Category: Policy

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.

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Education Lessons NYC Policy PPOH

Assertive Community Treatment.

While at PPOH, I spent two days a week working with an Assertive Community Treatment (ACT) team.

ACT is somewhat like a psychiatric hospital outside of a hospital. It is an evidence-based practice[1. From the New York State Office of Mental Health: “When comparing recipients before and after receiving ACT services, studies have shown ACT recipients experience greater reductions in psychiatric hospitalization rates, emergency room visits and higher levels of housing stability after receiving ACT services. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care.”] that features a multidisciplinary team (social workers, psychologists, psychiatrists, nurses, case workers) that works with a small group of patients who often experience impairing psychiatric symptoms. It provides comprehensive and flexible psychiatric services. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one program director (social worker)
  • one team leader (social worker)
  • one MICA (“mental illness and chemical addiction”) specialist (social worker)
  • one vocational specialist (social worker)
  • one entitlements specialist (almost-graduate from social work school)
  • two case workers (one who had recently earned a social work degree)
  • one registered nurse
  • one secretary (who did much more than clerical work)
  • two psychiatrists (our combined hours did not fill a full-time position)

During my time there, I provided care for about 35 patients. (The other psychiatrist provided care for the other 35 patients.) The staff to patient ratio is purposely kept low, as ACT is considered an intensive intervention.

Patients who are referred for ACT services must have been psychiatrically hospitalized (often involuntarily) at least four times in the past year. They often have multiple emergency room or mobile crisis visits. Other outpatient services have often failed or have been insufficient to prevent crises and hospitalizations.

Thus, a chief goal of ACT is to keep people out of the hospital.

The ACT model dictates that the team (as a whole) must make a total of at least six contacts with each client[2. There is a movement in mental health—and in other parts of medicine—to move away from the term “patient”. In this particular ACT setting, patients were called “clients”. Sometimes they are called “consumers”.] every month, preferably in the community. One of these visits should be a meeting with the psychiatrist. Some patients regularly came to the office for their visits. Others, however, could not or would not come in. We thus went out to them. (Hence the adjective “assertive”, which, in some cases, could be construed as “coercive”. More about coercion later.)

If I did not see patients in the office, I often saw them in their apartments. (Limits and boundaries do not blur, but they certainly shift. My experiences in these residential settings inspired this post. To be clear, there were a few individuals who I never met alone. I insisted they meet me outside or in the clinic. Some of this was due to their past behaviors; some of this was my gut instinct.) For those who did not feel comfortable meeting in their apartments, we met in lobbies, parks, or chatted during walks. (During my time on ACT, I came to value talking and walking as a therapeutic intervention.)

ACT was formerly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psychiatric hospitalizations despite ACT services.) Most of the patients had psychotic disorders (such as schizophrenia) and, surprisingly, many of them had actively involved family members. I suspect that this impacted who was referred to ACT; family members were often the ones bringing people to the hospital for care (versus calling the police, etc.) Most patients “graduate” from ACT within a few years: They stay out of the hospital, become more involved in the community, and no longer need that level of care.

I learned in this position that people with chronic psychotic disorders can get better. Their symptoms decrease. They learn how to temper their behavior so that they do not attract undue attention while out in the community. They set and reach personal goals, like earning high school and college degrees, securing employment, getting sober from alcohol and drugs, and taking care of their physical health. They stop smoking! Sometimes they need a lot of support and a number of years need to pass before things settle down, but people with diagnoses of schizophrenia are not doomed to a life of poverty and “low function”.[3. The public rarely hears about positive outcomes for people with schizophrenia. There is research that suggests that a significant number of people with diagnoses of schizophrenia either experience improvement or recovery of their condition. Anecdotally, I agree.]

I also learned the importance of seeing patients in their environments. So much of contemporary medicine now occurs outside of a person’s living situation. That is often appropriate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the intimate nature of medicine, meeting in a “third” location can help preserve privacy and security. However, we can learn so much about how people function (or do not function) when we see their living spaces. We also realize strengths that we would otherwise overlook. A neat home, a sack full of old prescription pills, vinyl records of classical music, papers all over the floor, photographs of friends and family, roaches climbing over dozens of empty cans of soda: All of that is information that doctors often never have.

It is amazing how people live their lives. It is remarkable how much people will tolerate. And it is humbling that people are willing to share their lives with you.

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Education Homelessness Informal-curriculum Observations Policy

Medicators.

Two recent events inspired this post:

1. My husband and I had dinner at Farestart, which is

… a culinary job training and placement program for homeless and disadvantaged individuals…. As members of [this] community are placed in housing, the need for job-training will play a critical role in ensuring the self-sustainability of these individuals.

