CHAPTER III
Professional Personnel
Malcolm J. Farrell, M.D.,and Ivan C. Berlien, M.D.
When the United States entered World War II, no professional specialty was fully prepared to participate in military medicine, but none was so ill-prepared as was psychiatry. Certainly, this was true insofar as numbers of available psychiatrists were concerned-before mobilization, there were fewer than 20 Regular Army medical officers with some training and experience in psychiatry. It was also true insofar as plans for mobilization and assignment were concerned. Although a neuropsychiatrist had been assigned to the Professional Service Division in the SGO (Surgeon General's Office) in August 1940, this officer had no responsibility for making plans and recruiting personnel for a program of psychiatric care. Indeed, it was not until August 1942, 7 months after Pearl Harbor, that a psychiatrist was assigned to serve as the chief consultant in neuropsychiatry to The Surgeon General to plan for the various aspects of such a wartime program (p. 29).
DISTRIBUTION AND UTILIZATION OF PSYCHIATRISTS
The proper distribution and utilization of neuropsychiatrists was one of the first problems facing the newly formed Neuropsychiatry Branch in 1942. This problem was intensified by the rapid expansion of the Army, which made it necessary for practically all Regular Army neuropsychiatrists to assume administrative and command assignments (p. 18), leaving psychiatric services without adequately qualified personnel.
In the haste to organize an army quickly, Reserve officers in the Medical Department were called to active duty and, often, without regard to specialized training,1 were assigned merely as physicians. Consequently, many psychiatrists were assigned to medical duties other than psychiatric, in spite of the fact that there was a serious shortage of officers qualified in this specialty.
To remedy this situation and to effect the desired distribution and utilization of this category of personnel, a card index was compiled, of the
1In 1942, the Surgeon General's Office did not have a current list of civilian psychiatrists even though, in May 1939, the Council of the American Psychiatric Association, foreseeing the need for such information, appointed a committee on military mobilization with Dr. Henry A. Steckel, Chairman, to make '* * * a survey of available personnel (NP).' On 16 October 1939, this committee met with The Surgeon General and presented a list of its findings. This list was also made available to the National Research Council.
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psychiatrists in the Army, giving such information as name, rank, organization, and duties, if known. Also, until the officer could demonstrate his ability, a professional rating, as listed by a special committee of the National Research Council, was used as the basis of his assignment. This rating list, drawn up by a group of leading psychiatrists, utilized the numerals I, II, III, and IV, as follows:
Group I consisted of outstanding specialists, well known nationally and internationally, who were competent to act at the consultant level.
Group II were neuropsychiatrists whose training and experience were sufficient to enable them to direct a hospital or service without professional supervision.
Group III were judged able to perform with a minimum of supervision.
Group IV required constant supervision.
Shortage of Psychiatrists
Even assuming proper assignment, there remained a serious shortage of adequately trained and qualified personnel. On completion of a survey on 13 August 1942, a total of 561 psychiatrists were found in the Army. Of these, only 51 were certified in psychiatry by the American Board of Psychiatry and Neurology; 38 in both psychiatry and neurology, and 4 in neurology. At the end of 1942, a total of 1,235 were listed in the files. Of these, 105 were certified in psychiatry, 89 in both psychiatry and neurology, and 16 in neurology. Many of the total number were psychiatrists only by virtue of their assignment to a psychiatric ward rather than their professional training and experience.
With so serious a shortage of well-qualified men and with the Medical Department expanding rapidly, including the fixed and numbered general hospitals and training centers, the Neuropsychiatry Branch was faced with the serious problem of not being able to place one qualified psychiatrist in each unit requiring psychiatric service.
Procurement
In an attempt to overcome these shortages, in May 1943, the Neuropsychiatry Branch wrote personal letters to over 100 neuropsychiatrists on the list of those certified by the American Board of Psychiatry and Neurology, stating the urgent need for men of their qualifications. A mere handful of replies, saying that the writers were in essential positions, was received. No psychiatrist was obtained through the medium of these letters. Some of these men preferred service in the Navy, Army Air Forces, or other Government agencies, such as the U.S. Public Health Service and U.S. Coast Guard, because of the poor publicity regarding
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proper assignment, poor personnel practices, and poor morale of psychiatrists in the Army.2
School of Military Neuropsychiatry.-Because prewar psychiatry was largely limited to institutions, the civilian pool was soon exhausted, and it became apparent that the Army would be compelled to train medical officers in order to meet the demand. Accordingly, the School of Military Neuropsychiatry3 was established. Its primary function, in the beginning, was to offer an opportunity for review and military orientation to newly joined, already trained or experienced, psychiatrists and neurologists. Later, it became an intensive training center in psychiatry and neurology for general medical officers to function, subsequently, as neuropsychiatrists.
