PRESIDENTIAL ADDRESS


Hope, Pride, and Leadership

Pierre AM Beauséjour, MD, FRCPC1


Over the years, presidents of the Canadian Psychiatric Association (CPA) have focused their addresses on the challenge of change, the need to clarify our identity as a profession, and a vision for our future. Focusing on humanism and psychiatry, Dr Jean-Yves Gosselin in his 1993 address commented that “As physicians, we now have a unique opportunity to reaffirm our traditional values and our obligation to care for the sick by taking an active role in health care reform and influencing the decision-makers” (1). Dr William Bebchuk in 1994 focused on the interwoven concepts of partnership and change, emphasizing the need for psychiatrists to look at their changing roles and for psychiatry to take a leadership role in a health care reform driven by cost containment (2). Dr William McCormick’s 1995 theme of “Meeting the Challenges” expressed both worry and encouragement about our future (3). Dr Diane Watson in 1996 asked, “Will psychiatry be a subspecialty of neurology in the 21st century? . . . We are in the midst of transition, and major change in the health care system is inevitable. Psychiatry is a profession with a crisis of identity” (4). In 1997, Dr Renée Roy, redefining the role of the psychiatrist, said, “I hope that we will find even more time to make social commitment an integral part of our practice because this involvement will have an even greater impact on our patients. Our primary goal remains staying relevant to society” (5).

This preoccupation with the role of the psychiatrist and the future of psychiatry is not new. In his 1965 Presidential Address, Dr Charles A Roberts stated that psychiatry was at a crossroads. His insight is equally relevant today and will remain so. As long as dealing with change remains part of our daily life, as long as our profession continues to evolve, we will find ourselves at crossroads and will need to face the challenge of renewing and reaffirming our professional identity. Dr John J Boronow and Dr Steven S Sharfstein wrote:

Psychiatry today faces the greatest challenge to its professional identity since its inception. External economic and social forces have coalesced in such a way that the very rationale for the existence of the field has been challenged . . . it is important to keep in mind that although these forces may dramatically affect the praxis of our profession, they do not directly bear on its essential medical/scientific knowledge base (6).

I agree with their view that, as long as we focus on the foundations of psychiatry, that is, our psychiatric knowledge base (medical model), our biopsychosocial approach (Engel 1977), and the doctor–patient relationship (Hippocratic oath), this part of our professional identity will remain meaningful and will survive the impact of social and economic forces.

In contrast, the practice of psychiatry is more vulnerable to and influenced by social and economic factors. Should psychiatry be seen solely as a product and its practice as a business enterprise? Should the role of a psychiatrist be limited to that of a consultant to the mental health system? Should we define our identity according to what we are paid to do or what we have expertise and skills to do? These essential questions need to be debated and the factors influencing our responses closely examined.

The Canadian health system is pressured by social and economic factors. Health reform was initially needed to improve the system but was too slow in its implementation. Some would say that dynamic conservatism was at play. Our national and provincial financial crises created a needed sense of urgency to implement reform. Unfortunately, the restraint agenda took the driving lead and has competed with the reform agenda. As a consequence, our health care system has been undergoing dramatic changes at an accelerated pace.

The principles of universality, accessibility, comprehensiveness, portability, and public administration of the Canada Health Act (1984) are challenged. In addition, a more active role of the provincial governments in the management of the health care system is having its impact. Access to treatment differs from province to province. If we are not careful, the shift to regionalization of health services may create even greater regional differences in access to care and negate its positive consequences. Health Canada recognizes this, to some extent, as a potential danger in its working paper on “Best Practices” (7), and it also recognizes the need to harmonize waiting list management systems across Canada and to establish a national health report card.

While most stakeholders agree that improvements to our health care system can and should be made, there are disagreements regarding how to make these changes, in what sequence, at what pace, and at what human cost. Moreover and more fundamentally, beyond the veneer of some common language, there is no real consensus on the underlying goals of and need for change. Our challenges: how to achieve the best use of decreasing resources in a time of increasing needs, and how to address this problem proactively while maintaining our core values. If our goal is to provide quality care in the most cost-effective way, we need to pay much more attention to the management of clinical risks. This principle can be stated in a simple formula: improved quality + decreased utilization = increased clinical risk management.

Canadian author Carol Shields is well known for the literary awards she has received over the years. She is also Chancellor of the University of Winnipeg, and recently she addressed the Association of Commonwealth Universities at a conference in Ottawa. She stated that our universities are “no longer driven by a passion for ideas but by social and economic imperatives.” Bercusson, Bothwell, and Granatstein echoed her comments in their 1997 book “The Crisis in Canada’s Universities - Petrified Campus” (8). We need to rethink our academic system. With decreases in federal transfer payments and provincial funding, students are facing higher fees and lower career expectations. Tenure, originally designed to protect academic freedom, has become ironclad job security without effective review. Universities have become instruments of public policy rather than institutions of change. We need excellent Canadian universities to provide a system of higher education that can educate and train our future leaders. But all is not bad. New knowledge, technological changes, rising public expectations, and increased demands for public accountability are all having impacts. We need to transform our universities and to recognize that clinical practice, teaching, and research are interconnected.

