Community Mental Health Journal, Vol. 30, No. 3, June 1994

Why Don't Psychiatrists Do Their HomeWork?

Kenneth S. Thompson, MD Andrea R. Fox, MD

In the days when most physicians made house calls, most psychia- trists actually lived on the grounds of state hospitals. In a sense they shared their homes with their patients. Now things are clearly differ- ent. Few psychiatrists and patients live "together" and, like other physicians, few psychiatrists do home visits, as demonstrated in this issue by Reding, Raphelson, and Montgomery, 1994. Given the gener- ally positive regard in which home visits are held, this gap in the service repertoire of psychiatry is quite striking, especially in psychia- trists based in community mental health centers. What keeps psychia- trists in their offices? High on our list is inertia, or perhaps better, habit. It is not an easy thing to change established patterns of work. The psychiatrists studied by Reding, Raphelson, and Montgomery, 1994, endorsed a number of other reasons. These run the gamut from believing that non-physicians should do the job (despite a concurrent belief that non-physicians assessments are not as effective as psychi- atric ones) to the expressed fear of encountering violence or legal lia- bilities in going to patients' homes. And, of course, there is the concern that home care by psychiatrists is not remunerative enough.

Kenneth S. Thompson, M.D., is Assistant Professor, Dept. of Psychiatry, University of Pit- tsburgh.

Andrea R. Fox, M.D., is Assistant Professor, Dept. of Internal Medicine, University of Pit- tsburgh.

Address correspondence to Kenneth S. Thompson, M.D., Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213.

303 �9 1994 Human Sciences Press, Inc.

304 Community Mental Health Journal

All of this leaves most psychiatrists stuck in their clinics, offices, or hospitals, including many of us who call ourselves community psychia- trists. As we all know by now, breaking out of institutions is not easily accomplished. Yet change is in the wind. Economic, political, legal and demographic forces have increasingly located our patients and their care in their own homes in the community. These forces are syner- gistically propelling reform in the provision of mental health care. Many of these relocated patients, such as the homebound elderly or young adults with severe and persistent mental illness, cannot or will not be regular office or clinic attenders. If they are to be cared for by us, we will have to go to them. Moreover, even for those patients who can come to us or who are brought to us, there is mounting evidence of the efficacy of providing treatment and rehabilitative care in the home and in other non-institutional community settings.

These changes are occurring throughout medicine, not just in psychi- atry, as the post modern ~hospital without walls" is being created. The New York Times (June 6, 1993, pg F13) notes that home health care is generating jobs faster than any other segment of the economy. How long can we psychiatrists pay lip service to the idea of providing psychi- atric and medical care in the community without ourselves going to patients' homes? It is time to start gearing up and extending ourselves beyond our office walls. Accepting this proposition, a number of issues become paramount. To begin with, psychiatrists in t raining need to be exposed to psychiatrists who '~break set" and already go into the communi ty- in to peoples' homes, into the streets, into shelters, and into jails. Indeed, residents need to go to these places themselves. Yet, even the recent article by Brown, Goldman, Thompson, and Cutler outlining a model curriculum for t raining residents in community psy- chiatry neglected to explicitly mention home care experiences as a critical element in t ra ining in community psychiatry (Brown, Goldman, Thompson, and Cutler, 1993). In this we are behind developments in other specialties such as geriatrics, which requires home care experi- ences in training.

Of course, practicing community psychiatrists must continue to strug- gle with determining what our roles are in providing home based care. How do we bring our knowledge and our skills to bear? What kinds of approaches should be employed? What are the best ways for us to work with the other mental health care providers who also provide home care? This is an increasingly complex issue. There is an expanding range of different approaches to housing and an increasing diversity of people being cared for in the community. Each type of housing and each

Kenneth S. Thompson, MD and Andrea R. Fox, MD 305

populat ion implies a different role for the psychiatr is t and those wi th whom he or she works. (See, for example, Ron Diamond on the role of psychiatr is ts in supported housing (Diamond 1993).

Final ly , we mus t face the fact t ha t one of the major reasons we as a profession don't often do house calls or provide home-based care is because in the past we have chosen not to, often for reasons not re la ted to pa t ien t needs. While critical to pursue, ha rd evidence tha t home- based care is viable and efficacious is unl ike ly on its own to shift the cu r ren t pa t te rns of care. Significant change will also require a sense of vision and s t renuous effort at advocacy, to some degree based on fai th t ha t home-based care makes sense. It is our belief t ha t in this era of hea l th care reform it is t ime for us communi ty psychiatr is ts to en large our dreams of community-based care and join wi th other medical spe- cialt ies in an effort to t ru ly incorporate the notion of home care into hea l th care.

REFERENCES

Brown DB, Goldman CR, Thompson, KS, Cutler, DL (1993). Training residents for community psychiatric practice: Guidelines for curriculum development. Community Mental Health Journal, 29(3):271-296.

Diamond RJ (1993). The psychiatrist's role in supported housing. Hospital and Community Psychi- atry, 44(5):461-464.

Reding KM, Raphelson M, Montgomery CB. Home visits: Psychiatrists' attitudes and practice patterns. Community Mental Health Journal (In press).