Barry Blackwell’s reply to Samuel Gershon’s comment

Barry Blackwell: Adumbration: A History Lesson - Barry Blackwell’s reply to Sam Gershon’s comment

Sam’s kind comment is directed not so much to the specifics of my essay but to the underlying issue, which is “exploring or ignoring the past to explain the present.” This is a topic for which he advocates a “wider discussion” involving contemporary medical practice, medical education and scientific journalism.

I believe it is true that economic factors, eroding ethics and professional greed have created a radically different modern Zeitgeist compared to the early days portrayed in the ten volumes of The Oral History of Neuropsychopharmacology edited by Tom Ban (ACNP, 2011). Much of this is discussed in my memoir, Bits and Pieces of a Psychiatrist’s Life (Blackwell, 2012) and some of the impact and implications for contemporary psychopharmacologists are portrayed in the biographies of prominent pioneers in our field. (See INHN.org in Biographies).

With this larger scope available as background, I will comment briefly here on the three domains Sam mentions. With regard to medical practice Sam draws attention to the consequences that flow when formerly independent practitioners become salaried employees of large healthcare corporations, a rapidly increasing problem including all full-time hospitalists, many primary care physicians, some psychiatrists and occasional psychiatric administrators or CEO’s. Despite their alleged “not-for-profit” status (to evade taxation) these corporations are driven by a “bottom line” mentality expressed by the administrators at my former hospital uttering the glib axioms “No Margin, No Mission” and “Every bucket must carry its own water.” Resources were diverted away from faculty stipends and medical education towards administrative salaries, advertising campaigns and competitive building programs to create hegemony, aggravated by declining bed occupancies and income due to federally mandated DRG’s, managed care guidelines, insurance company parsimony (prior to alleged parity) and low Medicaid reimbursement. During the 1980’s and 1990’s, five inner city hospitals in Milwaukee merged and later went bankrupt. Some of these events are described in my JAMA editorial (Blackwell, 1994).

Eventually, the hospital, where I was Chair of the academic program in psychiatry, was taken over by the largest health care consortium in the region. In the Department of Family Medicine, faculty was given the choice of no longer treating inner city Medicaid patients or resigning. The Department of Psychiatry was disbanded, the inpatient unit closed and the residents dispersed, contributing to a lack of psychiatrists and beds in a city plagued by homelessness and chronic recidivism reminiscent of the early days of deinstitutionalization, aggravated by the remaining psychiatrists in private practice declining to accept Medicaid patients.

The academic family medicine department and its residency program were eventually closed; the Chairman accepted a job with the health care corporation and is now it’s CEO, earning an annual salary in excess of $4 million.

Sam notes that employed physicians are now subject to productivity quotas and hospital residency training programs now progressively restrict the time allowed for interviews. After entering practice, salary levels are adjusted according to “productivity”. This discourages physicians from accepting time consuming patients, the elderly, mentally ill, Medicaid or Medicare recipients.

As a medical student at our local private Medical School, my son’s tuition was $40,000 a year. A previous magna cum laude student at another university in politics, philosophy and economics, he was ineligible for health insurance under his parent’s policy. The medical school, with a large well organized practice plan, offered no heath care to students but would loan him another $10,000 to purchase it. He declined, obtained Medicaid and was offered food stamps he never asked for! The medical school auditorium has a ten foot statue of Hippocrates guarding the entrance to its library. His oath, that students are asked to endorse, states medical education should be “without fee or covenant”. There is no better example of the greed that is now endemic in medicine than the disappearance of “professional courtesy” coincident with the ability of our procedure performing colleagues to become millionaires. My son opted for family medicine and is very happy, living one block away from where he grew up and in walking distance to his office.

During my fifty year career as an academic with the “publish or perish” motto hanging over my head, I had cordial relationships with the editors of many journals who accepted my research or for whom I worked pro bono as a reviewer. After retirement, I sought to obtain a copy of the editorial I had written for JAMA twenty years before (No Margin, No Mission). I was told I could only do so after paying a substantial fee and even then, only if I rejoined as a subscriber. I reluctantly did so, leisurely scanning the contents of the journal for psychiatric material. Some months later, I read a review of an article on emergency room visits and admissions due to the side effects of psychotropic drugs (see Blackwell, 2015). In brief, the author of the review noted that lithium was the most frequent cause of admissions and attributed this to excessive and unwise use of the drug. Evidence for this was absent, as well as any attempt to address or establish the use of well-established prescribing guidelines. I wrote a letter to the Editor suggesting this was incorrect and eventually received a reply stating that a group of sub-editors had decided my letter lacked sufficient “impact”. The journal made no attempt to contact either the original authors of the study or the reviewer who had drawn a faulty conclusion. The letter informed me I could contact them myself but it was uncertain they would reply. I concluded that editorial ethics had deteriorated since the days when I was a resident and wrote anonymous editorials and annotations for the Lancet.

It remains to speculate on the degree to which a changing Zeitgeist in the future may create barriers to success for psychiatrists, in general, and psychopharmacologists or neuroscientists, in particular. In writing the biographies of our pioneers, three attributes appear to assist in negotiating the unexpected but inevitable obstacles to be faced during a career. They are prescience (an ability to anticipate change), flexibility (a capacity for adaptation) and fortitude (a resilient attitude to surmount challenge and frustration). A forthcoming biography to be posted on INHN describes and explores this aspect in more detail (Blackwell & Charalampous, 2015).

References:

Ban TA (Series Ed.) An Oral History of Neuropsychopharmacology, Brentwood, Tennessee, ACNP, 2011.

Blackwell B. Bits and Pieces of a Psychiatrist’s Life, Xlibris, 2012

Blackwell B. No Margin, No Mission. JAMA, 1994; 271: 1466.

Blackwell B. Risks and relevance to lithium usage: Unpublished letter to the Editor of JAMA on INHN.org in Perspectives; 6.25. 2015

Blackwell B & Charalampous K.  Kanellos Charalampous: Confronting the Zeitgeist on INHN.org in Biographies. 12. 24. 2015.

Barry Blackwell
December 17, 2015