UHS: More Psychiatry, More Trouble

In 1963-64, there were 163,206 visits to the Harvard University Health Services--about 63,000 more than in 1958-59. With 138 medical professionals on its staff and over 25,000 customers (14,000 students and 11,000 faculty and employees), the UHS has become a curious combination of big-city hospital, small-time doctor's office building, business corporation, and Harvard department.

Harvard is regarded as the nation's leader in college health facilities. After three years in operation, Holyoke Center is regarded as about the best central health clinic on American college campuses, and it has been the subject of numerous articles in medical journals. The services available are through and all-inclusive, and now amount to a pioneering program in prepaid medical care (administered through the Blue Cross-Blue Shield system). Last year over 20 members of the staff collaborated in the production of a sort of encyclopedia to college health affairs, College Health Administration, which does everything from reproducing the forms Harvard requires freshmen to fill out to explaining the legal aspects of university medicine, does everything from reproducing the forms Harvard requires freshmen to fill out to explaining the legal aspects of university medicine.

With all the teaching hospitals in Boston closely affiliated, the Harvard Health Services cannot help but have the finest in medical facilities at its command. But it has even begun to acquire outstanding and unusual equipment of its own. Just this spring a member of the Class of 1915 presented the UHS with a "Pacemaker," the newest and most effective device for diagnosing and treating disorders of the heart. Used to monitor the hearts of people suspected to have heart disease and to provide emergency resuscitation, the Pacemaker will permit the treatment of serious emergencies right in Stillman Infirmary on the fifth floor of Holyoke Center. The Health Center is one of very few institutions in the Boston area that have a Pacemaker.

The dramatic advances and development of facilities are in a sense the climax to a long-range program that began with the appointment of Dr. Dana L. Farnsworth, then of M.I.T., as director (and as Henry K. Oliver Professor of Hygiene) eleven years ago. Farnsworth led the long search for funds for a new building, planned it carefully, and has shaped the very-much-expanded facilities in his own image. Dr. Farnsworth himself is an institution. The recipient of about as many honorary degrees as anyone else at Harvard, he is widely regarded as the "dean" of American college health care. He has collaborated in a series of health textbooks for the grade schools and a progressive text for the teaching of hygiene in college, and is the author of countless magazine articles. Dr. Farnsworth's office has him booked for an incredible number of speeches--to audiences of all degrees of sophistication. (Recent ones included an address before the annual meeting of the American Orthopsychiatric Association and a commencement speech at New York's Horace Mann School.) He has been a leader in the aggressive attempt to integrate psychiatric services into college health operations.

But the presence of outstanding facilities and personnel does not save the University Health Services from having manifold problems--some inherent in the operation of a clinical, depersonalized institution, others resulting from the close juxtaposition of the Health Services and the Medical School, and most from the fact that this is, after all, Harvard.

Most student complaints involve dissatisfaction with the open clinic operation; there are complaints of long waits, and diagnoses that vary with the doctor one sees each time--perhaps several different one in the course of a single week. Continual dismay with the clinic arrangement, on the part of both patients and doctors, led to an intensive campaign last year to establish an appointment system. A flyer distributed in Holyoke Center urges students, faculty, and employees to "choose your own doctor" and "whenever possible make an appointment to see him. In other words use these to see him. In other words use these facilities just as you would use you medical facilities at home." This system has, for the most part, been successful; there are now many more hours spent by staff physicians on appointments than in the walk-in clinic. Some doctors, however, seem to prefer the clinic arrangement, and patients have not been thoroughly cooperative; about 20 per cent of the appointments for the special visits of dermatologists are not kept, for example.

When complaints do become specific, they usually refer to a particular experience, when a diagnosis was wrong or a student was in extreme danger. The Health Services is invariably able to discuss the difficulty in presise detail and explain the problem quite reasonably. But as Dr. Farnsworth points out, anyone is likely to blame even his family doctor for an error, and the frame of mind induced by a communal medical setup only tends to exaggerate the anger.

