Ryan Burns / Friday, Feb. 27, 2015 @ 6:36 p.m. / Government, Health Care
County Mental Health Branch in Crisis After Mass Resignations of Doctors, Nurses
There is an exodus of doctors and nurse practitioners underway at the Mental Health Branch of the Humboldt County Department of Health and Human Services (DHHS). While the current county budget includes funding for 10 full-time physician/psychiatrists in that unit, just half that number were employed at the start of the year, and four of those remaining five doctors have since submitted their resignations.
If those positions aren’t filled in the next six weeks it will leave just one full-time, local psychiatrist, Dr. Jennifer “Katy” Wilson, employed at the county Mental Health branch, and Dr. Wilson works primarily at the county jail rather than Sempervirens (the county’s psychiatric hospital) or the Crisis Stabilization Unit.
Meanwhile, all but one of the branch’s nurse practitioners have also resigned. (The one who remains, Jennifer Albrecht, has been on leave since Aug. 2013; she’s scheduled to return March 10.)
In interviews and documents obtained by the Outpost, insiders describe a program in crisis, a mental health unit where gross mismanagement and chronic understaffing have led to employee burnout and dangerous conditions for patients and employees alike.
Perhaps the most significant of these recent resignations were those of Dr. Jonathan Greenberg, Mental Health’s interim medical director, and Dr. Jasen Christensen, medical staff president, both of whom have their last day with the county scheduled on April 10. On Feb. 5, shortly before resigning, the two doctors submitted a seven-page letter to the Board of Supervisors, sounding the alarm about a program they say is falling apart.
“[T]he Mental Health unit is in crisis,” the letter says, “and if drastic measures are not taken immediately, the people of Humboldt County stand to lose their invaluable Mental Health Services.”
The Outpost obtained the letter through an anonymous source, though the county later released it, with some minor redactions, in response to a California Public Records Act request. That request also yielded the resignation letter of Dr. Paula Edwalds, who is currently the only child psychiatrist at the county’s Child Family Services clinic. Like her colleagues, Edwalds cites understaffing and a lack of urgency from administration to rectify the problem. Her last day is scheduled for Mar. 4.
County administrators say they are actively and vigorously recruiting to fill the vacant positions, and in the meantime, they say, patients will receive all necessary medical care via physician assistants, traveling physicians, called “locums,” and videoconferencing, or “telepsychiatry.”
On Thursday the Outpost sat down with Humboldt County Mental Health Director Dr. Asha George, who several sources blame for allowing this situation to develop, as well as Department of Health and Human Services (DHHS) Assistant Director of Programs Barbara LaHaie and DHHS Assistant Director of Administration Connie Beck.
George said the past year has seen a number of extra difficulties on top of the already challenging work done in her branch. For one, staff has had to transition from paper to electronic medical records, with a program that has proven difficult. Plus the branch has faced reviews from both the California Department of Health Care Services and the Centers for Medicare and Medicaid Services — routine reviews but nonetheless cumbersome.
Furthermore, LaHaie and George noted, many regions in the state — especially rural areas like Humboldt — have had difficulty recruiting and retaining doctors and nurse practitioners. But all three women acknowledged that the current situation is serious.
“We’re clear that we’re in crisis,” LaHaie said.
The first major blow to the Mental Health Branch’s medical staff came back in October with the resignation of Medical Director Dr. Harpreet Duggal. According to George, Duggal left for personal reasons, though another source (who spoke with the Outpost on condition of anonymity for fear of retaliation) said that while it’s true that Duggal’s father died, he also complained that the job was too stressful and “not worth it to continue.”
Doctors Greenberg and Christensen reached the same conclusion, according to their letter to supervisors. The problems outlined in the letter include poor employee recruitment and retention strategies, low morale and burnout among existing staff and poor management communication. The resulting understaffing, according to the letter, has wreaked havoc not only on Sempervirens and the Crisis Stabilization Unit but also the Child Family Services Clinic, with the pending loss of Dr. Edwalds, and the Adult Outpatient Clinic, where wait times to be seen average four months.
There had been “at least four written patient grievances” in the previous month, the letter said, and the doctors worried that the risk of legal liability would increase as patient outcomes suffer. They also warned of increases in crime, homelessness and emergency room visits community-wide.
The doctors also complain that their salaries are insufficient given the demands of the inpatient psychiatric hospital, potentially dangerous patients and other challenges, including living in such a rural, isolated location.
According to data compiled by Transparent California, doctors Duggal, Greenberg and Christensen were the three highest paid county employees in 2013 (the most recent data available), with salary and benefits amounting to $362,785, $311,982 and $282,231 respectively. DHHS Director Phil Crandall, their boss, came in seventh place at slightly under $250,000.
But Greenberg and Christensen argue that the alternatives — locums and telepsychiatry — are even more costly, with the former’s hourly fees equalling an annual salary of $364,000 and the latter’s equalling between $400,000 and $500,000, for inferior care.
“Locum doctors are temporary, costly, require a steep learning curve, are time-consuming to train, are less reliable, and do not add to the overall stability and consistency of care,” the letter says. “In addition, telepsychiatry has been anything but smooth from the start, with poor productivity and time-consuming … .”
Psychiatrist Dr. Gail Ingram gave the county a full year’s notice before resigning at the beginning of this month, though the county has yet to hire a replacement. Earlier this week Dr. Ingram spoke to the Outpost during a free moment at her new position in Los Angeles County.
The No. 1 reason she quit was job stress, she said. While working at Sempervirens Thursdays through Saturdays she was the only doctor on site, working with only female nurses. Without regular security (the county will occasionally hire private security guards), Dr. Ingram and her colleagues felt perpetually unsafe.
