it seems like such a wasted effort.’’ Finally, psychiatrists expressed challenges related to the broader healthcare system. A common complaint was not being able to access necessary information about patients across different providers. Basic information about ‘‘what medicine someone has been on before, what their history has been’’ was often difficult or impossible to access.
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Community Ment Health J Table 1 Provider perspectives on community psychiatry as meaningful practice Themes
Selected quotes
Relationship-centered work Cultivating relationships with patients
‘‘they almost feel like family members’’
Working as part of a team
‘‘I couldn’t keep doing it without the team’’
Mission-driven work Caring for marginalized people
‘‘I have been interested in the outsiders’’
Providing care that ‘‘this is a population where I am really contributes to recovery making a difference’’ Complex and stimulating work Being intellectually challenged
‘‘I don’t get bored. It is always challenging’’
Playing a range of professional roles
‘‘I see what I do there as much more than medication management’’
Community Psychiatry as Meaningful Practice The psychiatrists in the study found community psychiatry to be profoundly meaningful in spite of the many difficulties of this work. Psychiatrists in the study were motivated and sustained by three aspects of their work. As they reflected on what had drawn them into their careers and what they found meaningful in their work, the psychiatrists spoke of community psychiatric practice as (1) relationship-centered, (2) mission-driven, and (3) complex, stimulating work (Table 1). Community Psychiatry as Relationship-Centered Work Relationships with patients and with fellow clinicians were highly valued by the psychiatrists in the study. Cultivating Relationships with Patients The psychiatrists emphasized the importance of cultivating therapeutic relationships with patients. They valued the relationship in itself and spoke of the privilege of being able to work with individual patients over long periods of time. One psychiatrist stated that his patients ‘‘almost feel like family members.’’ Another noted that a ‘‘gratifying’’ aspect of this work is ‘‘being a part of [patients’] lives and a witness to their lives.’’ Furthermore, as the quote below illustrates, strong therapeutic relationships were not limited to those patients with more ‘‘successful’’ outcomes: I am not sure that my most satisfying cases were my successes, where somebody got well and the problems were done. The most satisfying, in a way, were where they stayed with me and I stayed with them.
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Over the years we had each other. And we worked with each other. And it didn’t always go well. Sometimes it is better. And sometimes it is worse. But we muddled our way through a chunk of years. It was just—where we were just at it for a long time with each other, hanging in there together that way. It was not always my most successful in terms of some outcome. Strong therapeutic relationships were understood to be partnerships between patients and providers. Many participants emphasized the importance of patients playing an active, informed role in their own recovery process: And just to emphasize that alliance is very important. But if you can honestly look at them and say, ‘We will not go away. We are here to walk beside you side by side on this pathway. And we will go the way that is your best and highest good,’ it really—it is remarkable what that stance is. You are not doing it for them, but they know that you are there if they need you. And then if you are able to get that across, that is a partnership. The doctor is not dictating how this goes. This is your life. And you need to walk it. And we will be here walking it hand in hand until you need to go on. I think that is really powerful. Time was a crucial aspect of cultivating strong relationships with patients. From the providers’ perspectives, having enough time to interact with patients strengthened therapeutic relationships and provided opportunities to learn from patients: I think that if you really sit down with someone and give them a chance to actually talk, rather than having it be question, answer, question, answer, you learn a whole lot more. Similarly, having time to review patients’ medical histories helped to build strong relationships: And then when I do see someone, I try to take the time. And in this business time is everything at times. We really review their chart and their med history. And when I can convey to the person, ‘I know what you have been on,’ they really like you and are invested. I think it really helps. Strong therapeutic relationships were seen as the foundation for effective practice in community psychiatry. My relationship with the patient, I think that is really key. Do they feel I am listening to them? And do I care about them? I think that, more than anything, shapes what the outcome is going to be. I would say mutual trust that leads also into motivation for the person to make changes.
