UP CLOSE | At Yale Health, a differential diagnosis

Henryehrenberg_yale-health-3
Photo by Henry Ehrenberg.

There are few events shared among the majority of Yale’s undergraduate students. Most will dance around Old Campus next Saturday for Spring Fling. Many will make their way to Toad’s, if only once. And during their time at Yale, most will visit Yale Health.

Yale Health’s Mental Health & Counseling services have long been at the center of campus dialogue. But of Yale Health’s 132 staff and affiliated physicians, 107 do not treat the mental health needs of the Yale community, and instead serve students in the institution’s over 35 other medical departments.

Conversations with nearly three dozen students and administrators, as well as an online survey of 368 undergraduates reveal significantly lower satisfaction with MH&C than with other departments.

Students interviewed identified very different problems with Yale Health than administrators — so it is unsurprising that the two have also arrived at different solutions.

When seeking treatment at Student Health and specialty departments, students find themselves glued to waiting-room chairs, sitting longer than they think is reasonable. But Yale Health administrators interviewed are unaware of these complaints.

When students seek MH&C services, they bemoan the time spent between seeking treatment and walking into their first therapy session, a period significantly longer than in other departments. They report longer waiting times than administrators’ data reveal. And while they think MH&C needs more physicians, administrators are less convinced.

Though recently published grievances against Yale Health have centered on quality of care, based on interviews with 34 students, these incidents appear more the exception than the rule. Indeed, quality of care seems less an issue than getting care at all.

When asked about Yale’s progress on mental health issues, University President Peter Salovey said gathering data will be central to driving future efforts.

“I’d very much like to move beyond anecdotal and impressionistic understandings, and toward understandings of the challenges and the solutions and toward ones that are rooted in some kind of empirical evidence. ”

 

WAITING TO BE CALLED 

Kim Huang ’17 was less than thrilled. First, she had fallen on ice and hurt her knee. Then, she had made her way to Yale Health’s Acute Care department only to wait for an hour before being seen. This was on a Friday. When she finally crossed the threshold of the doctor’s office, she was informed that the earliest available X-ray appointment was the following Tuesday. It would only take 30 minutes, the staff said, but because they forgot to submit an X-ray request on Friday, Huang ended up waiting four hours.

Only a small portion of students interviewed and surveyed recounted experiences with non-mental health services as extreme as Huang’s. However, many expressed frustration with how long they waited before seeing a physician.

It is not that it is difficult to secure an appointment with Student Health. In fact, 79 percent of students surveyed said they felt the length of time they waited between scheduling and walking into their appointment was “reasonable.” But many students interviewed said the time they spent sitting in waiting-room chairs before hearing their names called was simply too long.

Colleen McCormack ’17 is one of those students. She had spent the morning vomiting, and assumed she would be treated immediately. When she waited for two hours, McCormack said she was beyond frustrated.

Andrea Villena ’15 had a similar experience. For two hours in the waiting room, Villena watched as doctors passed her and headed to lunch. She left with a poor impression of the department.

According to students interviewed, the wait problem is especially prevalent in Acute Care. After jumping off a few stairs and hitting his heel, Peter Nguyen ’15 needed an X-ray. He heard his name called three hours after arriving at the department. Other students interviewed recounted unreasonably long wait times in the Acute Care Department.

Of Yale’s roughly 5,400 undergraduates, approximately 700 are assigned to one doctor, John James, assistant chief of student health and athletic medicine. Most athletes interviewed appreciated having a doctor who understands their medical history. But five of ten athletes interviewed also said that hiring a single physician for 700 athletes, many of whom need more frequent treatment than the average student, is nonsensical.

“It’s absolutely outrageous that out of every single [doctor] at Yale, we’re only allowed to see one,” said Matt Nussbaum ’15, a runner on the men’s track & field team. “There’s a real feeling among athletes that Yale Health is entirely inadequate.”

James Shirvell ’14, another member of the track and field team, echoed Nussbaum’s sentiment. James is knowledgeable and helpful, he said, but he is completely overworked.

“No matter how qualified a person is, that’s just a lot of people to treat without getting burnt out,” said Liana Epstein ’14, a member of the Women’s Cross Country Team.

