Some Psychiatrists Find Practice Far From Routine

When that commute across town to the hospital or another 15-minute med check starts to seem routine, Uncle Sam has a job for you, one that doesn't require wearing a uniform.

Sixteen psychiatrists serve at regional posts in U.S. embassies around the world, coordinating mental health services for American officials assigned overseas.

Jaime Suarez, M.D., decided 16 years ago that he was ready for a change. Less than happy with the rise of managed care, he joined the State Department after 15 years of practicing child psychiatry at the Ochsner Clinic in New Orleans. He was first posted to Mexico City for 30 months and then stationed in Bangkok, Pretoria, and London. He has served for the last two years in Lima, covering 14 countries in Latin America.

“There's a lot of responsibility, a lot of independence, a lot of variety, and no payment problems,” said Samuel Thielman, M.D., Ph.D., until recently Suarez's boss as director of mental health services for the U.S. Department of State, in an interview in his Washington office.

The State Department's Office of Medical Services provides care not just for Foreign Service officers but for all civilians who fall under the embassy's umbrella, including those who may be attached to other government departments. Most American embassies have a health unit, typically staffed by a nurse practitioner or physician assistant because there isn't sufficient work for a full-time doctor. Embassy health units are backed up by local health practitioners, often U.S. Or other English-speaking expatriates.

Forty-five physicians serve as regional medical officers, in addition to the 16 psychiatrists. Psychiatrists based overseas spend 60 percent of their time at their home posts and 40 percent traveling to other embassies or consulates in their geographic region. They mainly handle adjustment problems, work-related issues, depression, and some alcohol issues. Severe psychiatric problems are rare. The regional psychiatrists also look after the families of embassy personnel, who often present more problems than the diplomats themselves, said Thielman.

As a result, when hiring, the department looks for psychiatrists with a range of skills. This is not a job for adventurous young doctors just out of residency, said Thielman, whose doctorate is in the history of medicine. Nor is it a cozy working retirement in an exotic location for older physicians. The Foreign Service mandatory retirement age is 65, so most of the physicians hired are in their 40s or 50s, tested but not about to retire soon.

“We want experience, at least five years' experience,” he said.“ The ideal candidate is someone who likes to travel, feels comfortable in a foreign country, and has a sense of service to his or her country. A child psychiatrist who has also worked with adults might make a good candidate, given the broad range of people served.”

It also helps if the psychiatrist's family enjoys overseas life. Service in a regional post usually runs for two to four years.

Elmore Rigamer, M.D., M.P.A., was the department's first regional psychiatrist. He had served as a doctor in the Peace Corps in West Africa and then worked at a WHo hospital in Liberia in the early 1970s, where he found that residency training in community psychiatry was applicable to African villages. Originally a child psychiatrist, Rigamer joined the department in 1977 on a “proof-of-concept” basis. He was based in Afghanistan and also covered Iran, Bangladesh, and Sri Lanka.

“I would get a call from the ambassador about a member of the senior staff about depression, alcohol use, or family problems. The idea was to keep people on the job,” he said. Rigamer didn't have to wait long to see what else he could do in his region, though.

The next two years saw the assassination of the U.S. ambassador to Afghanistan; the burning of the embassy in Islamabad, Pakistan; the Iran hostage crisis; and the Soviet invasion of Afghanistan. Rigamer remained as regional psychiatrist for South Asia until 1983, then moved to Vienna to cover Europe and the Soviet Union from 1983 to 1987. Eventually, after taking time to earn a master's degree in public administration at Harvard, he became the State Department's medical director from 1994 to 1996. He is now medical director for Catholic Charities' mental health programs in New Orleans.

Rigamer said there is less stigma among department personnel since he first came on board. Before 1977, anyone with a psychiatric diagnosis was medevaced home to the States and grounded there. To avoid harm to careers, he often saw people at home and didn't keep records.

While in the last 10 years things have improved, there is a limit to what can be done in the field, said Rigamer. “If I had a patient with bipolar disorder, I wanted the person to go to someone who sees 50 bipolar patients a week.” Sometimes he sent children back to the psychiatry department at George Washington University in Washington, D.C., for an evaluation, and then set up a follow-up treatment program at the overseas site where the parent was working.

In some ways, the role of State Department psychiatrists is similar to that of their military counterparts. They try to intervene as close to the front line as possible.

“We want to support them there,” said Thielman. “Even for people with a history of psychiatric disorder, we would only recommend evacuation if the condition impairs their judgment.”

Someone evacuated back to the United States for psychiatric reasons might well be cleared for a return to duty overseas or in Washington, D.C., after treatment.

Suarez's work is typical of State Department psychiatrists. He travels away from his base in Lima every other week visiting two or three other posts a month. He may provide short-term clinical interventions, check on medications, consult privately with patients, or follow up on work from previous visits. He provides guidance as needed in employee-management relations and offers one of 25 talks he has developed over the years on mental health issues. He pays“ courtesy calls” on embassy staffers, part of a process that helps him understand and assess morale.

“I've had to extrapolate from my knowledge of family dynamics to organizational dynamics,” he said recently in an interview by phone from Lima.

He also consults with the American International Schools in each capital. Children of embassy personnel who need help are eligible for allowances for special needs students, tutoring, or remedial classes. He also visits with local mental health professionals to assess their ability to help care for staff when he is not in the country or when more expertise is needed than the embassy nurse or physician assistant can provide.

“I like all aspects of this job,” said Suarez. “I still see patients. I enjoy the management consulting role, and I like the liaison with local practitioners.”

The inevitable bureaucratic side of working for a government organization is less attractive, he added. “Travel can get to you, too, especially in South America, because airline schedules are less convenient than in Europe.”

A State Department psychiatrist's work is varied enough, but sometimes it crosses over into the realm of headlines, as Suarez found out eight years ago.

On August 7, 1998, terrorists bombed the U.S. embassies in Nairobi, Kenya, and Dar es Salaam, Tanzania, killing over 220 people and wounding 4,000. Suarez was based then in Pretoria, South Africa, responsible for 22 countries in sub-Saharan Africa. He learned about the bombings from CNN within minutes of the simultaneous explosions. Twelve hours later he was in Nairobi. Another regional psychiatrist went to Dar es Salaam.

He quickly assembled a team of six to help survivors or their family members, he recalled. Several were local professionals he had met on earlier visits. They first helped doctors and nurses with the physical and medical needs of victims, then saw to their psychological needs. He quickly sized up the skills and quality of his group of volunteers, now 13 strong, who included social workers and psychologists, as well as physicians.

Suarez also organized care for the Kenyan employees—who accounted for most of the embassy casualties—and their families by engaging local professionals to provide psychological support.

Night flights to Rio may seem tame by comparison.

“I don't think you can find any comparable setting that provides the opportunity to do the work that we do,” said Suarez. “Certainly there's nothing that compares to the type of responsibilities and duties that we have, with the rotations that move you around the world. That in itself could be fascinating for some people. And it truly is. But I find that the work itself is the most interesting thing.”

A job description for State Department psychiatrists is posted at<http://careers.state.gov/specialist/opportunities/medpsych.html>.▪