The first class was enrolled on 20 December 1942, and by V-J Day, a total of 1,000 had been graduated. Without the graduates of this school, the work of psychiatry in the Army could not have been accomplished. Their enthusiasm, lack of prejudices, and, for the most part, freedom from self-esteem needs made them excellent assistants. Indeed, they were welcomed by the various psychiatric consultants who believed that for military purposes it was a good thing to receive young men with drive who did not need to 'unlearn' certain civilian attitudes and practices, but who could be molded to function as psychiatrists in the Military Establishment.
Although the graduation of medical officers from the school to a limited extent met the need for neuropsychiatric ward officers, the graduates were handicapped by lack of experience and needed supervision by mature men. For this reason, the relatively few experienced psychiatrists found their time largely consumed by board meetings, paperwork, and supervisory duties, leaving but little or no time for them to actually treat patients.
CLASSIFICATION AND ASSIGNMENT
Classification
The professional classification of psychiatrists by the National Research Council (p. 42), while most helpful in the early stages of the war, soon became antiquated, for the original ratings did not reflect the further professional development of the psychiatrists. However, professional classification in all medical specialties was in the process of receiving considerable attention from the Personnel Service of the Surgeon General's Office. Various criteria were used, and finally, definitions of medical officer pro?
2In January 1942, one of the country's leading civilian psychiatrists, Dr. Edward A. Strecker, had been asked by Maj. Gen. James C. Magee, The Surgeon General, to come on active duty and direct the Army's neuropsychiatric program. One of the chief reasons for Dr. Strecker's refusal of this offer was General Magee's lack of authority to control assignment of psychiatrists. (Personal communication from Dr. Calvin S. Drayer.)
3School of Military Neuropsychiatry, established at Lawson General Hospital, Ga., on 20 December 1942; moved to Mason General Hospital, Long Island, N.Y., in October 1943; Col. William C. Porter, MC, Director.
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fessional capabilities, including psychiatrists, were published in WD (War Department) Circular No. 232, issued on 10 July 1944. Included in the definitions were the letters A, B, C, and D to indicate the degree of training and professional proficiency of the officer.
Since professional consultants had already been appointed to the various service and oversea commands, these consultants could now use the standards as set forth in the circular of 10 July 1944 to evaluate the professional ability of the medical officers, as observed personally. The function of the psychiatrists having changed considerably during the war, this evaluation served several purposes, not the least of which was transfer to a higher classification or change of an initial classification which definitely had been inadequate.
Assignment and Misassignment
Throughout the war, constant effort was required to maintain psychiatrists, especially younger men and graduates of the School of Military Neuropsychiatry, in neuropsychiatric work. As the war progressed, and more and more medical officers were required for combat units, these young psychiatrists were often lost to neuropsychiatry by their assignment to combat units. This was of such frequent occurrence that one officer in the Surgeon General's Office spent a considerable portion of his time trying to counteract this practice.
Constant liaison with the Personnel Service, SGO, and insistence that these officers be returned to neuropsychiatric work was required. But, once assigned to a Ground Forces unit or to a 'hot outfit' alerted for oversea movement, the psychiatrist was often lost so far as functioning in neuropsychiatry was concerned. Not infrequently, the Surgeon General's Office received information from various sources, concerning misassignment of psychiatrists, often from the officers themselves who assumed that The Surgeon General had authority to take action on such matters. Because of decentralization of control, however, The Surgeon General had no assignment jurisdiction over medical officers in the Army Ground Forces, the Army Air Forces, or in any oversea theater.4 Consequently, even though the need for trained men was tremendous, The Surgeon General was often powerless to effect proper use of these specialists. Thus, the situation resembled that of a fire department which procures and pumps water through its hose but is denied the right to direct the nozzle at the fire.
Control of assignment.-As the war went on, it became obvious that the control of assignment and reassignment of key individuals must be centered in the hands of the chief consultant in neuropsychiatry who was responsible to The Surgeon General for the care and treatment of neuropsychiatric patients. On 12 May 1944, ASF (Army Service Forces)
4For a discussion on decentralization of personnel administration, see Medical Department, United States Army. Personnel in World War II. Washington: U.S. Government Printing Office, 1963, pp. 21-25.
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Circular No. 138 was issued, which charged The Surgeon General with 'the responsibilities for distribution of Medical Corps officers and nurses among the various major organizational elements of the Army Service Forces.' The circular empowered The Surgeon General to 'direct * * * required transfers of Medical Corps officers, by qualifications * * * between commands to effect * * * readjustment.' Further, The Surgeon General was authorized to effect transfers of 'key' personnel by name. The circular further provided that '* * * commanders will be directed to take corrective action when the staff assigned does not meet required standards or is not properly utilized.'