Rigsby said it is not true that their Yale Health resources are limited to James, contrary to some athletes’ beliefs. If an athlete has a sports-related injury, James is the first stop. But for a sore throat, they can just walk into Student Health like any other Yale student. Still, if an athlete needs to see a specialist, he or she must first get a referral from James, Genecin added.

While undergraduates are not wholly satisfied with their Student Health and specialty department experiences, the data collected by the administration paints a different picture. Yale Health’s internal patient survey data show high satisfaction rates that consistently fall in the 80s and 90s on a 100-point scale, Rigsby said.

In a News survey asking students about their experiences with Yale Health that was sent out to 1,600 students and answered by 368, student satisfaction across departments fell within the mediocre mid-4 to mid-6 range on a 10-point scale.

When asked about the negative experiences of students like McCormack and Villena, Rigsby was surprised.

“Waiting two hours after an appointment time would be an extremely unusual circumstance,” he said. “I’d like to hear from people who have experienced this, so we can see what went wrong.”

 

STRENGTH IN NUMBERS?

According to Yale Health administrators, the issues facing student health are few and far between. But according to students, the unreasonable time spent in waiting room chairs points to a need for more staff.

“The phrase ‘understaffed’ comes up in every [conversation about Yale Health],” Simone Policano ’16 said.

And the majority of students interviewed who gave suggestions about how to improve services recommended hiring more physicians. To them, it is mostly a numbers game.

Athletes in particular think that Yale Health needs more physicians.

“Think about it — there’s one doctor for every single athlete at Yale,” Nussbaum said. ”Do you really think we don’t have the money to get additional doctors?”

To Genecin and Rigsby, it is not money that matters — in both Student Health and Athletic Medicine, they simply do not see understaffing as an urgent problem.

Though Genecin said in an email that Yale Health is “recruiting in Student Medicine and [anticipates] some growth in other areas based on increasing demand,” he emphasized that students’ perceptions of staffing problems are incomplete.

Rigsby added that access and wait time are more complicated than staffing levels.

“They’re generally one part of that puzzle,” he said. “In student health, we’re pretty comfortable with what our staffing levels are currently.”

When asked what patient concerns Student Health had recently addressed, Risgby spoke about rolling out lower barrier STI testing and extended clinic hours. Just last week, Yale Health held its first rapid STI testing clinic, providing patients with test results in 20 minutes.

Student Health now holds extended evening hours throughout much of the academic year. Paradoxically, they are underattended, he said.

But of the 34 students interviewed, none mentioned reducing barriers to STI testing as a pressing issue at Yale Health, and only one said she would like to see longer clinic hours.

 

THE DATA DIVIDE

In December 2012, Robert Peck ’15 was optimistic about beginning therapy at Yale Health. After his preliminary MH&C assessment, he picked up the phone and called the receptionist desk to schedule his first therapy appointment. The receptionist said she would make sure to get him an appointment within two weeks to catch him before he left for winter break.

The promised appointment never came, said Peck, a former staffer for the News. When he followed up after break, MH&C staff said they did not have an opening for the next three to four months. Peck never began therapy.

Another student, who requested anonymity out of a desire to keep her mental health issues private, said that MH&C had yet to assign her a psychiatrist five weeks after intake. She called the desk to follow up, and the receptionist said she would leave a message with her intake doctor. The student waited another five days before she heard from the psychiatrist.

Students surveyed reported significantly lower satisfaction with mental health than other departments. Sixty-five percent of respondents said they felt they had waited an unreasonable length of time between calling in to schedule an appointment and walking in for intake, compared to an average of 34 percent across other departments surveyed.

In contrast to non-mental health departments, where students and administrators are talking past each other, the two groups have started to engage in meaningful dialogue on mental health.

Salovey said the University Cabinet had a “substantial discussion” about the topic on its last retreat, and that although the Yale Corporation’s deliberations are confidential, it has also been involved in the discussion.

Chief Psychiatrist at Yale Health Lorraine Siggins did not respond to multiple requests for comment.

On March 31, Genecin reached out to the undergraduate student body, announcing three initiatives to improve dialogue with the Yale Health administration. This month, four residential colleges are hosting “listening sessions” for undergraduates to share their MH&C concerns with administrators. Genecin also announced the creation of a student advisory committee that will serve as liaison between students and administrators. MH&C will also improve its website to make resources more accessible.

