Category: Education

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Education Funding Homelessness Observations Policy Systems

Asylums are not the Answer.

The New York Times recently featured an op-ed from a psychiatrist, Dr. Montross, who argues for the return of the asylum.

I understand her frustrations: I have worked with homeless individuals in both New York and Seattle who, if they were in psychiatric institutions, would not have had to worry as much about their safety, getting food, or sleeping at night. Many of the patients I now see in jail should undoubtedly be in a psychiatric institution (though not necessarily for a long period of time).

However, I disagree with her assertion that we should return to the era of the asylum.

President Kennedy signed the Community Mental Health Act into law in 1963. The goal of this legislation was to move people out of long-term psychiatric institutions, such as state hospitals, and help them integrate into the community by enrolling them in outpatient services. This is what “deinstitutionalization” refers to.

The Community Mental Health Act, however, only provided funds for the construction of the community mental health centers. The law made no provisions to fund the services that would occur in these buildings.

What we see now—the “transinstitutionalization” of people with severe psychiatric conditions into homelessness and jails—is a consequence of this lack of funding and support for patient care services.

Think of it this way: A city wants to improve its public transportation system. The city passes a law that provides funds to buy a lot of buses. However, the law provides no money to hire and retain bus drivers. There is also no money to hire and retain mechanics for bus maintenance.

The people of the city are frustrated: “Our public transportation system sucks! The city should build a subway system!”

The bus system never got a fair chance.

We also moved away from asylum care for good reasons: Conditions in psychiatric institutions were often terrible. It was not uncommon for state psychiatric hospitals to have insufficient staff for the number of patients in the institution. In Alabama in 1970, one psychiatric institution had one physician for every 350 patients, one nurse for every 250 patients and one psychiatrist for every 1,700 patients.

Dr. Montross herself notes (emphases mine):

But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months.[2. Unfortunately, 20-minute appointments every three months for the sickest patients is also a common occurrence here in Washington.]

If that is the quality and quantity of care “the sickest patients” in outpatient settings receive, then of course “many patients struggle with homelessness” and “many are incarcerated.”

Dr. Montross calls for “modern” asylums, though it is unclear to me what incentives government has at this time to build and support institutions that “would be nothing like the one in ‘One Flew Over the Cuckoo’s Nest'”. Asylums from years past did not receive sufficient funding to provide adequate care. Current outpatient centers often do not receive enough funding to provide adequate care. (How much longer must we wait before this changes?)

To be clear, I do believe there is a role for asylums in patient care. There is a small segment of the population with severe symptoms who would benefit from care in an institution. I’m talking about people who keep trying to jump off of buildings because they believe they can fly. Or people who cannot stop smashing their heads against the wall because they are trying to dislodge the computer chip they believe is in their heads. Or the people who eat their own feces and literally cannot use words to explain why.[1. As I have noted before: If you do not believe that these scenarios actually happen, I encourage you to volunteer at your local emergency department.] These individuals can and do recover; they are not necessarily destined to spend the rest of their lives in an asylum.

We also now have interventions such as assertive community treatment, assisted outpatient treatment[3. Assisted outpatient treatment is controversial, though preliminary data support its use. You can read an admittedly biased summary about it here.], and supportive housing/housing first. There is evidence that these intensive outpatient services keep people in the community and out of psychiatric institutions. What would happen if government and communities supported these interventions?

Modern psychiatric services—in an asylum or elsewhere—will not be modern at all if there are not enough staff to provide care for patients. It also will not be modern if the staff do not receive ongoing training and supervision for the care they provide. It cannot be modern if administrators do not understand the work and are unwilling to provide financial, technical, and emotional support to the front-line staff.

We must get away from the idea that where people receive services is more important than the quality of those services.

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Education Lessons Medicine

Negotiating a Job Offer (IV).

Negotiating a job offer can make us all feel uncomfortable because the noise in our head stops us from asking for what we want (and often deserve). Ladies, this post is for you because, even as physicians, we still earn less money than our male colleagues[1. From the White House: In 2014, Women Continue to Earn Less Than Men. From Forbes: Even Women Doctors Can’t Escape The Pay Gap.] and we often do not assert ourselves as much as we could during negotiations. That doesn’t help us as individuals or as a population.

One of the most important things to keep in mind during negotiations is that you’re not asking for “too much”. You are going to work hard for your employer. You want to arrange the details of your job so that you can create your best work with as few obstacles as possible.

As a resident, we had to pay for parking on nights when we were on call. We all hated that. Why do we have to pay for parking when we’re in the hospital working all day, then all night, and then for most of the next day? If we could have negotiated our jobs so that parking was covered when we were on call, then we would have felt less resentment about our roles. This is an example of a psychological obstacle that could get in the way of doing your best work.

First, consider that it is your employer’s job to say “no” to any negotiation request you make. That doesn’t mean that s/he will say no. If you assume that it is your employer’s job to say “no”, though, it’ll make negotiations feel less personal. (This is an example of a mental shift that is meant to help you, even if it is inaccurate. Sometimes cognitive distortions are helpful.) This mindset will also help you assess your priorities during the negotiations: What matters most to you, where you won’t take “no” for an answer? What is less important, but would be nice to have?