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Working as Part of a Team Psychiatrists also highly valued their relationships with fellow clinicians in the community mental health center. Participating as part of a multidisciplinary team was felt to be ‘‘one of the glories of working here [in community mental health].’’ The clinical team was understood to be a ‘‘system that backs you up’’ and providers looked to fellow colleagues as a source of support: I like the team approach as well. I couldn’t keep doing it without the team. It is fantastic. But I also like being able to talk to people—and have colleagues and the support. Study participants preferred the collaborative culture of community mental health over the perceived isolation of private practice: I would have hated not having people that I could go and talk to when we have something difficult that has been going on. Working as part of a team was viewed as essential to facilitating recovery for people with severe mental illnesses: For me, [what I find meaningful] is that people can and do recover. And I think that having a system of care around people really facilitates that. It is great to see. It is very gratifying. And you are not isolated, you know. You do have people that are around you and pulling together. It is good. Community Psychiatry as Mission-Driven Work Providers’ genuine interest in, and passion for, working in community mental health settings were palpable throughout the site visits. Caring for Marginalized People Whereas working with predominantly low-income, often severely ill and disenfranchised patients might deter some from entering this field, for the providers with whom we spoke, these were some of the very characteristics that drew them into this work and continue to motivate them in their clinical practices. One participant said simply, ‘‘I think it is really important for me to serve an underserved population.’’ Many spoke of a deep commitment to vulnerable populations and a strong orientation to social justice: And, the community psychiatry piece, I would say from the early on, I have been interested in the outsiders. I have been interested in the ones who are invisible, or who stand out in a negative way. I am interested in people, who might have a hard time. I
am interested in seeing that their lives have value, or have much meaning. And, you know, who more than the chronically mentally ill on the fringes of society, fit that bill? And, those are the people that I have felt more of an urge to help. And, so, that was a big draw to coming here to work in community psychiatry. Providing Care that Contributes to Recovery Participants valued the opportunity to play a role in people’s recovery through effective care. In discussing effective care, they emphasized the importance of functional goals and milestones rather than a narrow focus on reducing symptoms: I also feel like this is a population where I am really making a difference… because of my work with them was able to—continue working, or get a job, or stay out of the hospital. The context of community psychiatry created opportunities to witness—and celebrate—healing, growth, and achievements among their patients: And working with people long term is very different from inpatient. And people get stabilized and strong. So, just actually being there to celebrate their recovery with them—and being [there] just long term is just a huge piece of it. Community Psychiatry as Complex and Stimulating Work Psychiatrists were also motivated by the intellectual challenge of caring for people with severe mental illnesses and the ability to play a range of professional roles in their clinical practice. Being Intellectually Challenged Providing care for people with severe mental illnesses is inherently complex and challenging work. As discussed above, some of these inherent challenges are experienced negatively. But mostly, participants viewed the difficulty and complexity of the work in a positive light: The most interesting thing is the intellectual challenge. The complexity is fascinating. Sorting through all of the different dimensions of thinking about human beings and, you know, strengths and challenges that we all face and the folks that I am trying to help. Participants felt stimulated by their work: And, it is sort of fun in a way because it is intellectually stimulating to be pulled in a lot of directions.
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Participants noted that they ‘‘don’t get bored’’ and that they ‘‘never have a dull day.’’ In this context, ‘‘There is always something new. Playing a Range of Professional Roles Although managing psychotropic medications constitutes a primary responsibility in psychiatric care, psychiatrists in the study viewed themselves as more than ‘‘just prescribers.’’ The leader of one organization spoke put it bluntly: So, you will hear a big bias of mine, which is that I have told the psychiatrists here. It was when I was the medical director. If you are here just to prescribe medicines and you are not doing psychotherapy…in the time…that you meet with people, then I don’t need you here. You need to do something that is therapeutic with folks and that is besides prescribing medications when you see them. The psychiatrists with whom we spoke downplayed the medication management activities they conduct; indeed, on the whole, we heard very little about prescribing practices and medication decision-making. Instead, they emphasized their roles as ‘‘educators,’’ ‘‘advisers,’’ and ‘‘consultants’’ in relation to patients and families: I do view doctoring as, fundamentally, as being like a teacher. It is, you know, educating people about things… and how to make good choices about their own health care. Participants