AMA member Meghan M. Schott, DO, is a rare specimen. While there are some 10,500 practicing child and adolescent psychiatrists in the U.S., precious few of them—maybe only a dozen or so—work exclusively in emergency departments. On top of that, Dr. Schott knew she wanted to become a child and adolescent psychiatrist all the way back in seventh grade.
“At first, I wanted to be a teacher, but when I tried teaching math to my little brother, he just didn't get it, which made me so mad and I thought there was no way I could do that professionally,” Dr. Schott said. “Around the same time, I happened to be really into nonfiction and was looking into self-help books at the library. There on the shelves next to self-help was psychology, and I remember picking up a Freud book and thinking, ‘This is great! This is what I'm going to do!’”
Working in the ER was another story.
“I thought I was going to hate the emergency department, but I have ADHD [attention-deficit/hyperactivity disorder] and didn't realize until medical school that I need constant stimulation,” she said. “I can't just sit in an office knowing exactly what's going to happen every day. I’d be bored out of my mind.”
At the 2023 AMA Annual Meeting in June, she took time out from her job as medical director of psychiatric emergency services at Children's National Health System, in Washington, to serve as an alternate delegate to the AMA House of Delegates representing the Medical Society of the District of Columbia.
She has since joined the AMA Ambassador Program, which equips members with the skills and knowledge to confidently speak to the AMA's initiatives and the value of membership.
In an exclusive Q&A, Dr. Schott discussed the biggest physician advocacy issues she sees in practice. At the top of that list: Helping other doctors understand what kids presenting with mental health challenges are up against.
AMA: How did you get involved in physician advocacy?
Dr. Schott: I went to Oberlin for my undergrad, and that school is really into policy change. So I did a little bit of advocacy work there, but my first job was in Denver, where I did some work to prevent marijuana from being approved for autism spectrum disorder.
Then I came to D.C., and because of my work triaging kids in the emergency department, I came to understand what's going on in the community, like how do referrals work? What’s child protective services doing? How are police handling mental health?
I'm almost like a community psychiatrist who’s not really in the community. When I arrived, people were upset with me because I was changing who was and wasn’t being admitted in an effort to help with the boarding crisis.
AMA: The boarding crisis is not a new thing, but some outside of emergency medicine and psychiatry might not know what exactly is going on. Can you summarize the situation nationwide?
Dr. Schott: Once a child or an adult is slated for admission in the emergency department, boarding is the amount of time it takes for them to get a bed. It doesn't matter if it’s a psychiatry bed or anything else. The Joint Commission has said that anything more than four hours is considered boarding, yet historically psychiatric patients are boarding for days or even weeks on end. And the situation is even worse in child psychiatry.
Unlike a lot of medicine, child psychiatry is an art. True, much of it works on an algorithm, and in some places when you say suicidal ideation, you are guaranteed an admission. But sometimes that can worsen the prognosis because the patient is always suicidal.
When people ask me how I make that decision, I don't have a short answer because it's really about taking into account the whole system and the whole child. I'm relatively risk-tolerant in sending kids home because an inpatient admission is not without its problems. For example, you can't be with your parents. You're missing school. And if you're sitting in a hospital not getting treatment for a week, did the crisis really pass?
AMA: It sounds like a difficult job.
Dr. Schott: I jokingly say my job is to make everyone mad because parents often want their kids to stay in the hospital because they're doing something offensive or violent, and they're afraid to take the child home. But I tell them I can't fix a problem that's been running for 16 years because, say, you took away their cellphone.
AMA: Speaking of that, cellphones and social media seem like some of the biggest challenges facing kids these days in terms of their mental health. Is that a correct assessment?
Dr. Schott: Even before the pandemic, I would say phones were responsible for about 50% of the kids coming into ERs suicidal, and it wasn’t just from being bullied on social media, but also from their parents taking away their phones. They perceive their phones as their lifelines, and they're at a loss without them and will overdose or get in a fight or something without them.
But it’s not just phones that kids are up against. When the pandemic hit, some kids really thrived because they previously had been getting bullied in school, and it was really helpful to be away from that. Then others suffered because there wasn't anything to do at home. Not going to school creates problems with socialization and actually feeds depression.
Add to that, during the pandemic we saw a decrease in abuse cases being reported because the No. 1 reporter is school. Some of the kids who came in were almost dead. So there was no one right answer for everyone.
AMA: What do you most want other physicians to know about child and adolescent psychiatry and how they can help kids in crisis?
Dr. Schott: Don't be afraid of mental health. If there's any sign of trouble, try to get on every single waitlist right away and take whatever you can get—and then don't remove the patient until you find something else. It's going take forever to get anything. Along the same lines, don’t come to the emergency room thinking you can get patients outpatient care faster that way. I have no ability to move patients up on the waiting list.
Plus, a lot of these things—the basic stuff—can be handled in primary care, such as simple depression, anxiety and ADHD. There aren’t enough child psychiatrists in the world, so you have to be OK with treating mental health, especially the basic stuff.
Also, use your state-access lines. I think 40 or so states have them. HRSA [the U.S. Health Resources and Services Administration] has a webpage with contact numbers for each state, as well as a list of pediatric mental health care access resources.
