"I thought I was here and here I would stay," said a gray-haired woman sitting in the day room of a turn-of-the-century building at Springfield State Hospital, the state's largest institution for mental patients.
She was wrong.
She had just returned from a shopping spree at a nearby mall, the proud owner of a new pink-flowered blouse and white sneakers. And after five years at the hospital for behavior problems resulting from head injuries and alcoholism, she expected to be released into outpatient treatment within a few months.
"They allow me to keep my own money," she said. "They help us to manage what we've got. I'm dying to go into the community."
Until recently, the musty, old buildings on the sprawling hospital grounds were run with an equally antiquated approach to psychiatric care. The low-prestige staff positions were filled with foreign medical graduates and American doctors with few other places to go. Many patients spent years in hospitals yet received little treatment or were dumped, ill-prepared, back into the community.
But during the past seven years, a revolution has occurred, and Springfield has become the showcase for an overhaul of the entire statewide system that is attracting national attention.
Behind the transformation are a small band of young, superbly trained psychiatrists with a 1960s zeal for public service and reform, and an impressive list of accomplishments:
* They have taken over the state Mental Hygiene Administration and forged a new training relationship between the once-hidebound state mental hospital system and the University of Maryland School of Medicine.
* They have replaced nearly half of the 130 psychiatrists working in the 12 state inpatient hospitals.
* They have introduced the latest professional tools of their trade--state-of-the-art diagnoses and treatments that they believe translate into better outcomes for their patients. Droves of patients once lumped together as difficult-to-treat schizophrenics, for example, are now diagnosed as having depressive disorders that may respond to newly available drugs.
* There is, they say, more patient access to doctors, careful review of old and new case records, greater continuity of care, more variety in therapies--group, family, art, dance, psychodrama--and attention to creating a more normal hospital environment and preparing patients to return to the community.
As a result of these efforts, the traditional hopelessness associated with many state psychiatric institutions has been replaced with a surprising degree of hope. "We don't want to get to the point where we say this is all we can do and that's it," said Dr. Thomas Krajewski, 34, the new head of the 1,100-bed hospital at Springfield.
Dr. Herbert Pardes, director of the federal National Institute of Mental Health (NIMH), calls the Maryland program "unique." The American Psychiatric Association recently cited it for its innovations. And mental health specialists from around the country are coming to see why Maryland's program is succeeding when others have failed.
Dr. Harold McPheeters, mental health director for the Southern Regional Education Board, recalled the brash optimism he encountered on a visit last fall. "Obviously that kind of enthusiasm makes it work," he said.
"Most states have been having a real problem in losing psychiatrists from the state system. Maryland is gaining young, American university-trained psychiatrists. It's a very impressive countertrend to what's going on nationally."
"We're the only state that's changing the quality of the professionals involved in the public sector on a statewide basis," said Dr. Henry Harbin, an assistant director of the State Mental Hygiene Administration. "We've attracted the brightest minds to work with the most difficult patients. We bring them in for one major purpose: to change the system." The change began at the top of the state's Mental Hygiene Administration in 1976. The new commissioner was Dr. Gary Nyman, a 35-year-old University of Maryland psychiatrist who "applied for a job nobody wanted."
"It was considered a hopeless situation. Having no previous experience in state government, he didn't realize he couldn't do anything," said Dr. Walter Weintraub, a senior psychiatrist in charge of the university's residency training program.
Nyman's deputy commissioner was Dr. Alp Karahasan, then 31, an MD and PhD who later took over the top spot.
"It was a challenge," he said. "The chronically ill patients were getting no care. The role of the physician had deteriorated into a minimal duty person who just signed prescriptions. It was horrendous."
But, he admits, it was also an opportunity for an "aggressive, arrogant but competent bunch of people" to test the system. "We had our roots in the 1960s' student movement . . . . We smelled blood a little bit. There was going to be an old-school, new-school fight as people-oriented physicians took over."
This was the start of a young-boy network that offered an ideal opportunity for getting the university and state together in training psychiatrists. Their mentor Weintraub suddenly found it possible "to do things that proved to be impossible before . . . . Without the ideological rigidities of working in the system for 20 to 30 years, they were willing to try new things."
In the past, he said, "the state officials said the academics have their heads in the clouds, and the academics said the state was inferior." Now the two groups set up a new state hospital training program, staffed with doctors looking for opportunities to advance, flexibility and a teaching connection with the university.
All of this was accomplished using existing state funds, with a small boost from federal seed money. "There have been no new costs incurred by the state to establish this whole program. We just used existing funds differently," said Harbin.
The program was initiated under the administration of Marvin Mandel but has undergone its major growth under Gov. Harry Hughes.
Nyman, now chief of psychiatry at the Veterans Administration medical center in Baltimore, said the attitude of elected officials in Maryland has generally been one of "passive support" with limited resources. "As long as we did it ourselves, they didn't kill it."
With no new state money to launch the effort, Maryland psychiatrists' salaries remain among the lowest in the country. Nevertheless, state officials say 73 new physicians with university training in America have come to work in their in-patient hospitals in the last seven years--including about 20 chief residents who could have their choice of jobs elsewhere.
Moreover, all 12 hospitals in the system are now headed by university-trained physicians most of whom are recent graduates with excellent records but little administrative experience.
In the process, the University of Maryland has doubled its residency training program at a time that many schools have difficulty getting doctors into psychiatry. Training relationships also have been made with the Johns Hopkins University and Georgetown University medical schools, as well as Maryland's private Sheppard Pratt hospital.
And the program is branching out, seeking to improve nursing, psychology, social work and other aspects of patient care at the institutions.
The project's first major test came in 1978.
