A Raisin Brings the Sun

It was a cold Saturday afternoon in December of 2005 when I received a call from Walter Nathanson (pseudonym), the medical director of a safety-net institution that was recruiting for a chair of psychiatry. This venerable institution, well known for its teaching, research, and clinical care, had fallen on hard times. The Department of Psychiatry needed a new chair. I was intrigued, and a few days later, I met Dr. Nathanson in his office to discuss the position.

It was late one evening, a week before Christmas. The hospital was strangely quiet and lacked any gaiety. The corridors were empty and poorly illuminated to save power. Even though the building was impressive, it lacked regular maintenance, and it showed. Dr. Nathanson described at length the problems faced by the hospital and the Department of Psychiatry. Similar to many other safety-net institutions in America, it was unable to meet its obligations due to changes sweeping the field. Dr. Nathanson mentioned several maladies of the department, and I made special note of the lack of regular and effective communication among various disciplines that made up the behavioral health team. Instead of discouraging me, the conversations with the medical director had the opposite effect. He arranged meetings where the staff was instructed to be open and hold nothing back. I found the staff to be bright, dedicated, and articulate but demoralized and deeply frustrated by the lack of resources, increasing clinical demands, and absence of any reward system. After this process, we agreed that the department had the potential to be turned around. I submitted my plan of action to the hospital. The hospital fully supported it, and thus began my long and arduous journey as a leader of a large department in a safety-net institution.

One of the early initiatives we introduced was to organize a daily “Morning Report” to improve communication among all disciplines. This consisted of a one-hour mandatory meeting in which the staff discussed new admissions, discharges, consults, investigations, and administrative issues. Even though the hospital was located in one of the richest counties in the nation, the social safety net was full of holes. The initial reservations of the team about the Morning Report disappeared when we received plaudits from regulatory agencies. They described the Morning Report as a best practice to improve clinical care and encouraged us to share it with others.

The staff responded to this and other initiatives with great enthusiasm, and improved clinical care was the result. The institutional leaders identified the Department of Psychiatry as the flagship department of the institution.

With the passage of time, institutions change, sometimes for the worse. Our department was no exception. By the early 2010s, the impact of the Great Recession began to affect the hospital finances. Disasters, such as Hurricane Sandy and the building heroin epidemic, also took their toll. In addition, the need to manage highly complex cases without adequate resources; a demanding local, state, and federal regulatory climate; a highly litigious clientele; and a rapidly changing health care delivery system created enormous strain. Consequently, even the most dedicated physicians of the department suffered from burnout, which led to several departures. Staff members who chose to stay felt increasing pressure to care for a greater number of patients and to deal with the consequent problems that came with doing so.

The attendance at the Morning Report started to become erratic. Sharp differences among attending physicians became more frequent. Pervasive feelings of ineffectiveness and helplessness started to spread like cancer. One of our responses to this crisis of spirit and morale was to introduce a mindfulness practice session to follow the Morning Report every Wednesday, or at least once a week. Such was the situation within the department when an incident occurred.