Dr. Robert W. Gibson remembers well his initial meeting with the Board of Trustees at the Sheppard and Enoch Pratt Hospital. It was 1963 and he had just been promoted by the board from clinical director to medical director -- the title, in those days, of the hospital's chief executive officer.
He'd spent his whole career as a psychiatrist in public and private hospitals and was convinced that the stagnant feeling which seemed to pervade Sheppard -- "it just seemed to be going no place," is how he remembered it -- was more a product of lack of vision than anything else.
He wanted to divert the trustees from their tentative plans to sell the hospital that had been born out of the vision of Baltimore entrepreneur Moses Sheppard more than a century earlier.
To bring some Knute Rockne-like flair to his first meeting, Dr. Gibson had been studying one of Peter Drucker's management books in which he described the fatal flaws that had ruined the railroad business. They had made the colossal mistake, wrote Mr. Drucker, of believing they were in the business of running a railroad and not in the business of transportation or communications -- concepts that by their nature suggested a sympathetic understanding of their riding public.
It was just such a point Dr. Gibson hoped to make, that Sheppard needed to broaden itself and take more notice of the world around it, and especially to develop a new attitude of understanding toward the people it served.
"And so," Dr. Gibson recalls, "I said to the board at that first meeting, 'The greatest mistake we could make is to think we were in the business of running a psychiatric hospital.' "
He waited a moment as the words sunk in.
"I still remember the look of despair on their faces," he smiles. "It was as if to say, 'What have we done? Where did we get this idiot?' "
Now, almost 30 years later, the idiot is finally retiring, but with a much rehabilitated image. For it was largely the vision of Dr. Gibson that transformed Sheppard from a 19th century-style asylum into a 21st century comprehensive psychiatric hospital, nationally known and locally appreciated for its non-railroad approach to things.
Only the fourth chief executive the hospital has had since it accepted its first patient 100 years ago, Dr. Gibson will officially relinquish his title as president at the end of the year. He will be remembered for having opened Sheppard to volunteers and for establishing an outpatient department, allowing patients for the first time to come and go from hospital grounds.
Early on in his tenure, he ended the practice of custodial care, the long-term warehousing of treatment-resistant patients. Today Sheppard has a reputation for its effective treatment of the most difficult mental patients, and receives admissions from across the country.
Over the years Dr. Gibson expanded his psychiatric residency program and his medical staff. He took the hospital into the world of Employee Assistance Programs -- the counseling of employees for various businesses nationwide. The EAP program located in the hospital's new education center, a building equipped with its own TV studio and lecture hall from which Sheppard prepares programs, lectures and classes aimed at educating the public in everyday topics like depression or family stress.
When his colleagues warned him against advertising -- "Gee, don't advertise, they'll think you're in trouble," -- he put out the first annual report the hospital had published in 60 years and sent a copy to every psychiatrist in the country. "It wasn't very long before everyone knew about Sheppard Pratt," he says.
And whereas the pre-Gibson Sheppard Pratt saw very few patients under the age of 19, he began to notice that more and more young people were presenting themselves for care. He created an adolescent unit that today occupies an entire building and also has a fully equipped and accredited kindergarten through 12th grade school on the 105-acre campus. Half of its students are in-patients and other half are bused in daily.
Among his more novel accomplishments, Dr. Gibson made Sheppard the first and only private psychiatric hospital in the nation to run a public community mental health center -- operating one of Baltimore County's five centers.
"I was like a kid with a Montgomery Ward catalog," says Dr. Gibson. "I wanted to provide the broadest possible range of services to the mentally ill. Our world was wide open. It seemed like there were all kinds of things that could happen here."
THAT, ANYWAY, WAS THE hope of Moses Sheppard, the prune-faced philanthropist who turned his attention and wealth to the plight of the insane in the midst of the 19th century.
