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Book Forum: MANAGED CARE   |    
Between Mind, Brain, and Managed Care: The Now and Future World of Academic Psychiatry
Am J Psychiatry 2000;157:477-a-478. doi:10.1176/appi.ajp.157.3.477-a
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Belmont, Mass.

edited by Roger E. Meyer, M.D., and Christopher J. McLaughlin. Washington, D.C., American Psychiatric Press, 1998, 340 pp., $38.00.

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Can humane values and a comprehensive biopsychosocial model of human brain and behavior be conceptually maintained, clinically provided, and taught in a price-sensitive, market-driven economy? Can psychiatry, and managed care (in its myriad of changing identities), develop a scientific and intellectual base that will inform and drive clinical practice? Can our training programs and academic centers shape the roles and responsibilities that psychiatry and other behavioral health disciplines will embody?

Dr. Roger Meyer and his research associate Christopher McLaughlin set out on a quest to answer these questions. "Whither academic psychiatry?" they ask themselves and survey others. At the outset, they remark that they are "pessimistic." At the end of their quest, they say the glass seems "as full as it is empty." From their data and their reports, however, I was left feeling that academic psychiatry saw its bull market some time ago and that prospects for a rally are not very good, with the exception of research.

The story starts in 1992, when Dr. Meyer spent a sabbatical year at the Center for Advanced Study in the Behavioral Sciences at Stanford University. With the support of the MacArthur Foundation, he conducted a study on the impact on academic psychiatry of the profound economic changes affecting clinical practice, teaching, and research in our academic centers. His work was further informed by a distinguished advisory committee developed through the Association of Academic Health Centers, which also hosted the study. Like the fine researcher he is, Dr. Meyer posits the questions noted, designs his method and instruments, and journeys to many departments within the academic landscape. His report encompasses 1) the academic faculty, including the sources of their support, 2) the clinical service delivery systems, as they are now termed, within academic centers as they try to respond to managed care, 3) the past, present, and future educational missions of academic psychiatry, 4) the place of research in the mission of academic psychiatry, 5) psychiatry and primary care, and 6) academic psychiatry’s role in and effects on the system of care of the Department of Veterans Affairs and veterans. Although the book is an edited text, all of the chapters but one are written by the editors.

At each stop in the journey through the world of academic psychiatry, we are offered an abundance of data, clear thinking, and careful questioning and discussion. At each stop, Dr. Meyer and Mr. McLaughlin offer their best recommendations for future success, if not survival. The reader also is exposed to six case studies (Stanford, the University of Louisville, the University of Maryland, the University of Colorado, Dartmouth, and Sheppard and Enoch Pratt), which tell compelling and very different stories. The reader is left with a set of project conclusions that describe not only what they discovered but also what they regard as lessons learned and essential ingredients for the future world of academic psychiatry.

This is a book for the serious student of academic psychiatry and will be of considerable interest to a select leadership group of academic psychiatrists, department chairs, deans, physician executives, training directors, faculty practice managers, and research administrators. These readers will be treated to concise case histories, clear survey material, and scholarly discussion of a remarkable range of material.

I was troubled by reading this text, perhaps because the research and discussion make such a case for how imperiled clinical practice and faculty support are. Research seems to be faring the best and can envision a sanguine, though highly competitive, future. Academic departments of psychiatry are financially at great risk to lose money by taking care of patients. Faculty support is on the endangered species list. Even departments that are holding their own seem to be doing so by having everyone (physicians, patients, and executives) running as fast as they can with little if any financial, professional, or personal margin.

This text adds to a small but growing body of critical information on our academic medical centers by shining a halogen lamp on psychiatry. The picture that Dr. Meyer and Mr. McLaughlin offer should concern us because "the now and future world of academic psychiatry" has its survival at stake.




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