Since the various service command psychiatric consultants and psychiatric consultants in oversea theaters had begun exercising strong influence in personnel matters in their headquarters, a neuropsychiatrist was seldom transferred without their concurrence. These consultants, however, worked in close liaison with the Neuropsychiatry Consultants Division. After the middle of 1944, no assignments or allotments of neuropsychiatrists were made by the Personnel Service without concurrence from the Neuropsychiatry Consultants Division. It should be understood that, while the Personnel Service could assign officers to a unit, theater, or service command, their subsequent careers and assignments were influenced by the theater or service command psychiatric consultant. Therefore, close liaison between the various consultants in the Neuropsychiatry Consultants Division was mandatory and fully attained in the latter part of World War II.
CONTINUED SHORTAGES
As the war continued, the need for qualified psychiatrists became even more acute, as the mission of psychiatry had changed considerably toward a more comprehensive program. This included emphasis upon prevention; requirements to retain and treat psychiatric casualties 'as far forward as possible' both in combat and in mental hygiene centers at training camps; and, finally, the establishment of treatment and rehabilitation programs in Zone of Interior convalescent and fixed hospitals. It was therefore necessary to 'spread' psychiatrists even more thinly than before.
In July 1944, at the Service Command Conference, Fort Leonard Wood, Mo., Lt. Gen. Brehon B. Somervell, Commanding General, ASF, who had learned of the critical shortages of the various categories of neuropsychiatric personnel, directed The Surgeon General to procure and train sufficient psychiatrists and psychologists to meet the overall need of the Army.
To comply with General Somervell's order, The Surgeon General requested Col. (later Brig. Gen.) William C. Menninger, MC, Director, Neuropsychiatry Division, for all pertinent information on the procuring and training of neuropsychiatrists and clinical psychologists. In reply to this request, Colonel Menninger, in a memorandum of 1 August 1944, furnished
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the desired information to The Surgeon General. On 4 August, The Surgeon General relayed this information to the Commanding General, ASF, in part, as follows:
A. Psychiatrists.
* * * we can expect few, if any, additional qualified psychiatrists from civilian life. Repeated efforts have been made from this Office to secure the services of additional civilian neuropsychiatrists and various appeals have been made by the American Psychiatric Association. It is estimated that approximately 26 percent of the membership of the American Psychiatric Association are now in the military service. These men do not need training.
* * * it has been necessary to provide training in basic psychiatry and neurology for newly commissioned interns * * * 70 being trained at the School of Military Neuropsychiatry, 40 at Columbia University, and 30 at New York University.
* * * 53 student officers are being trained at the School of Neuropsychiatry at Mason General Hospital * * * approximately 15 are newly commissioned medical officers.
* * * for the present and contemplated requirements for the services of neuropsychiatrists in the Zone of Interior and for proposed numbered units in 1944, * * * 1,060 such medical officers will be required * * * there are available * * * approximately 765 qualified officers, leaving a shortage of approximately 295 psychiatrists in the ZI.
B. Psychologists.
* * * 58 Clinical Psychologists are assigned to Army Hospitals in the Zone of Interior, and 63 are assigned to Induction Centers.
* * * survey is being made among enlisted men with the view of commissioning those with adequate qualifications. * * * believe that a sufficient number of psychologists can be commissioned from enlisted men to meet immediate needs in the Zone of Interior hospital installations.
The question of training of Clinical Psychologists is being given consideration * * * whether 'on the job' training in hospitals will be utilized or whether the training will be taken over by the Adjutant General's School.
Although by July 1944, a total of 1,490 medical officers were listed as psychiatrists, it was more noticeable than ever that the majority of these men were merely psychiatrists 'by command.' Of this group, only 136 were certified in psychiatry, 121 in neurology and psychiatry, and 14 in neurology. Another attempt was therefore made to secure these specialists from civilian sources.
On 12 August 1944, the Chief, Personnel Service, at the request of the Director, Neuropsychiatry Consultants Division, with the approval of The Surgeon General, formally requested the Procurement and Assignment Service for Physicians, Dentists, and Veterinarians, of the War Manpower Commission, to increase the number of civilian psychiatrists as available for appointment in the Medical Corps of the Army. This letter was answered on 31 August 1944. The reply acknowledged receipt of the request and promised to present it before the Directing Board at the board's 23 September 1944 meeting. However, it called attention to the fact that the shortage of psychiatrists was also acute in civil life and that a balance must be observed between the Armed Forces and the civilian population.
On 14 October 1944, a further communication from the Procurement and Assignment Service stated that its Directing Board had called the Army's needs to the attention of the various State chairmen who, pre?