Some areas of the Health Services receive high praise; while the admissions policy often seems to be peculiar strict, Stillman Infirmary gets raves from most people who have spent any time there. The nighttime emergency services, however, are commonly distrusted and characterized as too understaffed and unconcerned. Perhaps the most serious criticism is that the Health Services does not have an ambulance and sometimes appears unequipped to handle emergencies; house calls are made under only the gravest circumstances. 'Cliffies complain of the rather long walk from the quad to Holyoke Center when they are ill during the winter months. When they have called, they were merely told to take a taxi.

Whatever the extent of the difficulties, one of the most impressive aspects of the Health Services is its perpetual self criticism and its encouragement--even active recruitment--of complaints from patients.

If there are problems of adjustment to this kind of medical care for students, there are difficulties for the doctors as well. It is difficult to pinpoint the reasons a physician might have for choosing college health service over a generally more lucrative practice. Appointments to the staff are made in a similar manner to Faculty appointments; there are physicians, associate physicians, and assistant physicians. Most conduct private practices on the outside, within limits set by the Corporation. It has been suggested that one reason these doctors have chosen this form of practice is that they would be unhappy with the political views of many of their colleagues on the outside; approximately half of the staff members belong to the American Medical Association, but almost all apparently disagree with some AMA political positions. One observer commented that these men had essentially made a commitment to a form of "socialized medicine" which the AMA fears on a national scale.

The variety of activities that go on within Holyoke Center and the other branches of the Health Services is astonishing. There has been an increased preoccupation with research over the past few years, and the Harvard Student Study is now in its seventh year of research under grants from the National Institutes of Health. Novel new projects have begun, and one task force is now studying the extent to which athletes use the psychiatric service--focusing on the kind of sport in which each person engages and the length, type, and treatment of his illness.

According to the 1963-64 annual report of the University Health Services, the activities of the psychiatric service have changed very little over the past few years. The report explains:

The main purposes of the service are to furnish emergency and diagnostic care to those who desire it, to aid in the resolution of crisis situations based on emotional disturbances that may arise anywhere in the University, to furnish brief psycho-therapy to those who may readily surmount their difficulties with timely help, and to aid those in need of long term treatment to find a suitable therapist. Many students who need extended treatment and cannot obtain it elsewhere are treated in the Department to the extent that available time permits.

Five years ago a CRIMSON feature reported that the old skepticism toward psychiatry frequently noticed in the Harvard Faculty was disappearing; professors just weren't saying "Those damned psychiatrists want to run the University" any more. The ascendancy of psychiatry represents a deeper recognition of Dr. Farnsworth's theory that educational institutions have a responsibility to care about the emotional development of their students. As he once put it, "education and educators should acknowledge that skill in handling emotional conflicts and tensions and the training of character are just as important as traditional subject matter."

In 1963-64, UHS psychiatrists saw a total of 1411 patients in 7251 visits. Many of these were routine interviews for entering students in certain graduate schools, but there has been a sharp increase in the service administered to others over the years. (In 1958-59, only 1013 patients saw psychiatrists in 5528 visits; there were only slightly fewer psychiatrists on the staff at that time.). Last year's visit included 408 Harvard undergraduates and 159 at Radcliffe, or 8.6 and 13.7 per cent of those eligible, respectively.

Some perpetually alert Harvard critics have been quick to point to Harvard's propensity to admit neurotics, but the reasons for the increase appear to be subtle. The annual report utters the comforting pronouncement that while the number of students who did require admission to a mental hospital increased by 25 per cent (from 20 to 25), "the reasons for the increase are not clear; no significant new distressing factors were evident." Most people's problems were apparently solved with some ease; "usually five to ten interviews spaced at weekly intervals served to resolve their immediate difficulties or at least to modify them favorably." Techniques used by the psychiatric service are presumably the same as in private practice, despite the attempt to keep the number of visits per person down. "Always with scrupulous regard for privacy and confidentiality," reports the annual summary, "all staff members spend much time consulting with parents, roommates, friends, Faculty members, tutors, deans, and others who are involved in the quandries of any particular person."

Particularly because of the increased attention to mental and emotional health, the University Health Services has come to play a crucial role in all areas of University life. Regular conferences are held between the members of the Administrative Board of deans and the psychiatric service. Dr. Farnsworth sits as a member of the College AdmissionsS-1