While eating the tasty food and learning about the mission of Farestart, I reflected on my experiences working with the homeless. I have encountered them outside of the health care system, in emergency rooms and psychiatric hospitals, and in medical hospitals as a psychiatric consultant.

I realized that, as a group, psychiatrists are skilled at prescribing medications for the homeless. Unlike Farestart, however, we offer little to help the homeless help themselves.

2. Since starting my new job in Seattle, several patients have come to me with the chief complaint[1. “Chief complaint” is a medical phrase that refers to the reason why a patient has come to see a physician. It is not a sardonic comment.] of wanting to stop their psychiatric medication(s).

One of the greatest pleasures of my job is helping people taper off of their medication(s).[2. To be clear, there are instances when I actively discourage people from tapering off of their medications, as some people end up in psychiatric hospitals when they stop taking medications. A personal goal of mine is to help keep patients out of hospitals.] My colleagues and I have all seen patients who are taking large numbers of psychiatric medications for unclear or invalid reasons. There is also data to suggest that certain classes of people are more likely to receive psychiatric diagnoses that may not be valid, which results in prescriptions for medication that they don’t actually need.[3. African Americans are more likely to be diagnosed with schizophrenia. Anecdotally, I’ve worked with several African American patients with diagnoses of schizophrenia who were taking antipsychotic medications, though neither the diagnosis nor the medications seemed indicated. We gradually tapered off the antipsychotic medication and nothing happened. They were fine. Which makes me wonder.]

Some people eventually come off of all of their medications without incident. Some people significantly reduce the number of medications they take. And, unfortunately, a few people end up in the hospital during the tapers.

That never feels good.

I realized, again, that psychiatrists are skilled at prescribing medications, but we know little about stopping medications. (In my brief review of Pubmed, I found only one article that offers suggestions about stopping medications.) Furthermore, as a group, we lack the knowledge about treatments other than medications and psychotherapy.[4. Psychiatrists in private practice are more likely to offer both psychotherapy and medication services. Psychiatrists who work in medical centers often only provide medication services due to the institutions’ financial systems.]

Perhaps this is due to the belief that patients who come to see psychiatrists have already tried everything else. They have gone through trials of exercise, counseling, deep breathing, meditation, naturopathic medications, etc. Because none of that has been helpful, they come to see a psychiatrist as a last resort.

That could be true.

This may be a function of our training. Contemporary psychiatry, for better or for worse, follows the medical model. The medical model focuses on biological causes of illness and disease. Current medical treatments (i.e. medications) aim to correct the presumed underlying biological causes.[5. The underlying biological causes of psychiatric conditions remain unclear. Discussions about “chemical imbalances” are still hypotheses, not theories. Psychotropic medications are primarily empirical treatments.] Thus, psychiatrists end up prescribing medicine because that is what we were trained to do. Furthermore, patients often expect us to prescribe medication. (Like other human beings, psychiatrists sometimes feel the pull to “do something”, even though “doing nothing” may be the most prudent choice.)

Psychiatrists, often rightly so, have reputations as “medicators”. A friend of mine works as a psychiatrist in Canada. She came to the US for fellowship training. An administrator told her that her role in the American clinic was that of “the medicator”. My friend was horrified. Because of the funding system, Canadian psychiatrists routinely provide both medication management and psychotherapy services. She could not believe that her role would be limited to the prescription of medication.

“What? You believe in the biopsychosocial model? You think context matters?” the American fellowship cohort dryly commented.

If the knowledge and practice of psychiatrists is limited solely to medications, of course the general public will believe we are simply “medicators”. This is problematic, as we have incomplete knowledge of how psychotropic medications work. (All psychiatrists should read Healy’s The Antidepressant Era. Healy does not outright dismiss antidepressant medication, but he provides data that strongly argues that antidepressants are not as effective as the public believes.)

I cannot speak for all psychiatrists, but I believe most of us did not choose to enter this field to become “medicators”. Thankfully, many psychologists were involved in my education. I’d like to think that, as a result, I am less inclined to pursue medications as the sole mode of treatment. I must admit, though, that I am unfamiliar with the literature for non-pharmacological treatments. (I am familiar with the literature for housing as treatment…. but what is the evidence—or lack thereof—for exercise? meditation? diet changes?)

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Education Homelessness NYC Policy PPOH

The Homeless Outreach Team.

During my time at PPOH, I spent one and a half days per week with a homeless outreach team.