As a Quaker, Sheppard believed a man's life was his best testimony; as a shrewd entrepreneur he believed a penny saved was even more stimulating than a penny spent. Many thought his bachelor status had something to do with it being cheaper to remain unmarried. He was clearly a man whose life was his job and whose job was his hobby.
He had first viewed and sympathized with the mentally ill in his capacity as warden of the poor of Baltimore and then as commissioner of the city jail. In those days, almshouses were the joint holding pen of the indigent and mentally disturbed. Conditions in such facilities were stark at best. Reformers like Catholic activist Dorothea Dix helped convince Sheppard that the mentally ill deserved better, and after touring modern asylums in Europe he declared in 1853 that he would build a haven for the insane in Baltimore.
"If but five insane persons could be restored to health, or even four, nay, if but one recovers," he wrote, "I shall feel I have not lived in vain."
He died in 1857, leaving about $500,000 to the establishment of his asylum. He also left a warning: Spend only the interest, not the principal. In those days the half million generated about $34,000 a year. It was enough that within two years the board of trustees bought the 377-acre Mount Airy Farm in Baltimore County between York Road and Charles Street for $70,000.
It would be four years before the first brick of the Sheppard Asylum was laid, and 34 years altogether before the structures were ready to accept their first patient. In the meantime the board husbanded its endowment, meeting regularly -- although one year they had only enough money to purchase doors.
The original design of the two principal hospital buildings called for tall, squat chimneys connected to fireplaces on each floor and meant for heating. But the buildings took so long to erect that by the time they were finished, central heating had been perfected and the fireplaces were redundant.
Sheppard's desire was for a frill-free asylum, and he was insistent that the structures be solid enough to reassure anxious patients they would not blow over in a stiff wind. "I wish the buildings to be fireproof," he told a friend, "and for no patients to be confined under ground, but all of them to have privacy, sunlight and pure air, every patient to have an attendant or companion. I wish everything done for the comfort of the patients that the ratio of cures may be increased."
Meanwhile, in 1896, Baltimore's most famous philanthropist, Enoch Pratt, benefactor of Baltimore's Enoch Pratt Free Library, died and left $1.6 million to the asylum. Like Moses Sheppard, Pratt was a careful man with a dollar and had been impressed with the frugal way the board of trustees was administering the asylum. But unlike Sheppard, who only reluctantly attached his name to the endeavor, Pratt left his fortune with one significant string attached: that the name be changed to include his own.
One trustee resigned in protest, but the bequest and request were accepted. Not only was Pratt's full name added, but so too was the word Hospital. The word asylum had developed a negative connotation over a half century. Once considered a place where patients were protected from society, it was now seen as a place where society was protected from patients. Still, the name change sparked rumors that the "hospital" was being turned into "a madhouse," and in spite of official denials and reassurances by newspaper editorials, public wariness of Sheppard remained for decades. It was certainly enhanced by the brooding architecture of the main buildings, which resemble something from a Bronte novel. Most people, though, seldom saw those buildings and based their impressions of the hospital on the equally Gothic nature of the Gate House on North Charles Street, along with a white fence that once surrounded the heavily wooded boundaries of the grounds.
"I've been told by people who grew up around here," says Dr. Gibson, "that you were warned, 'Do not cross that white fence. There is danger there.' As a result there was no interaction with the community."
And yet, very quickly, the hospital set the late Moses Sheppard's soul at rest, reporting in 1908, for instance, that of 282 patients seen that year, 52 were "entirely recovered and restored to reason." This was double the number from the 1903 report. Dr. Edward N. Brush, the hospital's first physician-in-chief, wrote, "While there has been no sensational discovery as to the treatment of insanity . . . the increasing proportion of recoveries is evidence of the success of the modern methods of treatment."
