When Idealism, Reality Collide

No one has to tell Adam Bowman, M.D., about a shortage of child psychiatrists.

His days at Delaware Guidance Services in Lewes, Del., are crammed with brief med checks, hemmed in by insurers' rules, and pressed by the needs of children from the coast and farmlands of Sussex County. Like all child psychiatrists, he has to deal with the educational and social problems that many of his patients experience. To top it off, the local hospital has no inpatient psychiatric ward.

Bowman is just two years out of residency, but reality has begun to temper the idealism that drew him to the field.

“I went into child psychiatry because I thought if I started working with children and their families early, I could change the outcomes in their lives,” he said. “I still feel that way, but now I'm more skeptical. I see the effects of poverty, school problems, lack of insurance, poor coordination among social agencies, and a disjointed medical-records system.”

Most children he sees are covered by Medicaid or by Delaware's child mental health services program, which provides mental health and substance abuse treatment to children without health insurance, or children with Medicaid who require services more intensive than the basic 30 hours of outpatient treatment can provide.

Following Medicaid's rules, children who come to Delaware Guidance Services are initially evaluated by a psychologist or social worker, and if appropriate, are then referred to Bowman or his colleague, Ruben Portnoy, M.D.

Bowman does his own evaluation but will only be paid for one hour, even if he feels that a longer time would be preferable. After that, the child may see the therapist once a week and Bowman once a month to monitor medications. Ideally, Bowman would like to hold some sessions with the patient and others with the patient and the family, but rarely has that luxury, he said.

This split therapy is complicated even more by the absurdities of insurers, he said. “Some companies won't reimburse a psychiatrist and a psychologist or social worker if they see the patient on the same day. That's ludicrous when patients live an hour away.”

If split therapy is not easy for the children, it's not easy for Bowman, either. He was trained in psychotherapy in his residency at Jefferson Medical college in Philadelphia, preparation for a more intensive approach to patients, but that's hard to do in a 15-minute med check.

Overall, the county's children need more support for mental health services from many sources, not just psychiatrists.

“There's also a shortage of good therapists to work with, and there's a real shortage of insurance or government funding to pay for these services,” he said.