Current trends in mental health care, demographics, and policy are changing the scope and practice of psychiatry and mental health care. Accountability for patient-centred services is at the forefront. Here the emphasis should be more on what, as a psychiatrist, a mental heath care provider, a government, a patient, a family member, a Canadian, I am accountable for rather than to whom I am accountable.

Current trends in Canadian mental health care include the following: the development of more specific and targeted treatments and interventions; the emergence of psychosocial rehabilitation assessments and interventions; the importance of interdisciplinary teamwork in the care of severely mentally ill persons; the emphasis on evidence-based, best practices; the move to continuous quality improvement and outcome measures; and the goal of an integrated patient-based approach to care. Early detection, diagnosis, and treatment together with early functional assessments and rehabilitative, psychosocial interventions are major keys to better care.

Current trends in mental health demographics include a focus on population-based needs and mental health human resources. A decade of decrease in the number of available residency training positions, the aging of psychiatrists, and the increasing number of women psychiatrists will have a direct impact on the mental health reform and the practice of psychiatry. Increasing needs for the care of the elderly and an expanded focus on health promotion and prevention for children and adolescents are acknowledged. However, greater attention to mental health as the ultimate productivity weapon in the workplace is also emerging as a priority. It is becoming obvious that mental illness and addictions are a business issue and that mental health is a business asset. The negative economic impact of neglecting mental illness is enormous. Dr Edgardo Peréz and Mr Bill Wilkerson offer the following principles or statements of fact, which must anchor business practices as a strategy of corporate performance (9):

As work stress increases, so do mental illness disability claims. Downsizing creates an atmosphere of tension in many organizations as workers fear losing their jobs, feel guilty about keeping their jobs, or are stressed out about work overload. It is also harder to get away from work, to quit for a day, even during vacations, thanks to laptop computers, cellular phones, pagers, and voice mail. Stress leads to depression, loss of self-esteem, decreased productivity, and increased absenteeism. Short-term disability stretches into long-term disability. Some estimate the loss to Canadian business in sick pay and productivity at $15 billion a year.

Current trends are influencing mental health policy: the devolution and regionalization of mental health services, the changing role of hospital psychiatry, the shift toward community-based care, primary care reform and the evolving role of the primary care physician, and the integration of information technologies. These trends trigger changes, challenges, and opportunities on the diverse roles of the Canadian psychiatrist. More than ever, there is a need for cohesive, national mental health strategies to harmonize our mental health policies.

Our leadership on issues of clinical practice and service delivery, education and research, and advocacy is therefore more important than ever. But what is leadership? According to John Kotter, Professor of Leadership at Harvard Business School, leadership “defines what the future should look like, aligns people with that vision, and inspires them to make it happen despite the obstacles” (10). Leadership always coexists with creative thinking. The current period of profound change in the mental health system requires innovative solutions. Unfortunately, the process of change can be overmanaged and underled. We can resist change, manage change, or lead change.

As Derm Barrett, author of “The Paradox Process,” puts it, “The more change there is, the more innovation we need; and the more innovation there is, the more change we will get” (11). Allowing innovation is in itself a strategy for change. Change triggers diversity. A major pitfall of our current emphasis on evidence-based best practices is that it may prevent innovation and diversity from occurring. Yet, our patients have a diversity of needs and a one-size-fits-all solution will not work. Change can also trigger unintended, undesirable, and disruptive consequences. I have a lot of respect for the law of unforeseen consequences. However, the problems produced by change will not disappear if we decide to stop being creative and innovative.

Two men were laying bricks. A passerby asked the first man, “What are you doing?” “I’m laying bricks,” was the reply. The passerby asked the second man, “So, you’re laying bricks?” “Not me,” replied the second man, “I’m building a house.”

We need leadership. Peter Urs Bender writes that leadership starts from within ourselves, that there are skills we can learn to develop leadership, and that the biggest obstacle to leadership is fear and not believing in ourselves (12). Many people believe that leadership is leading someone else. I believe it begins with leading ourselves.

Many believe that leadership is about finding ways to accomplish tasks more effectively. For example, they may talk about downsizing, restructuring, and reengineering. These are only tools to reach a goal. “If you do not know where you are going, any road will get you there,” or better still, “If you do not know where you are going, you may end up somewhere else.” I believe leadership is about creating a vision of what should be, getting others to share it, and putting it into action with passion and integrity. Vision stimulates energy. Energy is contagious. Leadership is about having energy.