“It was a pressure cooker situation,” she said. “There was no protection.” Last year someone threw a chair through the front door of the facility. In another incident, three patients ganged up and attacked one staff person. Later, there was “a very bloody fight, broken up by Dr. Greenberg,” Ingram said.
With more than 20 years in the field, Ingram said she loves psychiatric patients, but here in Humboldt County “the administration working 9-5 has no idea the level of threat we deal with on a regular basis. … For me, the violence level was more than I could handle.”
Her traumatic experiences at work affected her quality of life outside the job as well. And with the transients and drug addicts in Eureka, she said, “I was afraid everywhere I was. I couldn’t walk on a path, I couldn’t go hiking, I couldn’t enjoy going out at night — I was too aware of the danger around me in the community.”
Ingram said she’s still suffering from emotional trauma, but she wanted to get out of Humboldt County so badly that she didn’t pursue worker’s compensation. “I’ll pursue help down here, where I feel safer,” she said. “And I’m near Inglewood.”
Like others the Outpost spoke with, Ingram said the branch head, Dr. Asha George, minimized medical staff concerns and was ineffectual at finding solutions and recruiting replacement psychiatrists.
Dr. Edwalds’ letter strikes some of the same notes, but unlike Ingram, Dr. Edwalds wanted to stay in Humboldt County. However, being overworked, with no sign of relief on the horizon, eventually proved too much. “Once Dr. Duggal resigned and it was clear no one else would be joining the staff, I made the decision to resign,” Edwalds said in her letter. “I had hoped to continue in this position for a number of years, and at the minimum until my youngest finished high school (June 2016), but I decided that working conditions were more important. My husband, who is a hospitalist at both St. Joseph Hospital and Mad River Hospital, hoped to stay here until retirement … . He is certainly supportive of the change now… .”
In the DHHS administration building Thursday, administrators George, Beck and LaHaie said they are working diligently to address the issues at the Mental Health Branch, particularly the psychiatrist shortage. Despite being the branch director, George said that for the past six years doctor recruitment has been the responsibility of the medical director.
“Really it wasn’t in my purview until after [Dr. Duggal] left,” George said. “And then we were just like, ‘Oh shit. We have to do something.’”
“Now it’s a whole team effort,” LaHaie said. That effort includes going to job fairs, sending flyers to residency locations and checking the website of the National Health Service Corps (a program that allows student loan repayment for doctors who serve in rural settings). They’re also considering hiring an independent staffing contractor and even posting job listings on Craigslist.
Should more have been done sooner?
“I would say yeah,” George acknowledged. In hindsight, she said, she should have assumed recruitment duties earlier and led more focused recruitment efforts at the human resources and employee services levels.
As for communicating better with medical staff, LaHaie said administrators, including Crandall, have committed to meeting with them at least weekly.
Many of the issues identified by the disgruntled doctors are complex and difficult to remedy, the administrators said. Doctor recruitment is difficult not only because of Humboldt County’s remoteness and rural setting but also because places like Pelican Bay State Prison can afford to offer much higher salaries.
An anonymous source who has worked in the Mental Health Branch told the Outpost, “It’s hard to practice medicine in this town because there are so few doctors of any variety. It’s hard to keep doctors here, so the problem perpetuates itself.”
The administrators also acknowledged that the electronic medical records program chosen by the county, called Avatar, has indeed proven cumbersome and problematic. It had never been used for an inpatient psychiatric hospital before, and it wasn’t set up to facilitate Medi-Cal billing in small, rural counties. But the primary alternative program couldn’t accommodate hospital billing at all, George said, and since the county only received one-time funding to transition to electronic records it can’t simply replace the program now.
Nonetheless, LaHaie admitted, the rollout of the program could have been handled better. “We still need to make changes to make it better,” agreed Beck, the assistant director of administration.
Regarding staff safety concerns, George said the branch is “starting with the premise that we treat acutely, seriously mentally ill folks who come in with issues, violence being one of them.” Not many other counties in California even have hospitals like Sempervirens. Exacerbating the problem locally, Eureka police officers have historically dropped off people they nab on the streets who are often under the influence of drugs and/or alcohol. LaHaie and George say they’ve been working with EPD Chief Andy Mills and his department’s captains to make sure people are taken to the appropriate facilities locally.
While the county has the capacity to call in private security guards — and sometimes does so — they prefer not to. “The whole premise of what we do is to help people get better and recover,” George said. “We’re not a shadow prison or a shadow jail, so we really don’t want to get into that, having armed guards at the door. It changes the feel, the ambiance of what we’re trying to do.”
The administrators said the locums and telepsychiatry will be essential tools to meet patients’ needs in the coming months, but they acknowledged that those are less than ideal replacements for the one-to-one contact and continuity of care provided by local, permanent caregivers.
“That’s a short-term fix,” LaHaie said, “because nobody wants our community to not have ongoing relationships with their medical doctors.”
But will that short-term measure actually be a fix? Or will this shortage of psychiatrists and nurse practitioners lead to the dire consequences some of them are predicting — worse patient care, increased crime, public disturbances, homelessness and emergency room visits?
The letter from doctors Greenberg and Christensen concludes with a warning. “Humboldt County is on the verge of collapsing due to the lack of retention and recruitment, and by poor administrative decisions and management. Many spheres of the county will be negatively affected as mental health services fade.”
“That’s the problem,” said one anonymous source. “We’re not managing things before they turn into a crisis.” That’s true on both large and small scales, the source said, explaining that patients who wind up in the crisis center often say they wouldn’t have if only they’d been seen sooner at the outpatient clinic.
George said she and her branch’s employees will be working hard in the coming months to integrate the new treatment providers — locums and remote doctors working through videoconferencing — while continuing heavy recruitment efforts.
“We’ll be doing much more work in building relationships, so we can start stitching that back together again,” she said.