Our Gal Candy * - "the story which asks the question, 'Can a girl from a mining town in the West fina success and happiness' " with the District Branch, Area Council, and Assembly of the American Psychiatric Association?*
If you have followed the allegory and understood it, you probably belong to the minority of being (1) female, (2) of sufficient age to recall radio soap operas, and (3) cosmopolitan enough to know that Bismarck is sitting on the edge of a tremendous deposit of low-sulfur coal that is now being developed.
Although this article was to be written from the standpoint of being a member of a minority group, specifically that of women psychiatrists, I belong to many minorities in addition to those listed in the above paragraph. To be a psychiatrist in North Dakota is to be a member of a minority specialty. A psychiatrist in private practice in a primarily rural area is in a minority of psychiatrists. The North Dakota District Branch is the smallest district branch within the A.P.A. structure and, therefore, in the minority. I describe myself, in a very strict sense, as a Wasp; I am, therefore, in a minority in Bismarck. I am a non-coffee drinker, and that is my greatest minority. Because of these many minority memberships, I choose to approach my discussion from the standpoint of what is happening here at the grass-roots level of psychiatry, as well as from where I stand as a woman and how, on a very personal basis, I maintain myself.
The North Dakota District Branch was born in 1968 after approximately two years' gestation. Originally, North Dakota had been part of the Sioux Psychiatric Society, which included both of the Dakotas and Nebraska. The members of this group shared a number of ecologie similarities, but the branch encompassed a tremendous geographic area. The cohesiveness of the society was limited by the fact that the major transportation routes for automobiles, airplanes, and trains go east and west, not north and south. Although this problem was not the majoT reason for the formation of a separate North Dakota District Branch, this geographic fact did make North Dakota psychiatrists feel isolated.
The major factor that incited action for district branch formation was the need of private psychiatrists in North Dakota to have better methods for dealing with the restrictive and uninformed decisions made by the local Blue Cross-Blue Shield program. In the process of working on this problem, we found that we had not only the beginnings of cohesion but also a feeling that our individual isolation need not be so complete. We were able to share information concerning transfer of patients, location and types of other treatment facilities, solutions to local ethical issues, fees, and many other matters. Each of us - whether in private practice, in a mental health center, or in a state hospital - is highly individualistic in her/his theories and approaches to patients. But we learned that together we can solve some of the problems that are universal to psychiatric practice. (Incidentally, we still maintain our primary purpose. We are the only professional society dealing directly with the Blue Cross-Blue Shield Board to achieve fair and equitable coverage for patients under their contracts.)
Our district branch membership has expanded since 1968 with the establishment of community mental health centers. State population increases and the four major population centers have been adding personnel in private sectors. For example, the first child psychiatrist came to North Dakota (BismaTck) in December, 1976.
The district branch is now maintaining active affiliation with the Area Council and Assembly structures. Because of the small membership, the branch has chosen to handle most committee issues as a "committee of the whole." One person, designated "chair," follows the issues in depth and reports to the group at large. For example, the president is automatically the deputy district branch representative. She/he also chairs the Ethics Committee. The secretary-treasurer chairs the Membership Committee.
I chair the Peer Review Committee as well as working with the Continuing Medical Education Committee. The latter group is organized under the Medical School Chief of Psychiatry's "chair," with a membership of one person from each major population center so that we can address the needs of all our members. It is very expensive for a member to obtain Category I credit outside North Dakota. It currently costs $20 to $30 for each Category I credit, excluding the cost of substitute child care or transportation. We have recently been able to obtain Category I credit through the Medical School. In order to produce programs applicable to psychiatry, we are joining other treatment facilities, such as the mental health center and the alcoholic treatment centers, in jointly sponsoring programs.
Working on issues as a "committee of the whole" has worked out quite satisfactorily for us; it gets information to the members very rapidly and also allows for instantaneous individual response. Despite problems of weather and distance, the district branch meetings are well attended. The location of the meeting is usually moved around the state, which means that we rotate the problem of driving 200 to 400 miles to a meeting.
The North Dakota Medical School has just expanded to a four-year program. It is described as a 2-1-1 system. Students spend the first two years in Grand Forks, North Dakota. Third-year students are divided between Mayo Medical School and the University of Minnesota. The fourth year is spent in a giant preceptor system within the four AHEC areas of the state. Psychiatry offers a six-week elective during the fourth year. This program acquaints the student with the community facilities - such as mental health centers, human resource centers, and alcoholic treatment programs - and with experiences with private practitioners. The elective was formulated with the assistance of all the psychiatrists in the state, since most hold staff positions in the Medical School Department of Psychiatry.