In 2004, the mayor of New York wanted to reduce the number of people who experience homelessness in the city.[1. Mayor Michael R. Bloomberg Announces Citywide Campaign to End Chronic Homelessness] National data suggests that the vast majority of people who become homeless are only homeless for a short period of time (less than one month) and never become homeless again.[2. From a National Alliance to End Homelessness fact sheet.] Thus, the mayor’s plan focused on people who experience chronic homelessness.[3. “In general, a chronically homeless person is an unaccompanied disabled individual who has been continuously homeless for over one year.”] Of that population, between half to two-thirds of them have significant psychiatric conditions.[3. Page 4-4 of The 2007 National Symposium on Homelessness Research.]

Before describing further details of this plan, let me explain “housing first”:

Traditional housing models for the homeless are built on “merit”. The entry points for housing are generally homeless shelters (which excludes those who are homeless on the streets). Once these individuals connect with housing services, they must follow certain steps to “earn” housing. These steps include regular meetings with staff, taking medications (if indicated) as directed, abstaining from drug and alcohol use, and abiding by other (sometimes arbitrary) rules. Thus, people will only secure housing if they “follow the program”. Unfortunately, many people are unable to “follow the program” (due to psychiatric symptoms, drug and alcohol use, etc.).

“Housing first” is a model where chronically homeless individuals are given housing first. People only need to accept housing.[4. To be clear, people who are enrolled in “housing first” programs are not getting “free” housing. They sign leases, are expected to pay rent, etc. Their rent is generally one-third of their total income. If they receive entitlements, rent is usually taken directly from their monthly cheques.] There are no requirements to take psychiatric medication, to abstain from drugs and alcohol, etc. The underlying premise is people must have homes before they can address their other problems.[5. See Maslow’s hierarchy to learn a view about the importance of housing.] There is evidence that the “housing first” model saves significant health care dollars and improves health outcomes (decrease in number of homeless people; decrease in ER visits and hospitalizations; less time spent in jail).

Major social service agencies in New York City came together to form consortia (consortiums?) to house the chronically homeless according to the “housing first” model. Some agencies built or provided the physical housing; others supplied the staff to work in the residences. Still others provided the manpower to perform actual outreach to the homeless.

Each borough has its own consortium. I was assigned to work on a team in the consortium for Manhattan.

The borough of Manhattan was initially divided into seven sections, though these were ultimately condensed into five. Each section has its own outreach team. The outreach team I worked with was comprised of:

  • a program director (social worker)
  • a team leader (social worker)
  • five housing workers (high school graduates to social workers)
  • a receptionist (who also answered 311 calls about homeless individuals in Manhattan)
  • and a psychiatrist (me)

The section we worked in was bounded by the southern tip of Manhattan, the East River, the Hudson River, and Houston Street. Our job, as a group, was to identify chronically homeless individuals, build rapport and encourage them to accept housing, and shepherd them through the housing process until they moved in.

Two of the housing workers were on duty from 5:30am to 1:30pm. They would travel throughout our designated section, either by car or on foot, and seek out people who were “bedded down”—those individuals who were sleeping on the street (or in other public spaces). After rousing people and introducing themselves, the workers would ask for homeless histories to learn if people were eligible for the program. If the individuals could tolerate it, the workers would then start to build rapport with the ultimate goal of encouraging them to accept housing.

You can imagine the reception they often got. Few people want their sleep disturbed, let alone by strangers. Furthermore, homeless individuals are only too familiar with police officers and people with malicious intent waking them while they are sleeping.

Housing workers who worked the day shift from 9:30am to 5:30pm also engaged in outreach, though they generally worked with homeless individuals who had already established connections with the team. They often helped people secure birth certificates, identification, and entitlements. They accompanied individuals on housing interviews, provided transportation for appointments, and advocated for them in various contexts.

There were also evening and overnight teams, though I never worked with them directly.

The team leader and program director provided supervision and support for the rest of the team. They also compiled data about housing placements. The more people a team housed, the more funding that team would receive. Despite the productivity expectation, we reminded ourselves that these people were people, not merely numbers.

The psychiatrist’s official job was to administer psychiatric diagnostic interviews to determine if the person had any psychiatric or substance use disorders. The diagnosis (or lack of one) would determine what type of housing the person was eligible for. (There were always more people than available housing. Yes, this is where a psychiatrist can become an agent of social control. More about this later.) Though I could meet with people in the office for interviews, I often went out with different workers to talk with people wherever they were. (Some people had significant psychiatric symptoms that interfered with their ability to meet anyone at a specific time or place, so I would often find them in subway stations, in public parks, behind garbage bins, on stoops, etc.)

I also provided education to the outreach workers, did regular outreach myself with a few clients whose psychiatric symptoms (often delusions) interfered with their ability to even consider housing, and provided informal supervision to the staff members. These housing workers, particularly the ones who work early in the morning, have tiring and often thankless job.

