Psychiatric Staffing

To the Editor: The VA managed care model for psychiatrist staffing offered by Dr. James Morrison in the August 1998 issue assigns 200 new patients and 1,150 current patients per year to one psychiatrist and 2.5 nonpsychiatrists. The entire article contains only one sentence that mentions patient outcome data. Before other mental health systems hasten to apply the model, we want to raise two questions.

First, during the study year at the three clinics, what was the quality of patient care as suggested by treatment outcome and patient satisfaction? Our reply: clinical outcome was poor, and patient satisfaction was low. This conclusion is difficult to quantify but comes from perceptions of almost every psychiatrist working in the system during the study year. These collective perceptions outweigh those of a single care provider cited by the author, who said she had time available to do more, a remark that may have been made in jest or out of fear of "the boss."

The 1995-1996 VA fiscal year, during which the research data were collected, was marked by health care cost reduction and staff cuts. Earlier in 1998, without knowledge of the Morrison study, one of the signers of this letter performed a quality assurance survey of patient suicide attempts recorded in the entire VA outpatient system in Northern California from 1993 through 1997. It shows a peak in such events for the year 1996, an observation possibly relevant to diminished provider-patient ratios. Psychiatric patients constituted the majority of those attempting suicide.

Second, during the 1995-1996 fiscal period and in the following two to three years, what were the morale and satisfaction levels of the psychiatrists at the three sites? Our reply: both were low. Medical care providers have voted with their feet. Half of the psychiatrists at these sites resigned between 1996 and the present, while two others have given notice to leave in 1999. Retirement, expected employee turnover, and budget cutbacks explain part but not all of this mass exodus, and several of these positions still remain vacant in an economic climate favoring employers. Another psychiatrist who left our clinics before 1996 refused an offer to return to our department and accepted a VA job nearby.

To borrow a military metaphor—the general sitting at his computer at headquarters has quite a different perspective on good psychiatric care than the soldiers in the trenches treating mental illness.