Those methods were largely based on sympathy and understanding, for the miracle drugs like Thorazine hadn't been invented. But techniques like a wet pack -- wrapping a disturbed patient, mummylike, in wet sheets, producing a soothing, soporific effect -- worked well and are still used today. As is the idea of Dr. W. R. Dunton, who essentially invented occupational therapy at Sheppard by keeping patients constantly busy with basket weaving and woodworking and embroidery, along with a steady schedule of recreational pursuits.
Even so, most patients who came to Sheppard were there for the long term. They signed authorizations allowing for the storage of out-of-season clothing. Weeks and months would pass before any kind of specific treatment plan was worked out for a new patient.
By 1960, when Dr. Gibson arrived as clinical director, there were 700,000 people in mental hospitals in the nation, the majority doing nothing more than vegetating. At Sheppard, for instance, half of the 200 patients had been there for more than 5 years.
"If you look at the way things operated here, even in 1960," said Dr. Gibson, "it was more like an asylum than a hospital. It was a protection, a closed community. I said, 'Why not have a volunteer department?' They said, 'Oh, that would be bringing in outsiders.' I said, 'Why not have outpatients?' They said, 'Oh, then you would have people coming and going from the community.' "
But things were changing in the world of psychiatry. Thorazine was hailed as not only the cure-all for mental patients, but the drug that would put an end to psychiatric hospitals altogether. The age of deinstitutionalization was on.
"There was a belief here of two things," he says. "Drugs would empty the hospitals and community mental health would change the locus into the community. There was almost the attitude here of 'Don't stir things up too much.' The physical plant had been allowed to deteriorate and there was a lot of uncertainty about the future. My predecessor put forth the idea of selling the grounds to Towson State University and building a small research hospital."
The drugs, meanwhile, had been effective for many patients, but a significant number proved to be treatment resistant. Things got much tougher for these patients as they moved into the community and found support systems less than had been promised. A lot of patients began slipping and soon were heading back.
In spite of the uncertainties, Dr. Gibson had been impressed with the potential at Sheppard. "We had 400 acres. [They have since sold it down to 105 acres.] We still had a good reputation. We had a good teaching program. We were near Washington and the National Institutes of Mental Health and we had an endowment of $7 million."
His first action on assuming the medical director post was to create an outpatient department. When he accepted Baltimore County's offer of a grant to run one of its community mental health centers on the grounds, he met with resistance from staff members who feared the public influence would limit them. "There was a tendency to be restrictive," he says, "but I persuaded people that we should accept the grant, and become part of the community."
He even had new ideas regarding finance.
In 1963 Sheppard's daily rate for a patient was $25 (it's about $500 today). "We were considered cheap," he says. "The typical hospital charged $50. I remember the first budget. We were basing it on 250 patients a year times $25 a day times 365 days. I said, 'But we are only getting 210 patients a year.' They said, 'Yes, but we don't want to upset the board.' "
It turned out the board each year voted a supplemental budget, meaning the hospital had been regularly working with a deficit every year.
"I said, 'We aren't going to do it that way anymore.' I said, 'Let's go with 210 patients at $30 a day. The trustees were concerned. They said, 'Gee, will anyone pay that?' I said, 'They're paying $50 everywhere else.' By that simple act I became known as a financial genius. We went from a deficit to a break-even point. Suddenly we became solvent, and they'd long since forgotten about selling the place."
TWENTY EIGHT YEARS LATER, Dr. Steven Sharfstein is preparing to do as Dr. Gibson and Sheppard's three other chief physicians have done since 1891 -- move his family into the house built on the hospital grounds for the No. 1 man. In December Dr. Sharfstein, currently the medical director, will assume the hospital's presidency.
"Bob did a masterful job moving the old asylum mentality along, in providing modern treatment," says Dr. Sharfstein. "He linked up the hospital with the public, and we are now well positioned as a hospital that provides quality treatment to a range of disorders."
There is a "but" in his voice.
"We are facing major challenges, new realities, new economic realities," he says. And they have less to do with the treatment of the emotionally disturbed, he says, than they do with paying for it.
