The Decline of Academic Psychiatry in the U.S.

Source: Flickr: Medical Readiness Training Exercise 15-2 by US Army Southern Europe, CC by 2.0

In an article called “The precipitous decline of academic medicine in the United States" from the American Academy of Clinical Psychiatrists by Richard Balon, MD and Mary K. Morreale, MD, the authors describe how the profiteering currently infecting medical treatment in this country is also in the process of negatively affecting medical education and research. Problems they mentioned included difficult-to-navigate electronic medical record systems, demands on productivity in the form of ever-increasing office visits and procedures, and education increasingly regulated by what has been referred to as the ‘medical-education industrial complex.’

According to the article, Johns Hopkins, for example, imposed a hiring freeze, canceled all raises, and warned about impending furloughs and layoffs despite having had $10 billion in assets and a $6 billion endowment. The university’s president earns $1.6 million in salary and an additional $1.1 million in other types of compensation.

They added that in psychiatry, due to profiteering, “Academic research does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry.” Integration of research with clinical judgment seems to be a thing of the past. In my opinion, this problem is particularly impactful in the study of personality disorders, the main topic of this blog.

And here I thought that this had only been happening at the medical school I worked at. When I first started there in 1992, the faculty practice group was a delight to work with. The administrators worked for the doctors. We were told that we had to bring in 160 percent of the practice portion of our annual salary with patient care activities. The psychiatry department was flush with cash, with a million dollar reserve for research and other academic activities. Faculty could earn extra money by seeing extra patients, keeping a percentage of every additional dollar they brought in.

The psychiatric emergency room at the public hospital, run by our department, was a model. We also trained police to deal with mental illness through the formation of what was called the Crisis Intervention Team, which was copied by several police departments throughout the rest of the country. Police became experts at de-escalating conflicts and apprehending the seriously mentally ill safely, and transporting them to the psychiatric emergency room for evaluation. (Does this sound like something that might help the police regain public trust in today’s atmosphere? I think so).

Meanwhile, pressure was building to install managed care models, especially after Medicaid in Tennessee was changed into Tenncare, which called for the formation of several HMOs to provide treatment. Our practice group decided that they wanted to form one. Having experienced managed care in California, I warned everybody what might happen, but no one would listen. One child psychiatrist thought managed care was a good idea and enthusiastically advocated for it.

Before long, the doctors were working for the administrators instead of the other way around. Top administrators were paid big salaries. Our department’s reserves suddenly disappeared. Although I did not see anything in writing, the word around the department was that the practice group was draining the psychiatric emergency room of funds. It soon closed. The child psychiatrist who advocated for managed care had his own pet project, a daycare center for teens, destroyed. Faculty members were told they had to keep working any extra hours that they had been working – but without any of the extra pay they had been getting! Faculty members (I was one) were also suddenly told they were “losing money” for the organization, even though we were all bringing in the same amounts we had been, and even though the state — not the practice group — was paying for the faculty’s office rent and the cost of their phone system.