Of all the positions I had at PPOH, this was by far the most challenging for psychological and ethical reasons. Some people had severe psychiatric conditions. Many individuals lived in squalor. A lot of people experienced terrible things at the hands of their fellow human beings. People suffered.

As a team, we interacted with a lot of people. These included not only homeless individuals, but also police officers, ambulance crews, emergency rooms, hospitals, private property owners, homeless shelters, medical clinics, government agencies, staff at supportive residences, and the general public. Working with and in all of these different systems was often taxing and frustrating. Everyone in all these different arenas wanted to do “the right thing”, except people often had contradictory ideas as to what “the right thing” was.

In this position, I witnessed human dignity, creativity, and resilience. No one wants to be homeless. Many homeless people, whether they have psychiatric conditions or not, feel shame about their circumstances. They want things to be different, but they don’t know what to do. They try their best with what they’ve got. Sometimes their strategies work, sometimes they don’t. We can all recognize that in ourselves. And that’s how the line between “us” and “them” dissolves.

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Education Funding Homelessness NYC Policy PPOH

Project for Psychiatric Outreach to the Homeless.

In New York, I worked for an organization called Project for Psychiatric Outreach to the Homeless (PPOH). It has a humble history: Over 20 years ago, a group of psychiatrists were sitting around and discussing the need for psychiatric services for the homeless. They decided to volunteer their time and skills to this population.

The organization grew and, for both administrative and financial reasons, eventually became part of another social service organization, CUCS. At this point, PPOH serves more formerly homeless individuals than people who are currently homeless.

PPOH is not a big outfit. By the time I left, there were about 12 full-time psychiatrists, several part-time and per diem psychiatrists, and a handful of psychiatric residents. As a group, we worked at nearly 60 sites in three boroughs of New York City.

The job is atypical in many ways. PPOH psychiatrists are paired with different social service agencies to provide psychiatric services. The rationale is that social service agencies often don’t have the resources to employ psychiatrists. Furthermore, these agencies often do not know how to provide the support and supervision to psychiatrists. What they do have, however, are patients who would benefit from psychiatric services, but the patients either cannot or will not visit a psychiatrist in a clinic or other typical setting.

Thus, PPOH brings psychiatrists to the patients.

Funding for PPOH differs from funding for “mainstream” psychiatric services. PPOH receives funding from state and city agencies (government money), grants (from organizations like Robin Hood and van Ameringen), and fees from the social service agencies themselves. These fees are usually lower than what it would cost to hire a per diem psychiatrist directly.

Because PPOH did not receive money from Medicaid, it did not have to follow Medicaid rules and regulations. (PPOH would not be able to fulfill its mission if it did accept Medicaid funds, as Medicaid has requirements that physicians see patients in a physical locations designated as clinics. This contradicts the organization’s mission. While at PPOH, I often saw patients on sidewalks under scaffolding, in their apartments, etc.)

I was one of the few psychiatrists in the group who worked with an agency who worked with Medicaid, though because of the nature of the program (an Assertive Community Treatment program; more on that later), the regulations had little effect on my actual clinical work. It did influence the documentation I had to provide.

PPOH does not have any contracts with insurance companies (as the target population often did not have traditional insurance), which also means that there were no negotiations about reimbursement rates or discussions about concessions to have access to the patients on an insurance panel.

Thus, I essentially had a job outside of the US healthcare system, which, in many ways, was appropriate: The population I worked with was also generally outside of the US healthcare system. Despite this, we often viewed ourselves as “hot spotters“, as a few of our patients often crossed into the US health care system through ERs and hospitals.

Because of this funding structure, I worked as a salaried employee. There were no productivity expectations or bonuses. While this arrangement can result in people slacking off, my boss chose his employees carefully to prevent this problem.

Psychiatrists who choose to work at PPOH, however, do not work there for the money. The median salary for a psychiatrist in New York is apparently $228,815. During my time at PPOH, over 90% of psychiatrists in New York earned more money than me.

(Yes, the specter of student loans continues to haunt me and, of course, it would be nice to make more money, but let’s be honest: I was earning enough money to live comfortably in New York. Not everyone who lives there can say that.)

In exchange, I had the time and opportunity to work with those who often do not receive care. Many of these individuals had significant psychiatric conditions that contributed to their lack of employment, homelessness, and poverty. I had more control over how often and how long I got to see patients. Patients had easier access to me and I had the flexibility in my schedule for urgent appointments.

The idealist in me finds the fiscal realities of health care demoralizing. I don’t like thinking about how economics affects the relationships I have with patients. I didn’t go into medicine to think about that stuff. However, I do firmly believe that physicians should have a basic understanding of their clinic or department budgets. Form follows function. And form follows funds.

Next: What my job at PPOH actually looked like.