Undersecretary gives VA psychologists hope

Leadership opportunities and mind-body collaboration are changing attitudes.

By Patrick A. McGuire
Monitor staff

After four years of
tempestuous organiza-tional change that has shaken their sense of professional identity, some psychology leaders in the Veterans Health Administration (VA) have begun to express cautious optimism that "the new VA" may offer opportunities to assume different leadership positions and other emerging professional roles.

That hope comes out of a supportive visit paid to an APA-
co-sponsored April gathering in Dallas of the Association of Veterans Affairs Psychology Leaders (AVAPL), by the man most responsible for the change.

Yet, Kenneth W. Kizer, MD, Undersecretary of Health in the U.S. Department of Veterans Affairs, didn't wrap his encouragement in a conciliatory tone. In fact, the man whose 1995 re-engineering plan swept away psychology's long-held power bases in the nation's VA hospitals, warned, "It's a tough time to be in health care anywhere, certainly a tough time in the VA, and the dust isn't going to settle anytime soon."

What he did do, however, was to assure psychologists that the same change that had upset their traditional ability to stay organizationally even--and therefore professionally viable--with VA psychiatrists and other physicians, had also done away with the need, even the tolerance for competition between professions.

"Health care today is a team sport," said Kizer. "There's been so much culture built around separating the mental self from the physical self. The brain just happens to be the most powerful organ, but it's connected to the rest of the body. It's all part of the same package, and somehow we've got to make sure we have the psychologists and other mental health people, along with the internists and cardiologists, complementing each other."

What that means, he said, is that psychologists are now as eligible as physicians to hold the highest VHA leadership positions, whereas "eligibility rules before were the epitome of body-part medicine."

Pressure to modernize

In those days, VHA operated under a centrally controlled system of 172 medical centers across the country, with separate departments for each discipline, including psychiatry and psychology. VHA was then, and is now, the country's largest employer of psychologists with about 1,400 positions, as well as being one of the most sought-after locations for predoctoral internships.

Of course, the VA was also known for its unwieldy size and had been under pressure to modernize. Four years ago, Kizer promulgated his decentralized restructuring plan, folding the 172 medical centers into 22 regional networks, each with local decision-making power and responsibility for improving care and for holding down costs. The networks were designed around the delivery of health-care "products," such as mental health services, with all separate discipline-based departments eliminated.

"The philosophy of the network," said Kizer, "is that the patient is the center of the universe and the facility no longer is, nor are professional disciplines. This is all about taking care of patients and the question becomes how do you mix and match services in a way that provides the best for the patient."

But without those psychology departments, and especially without the positions of department chief and assistant chief to serve as anchors, VHA psychologists began feeling disconnected from the system and from their colleagues--many have described the experience as an identity crisis. It fueled fears that the new system would simply put psychiatrists in charge and diminish the role of psychology.

As these concerns grew, APA's Practice Directorate sponsored its first conference with the AVAPL last year in Dallas, to encourage members to find ways to make the new system work for them--much as it has provided support for non-VA practitioners facing similar changes through the managed-care revolution.

"The VA is a microcosm of the larger health-care delivery system as it is being transformed in this country," says Randy Phelps, PhD, APA's assistant executive director for professional issues in the Practice Directorate. "As the cradle of psychological practice in this country, VA has a very special place in our hearts at APA. What happens to VA affects us all."

While last year in Dallas the mood was one of anger at the changes in the system, many among the estimated 100 VA psychology leaders from across the country who attended this year sensed a different attitude.

"Many have accepted the reality of the reorganization and are looking for ways to optimally participate in the leadership of a reorganized VA health-care system," said Russ Newman, PhD, JD, APA's executive director for practice. "People seemed more optimistic that, in fact, psychology is finding its place in the new system."

In fact, as pointed out by Russell Lemle, PhD, chief psychologist of the new San Francisco network--and one of the conference organizers--many paid their own way to the conference.

They were especially heartened to see the large contingent from VA headquarters' central staff, including Robert C. Gresen, PhD, the Acting Deputy Chief Consultant, Linda Johnson, PhD, RN, from the Office of Academic Affiliations and Kenneth Clark, JD, the Chief Network Officer.

During the intense two-day meeting, members heard not only from their own leaders--including Matthew J. Blausewicz, PhD, AVAPL's president--but from speakers such as Newman, former APA president Norm Abeles, PhD, and APA board member Kathy McNamara, PhD, who stressed the need for sustained advocacy by the group.

Many were curious to see how Kizer would react to their growing insistence on playing a key role in the new system. Indeed, between last year and this, Newman had exchanged cordial but firm correspondence with Kizer, insisting that psychologists were being passed over for key leadership jobs in favor of psychiatrists. Earlier this year, Kizer wrote Newman to reiterate his policy that leadership positions would not be limited to psychiatrists.

At the recent Dallas meeting, Kizer unveiled his new directive (VHA 99-018) to the field, affirming that "it is VHA policy to recruit and hire the most qualified individuals for key leadership positions in mental health." The directive further states that announcements for filling VHA leadership positions in mental health shall not contain language restricting applicants to any one specific professional discipline.

But even before he arrived, his acting chief consultant, Larry S. Lehmann, MD, had primed the audience.

"There are opportunities for psychologists that we probably haven't realized yet in the system."

Kenneth W. Kizer, Undersecretary of Health, Department of Veterans Affairs

"Leadership should be based on ability," he said, and "if we allow ourselves to become fragmented, isolated from each other and competitive instead of collaborative, we will fail."

Creative models

That sentiment was advanced by Paul Nelson, PhD, deputy executive director of the Education Directorate.

"The times have changed," he told the group. "We need to think of creative new models, not be stuck on traditions. The VA is on the forefront of where the nation's health-care system needs to be, and there is no body of educators or clinicians that I can think of with more opportunity to lead the way than the VA psychologist."

Other speakers, including APA's President-elect Pat DeLeon, PhD, went past encouragement and straight to challenge.

"VA is on the cutting edge of defining quality care," he said, "and I really hope a lot of psychologists are involved in determining the definition of quality. But no one's going to reach out and say, 'Get me a psychologist.' You've got to educate people about why a psychologist is important. The 21st century is not going to provide high-quality care unless psychology matures, and the 21st century is not going to care about psychology unless you mature."

DeLeon, who is the only candidate AVAPL has ever endorsed for APA's presidency, told the group to aim high.

"I want to see us, as psychologists, understand that the chief medical director of the VA could be a psychologist," he said. "We all act like the person who is number one should be a physician. We are extraordinarily well respected, yet internally we act like we're the flunkies. We need to stop pretending we're not educated."

Kizer, when he spoke, didn't disagree. In fact, for the first time in the VA's history, he has opened recruitment for the permanent chief consultant for mental health--the top mental health position in the system--to psychologists as well as psychiatrists. Newman has been asked to represent APA as a member of the selection committee for this position.

But Kizer also went straight to the challenge in his remarks, though from a different angle.

"One of the biggest frustrations I have is the turf wars," he said. "Turf wars in health care are lose-lose ventures. What we really should be looking at is how do we complement each other, how do we work together to provide the best care. There are opportunities for psychologists that we probably haven't realized yet in the system."

During an hour-long question- and-answer period, both Kizer and AVAPL members took pains to make sure each side understood the other's position; at the end, each seemed satisfied it had been heard.

"Getting the undersecretary of health to come and have a dialogue is a recognition that you count, that your input is valued," said Newman. "Kizer does not appear to be caught up in physician-chauvinistic issues. He seems to be a person who wants to take the VA health-care system in the right direction. He definitely has the potential to be a strong ally."Y



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