COMMENTARY

Launching a Psychiatry Program (and a Med School) From Scratch

Stephen M. Strakowski, MD

Disclosures

January 10, 2017

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Howdy, y'all. I have been in Austin, Texas, now for about 8 months and I'm practicing my Texan. One of my faculty members from Lubbock, Dr Lowell McRoberts, has been trying to teach me how to understand and speak Texan. There is still a lot to learn. Anyway, my [Medscape] editor and I wanted to do something a little bit different that might be of interest to general psychiatric practitioners and others who come to Medscape—namely, to discuss the building of a brand-new psychiatry department. With that in mind, how are we doing it? I would like your feedback; I'm curious as to whether you find this thought-provoking or interesting.

Dell Medical School

To frame this, I first want to talk about what is going on here in Austin. The University of Texas in Austin has embarked on creating a brand-new medical school. Dell Medical School is the first new medical school at a tier 1 research university in over 50 years. That alone makes it relatively unique. It has an unusual foundation. First of all, it is based heavily on both philanthropy and community support. The Michael & Susan Dell Foundation committed significantly to forming the medical school, and we are grateful for that. Additionally, the taxpayers in Austin voted to raise their own property taxes to create this medical school. Money from philanthropists, including the Dells, the community itself, and the University of Texas system, established this medical school. We took our first class last summer, which is very exciting.

Its Mission

Because of this unusual foundation, our mission is a little different from that of traditional medical schools. We are committed to working within our community to try to measurably improve health. We are trying to educate leaders who will transform healthcare directly by using new models of person-centered multidisciplinary care that reward value and outcomes, and doing research that closes the gap between research and deployment that we see now. We want to improve our community's health [using] a model that ideally can be scalable to the nation and then redesign the healthcare environment.

Transforming Psychiatric Care

With that as a framework, the psychiatry goal is to transform psychiatric care, illness prevention, and general mental health in the community. This transformation includes designing innovative mental healthcare delivery platforms, illness prevention platforms, and, ideally, things that improve the general mental health of the community. All of these are difficult to assess. There has been a history in psychiatry of overpromising prevention, and that is something we take very seriously; we want to use evidence-based methods whenever possible in our discussions and design. And when not possible, we want to find the evidence. We want to do research that is truly applicable to improving care. Again, research is going to be on a continuum and translate lab [work] to clinical practice; we want to keep the research focused on improving patient outcomes. Finally, we are going to train the next generation of mental health care providers in these new models.

How Will We Do This?

In order to accomplish our 5-year goals (which I will mention in a moment), our strategy is to partner with the community extensively. One of the hindrances that often prevents those of us in academic medicine from being innovative is that we own large healthcare businesses that are very closely tied to fee-for-service reimbursement models that do not necessarily incentivize outcomes improvements or value. We want to try to restrict how we own things by partnering and bringing value to partners, which will end up being revenue streams to support our mission. Our work then is to own healthcare facilities only when necessary in order to try to stay nimble and be able to deploy things quickly. The nice thing about academics is that given that we are starting new, we can leverage other academic fund streams to help us do this. We are trying to break down departmental silos, which will allow us to work across medical disciplines to look at the best integrated models of care. For psychiatry, my goal is for us to stop being thought of as a carve-out that you use when you have to, but instead as a part of a typical medical care pathway just like any other branch of medicine.

We want to build research teams rather than labs. To do that, of course, we have to get universities to acknowledge that team science is, in fact, how we solve big problems. That is still not true in most universities, and we are working through that here at University of Texas. Finally, we want to develop multidisciplinary teams and training systems to help psychiatrists—and this is true for all physicians—become part of teams and lead teams when it makes sense. To get the best value out of our workforce, we want physicians to work at the very top of their license, doing the medical evaluation and support that only they can provide, while allowing others to do the other pieces of support.

Goals

With those strategies in mind, our goals are to create a new integrated model of mental health care delivery. It is rolling out in Central Texas and has replaced the existing hospital- and jail-centric systems that tend to exist in most states. If you look at most states, a limited amount of resources are applied to mental health and tend to get spent in the most expensive places—jails, hospitals, and emergency rooms—so we get the least return on our small investments. The goal is to create a better continuum of care where we get a better result and return on our investment by treating people in venues that not only cost less but will produce better outcomes.

Another goal for us by 2021 is to have our psychiatric care as part of our integrated practice units. We are using the model that was developed by Michael Porter and Elizabeth Teisberg. We think about how we focus care around patients rather than around physicians or around structures. We are fortunate here at the University of Texas to have Elizabeth working with us. We want our research teams to be closing the gap measurably between research findings and clinical practice by doing deployment work and getting practice advances into our models, and then have our educational programs up and running by 2021 to train the next generation of psychiatrists.

Shifting the Focus

How will we decide that our academic institution made a successful shift to a different kind of focus? One way is that our academic psychiatry group is viewed within Austin as part of the community, not as the ivory tower that declares clever things but is not part of working through problems. We are not going to be able to take care of everybody and that is absolutely clear, but we can be intimately involved in leading changes that improve care for more people. In that role, all of us as psychiatrists in general, and particularly in academics, need to work to be much stronger patient advocates and remember why we went into this work in the first place—which is sometimes difficult to do in all the clutter surrounding medical care in the United States.

If we made a new focus, our care will be embedded into medical care, and there will no longer be these behavioral health carve-outs that are so popular right now and such a popular discussion. The term "behavioral health" trivializes the severity and magnitude of the brain-based genetic illnesses that we manage. We need to stop using that term. We need to start talking about brain health or psychiatric health and bring that into the general medical care pathway rather than leaving it as an outlier that gets dragged in when needed. That is a major goal not only for here but for us as a discipline.

Our researchers, if we are successful, will be moving the needle in outcomes—not worrying about getting tenure. They will get it because they are going to be successful. That is not a goal; it is an outcome. Our psychiatrists are physicians, who we often do not seem to remember are part of cross-disciplinary teams and are either leading or partnering to get the work done—not just consulting and disappearing. A major factor of our success will be that we have developed a structure that incentivizes these different areas of focus away from the traditional models which are primarily volume-focused, or even Centers for Medicare & Medicaid Services models which have picked outcome measures that are probably not ideal measures of optimal outcome. We want to move this toward what patients feel most improves their lives rather than government agencies or, frankly, even physicians.

We recognize that these goals are idealistic and they are not necessarily unique to us. They are shared by many. We hope that these unusual circumstances will allow us to be successful. We are starting something new that is relatively less hampered than trying to change a longstanding existing department's focus. Check back in 5 years. Keep an eye on what is going on in Austin and see if it is something that you all might want to somehow replicate in your own communities.

I hope this has been thought-provoking. I look forward to any feedback you might provide. Thank you and I hope to talk to you again soon.

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