Genecin knows that though there may now be more communication between students and administrators on mental health, the two groups still fail to see eye to eye. He understands that students are frustrated with the length of time they have to wait between scheduling and walking into an appointment, and he is trying to understand the underlying reason.

“For many years, we’ve rightly prided ourselves on our mental health services,” Genecin said. “We’ve been validated by visiting committees and corporations. When we look at [our mental health services], and when students look at [them], we see different things. So why is that?”

It may be that, listening tours and meetings with the newly created Mental Health Student Advisory Committee aside, some of the most important issues facing students — how long they are waiting between scheduling and intake, and between intake and initial therapy appointment — are not perceived to be as severe or pressing as students feel they are.

According to Genecin, a student will wait on average a few days between scheduling an intake appointment and walking into the appointment. The average wait between intake and first therapy appointment is around one to two weeks, he said.

Students surveyed told a different story. In their experience, the average wait time between scheduling and intake is much longer —around two and a half weeks. While some students surveyed waited only four to five days, others waited a month. The discrepancy in data suggests why students and administrators are proposing different solutions: they are simply not seeing the same problem.

Still, even when students’ concerns are clearly communicated, the challenge does not end.

“It doesn’t matter if they’re talking about their course work, the accessibility of faculty, whether courses are easy or hard to get into — everyone in higher [education] does struggle with how do you get information from students that’s actionable,” Genecin said. “We don’t think the waiting time [before intake] is too excessive. We think that students don’t come in with a good set of expectations based on what we’re providing.”

 

THE COMMUNICATION GAP

Students interviewed said they believed improving MH&C services largely hinges on hiring more physicians — larger numbers means quicker care, they said.

But Genecin is quick to push back against this belief.

“There’s a perception of a staffing issue being the be-all, end-all,” Genecin said in late March, soon after announcing his three mental health initiatives. “It’s more complicated [than that].”

Answering his own question about why students and administrators have drastically different perceptions of MH&C services, Genecin offered two ideas.

First, the process of accessing services is opaque. Many students are unaware that their first appointment is an intake appointment — the therapist or social worker is not there to help them address their problems, but simply to figure out what they are. And the wait between intake and the first therapy appointment, even if only two weeks, can feel like an eternity in a 13-week semester, especially when unexpected, Genecin said.

Second, many students believe their mental health challenges will be solved immediately, without any personal effort.

“You find out in therapy that the person who does the work is you,” Genecin said. “There isn’t really anybody you can go to [at Yale Health] who actually will be a life coach to tell you what to do about your roommate or how to deal with the fact that you didn’t get this or that that you wanted.”

Genecin thinks the solution to these issues lies in better management of expectations, an approach that universities have historically not considered.

Yale Health needs to follow the lead of more sophisticated companies that successfully manage expectations, he said, offering a hallmark corporation as an example. At Disney World, customers are told to expect waiting a few hours in line. When customers end up waiting only an hour, they are elated, Genecin explained.

Ernest Baskin GRD ’16, the Chair of the Yale Health Member Advisory Committee and one of its three student members, echoed Genecin’s statements. He added that while students may be frustrated with mental health wait times, it is important to keep in mind that those at Yale are significantly better than those at other institutions.

Echoing Salovey’s call for empirical evidence, Vice President for Student Life Kimberly Goff-Crews ’83 LAW ’86 said in an email that success going forward hinges on having the right information.

“The largest challenge ahead is one currently faced by all institutions of higher education — we do not yet have enough evidence to support and denote which practices are most effective at improving student mental health,” she wrote.

To Genecin, who will hold his final mental health listening session on April 24, gathering the necessary information and bridging the divide in understanding will be a collaborative process.

“There’s a big communication gap,” Genecin said. “We need a lot of help with that from our students.”

 

“THE REAL SHAME”

In Student Health and specialty departments, students and administrators are not talking over, but rather past each other. And in MH&C, where administrators have at least heard students’ concerns, neither can agree on the severity and extent of the problems facing patients.

Students interviewed expressed concern with wait times, both in the waiting room and between scheduling and walking into their appointment. But most said that once they crossed the threshold of the doctor’s office, their sagas of frustration ended.

Epstein said she worries that these barriers to entry could keep students from seeking care.

“It’s really discouraging because [Yale Health offers a] beneficial service, but if people think they’re going to have to wait a really long time, they’re not going to go,” she said. “That’s the real shame.”

Comments