CAUGHT IN THE CROSSHAIRS OF AMERICAN HEALTHCARE

Sederer recalls his fight to save a foundering mental hospital in this searching memoir.

The author, a former New York City mental health commissioner, recollects his 11-year stint, starting in 1989, as chief medical officer of McLean Hospital, Harvard University’s psychiatric teaching hospital and an institution storied for treating celebrities and poets. The hospital was hemorrhaging money; McLean’s model of monthslong inpatient stays, centered on psychoanalytic talk therapy, was too expensive—and medically ineffective, the author contends—to survive. Sederer introduced a radically different acute-care model based on two-week stays, during which doctors stabilized patients with the help of psychiatric drugs before discharging them for long-term outpatient care. The shift enraged the hospital’s more entrenched attending physicians; they were further miffed, the author asserts, by initiatives to expand the hospital’s services and bring in more patients, all of which meant more work for them. Much of the book is an intricate study of managerial change, with Sederer describing how he built his executive team, cultivated his board, and eased out opponents. He also recaps colorful psychiatric cases, including that of a doctor who eloped with a manic-depressive patient, necessitating a police manhunt. The author offers a biting critique of corporate medicine’s fixation on profits over patients while advocating for a more streamlined, cheaper, more pharmacological, and less Freudian psychiatric paradigm. He also attacks what he considers bad practice: Sederer opposes psychoanalysis for psychotic patients (he says it can destabilize them), calls for simplifying complicated drug regimens, and frowns on restraining and sedating patients. The author’s lucid, plainspoken prose makes medical issues accessible to laypeople while conveying the drama of McLean’s bitter office politics. (One attending physician “sat at his rather empty, big old oak desk, squarely facing me. He said I would fail, that I would be out of McLean in disgrace in short order, too. I said nothing in response. It was a brief meeting.”) Doctors and casual readers alike will find interesting food for thought here.

An absorbing insider’s view of upheavals in mental health care that explores the human impact of cold economics.