Like the first bricklayer, some people are so task-oriented that they fail to see the big picture of what they do, what they are participating in. I believe that leadership is about pride. Pride about what we do and about ourselves. Pride about our accomplishments. Pride about our profession. Leadership is not about being first, about having the highest position. Leadership is not about managing systems. Leadership is about people. Leadership is not about command and control. Leadership is about coaching and empowering. As Abraham Lincoln said, “Am I not destroying my enemies when I make friends of them?” Leadership is about partnership.

Leadership is not about “dynamic conservatism.” Leadership is about change, about making choices to bring about positive change. Leadership is not about being perfect. Leadership is about continuous quality improvement. Creating a vision is important, but not enough. Leadership is about creating results, but not at any cost. Results must be reached with respect, care, and integrity. Credibility is our major asset.

In times of change, we need to grieve the loss of what we are leaving. We also need to deal with the anxiety provoked by transition and the uncertainty of the future. How change is implemented is as important as creating results. Leadership is about reducing fear and increasing hope.

Bender, in his book “Leadership from Within,” explains that the best leaders demonstrate 5 key attributes (12):

We need leadership to address mental illness and to meet the mental health needs of Canadians. The 1997 National Forum on Health recommended focusing on national homecare, pharmacare, information technologies, and child programs. One in 5 Canadians at some time in their lives will need access to mental health services. Mental health must be part of these initiatives. Mental health must be on the political agenda. Health Minister Allan Rock showed leadership when, at the 1997 annual meeting of the Canadian Medical Association (CMA), he asked our colleagues to show him the needs in health care. We supported the CMA’s access to quality care response. During the CPA’s 1997 annual meeting in Calgary, we also called for federal government leadership to develop a national strategy on mental health. Our call is even more relevant today. Health Minister Rock recently stated that “the fundamental challenge we face is to make the health system more responsible and more responsive to Canadians.” The CPA fully supports this goal but emphasizes that mental health must be given more priority. In a recent press conference, the CPA called again for the government’s leadership in mental health, urging that the debate on reinvestment in health consider more strategically the state of Canada’s mental health system. CPA initiatives over the past year have been converging toward the development of a vision and building blocks for a national strategy on mental illness and health, for the roles of psychiatrists in that vision, and for how organized psychiatry and mental health partners can work together to put this vision into action. We must continue to provide our leadership.

I have had a unique privilege this past year to serve our association as president and as chairman of its Board of Directors. I met colleagues from across the country and feel very confident that we can work together to improve the mental health of Canadians with a united voice at the national, provincial, and regional levels. Thank you for the opportunity to participate in the strategic planning that is leading our profession into the 21st century.

References

1. Gosselin JY. Humanism and psychiatry. Can J Psychiatry 1993;38:579–83.

2. Bebchuk W. Psychiatry — a partner for change. Can J Psychiatry 1994;39:513–21.

3. McCormick WO. Psychiatry—meeting the challenges: I am worried, I am encouraged. Can J Psychiatry 1995;40:501–6.

4. Watson DB. Opening the doors—looking back to move forward. Can J Psychiatry 1996;41:543–8.

5. Roy R. Social commitment: redefining the role of psychiatrists. Can J Psychiatry 1997;42:1028–34.

6. Boronow JJ, Sharfstein SS. The identity of the field in the context of changing roles. In: Lazarus JA, Sharfstein SS, editors. New roles for psychiatrists in organized systems of care. Issues in psychiatry series. Washington (DC): American Psychiatric Press; 1998. p 239–60.

7. Health System Research Unit, Clarke Institute of Psychiatry. Best practices in mental health reform. Discussion paper for the Federal/Provincial/Territorial Advisory Network on Mental Health, 1997.

8. Bercuson D, Bothwell R, Granatstein JL. Petrified campus: the crisis in Canada’s universities. Toronto: Random House of Canada; 1997.

9. Peréz E, Wilkerson B. Mindsets - mental health: the ultimate productivity weapon. Guelph: The Homewood Centre for Organizational Health at Riverslea; 1998.

10. Kotter JP. Leading change. Boston: Harvard Business School Press; 1996.

11. Barrett D. The paradox process: creating business solutions, where you least expect to find them. New York: AMACOM; 1998.

12. Bender PU. Leadership from within. Toronto: Stoddart Publishing; 1997.

This paper was presented at the 48th Annual Meeting of the Canadian Psychiatric Association, September 15–18, 1998, Halifax, Nova Scotia.

1Associate Professor of Psychiatry, University of Ottawa; Clinical Director, General Psychiatry, Royal Ottawa Hospital, Ottawa, Ontario; Immediate Past President, Canadian Psychiatric Association.

Address for correspondence: Dr PAM Beauséjour, 5th Floor, Carmichael Building, Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, ON K1Z 7K4

Can J Psychiatry, Vol 43, December 1998