When Residents Speak Out

"But you’re usually so mild-mannered!” It was true. Far from an activist, I thought of myself as quiet, responsible, and deferential. Overjoyed to be at the Harvard Longwood Psychiatry Residency Training Program, I was in love with the unexpected beauty of patients’ stories and the elegance of psychodynamic thinking. I had especially sought training at Beth Israel-Deaconess Medical Center (BIDMC), one of three Boston hospitals (with Brigham and Women’s Hospital and the Massachusetts Mental Health Center) that make up the Harvard Longwood psychiatry residency.

I considered BIDMC a haven of wonderful teaching and humane patient care. My colleagues and I were looking forward to years of learning thoughtful psychiatry there.

All of that changed suddenly one morning in September 2000. Residents started to drift into the department office stunned and glassy-eyed. A few had read the e-mail sent the night before by the CEO of the financially ailing network that owned BIDMC. Others had heard the news on morning radio: The network had decided to eliminate virtually the entire BIDMC psychiatry department.

Residents, teachers, administrators, and patients were in shock. Placing financial priorities first, the CEO had set the goal of a smaller, more efficient medical center—but one without primary psychiatric services. BIDMC’s two inpatient psychiatry units and its outpatient department would be closed. Only a small consultation-liaison service would remain.

Shock quickly gave way to anger. Incredibly, the CEO had consulted with no one in the department or the community. There was already a shortage of psychiatric beds in Boston; the network’s move would exacerbate the crisis. Yet the CEO’s announcement proclaimed that “our patients. . .always will come first.”

For residents, there was an additional bitter pill. BIDMC was a major participant in the Harvard Longwood psychiatry residency. Without its involvement, our nationally recognized training program was suddenly in jeopardy. Neither the CEO nor anyone at the network had approached the residency before making the announcement.

Like my colleagues, I was furious. Yet deciding how to act was difficult. What would people think of residents who spoke out publicly? Would protest help or hurt? In supervision I described my dilemma: I wanted badly to write a protest letter. But to whom? The CEO? The dean of the medical school? And at what cost? If I spoke out angrily, perhaps people would look askance at me.

Finally, my supervisor asked me what I felt more than anything. “Betrayal,” I answered. I dismissed this strong emotion as an overreaction. But he repeated the word with a nod. “Betrayal.” Then he asked, “What do you think the dean would feel if you sent your letter to him—and used that very word?”

I paused, trying to imagine the dean’s reaction to my protest. “Anger.”

“That’s possible. But what else might he feel?”

“Well. I suppose he could feel. . .pride.”

It finally dawned on me that a thoughtless move deserved a vigorous protest in the name of patient care and education at Harvard. And so, for me, a protest movement was born.

I summoned my courage and drafted a letter to the dean. Deliberately I chose strong words like “hasty,” “misguided,” and “unworthy” to describe the network’s decision. I decried the loss of long-cherished relationships with patients. And I concluded, “Surely the residents who came to Harvard Longwood for its excellence as a training program have reason to feel betrayed when a major Harvard teaching hospital thoughtlessly undermines the integrity of their program.”

As I wrote, I took comfort in my colleagues’ support and activism. Suddenly all of us were rising to the challenge of opposition. One resident gave scorching interviews to the media. Others contacted legislators and joined a protest march on Boston Common. Still others worked with faculty and professional organizations, developing responses to the crisis.

With my colleagues’ support, I decided to present my letter to the residency’s house officers’ association—not as an individual protest, but as the draft of a unanimous statement by all 60 Harvard Longwood psychiatry residents. Residents were enthusiastic. But the group worried, as I had, about how outspoken it was acceptable to be. Some strongly favored an angry statement; many argued for toning the letter down. We finally decided that the word “shameful” and its variations, which I had used three times, should appear only once. But the tone of outrage remained intact, and the residents unanimously approved the revised letter. To my delight, a whole series of Longwood supervisors and mentors also made their support extremely clear.

Partly as a result of our massive outreach, our own protest was joined and strengthened by others. The CEO heard from faculty, BIDMC department heads, professional organizations, patient advocacy groups—and the dean of the medical school. Articles appeared in professional and general newspapers. Outraged over the network’s decision, Massachusetts Medical Society residents brought a measure opposing mental health insurance “carveouts,” which eventually became AMA policy. (These carveouts worsen the financial crisis at teaching hospitals everywhere.) Then APA president Dan Borenstein, M.D., condemned the network’s action in a forceful letter. The Massachusetts Department of Mental Health, the Department of Public Health, and the mayor of Boston all insisted that BIDMC’s inpatient beds were vital. There were threats to review the network’s decision publicly and to look closely at future building permits for BIDMC expansion.

Under such intense pressure, the CEO relented. In October he restored the outpatient psychiatry department and announced that BIDMC would continue to participate in the residency. In early 2001, to widespread cheers, he announced that the network would keep a scaled-back inpatient unit at BIDMC.

Against great odds, the BIDMC psychiatry department and the Harvard Longwood psychiatry residency have survived intact. Residents have realized that we can overcome our inhibitions and speak out against misguided decisions. But we’ve also learned that we can meet adversity by working together. A year after the crisis, we’re still teaching, still caring for patients, and proudly looking to the future. ▪