Second, consider it your job to ask for everything you want. By asking for everything you want, you demonstrate multiple things to the organization:

  1. You have the confidence to ask what you want.
  2. You show your strong communication skills in asking for what you want.
  3. You have the skills to advocate for yourself.
  4. You can use those same skills to advocate for your patients, your colleagues, the organization, and other parties.

On a practical level, naming everything you want also provides room for compromise. Your inner critic may balk at the idea of asking for everything you want (“I’m asking for too much!”). Organizations use your inner critic to their advantage because they know it is difficult for potential employees to ask for what they want. However, organizations need employees and, if they’ve already offered you a job, it shows that they specifically want you.

Know your style when it comes to negotiations. Some people aren’t “phone people”. Some people prefer conducting negotiations over e-mail, where one can take time to mull over options before responding. Some people prefer having conversations in person. This last preference has an advantage over the other two: It is hard to say “no” to someone’s face. Negotiating in person also sends a meta-message that you can manage potentially uncomfortable conversations with skill.

Lastly, remember that potential employers should be on their best behavior during interviews and negotiations. If they aren’t treating you with respect when they ought to be courting you, how will they treat you once you are formally working for them? All of these interactions provide information: Do you want to work for someone who isn’t putting forth a best effort to impress you? You’re likely working hard to make a good impression on them, right?

I hope the posts in this series will help you have more confidence and skills as you seek work. People often talk about “self care”, a concept that can sound hollow and corny. May these concrete suggestions help you in the realm of self care, as crafting a job that brings you satisfaction will help you take better care of your patients. Good luck.

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Education Lessons Medicine

Negotiating a Job Offer (III).

We’ve discussed the value of a job description and a table of organization when negotiating a job offer. You can negotiate specific items on either one of the documents, now that you know how your employer has structured them.

Common and obvious things you can negotiate include salary (usually on the job description) and title (usually on the table of organization). The reason why these are common negotiating items is that, in some ways, they are the most flexible. The job might be in a clinic and everyone is expected to see patients between 8am and 5pm; that is not negotiable. How much you are paid, though, could vary. Title may not be as flexible, but, depending on your interests, there could be room to craft your specific title if it will accurately reflect what you do.[1. To be clear, titles, at the end of the day, are just words. Some people believe that achieving an important title grants you leadership, influence, and power. I believe that who you are matters more than what your title is. We’ve all known people with fancy titles who do not appear to have the substance to support the description of their position. We also have met people who do not have fancy titles, but have integrity and wisdom and, as a consequence, influence and lead others. Yes, titles can give you access to information and people that you might not otherwise have. When you go home, though, you bring along whoever you are, not your title.]

For example, if you’re interested in education and would like to run a regular journal club and case consultation series, you could negotiate a title of “assistant medical director of education”. I’ve recently heard about some physicians who applied for “medical director” posts, but all the other leadership staff were “chief [blah blah] officers”, so they negotiated for a “chief medical officer” title. Again, from my perspective, the substance of what you do is more important than what words people call you.

Here’s a list—in no particular order—of stuff you can negotiate:

Bonuses. These seem rare in medicine, though some people are offered “signing bonuses”, particularly when they join hospital systems. You could negotiate the value of the bonus… or you can fold this into your salary so that your regular salary is higher.

Time off. If your employer can’t increase your salary, could they give you more vacation days?

Part-time, full-time, flex-time. Perhaps the job is posted as a part-time job, but you would like to work full-time. Or maybe vice-versa. If the fit is good between the employer and you, they might accommodate your preference.

Scheduling. Instead of working five 8-hour days, maybe you could work four 10-hour days or three 12-hour days. This depends on the setting, of course: Some clinics will much prefer that you are present five days a week for urgent appointments and coverage. They also may not have clerical and other staff available to work outside of the standard 8-hour day.

CME. Look at the job description: Does it mention CME? If not, ask for both time and money. Under the best of circumstances, you would get paid your regular salary while you are away and the employer would cover the cost—registration fees, hotel, travel—of attending any educational events.

Licensure. If the job requires that you maintain an active state license—which it should!—then you can ask if the employer will cover the cost of your license. You could also ask them to pay for your DEA license.

Transportation costs. If travel is part of your job—maybe you work in different clinics throughout the week—you can ask the employer to pay for your bus pass or reimburse you for gasoline or miles driven. Is there a company car you could drive?

Administrative support. Can you have a dedicated staff person to fax prescriptions for you? Format letters you write? Help with scheduling meetings or appointments? The employer is paying you to see patients; they don’t want to pay you to fax prescriptions.

Non-clinical time. If the job description includes administrative, teaching, or research duties, you can negotiate for more time or resources to do those things.

Office space. Maybe you can negotiate for a bigger room. Or the corner office. Or a room with a window. Or a quiet space.