in the study spoke about how medication management entails much more than ‘‘just their symptoms and their side effects’’: I don’t like the whole business…that it is called medication management. That is because I see what I do there as much more than medication management. I think the whole key to working with any patient is the relationship. And you really get to know them. And it is not just their symptoms and their side effects. So, you know, although, it is supposed to be a medication visit….certainly from the initial interview, though, I want to know who they are as people. I want to know what their hopes and dreams are. I want to know what their fears are, and what their challenges in life are. It is because with a purely symptom-based approach, you really can’t even understand the symptoms out of context. You just don’t know what they mean, without really having a psychological understanding, you know. You have to have some kind of existential understanding…of the patient. Similarly, this participant explains how scientific knowledge coupled with patient-centered education is
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equally important to empowering consumers and facilitating recovery: I possess expertise in—I possess psychiatric expertise and med management. It is related to my understanding a biological functioning organ and I want to understand how somebody’s brain can be helped by biological interventions and then, I also want to educate my patients, whom we call consumers. I want to educate my consumers, how to understand their illnesses and their strengths in understanding an illness and empower them to make informed and good choices about how to live happily with everything that they are dealing with. So, I sort of see those as being co-equally important and in terms of my role as a psychiatrist doing med management. Creating a Culture to Support Meaningful Community Psychiatric Practice: The Role of Senior Administrators The ability of psychiatrists to experience the benefits of their work depends in large part on the organizational culture in which they work. Many of the psychiatrists with whom we spoke had worked in organizations in the past in which they lacked time with patients and where they were not supported and valued by administrators: And so, it varies—the treatment setting, very much… the worst places [are] where the administration sort of takes you for granted. And you are expected to sign everything and not have much input on any of it or how it might get done or whether you think it is done well. You will see as many patients as you can possibly see in a day. You have programmatic decisions being made without any medical input. And so those are the most discouraging places. Senior administrators play a lead role in setting the tone for the organization and structuring the flow of clinical work. The psychiatrists in the study indicated that they need the support of agency leaders to remove obstacles to effective and efficient work in order to apply their skill and energy to the mission. Participants looked to the standard flow in primary care offices, in which patients are ‘‘roomed’’ by support staff and initial evaluations and vital signs are completed by a nurse, as a model for how community psychiatry could be improved. One participant noted that, ‘‘just clerical support alone… can save an hour a day.’’ Another participant articulated his vision for restructuring care delivery: [What I want is to] Have the charts on my desk when I walk in. You know, and have a nurse or some other clinician available to have blood pressures and weights and things that I might be interested in. To
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have it in some ways be sort of more of a medical clinic model. Anything that would give me more time to sit with the client and talk to them. One Medical Director saw his role as removing obstacles to the work: I was thinking about if I had a meter…that somehow measured frustration. I have been in community mental health now for like 10 years. And I am very interested in systems and making them work better. But, if I had like a system meter…a very simple meter that had a dial: is the system at any given moment working for me or working against me? Do you know what I mean? Is it making my job easier? Or is it, actually, making it harder to do my job? By ‘the system’, I mean everything from electronic medical records to the ten different forms filled out on any different patient on any given day. …And, so, I am pretty attuned to that. And I would definitely have a bad day if that meter was like that ninety-five percent of the day. I mean that is bad day. I would be pretty pissed off. And if it was…maybe only fifty percent of the time, then… it is a good day. Discussion The mental health providers in our study came from three unrelated sites but spoke with one voice about the challenges and satisfactions of community psychiatric care of adults with severe mental illnesses. Overall, the study participants felt that they had found a professional home in community psychiatry—they were glad to have a way to put their values into action in the world. They were gratified in the work to the extent that they could meaningfully contribute to a service-oriented mission, team up with patients, co-workers, and senior administrators to accomplish the mission, and continue to learn and grow professionally over time. The psychiatrists we spoke to find the work to be very important: they want to use their talents and training to support the recovery of people who experience severe mental illnesses. They are guided and sustained by a strong sense of mission. The narratives elicited in this study augment the finding of Garfinkel et al. (2005) that belief in the intrinsic value of psychiatry was the strongest predictor of satisfaction for psychiatrists. The psychiatrists in the study are in tune with what ‘‘really matters’’ in the lives of their patients in the moral sense discussed by psychiatristanthropologist, Arthur Kleinman (2006). Working in community settings, there is an emphasis on promoting functional recovery—work, housing, family—over and above symptom reduction (Torrey et al. 2005). In fact, they tended to downplay the importance of ‘‘medication
