September 15, 2000
Clinical, Administrative Skills Combine in Med Director Career
As young psychiatrists begin to map out a career, an increasing number are exploring the position of psychiatric medical director, which allows them to blend clinical and administrative skills and to influence a facility's system of care.
Columbia University’s Public Psychiatry Fellowship has for many years attempted to define the evolving role of the psychiatrist in the developing position of medical director. Last month, the fellowship published results of its survey of members of both the American Association of Community Psychiatrists (AACP) and the American Association of Psychiatric Administrators (AAPA). While most of the results were not surprising, some were enlightening and encouraging.
Psychiatrists began to play a role as "medical directors" in the mid-1960s, functioning in psychiatric hospitals largely as full-time administrators who did not have direct patient care responsibilities. Instead they usually supervised the medical staff and sometimes even the rest of the clinical staff.
Early on there was considerable flexibility and ambiguity in the role. Throughout the 1980s and 1990s organizations representing psychiatric administrators began to better define the medical director position, with the AACP publishing formal guidelines and a model job description in 1991, followed by a 1995 update.
However, according to Jules Ranz, M.D., an associate clinical professor of psychiatry at Columbia University College of Physicians and Surgeons and director of the Public Psychiatry Fellowship, much of the ambiguity noted in the 1960s remains.
Ranz and his colleagues published the results of the public psychiatry fellowship’s latest survey on psychiatric medical directors in the May issue of Administration and Policy in Mental Health.
"What the latest survey tells us," Ranz told Psychiatric News, "is that when people use the term ‘medical director,’ they think they know what they are talking about. But in reality, the term is used for about six different varieties of a generic position."
In both hospital and community settings, explained Ranz, the term is generally used to describe psychiatrists who function in an ill-defined relationship with a nonphysician executive director. The position invariably includes responsibilities for supervision of medical staff. Beyond that, many medical directors have varying degrees of clinical supervisory responsibilities, while others assume a variety of administrative responsibilities.
According to Ranz, the comparison of the membership of the AACP and the AAPA revealed that the variability comes from two main distinctions. "First, the survey revealed a distinction between an ‘agency medical director’ and a ‘program medical director.’" Within these two distinct levels of operation, there was then a differentiation between levels of supervisory authority—some medical directors oversaw only medical staff, while others supervised the entire clinical staff, including both medical staff and mental health professionals. Still others had clear authority over all of the staff.
The idea that a "program medical director" position exists is somewhat of a new development. "What [mental health services] administrators want," said Ranz, "is someone to do clinical consultation and possibly pick up some of the administration of the individual program as well." What administrators typically advertise for when trying to fill such a position is a "staff psychiatrist," but many are willing to hire the right person in a program medical director position.
While agency medical directors tend to be more advanced positions, the program medical director position, according to Ranz, is an excellent opportunity for the young psychiatrist to gain valuable experience.
Bridging the "old" positions of staff psychiatrist and administrator, the program medical director is an effective mixture that generally works well for both the psychiatrist and managed care organizations, said Ranz.
"These positions, many of which are entry level," he explained, "are excellent opportunities for early career psychiatrists. There are many more jobs than graduates, and there’s a wide variety [of such jobs] available."
Another intriguing finding of the survey was what Ranz calls the "disconnect" between tasks that responding psychiatrists think make their job satisfying and those tasks that analyses have shown actually do increase job satisfaction.
"Invariably," Ranz told Psychiatric News, "psychiatrists will tell you that what makes them happy in their jobs is the clinical consulting. But what we found in the survey was that the administrative tasks correlate more highly with job satisfaction." Ranz believes that the job satisfaction is closely tied to the psychiatrists’ overall ability to influence the quality of care through administrative, rather than clinical, avenues.
"In America, public sector psychiatry," said Ranz, "has a bad stigma associated with it. But now, as well as in the future, it is where the jobs are, whether directly in government programs, or in not for profits serving certain populations. For the young psychiatrist, as an alternative to the traditional private practice, this is an excellent, strong way to improve their experience and impact the system positively."
The AACP guidelines are available on the Web at <www.comm.psych.pitt.edu/ finds/leadership.html>. Information about the Columbia Public Psychiatry Fellowship is available at the Web address <cpmcnet.columbia. edu/dept/ pi/ppf>. —J.R.