"What we are confronting is a change in the perspective of the paying community." This is the euphemism for the federal government, third-party payers and insurance companies who have traditionally reimbursed hospitals for much of their costs. "Their perception is that medical care costs too much, that hospital care is too costly."
A large number of Sheppard's patients come from general hospitals, outpatient clinics and other places, where patients haven't responded to short-term care in the first line of therapy. "These are treatment-resistant patients, and they come here for lengthy treatment at a time when the payers are saying they don't want to pay."
But, he says, Sheppard has developed effective treatment programs for such patients. "Although we provide acute psychiatric care, where we are unique is our complex diagnoses and treatment of long-term care and difficult-to-treat patients. These patients, who will get better, not well, need ongoing treatment."
Sheppard's Mount Airy House, for example, houses 16 patients in what is called a "quarter-way" house, a setting where people learn to live and cook and care for themselves in a semi-independent, supervised setting on the hospital campus. The hope is that they would one day move out to a half-way house, off campus, the last bridge between their supervised care and ultimate independent living.
The problem is that programs like Mount Airy House, which cost about a quarter of regular hospital care, aren't covered by many insurance companies, although some, on a case-by-case review, have been willing to "flex" their benefits.
It leaves a hospital like Sheppard in a frustrating position. In 1960, when things were at a standstill in mental health, the hospital took in perhaps 150 patients a year. Now, with modern advances in the mental health field, Sheppard admits 2,500 a year -- almost double the number from just five years ago.
Much of that, says Dr. Sharfstein, is because the stigma of being treated for emotional illnesses "is not gone but it is better. As you get more effective it makes people think it's in their interest to get care. We are much more effective than 50 years, even than 20 years ago."
Of the 2,500 who will be seen this year, about 1,700 will be short-term patients with stays of three weeks or less. The other 800 are intended to be long-term patients, some needing up to a year's worth of treatment.
In 1986 the average length of stay at Sheppard was 70 days, but that has dropped to 35 days -- a direct result, he says, of "the payers pressuring patients out of beds." And that pressure affects all patients, not just the long-term variety.
"In psychiatry there is a clinical gray zone, a clinical uncertainty," says Dr. Sharfstein. "We can disagree about when does a suicidal patient leave. Everyone will agree the patient is in a major depression. He's beginning to improve. But is the patient safe? It's a very delicate clinical judgment call."
In many cases, "patients are denied the benefits when we feel they need to be in a hospital. It is much more problematic with severely ill, long-term patients. They are getting hurt the most."
Thus he spends much of his time searching out new "financial mechanisms" for payment. One idea is to disengage from the traditional fee-for-services approach and create a kind of health maintenance organization whereby the hospital assumes financial and clinical risk for a group of patients, much as HMOs do now for mainstream health coverage.
Whatever happens, says Dr. Sharfstein, "there is reason to hope because overall there is much more of an appreciation of mental illness and an acceptance in the community at large. And there is a recognition that psychiatry is much more a medical specialty with more to offer."
THIRTY YEARS AGO, SAYS DR. Gibson, "you had the choice of going to see a doctor -- usually just a general practitioner -- in his office or being hospitalized. There was nothing in between."
Today at Sheppard, where a white fence once kept people away, thousands come to the grounds each year to participate in classes or seminars on issues related to emotional upsets.
"Most people, if you asked them what is your hospital, would say GBMC [Greater Baltimore Medical Center] or St. Joseph's," he says. "But no one says Sheppard-Pratt. We have no constituency. But this is a way we can get people to relate to us.
"Ten years ago, if I was introduced to someone and said I worked at Sheppard-Pratt they would have said, 'Oh, yeah. I used to drive by that gate house. I've never been through it and hope I never will.' Now if I am introduced to someone, they would most likely say, 'Oh, yeah. I was at a conference there about father-daughter relationships.' And their reaction: 'My God, it wasn't what I expected a mental hospital to look like.'"