My first experiences in community based medical practice came in childhood. My father, now a retired family practitioner, frequently made house calls in the small Michigan town where I grew up. It was not unusual for him to come home with a fresh chicken as payment!
Another formative experience came in college when I volunteered as a "patient's advocate" at the Free Clinic not far from campus. The experience of reassuring the people seeking care at the clinic about their medical condition and explaining to them why tests or procedures were needed prepared me for medical school as much as my coursework did!
Mentorship has always been an important in shaping my career path. I was fortunate to be a psychiatric resident at the University of Wisconsin in Madison during the early 1980's and wish to acknowledge the mentorship of two men who supervised me during my training. I had the good fortune to have the late family therapy pioneer Carl Whitaker, M.D. as a supervisor for a year. His advice to me as a young resident was invaluable: "Don't try to be more like me, try to be more like yourself." My experience with family therapy has been an essential tool in community practice.
My identity as a Community Psychiatrist was formed through my work with Ron Diamond, M.D. at the Dane County Mental Health Center: first as a resident and later as a staff psychiatrist. Ron linked systems theory to community mental health practice and the Mental Health Center provided opportunities for second year residents to treat persons with serious mental illness in the places where they live. I remember accompanying a crisis counselor into the community to try and find a young man with schizophrenia who had missed his last appointment at "the Center." We found him at a downtown Laundromat, where we sat with him and talked with him about the need for continued treatment. Thus, my own career in making "house calls" began!
After completing my Child Psychiatry Fellowship, I was faced with the challenge of finding community-based programs for children that inspired me the way my experiences working with adults in Madison had. My journey took me to the annual meeting of the National Alliance on Mental Illness (NAMI) in 1991, where I met John Van Den Berg, one of the pioneers of Wraparound. My conversations with him led eventually to a job working with one of the early Child and Adolescent Service System Program (CASSP - now the Center for Mental Health Services) grant sites in Stark County, Ohio. There, I learned new lessons: the importance of building systems of care and the importance of partnering with parents to provide the highest quality care. I also had the opportunity to continue to make "house calls" when needed!
During those years, I also consulted to the Mental Health Center of Juneau, Alaska. For almost 2 years, I would fly to Juneau every three months and provide a week of child psychiatry consultation. Despite being the capital of Alaska, Juneau is quite isolated: you can't drive to Juneau, you can only arrive by boat or plane! I learned first hand how to provide intensive community-based services for children and adolescents: a necessity when the nearest psychiatric inpatient unit is a four hour plane flight away!
All of these experiences have prepared me for my current position as Medical Director for the Arizona Division of Developmental Disabilities. "The Division" is unique in the United States as we manage a Medicaid "carve-out" Health Plan for our members. The Division contracts with four health plans to provide medical care to our members and with the state's Division of Behavioral Health Services for their psychiatric care. Arizona also has one of the highest percentages of their members that are living in community based settings: either in family homes or in small (usually four persons or less) group homes. I believe that managing the health care of our members helps us to successfully support so many in community settings. Though I spend much of my time in an office or in meetings currently, about once a month I visit one of our members in their home or community setting to provide consultation on a complex issue. I hope to continue making "house calls" until the day I retire!
Robert Klaehn, M.D.
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