Malpractice insurance. Many large physician employers already pay for this, but if your employer doesn’t, ask them if they will.

Call. If taking call is part of the job description, you likely can’t negotiate the amount of call you take because people probably aren’t paid extra money to take call. You could negotiate a decrease in salary amount if you don’t want to take call. Or you could negotiate when you take call—for example, you’d prefer to take call in week-long chunks instead of every fifth night.

No compete clauses. This is that thing in a contract that states that, if you leave the organization, you can’t practice within fifty miles of the clinic for five years and you can’t take any of your patients with you. If you plan to stay in the area, keep an eye out for this and know that fifty miles is a lot.

This is just a short list: Depending on the context in which you work, there may be other (obvious) things that you can negotiate.

It may seem daunting to ask for any of the items in the above list… but it doesn’t hurt to ask. I’ll talk more about that in the last and final post in this series.

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Education Medicine Systems

Negotiating a Job Offer (II).

The second thing to ask for when negotiating a job offer is a table of organization. Like the job description, if you are able to review this during your interview, do so. That will give you the opportunity to ask clarifying (not negotiating) questions during the interview.

A table of organization is a sheet of paper with boxes and lines on it that tells you who reports to who. It shows the official hierarchy of the organization. Your position should be on the table; there should also be a line from your position that leads up to your direct supervisor. It should also indicate who reports to you. Many organizations will not share this information with you before you are hired unless you ask for it. Some organizations don’t share this information with you even after you are hired.

If you have Machiavellian ambition, the table of organization also provides a roadmap as to how you can get to the top.

But even if you are not a fan of Machiavelli, the table of organization gives you useful information. Say you want clinical consultation related to the practice of medicine. Your supervisor, however, has the letters “MBA”, “LICSW”, or “JD” after their names. You thus can expect limited assistance from them. Maybe your supervisor is a physician, but is in a different specialty. Clinical consultation may not be useful there, either. Find out before you start a job who will provide clinical supervision for you.[1. If you don’t have an official clinical supervisor, make a point of finding out where you can get help for clinical matters because we all need it sometimes.]

If you have questions or concerns about issues related to the system of care, it’s useful to know if your supervisor can help. It’s also useful to find out who your supervisor reports to (and so on up the chain) because that will affect what information you have access to, how you are treated, etc. For example, as a staff physician, the table of organization might show that you eventually report to the Chief Medical Officer, who might then report to the Chief Executive Officer. However, it is also not unheard of for staff physicians to report to a medical director, who then reports to a director of clinical services (who may not be a physician), who then reports to a deputy director, and then an executive director. If the director of clinical services doesn’t like doctors, or the medical director doesn’t advocate for the medical staff, then your requests might not get the attention they deserve.

You might also find yourself reporting to more than one person. Depending on who they are, that could be fine… or you might feel like a kid with bickering parents.

The table of organization will also tell you who you supervise (if anyone at all). Maybe you don’t want the responsibility of having subordinates. Maybe you do. Maybe you want that possibility in the future, but not now. And maybe the table shows people reporting to you that you are not qualified to supervise. For example, you might have a cadre of nurses reporting to you. There is overlap in the knowledge that physicians and nurses use in their work, but most physicians do not have the skills or expertise to provide satisfactory clinical supervision to nurses.[2. Just because you have the letters “MD” after your name does not mean that you are qualified to supervise everyone, just as someone with the letters “MHA” after their name doesn’t mean that they are qualified to supervise you.]

Do also note that the table of organization you receive from your employer is the “formal” table of organization. There exists in every organization an “informal” table of organization. You usually learn about the “informal” table through word of mouth. Maybe people are supposed to report to a specific individual, but they actually talk to someone else on the other side of the table for help and information. That’s not information you might get during the interview process, but if you have inside connections or opportunities to talk with current employees, you can ask.

For example, maybe the official supervisor doesn’t actually provide useful supervision and you’re better off talking to another staff physician. Or maybe the medical director isn’t assertive, so if people want the Vice President of Clinical Affairs to know something, they cultivate some sort of relationship with that VP or someone along that chain.

This sounds like “politics”. Where there are people, there are often politics. You, however, want to be prepared: When problems come up—and they will—you want to know who you can and should talk to.

Next post: Stuff you can negotiate for.

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Blogosphere Education Medicine

Wanna Help Me with My Talk?

I’ve been invited to give a talk to psychiatry residents about “psychiatrists and social media” and my own experiences as an online physician.

Could you, fine reader, help me by telling me why you read the writings of physicians online?

This can include blogs, the 140-character musings on Twitter, blurbs on Facebook, or the myriad options now available.[1. I started writing online when “social media” wasn’t in the vernacular, there were only “weblogs”, and a 56 kbit/s dial-up modem was considered speedy. Now get off my lawn.]

For visual interest, post your response on Twitter, Facebook, or Ello so I may snag a screenshot for my talk. You can also send me an e-mail; just make it clear that I can share the content of your note.

Thank you for indulging me.