xxAACP Newsletter, Volume 15, Number 2, Spring 2001

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On Saturday, March 31, 2001, the Columbia University Public Psychiatry Fellowship held a reunion to celebrate its 20th year. Fifty alumni and faculty members listened to presentations made by the three founders of the Fellowship (first director C. Christian Beels, second director William McFarlane, and training coordinator Steven Rosenheck) and participated in a discussion of current changes in the role of the psychiatrist in public sector organizations led by the current Fellowship director, Jules Ranz.

Each year ten full-time fellows, graduates of psychiatric residencies, are accepted into the fellowship training program. Training takes place at the Psychiatric Institute and at community facilities throughout the New York City metropolitan area. These agencies specialize in the community treatment of those who depend on public funding for their psychiatric care: the poor, the severely disabled, the elderly and the homeless. The fellowship selects young psychiatrists with a commitment to working with these populations and provides them with the required knowledge and skills to do so. It aims to prepare fellows for the responsibilities of leadership, teaching, and outcome evaluation.

The program provides (1) a three-day-per-week field placement experience in a community outpatient setting selected in consultation with the faculty from an exceptionally rich range of choices to best meet the fellow’s interests; (2) didactic training in psychosocial rehabilitation and psychiatric treatment techniques essential for work with the severely ill and the poor: assertive community treatment, clubhouses, vocational rehabilitation, housing programs, psychoeducation, crisis intervention, and advocacy, consultation and education with consumer, family and professional groups. (3) training, experience and supervision in the management, evaluation, politics and funding of public services, with the assumption that sensitive and skilled administration is the key to effective care.

As of June 2001, the Fellowship will have graduated 145 psychiatrists since its founding in 1981. Beyond the metropolitan New York City area, alumni now work in 17 states (NY, NJ, CT, MA, PA, MD, DC, VA, WV, IL, GA, FL, TX, MS, AZ, CA, OR) and six countries (Canada, Australia, England, Korea, Brazil and Pakistan). Several alumni surveys over the past five years (Psychiatric Services articles referenced on the fellowship web site: ppf.hs.columbia.edu) reveal that after twenty years of training psychiatrists, approximately 95% of the graduates of the fellowship are successfully pursuing careers in the public sector. Furthermore, more than half (70 of the 132 alumni whose positions are known) are functioning as medical director or equivalent positions. Alumni hold prominent positions in many national organizations, including the American Psychiatric Association (APA), the American Association of Community Psychiatrists (AACP), the American Association of Psychiatric Administrators (AAPA), the American Association of Emergency Psychiatry (AAEP), and the Association of Gay and Lesbian Psychiatrists (AGLP).

In recent years the Fellowship has gained national prominence, partly through the work of its alumni, and partly through publication of a variety of surveys that have explored the role of the psychiatrist as medical director in public sector organizations. When the fellowship was established, it was (in retrospect somewhat naively) assumed that the program would be training psychiatrists to function as directors of public sector mental health programs and agencies. While many graduates do indeed function in such positions, just as many assume the far more ambiguous role of medical director, in which case the psychiatrist is usually working alongside a non-medical program or agency director. Such a role can encompass a wide variety of tasks, from purely medication management to participation as an active partner in running a program or agency. Over the past decade the fellowship has developed a self-conscious strategy of training fellows to assume the role of medical director, and to explore the possibilities inherent in that role.

Alumni surveys conducted over the past few years have shown that psychiatrists who function as medical directors perform a wider variety of tasks and experience significantly higher job satisfaction compared with those who function as staff psychiatrists. Furthermore, it is the performance of administrative tasks that accounts for this higher job satisfaction, even amongst those who do not function as medical directors. These findings have been replicated in a much larger survey of members of two national organizations, the AACP and the AAPA.

The current survey, still in process, is exploring the role of the psychiatrist in relation to current changes in the field of public mental health. One preliminary finding of particular interest, relates to a distinction between working in hospital settings, including hospital outpatient departments, and community settings, including off-site hospital-run services. While more psychiatrists work in hospital settings than in community settings, the economics of the marketplace dictate that the proportion of psychiatrists working in community settings will increase over time. Indeed, the fellowship has noted that amongst its recent classes, more fellows have worked in community settings than in hospital organizations during their fellowship year.

Fellows and alumni report that there are advantages and disadvantages to working in community settings. On the one hand, working in less traditional environments can lead to more interesting jobs with greater flexibility. On the other hand, roles can be less clear, and there is a tendency to feel isolated from one’s professional peers. Preliminary analysis of the on-going survey suggests that psychiatrists working in hospital settings are more negative about changes in the field compared to psychiatrists working in community settings, especially in relation to economic changes.

Most fellows start the program immediately following residency training, but psychiatrists who have been in the field for several years are encouraged to apply as well. In recent years an increasing number of applications have been received from psychiatrists who completed their residencies 1-8 years earlier. Many of these psychiatrists report experiencing the pressures noted above, and take the fellowship not only to receive the formal training, but also to experience the support offered by the faculty and by the expanding network of fellowship alumni.

More information about the program is available on the fellowship web site: ppf.hs.columbia.edu, or you can contact Dr. Ranz at 212-543-5655.

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