management’’ as a stand-alone activity, seeing it as an integrated aspect of an overall therapeutic engagement. They spoke at length about developing and sustaining meaningful therapeutic alliances. This aligns with previous findings of the satisfaction derived from psychotherapeutic work among psychiatrists (Garfinkel et al. 2005) and the positive impact of interacting with patients on career satisfaction for psychiatrists (DeMello and Deshpande 2011). The findings have workforce implications. Many students enter medical school wanting to serve others who really need the help (Good 1994). The views expressed by the psychiatrists in this study underscore the moral motivations of clinical care (Good 1994). At a time when medical students are ‘‘flocking’’ to opportunities that resonate with their values of social justice (Kleinman 2012), community care of adults with severe mental illnesses needs to be promoted as a context for engaging with complex emotional and social issues. Exposing medical students to the human satisfactions of this work could draw more students into psychiatry in general and community psychiatry in particular. Psychiatry residents, too, are more likely to choose community care of adults with severe mental illness if some of their training is provided in community sites that do the work well and where they encounter inspiring role models (Torrey et al. 2005). Sustaining psychiatrists in the work appears to be largely related to workplace administrative leadership. Although money must play some role in recruiting and retaining psychiatrists it was not mentioned once in the focus groups or individual interviews. What mattered was having the senior administrators actively and visibly engaged in articulating and moving the mission forward. Psychiatrists felt valued and supported when senior administrators structured the work to give psychiatrists time to connect humanly with the patients, fostered teambased care, and dedicated supports and energy to removing spirit-draining hassles such as insurance preauthorizations and FAXing. These findings are consistent with the literature on burnout in psychiatry. Exposure to emotionally difficult situations and suffering such as one sees in this work can lead to burnout (Maslach 1982 cited in Lasalvia et al. 2009). Behavioral health workers have been found to be at high risk. Psychiatrists experience more work-related emotional exhaustion and severe depression than other physicians (Fischer et al. 2007). Interacting with patients puts people at risk for burnout but is also a source of reward. Team cohesion appears to mitigate workplace stress and a perception of lack of fairness is associated with burnout (Lasalvia et al. 2009). There is some evidence that an engaging leadership style can improve work performance, attitudes towards work, and well-being at work (Alimo-Metcalfe et al. 2008).
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Limitations This study is limited by its small sample size of three community mental health agencies. Sampling additional sites with a range of characteristics (e.g., urban/rural, size, client demographics) would be advisable in future studies. Furthermore, our aim was to examine perspectives on work in non-academic, routine community mental health settings. The three sites that agreed to participate may have diverged from the spirit of ‘‘routine’’ settings in their strong recovery orientation and the supportive and insightful nature of the agency leaders. The agencies had psychiatrist team meetings and were willing to devote this valuable time to this project, both of which may make them non-representative. Perhaps for this reason we did not hear frustrations with leadership from participating psychiatrists, which other studies suggest is a source of dissatisfaction in community mental health providers (Lasalvia et al. 2009).
Concluding Remarks Recovering from a severe mental illness involves developing hope, reclaiming power, and getting on with life beyond illness (Torrey and Wyzik 2000). Understandably, people who live with severe mental illnesses want their psychiatrists to support this kind of process of recovery. They generally want a human connection with a hopepromoting doctor who is able to communicate to them that how their life turns out really matters; they usually want the opportunity to meaningfully participate in the health decisions that will deeply affect their lives; and they typically want treatments (including medications) to functionally improve their lives, not just suppress symptoms (Deegan and Drake 2006). The good news from this study is that what motivates and sustains community psychiatrists is being able to offer just such recovery-supporting services. The challenge is creating the administrative infrastructure that supports engaged and meaningful therapeutic interactions, allowing them to take place sustainably over time. Our study illustrates the tenacity and creative agency of a group of psychiatrists and senior administrators as they strive to cultivate a recovery-oriented culture in their agencies and to structure the workflow to facilitate meaningful engagement with patients.
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