I had hoped to be involved with the women medical students. Few of them have even seen a woman physician. Many of them are asking the same questions about combining a professional and personal life as I did as a beginning mediceli student, and I think I now know some of the answers. Time and distance make such a relationship impossible, but I remain available to them as a corresponding consultant. Occasionally, I play the role of gadfly to the dean and the chairman of the Department of Psychiatry.
The Area Council and Assembly have offered me additional educational experiences. After working at the local level in a variety of capacities, including serving as secretary and president, I became the district branch representative. The development of criteria for local peer-review and medical-audit procedures was facilitated by the work of the A.P.A. task force. The experience and precedence of other district branches were utilized in decisions about ethical issues. Members of our branch are now engaged in helping rewrite the mental health legislation for North Dakota, and they are drawing on the discussions and experience of other branches from our Area Council in an attempt to achieve more model legislation. It would appear that there is greater movement of information into the district branch than from it. It is my impression that this situation has had an effect in many areas; it has improved the level of care for our patients, and it has kept us, as individuals, in contact with what is happening in psychiatry throughout the United States.
Until now, I have been speaking primarily as any psychiatrist from the North Dakota District Branch. This, I feel, is my role, and it makes little difference whether I am male or female. This does not mean that there are no chauvinists in the N. D. D. B. It does mean that there are opportunities for anyone to be active in the branch as long as she/he is willing to do a job, assume responsibility, and represent the feelings of the branch in the Area Council and at the Assembly levels. The excitement and stimulation of the interchanges of ideas on a national level have not only decreased my sense of isolation but also intensified my sensitivity to patient concerns and patient issues.
What is happening to me on a personal level? I have made a commitment to remain on a parttime basis in practicing psychiatry until all four of my children are out of high school and are leading independent lives. This, at times, has created problems of isolation, both socially and professionally. The working hours 1 maintain are roughly the same as school hours, leaving little time for "coffee" breaks. When at home, I try to remain fairly available to my children. This is a good idea in theory and worked best when the children were small. Perhaps the greatest difficulty has always been the question of having time available in the summers, when children were not engaged in any kind of structured school activity. It also means a great deal of communication through notes taped on the only universal gathering place - the refrigerator.
My employment is salaried, approximately half-time, in a general medical clinic. My office and secretarial help are furnished. I have a source of referrals in addition to those coming through former patients. Since there are three other psychiatrists on the staff, I usually have coverage for Area Council meetings, continuing medical education seminars, vacations, etc. It also enables me to vary the amount of my practice according to my needs. If I choose, I can accept more patients in the hospital or book more office hours. I also maintain a consultation service with one of the attorneys in town; this adds the spice of variety to my practice.
I have also been active in establishing a private social agency that provides small group homes, primarily for Indian teenagers who are potential "failures." The incidence of alcoholism and mental illness on our nearby reservations is great. The Hall Youth Service is trying to reverse these trends. As a member of the board of directors, I was instrumental not only in setting up a cohesive board but also in maintaining therapeutic guidelines. This project, now in its 12th year, receives most of its funds through donations and grants. It now enlists American Indian people on the board of directors.
Bismarck is a very small community, and I have problems of confidentiality of information within my own family. Since my husband is a surgeon, it is very difficult not to involve the whole family in medical discussions. My children have been very aware of peers who have been hospitalized by their father. But I believe I have avoided any confirmation that a friend of theirs might be a patient of mine. This has led to a few sticky situations in which patients of mine have been dating my children. I practice under my maiden name. I think that has helped to maintain some degree of privacy for myself as well as for my children. They can choose to claim relationship to my professional name or not, as they please. I spent too many years as "the daughter of - " not to be aware of that problem.
Currently, three of my four children are in college or graduate school or have already completed their educational programs. Fortuitously, they have also situated themselves near major airports, so visits to Assembly and Council meetings and other professional meetings frequently take us through their areas. We are therefore able to visit them individually on a one-day basis en route.
There are many problems unique to women for which I have not found good solutions. I now feel very strongly that training facilities should structure their programs to assist women who, for family reasons, must "drop out" of training or practice intermittently. I also think that board eligibility should be achieved during residency and the board examination taken at the completion of this period. The program of continuing medical education is going to be very helpful in keeping the "dropout" or part-time practitioner current.
I have not found a satisfactory formula for computing adequate part-time salaries. 1 have strong feelings that any part-time worker suffers from that standpoint in salary, as well as often being ineligible for hospitalization insurance, retirement plans, paid educational time, and other fringe benefits. I grapple with other solutionless concerns that necessitate difficult family decisions, such as the opportunity for only one of a professional couple to move into another type of position that may be geographically distant. Other concerns include decisions about the when, where, and what to do during retirement.
And so we ask the question, "Will Our Gal Candy survive the total empty-nest syndrome, will she stand the transition to full-time practice, will she continue to find success and happiness with the A.P.A. Council and Assembly structures?" Tune in tomorrow, same time, same station.