by Walter Weintraub, MD
[Spring 1999; Vol.26 No. 1]
Introduction: Knowing of my affiliation with Maryland's VA hospitals since 1956, Gerry Klee asked me to write a short "now and then" report on changes in residency training over the years. I am happy to do so.
Although not tied to managed care as rigorously as private psychiatry, VA psychiatric hospitals have substantially reduced lengths of patient stays. This has resulted in a change in the resident's hospital experience from one of learning formal psychotherapy to the management of patients with medication. This change has been associated with significant modifications in the patient population, treatment ideology, recruitment of residents, the position of women as staff members and patients, and the relationship of the VA to the universities.
V.A. Residency Training in the post World War II Era
When I began psychiatric residency training at the Perry Point VA Hospital in 1956, the VA was undergoing a period of unprecedented expansion. Under the leadership of World War II hero General Omar Bradley, the nation was committed to providing the best medical and psychiatric care to its sick and wounded veterans. Because of the size of the veteran population - an entire generation of American men - a huge influx of personnel and material were required to redeem America's promise to its fighting men. Fearful of medical school exploitation yet realizing that high quality training and treatment were not possible without the participation of the great university centers, the VA maintained autonomous but affiliated training programs in the various medical disciplines. Dean's committees, which brought together academic and VA leaders, defined the treatment ideology and strategies taught residents and medical students in the VA hospitals.
Psychiatric Ideology in the Post-World War II VA Hospitals
When I became a resident at Perry Point, all VA residency training took place in that hospital. Residents were sent to Baltimore for outpatient and child training but the "home base" was one hour away from Baltimore. When the VA could no longer compete with universities for American medical graduates, freestanding psychiatric residency training was abolished and VA clinical facilities became affiliates of university training programs. In Maryland, VA hospital residency training was moved from Perry Point to Baltimore where it now exists as an affiliate program of the University of Maryland.
Those who are unfamiliar with the post World War II VA picture will be surprised to learn that many VA centers like Perry Point devoted much of their teaching time to instructing residents in the art of dynamic psychotherapy. Under the Dean's committee headed by John Whitehorn of Hopkins, an all-star cast of supervisors and consultants commuted to Perry Point from the Baltimore medical schools and private psychiatric offices to teach psychotherapeutic skills to the VA residents. Residents commuting to Baltimore were taught by additional Hopkins faculty. During the year-and-a-half I spent as a trainee at Perry Point, I was fortunate in having a distinguished group of consultants and supervisors help me master the principal areas of psychiatric practice. Jacob Finesinger, Chairman of the Department of Psychiatry of the University of Maryland, conducted a weekly continuous case seminar. He was one of the first supervisors in the country to use audiotapes in his supervision. I was privileged to present my first psychotherapy case to him for over a year. Manfred Guttmacher, America's most distinguished forensic psychiatrist, consulted weekly about patients with legal difficulties. Wendell Muncie, Adolph Meyer's most distinguished student, gave me one-on-one supervision as did Barbara Betz who commuted from Johns Hopkins University. Al Dreyfus, an alumnus of Perry Point and a Baltimore psychoanalyst, supervised me in my first group therapy assignment. Another psychoanalyst, Sam Ingalls, was available to consult on the woman's inpatient unit.
Many VA residents were planning careers in psychoanalysis and a number of them were commuting to Baltimore for personal analysis. Pharmacotherapy was in its early stages and thought of as a "blue collar" form of therapy, not fit for intelligent, non-psychotic middle-class patients. It is true that Perry Point offered insulin coma therapy and ECT, but these were not considered first line treatments for psychotic patients.
Recruitment of Residents and Staff Psychiatrists
In the post-World War II period, greatly expanded VA psychiatric facilities required large numbers of trained psychiatrists. Although VA salaries in the 50's were competitive with what universities and the states were offering, there were serious recruitment problems. Many American medical graduates were anticipating careers in private practice and would only consider a full-time VA position as a temporary measure. A more serious problem was the location of many VA hospitals. Situated far from urban centers, they were not attractive to young psychiatrists, most of whom had grown up in large metropolitan areas.
To solve the psychiatrist recruitment problem, the VA developed a program of financial incentives. In return for promises to serve several years as VA psychiatrists, residents were given higher salaries during their training years. This attempt to deal with a serious recruitment problem with surface measures proved to be unwise. Many residents took advantage of the "buy out" provision of the agreement and left the VA system with feelings of bitterness and resentment. Many years later, when we attacked state psychiatrist recruitment problems in Maryland, we concluded that no recruitment program could succeed without dealing with the morale-eroding problems that caused the recruitment problem in the first place.
The VA finally abandoned autonomous residency training. The problems of resident and staff psychiatrist recruitment were left to the universities, which included rotations at the VA hospitals as part of residency training. The recruitment of staff psychiatrists has been facilitated by closer ties to the academic centers and with the policy of building new VA hospitals close to medical schools.
Changing VA Patient Population
The VA is unlike any other medical organization in that the size and nature of its patient population depend upon how recently the nation has been engaged in a major war. In the post-World War II era, there were many acutely ill veterans to treat and psychiatric casualties resembled the patients we read about in our textbooks. Post World War II conflicts have involved fewer soldiers and many have come from working class families. Veterans have been caught up in the drug epidemic to the point where 70-80% of psychiatric hospital admissions have a primary or secondary drug abuse problem. With the aging of the World War II veteran population, a higher and higher percentage of veterans seeking psychiatric care are in the over 65 group. Psychogeriatric treatment and research absorb many of the VA resources today. When the World War II veterans pass on, we can expect a sharp decline in the number of veterans seeking medical and psychiatric care - only another major war could change this outlook.
Women VA Patients
One of the shortcomings of VA psychiatric training has been a shortage of women patients. During World War II, few women served in the regular armed forces. Many of those who did serve were nurses and they were commissioned officers. Hospitalized nurses were an interesting but a small, atypical group of patients. With the inclusion of women in the regular armed forces, female veterans, more typical of mainstream American women, are beginning to appear in VA hospitals and clinics. For many years, their numbers will be much smaller than their male counterparts.
Compassionate Care vs. Medical Necessity
Before managed care, hospitals provided a combination of medically indicated treatment and compassionate care. By compassionate care, I mean that certain treatment and management decisions were made not because they had been proven to be effective but because they seemed to be the right and decent things to do. Keeping a mother in the hospital for a few extra days to allow her some respite from household duties would be an example of compassionate care. Of all the medical institutions I know of, the VA is most likely to provide compassionate care to its patients. This is probably due to the fact that managed care has made fewer inroads in VA medical institutions and that VA physicians are sensitive to pressures exerted from the myriad of federal officials who must answer to a voting constituency. Although these outside pressures are resented by VA physicians, they do give the patients somewhat more power when dealing with medical personnel than is possessed by patients treated by managed care organizatins who recognize only "medical necessity" in making treatment decisions.
The VA medical system will continue to be around for a long time, but we can't predict what the future holds for it. Faced with Federal budgetary pressures it will continue to change. Only the future will tell whether compassionate care will win out over the managed care model.
Dr. Weintraub is Clinical Professor of Psychiatry at UMAB, and continues to serve as a consultant at Perry Point VA Hospital.