The target: Springfield, a rural hospital about 45 minutes outside of Baltimore. The goal: to set up a new training unit where some of the sickest mental patients from Carroll, Howard and Frederick counties were admitted. The pioneers: Krajewski, then 30, and Dr. Jonathan Book, 29, two recent Maryland graduates, both former chief residents in psychiatry.
Krajewski and Book headed out to the new world of Springfield, harboring inner fears that their fancy academic ideas might not really work. "My first week I went to work every morning with butterflies in my stomach," said Krajewski.
Not surprisingly, their initial entry into the entrenched Springfield system did not go smoothly. The ward they were supposed to transform was overcrowded, and they were viewed with suspicion as the "golden boys." A group of "old guard" doctors even formed a "Responsible Concerns Committee" to keep an eye on the new psychiatrists.
"They saw them as ivory tower people who didn't know how to manage very sick people," said Dr. Sherrill Cheeks, one of the few university-trained psychiatrists in the Maryland state system at that time. The committee finally disbanded when some members "recognized that there was nothing to fear," said Cheeks, 49.
Meanwhile, Krajewski and Book, pushed by state officials, moved up. In 1981, Krajewski became hospital superintendent and Book the clinical director, second in command. Their predecessors had both retired at the age of 70.
Book recalls a visit from Dr. Bruce Regan, a former Harvard peace demonstrator who now heads the state's psychiatric education and recruiting program. "He walked into my office and sat down, saying 'Well Jon, we've taken over the administration building. Now what do we do?' "
At Springfield, Krajewski and Book are no longer alone. They and the state recruiters have managed to replace nearly half of the hospital's 40 psychiatrists with university-trained colleagues who work in about half of the hospital wards. The qualifications of nurses have also improved, jumping from only 7 percent registered nurses in 1979 to 21 percent, said Kay Sienkilewski, director of nursing.
Today, said Cheeks, staff relations are excellent. "Everyone considers it a positive movement. Well, almost everyone. Tom and Jon are both doing an excellent job." One staff member notes, however, that there is still a "sense among many employes that they're a bit too young. Some people feel they have not paid their dues."
It's difficult to measure how staffing improvements translate into better patient care, but both Krajewski and Book say they believe there has been a dramatic change, bringing state care closer to that provided in good private institutions.
In general, they say, psychiatrists are closer to their patients. Their offices, for example, are on the ward rather than on another floor or in another building. Breaking with tradition, the two young doctors still make rounds at the hospital's wards despite their administrative positions.
Institutionalizing a system initiated by Cheeks, there is also more continuity of care, with one staff member responsible for following each patient.
"In the old days, people who made all the noise got all the attention. That does not happen any more," said Cheeks. "The new system provides for no patient being overlooked."
The doctors also say that in the past five years, the number of patient assaults has gone down, as has the seclusion of patients following violent episodes.
Changing diagnosis and treatment has meant that patients diagnosed as schizophrenics, a severe emotional disorder accompanied by delusions and bizarre behavior, are today in the minority rather than the majority.
Doctors' skills are aided by access to more sophisticated equipment at the university. Krajewski tells of a patient originally diagnosed as a schizophrenic who was sent to Baltimore for a brain scan. A tumor was detected and, once it was removed, his symptoms cleared up, Krajewski said.
There was also a greater tendency in the past to overtreat with drugs. One patient with a long history of escalating drug treatment would "get confused and they would add another drug," said Book. "It took a review of her record to see a pattern of her symptoms always getting worse." Book stopped all her drugs. Suddenly, "she looked like a nice old lady who could talk coherently," Book said. "After a couple of months of being quite stable she said 'I really don't need to be here' and left. She'd been in the hospital for 20 years."
There is new emphasis on getting patients into the community. Krajewski recalls two patients who between them had been in the hospital for 60 years. One didn't talk and the other crawled around on his arms and legs for much of the day. Yet, when they were taken out to visit a "psychosocial rehabilitation center," both began to behave more normally. "It was like a miracle," he said.
At Springfield's chronic care wards, Dr. V. Rao Inaganti, 32, an Indian doctor trained at Maryland, is trying to convince staff and patients who have been at the hospital for 5 to 35 years that this is a "temporary place. This is not a permanent place. Patients initially didn't like it. Nobody wanted to go out into the community."
To improve independence, Inaganti has begun sending groups out to visit shopping centers, eat at McDonald's, ride the Metro and visit outpatient facilities. Concerned about housing and assistance, should the patients be released, he and others are "going aggressively into the community and telling them our needs."
At the moment, Maryland's state psychiatric institutions are blossoming with new talent committed to improving the system.
But resources to update the facilities and to provide additional services continue to be a problem.
Krajewski admits that his staffing levels at Springfield still fall far below the recommended national levels. The aged buildings prevent Springfield and several other large hospitals from gaining accreditation.
Other hospitals are just starting to tackle longstanding problems. Thirty-five-year-old Dr. Eva McCullars, who took over as head of Crownsville Hospital Center outside of Annapolis last year, sees her institution as a challenge. "It is untapped territory. It is the last frontier."
"It's a sense of being on a mission," agrees Dr. Bruce Hershfield, 36, head of Highland Health Facility in Baltimore.
No one knows whether the young doctors' idealism will fade in the face of harsh reality, whether changing state politics will drive out the new-wave bureaucrats, or whether the next generation of doctors finishing their training will have the same commitment to public service as their predecessors.
Surprisingly, it is Springfield's 20-year veteran Cheeks who is the optimist. "It has caught hold. It's clear to everyone the advantages of the program."
But the younger Book, immersed in the present, is more cautious about the future. "It's a group phenomenon. We're a very tight-knit group with shared commitment and values. I'm not sure how that can be extended or what longevity it will have."