Congratulations on being selected American Association of Geriatric Psychiatry clinician of the year. What does receiving the award mean to you at this point in your career?
Well, it is always nice to be recognized by one’s colleagues. I have been practicing geriatric psychiatry for almost 25 years, and hope to continue for as long as I am able, so if anything, the award is motivation for me to continue to live up to it.
What made you pursue this as a specialty?
When I finished my fellowship and entered practice in 1985, I started consulting in a few local nursing homes. This was at a time when very few psychiatrists were interested in geriatrics or in setting foot in a skilled nursing facility. I found that I loved working with the elderly. It was endlessly challenging, requiring the use of all my skills and training. It also forces one to keep up with general medicine, which I think is essential to practicing psychiatry well.
The announcement of your award states you maintained a high-level of professional competence adhering to the ethical and social standards inherent in the practice of geriatric psychiatry. Are ethical and social standards different with geriatric psychiatry? If so, how so?
I don’t think that the ethical standards are different for geriatric psychiatry, but the issues one faces often are. For example it is common in geriatric psychiatry to have to deal with ethical issues surrounding the end of life, advance directives, competency, etc. There are also some ethical issues that are unique to practicing in nursing homes. One thing that troubles me is that there has been a trend in recent years in Connecticut for some nursing home chains to have ownership in the psychiatric consulting group that sees patients in their facilities. This, in my opinion, is ethically problematic in a number of ways. Firstly, there is an incentive for unnecessary psychiatric consults to be ordered, since the ownership of the nursing home profits from the consults. Secondly, there are situations in which what is best for an individual patient can be in conflict with what is in the best financial interests of the nursing home. In these situations it is vitally important that the psychiatric consultant be independent, so they can operate in accordance with the Hippocratic oath and act in the best interests of the patient, rather than trying to serve two masters. The other problem with having joint ownership in the nursing home and the consulting group is that in these situations, the nursing home administrator does not have a choice in whom they utilize as a consultant. There is therefore less incentive for the consultant to render excellent care, since they know that, no matter what, they will not be replaced.
You’re founder and medical director of Connecticut Mental Health Specialists, the largest provider-owned and operated mental health consulting practice in Connecticut. So, how is geriatric psychiatry perceived in Connecticut? Nationwide? Is there any reticence to treating the elderly for psychiatric problems?
I think that geriatric psychiatry is still not well understood by the general public. There is also great mistrust of and resistance to psychiatry in general. I remember attending a seminar a number of years ago concerning the portrayal of psychiatrists by the entertainment industry. If you think about it, psychiatrists are portrayed in movies and TV generally in one of two ways: either as evil and/or unethical (think of all the portrayals of psychiatrists who have no boundaries and sleep with their patients) or as buffoons (think Richard Dreyfuss in “What about Bob.”) These portrayal reflect general societal attitudes. It is very common when I first meet family of patients for them to assume that I fall into one of those two categories (evil/buffoon). They assume I am either up to no good (“I don’t want you to drug my mother”) or that I am an idiot, the latter reflected by an attitude that says “I looked these medicines up on the Internet, so now I know far more than you do.” Many people seem to need much convincing that the psychiatrist is both knowledgable and caring. That is one of the challenges in doing this work.
We’re a business publication, so we have to ask. Is this a growth industry? Is there going to be an increasing demand for this kind of psychiatry?
There will be exploding demand for geriatric mental health care in the coming years. Unfortunately, the supply of practitioners will likely fall ever farther behind this demand. This is a press release issued last year by the AAGP, which states the extent of this problem far better than I can:
“Today there are just 3.9 geriatric psychiatrists for every 10,000 Americans age 85 and older and just 1.1 for every 10,000 over 75 years of age, according to the Association of Directors of Geriatric Academic Programs (ADGAP). It is estimated the country needs 5,000 geriatric psychiatrists, yet last year there were fewer than 1,600 board-certified geriatric psychiatrists in the United States.”
