Reported by Gerald D. Klee, MD
[Fall 1997; Vol.24 No. 3]
The changes taking place in psychiatry in Maryland are well illustrated by developments at Sheppard Pratt, long known as a bucolic retreat where patients could undergo long-term psychotherapy during extensive hospitalization. Under managed care, that’s a thing of the past. Sheppard Pratt is now not merely a hospital. It has become a health system. On Oct. 30, 1996, Donald Ross, director of the residency program, explained why its training program was merging with that of the University of Maryland Psychiatric Institute. Following are highlights of his remarks about issues that led to the merger.
The need for new psychiatrists is decreasing nationally. Most projections of the American medical work force suggest that we are training too many psychiatrists. The new models of practice, especially in the capitated and HMO worlds, use psychiatrists almost exclusively in a medical model. Psychiatrists are expected to be expert in the roles of diagnostician, psychopharmacologist, crisis manager, team leader, and consultant. Conspicuous by its absence is the psychiatrist in the role of psychotherapist. In this new world of managed care, psychotherapy is done primarily by lower-cost social workers and psychologists. Even then, psychotherapy is done in a brief, focused model.
Although we can argue against this model (which I do), and although we can assert the importance of psychotherapy training for psychiatrists (which I strongly do), when the workplace dramatically cuts the funds available to reimburse psychotherapy by psychiatrists, that has an impact on the number of available jobs. This has not gotten to the acute stage for psychiatry—yet—but it has for other medical specialties, such as anesthesiology and pathology. The national organization of psychiatric training directors is advocating a 25 to 30 percent cut in residency positions during the next few years because of projected job availability. We, reluctantly, agree with that recommendation. Consequently, we felt a merged program made sense. It would give us an opportunity to be less focused on training a large number of residents and intensely focused on giving the best training to the best residents.
The interest of American medical students in psychiatry is decreasing. The number entering psychiatry has dropped from a high of 844 in 1988 to a low of 476 in 1996.
The curriculum for an accredited residency training program in psychiatry is becoming more standardized.
The economics of psychiatric care are shrinking clinical resources and sources of payment for residency training.
Our conclusion was that we would do best by positioning ourselves in the most flexible and cost-effective posture we could, while maintaining a high-quality training experience. By combining forces, by having one program instead of two, we could pick and choose the best clinical sites for training from each institution and could save expenses by combining administrative costs and other overhead expenses.
At the 1997 annual meeting of the Department of Psychiatry and Medicine at Sheppard Pratt held April 30, Steven Sharfstein, president, medical director, and CEO, included the following in his “Year in Review” report.
Currently, Sheppard has in operation 168 beds, compared to the licensed 322. This year, there will be 4,000 admissions with an average length of stay of 11 days. Five years ago, there were 2,000 admissions with an ALOS of 50 days. The campus has changed as well. There are now residential and group homes and increased outpatient care on the Towson campus. Inpatient child and adolescent services have been moved to the main hospital complex and have added respite beds. We are now examining the campus to determine the best use for this land. As we increase patient care in the community, there is less need for this large campus.
We have a new residential school in Frederick, for which $5 million has been received. We have acquired a psychosocial rehabilitation program in Frederick called Waystation. Partners in Recovery is the outpatient chemical dependency program, which is a joint venture with Greater Baltimore Medical Center. Our residency program has joined with the program at the University of Maryland. For Upper Chesapeake, we are running the psychiatric inpatient unit at Harford Memorial Hospital and providing consultation liaison services at Harford Memorial and Fallston General Hospital. We are providing similar services at North Arundel Hospital for the inpatient and day hospital program.