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sumably, would declare available any psychiatrist who could be spared from civilian life.
To give The Surgeon General wider latitude in assignment authority, General Somervell, in a 17 August 1944 memorandum to The Surgeon General, on the subject 'Assignment of Neuropsychiatrists and Clinical Psychologists,' stated: 'It is desired that, pending the availability of a sufficient number, steps be taken by you * * * to assure the assignment of these individuals to positions where their services can be best utilized and are most urgently needed.'
As has been indicated, by the time it was recognized that modern warfare produced a flood of neuropsychiatric casualties, the breach between requirements for psychiatrists and available supply was so great that it was never closed.
Understaffing
It was not uncommon for a psychiatrist to be responsible for a hundred or more patients on his wards at any one time, while medical officers on other clinical services, not infrequently, found their time not fully occupied. Many combat divisions overseas were forced to designate an inexperienced medical officer as the division psychiatrist because of the unavailability of trained neuropsychiatrists. Special neuropsychiatric treatment centers and hospitals also found it necessary, in many instances, to use general medical officers as psychiatric ward officers. Training center mental hygiene units, reconditioning centers, hospital ships, redistribution centers, and separation centers were all understaffed as far as psychiatrists were concerned. Similarly, the Ground Forces early in 1944 pointed out that nondivisional ground force troops had not been provided with neuropsychiatrists. A tentative plan was drawn up providing for mobile neuropsychiatric units for these troops, but because of the personnel shortage, the plan was never activated.
Staffing Inequities
By the spring of 1945, the shortages and maldistribution created severe staffing inequities. For instance, the Second Service Command had only 30 percent of the number of psychiatrists required, while the Seventh Service Command had 70 percent of its requirement. This excessive deficiency in the Second Service Command was due to the doubling of the bed capacity of Mason General Hospital, Brentwood, Long Island, N.Y., and to the activation of a large convalescent hospital at Camp Upton, N.Y., without the assignment of additional psychiatrists.
Similar deficiencies due to personnel shortages existed in other service commands, but the larger ones could absorb them more easily than could the smaller ones.
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The unavailability of personnel was not, however, the only reason for staffing inequities; another was the lack of adequate information in the Surgeon General's Office concerning service command requirements. The need to correct improper distribution led to the practice of surveying the various commands before the graduation of a class from the School of Military Neuropsychiatry and of assigning graduates in proportion to the needs of each command.
The need for more medical officers on neuropsychiatric wards became so acute that, on 26 May 1945, ASF Circular No. 189, pointed out this fact and stated:
It is desired that the commanding generals of service commands and the Chief of Transportation make every effort to supplement neuropsychiatric services and sections at medical installations under their control when it has been determined that those services or sections are understaffed.
Apparent shortages will be met to the extent practicable, by the reassignment of carefully selected general duty medical officers, SSN 3100.
Special consideration will be given * * * to the temporary assignment of any grade D specialist at times when his services are not required in the performance of duties pertaining to his permanent assignment.
Summary
A recheck of the number of neuropsychiatrists in the Army was made on 21 October 1944. The following results were obtained:
There were a total of 1,895 on duty, of whom 18 were classified as A; 344, as B; 580, as C; and 853, as D.
This total was a striking increase over the 1,235 as of the end of 1942 (p. 42), due in the main, to the addition of graduates of the School of Military Neuropsychiatry. In spite of this increase, however, there still was a critical shortage of psychiatrists.
In November 1944, another survey was made, and according to the figures supplied by the Military Personnel Division, SGO, 1,063 psychiatrists were needed for Zone of Interior installations alone, to meet minimum standards as set forth in manning tables. Only 651 were available. Thus, there was a shortage of 412 psychiatrists, not including the needs for oversea installations, redistribution centers, retraining centers, rehabilitation centers, and units scheduled to be activated for oversea shipment. Requests were therefore made and granted that the School of Military Neuropsychiatry be enlarged
(p. 56), since the only source of officers with neuropsychiatric experience of any type would be interns who had entered the service and had had a brief course of military indoctrination. The increases derived from this source were evident in the following results of a survey made on V-E Day, 8 May 1945: There were a total of 2,402 military neuropsychiatrists of whom 422 were classified as either A or B; 729, as C; and 1,251, as D. It is obvious from these figures that strenuous
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efforts were made to alleviate the shortage. Nevertheless, it was not possible to even approximate the needs.
PSYCHIATRIC WORKLOAD VERSUS PSYCHIATRIC MANPOWER
A graphic picture of the situation as regards neuropsychiatric personnel can perhaps best be had by quoting the following excerpt from a statement given at a conference at Percy Jones General Hospital, Battle Creek, Mich., on 21 August 1945, by Dr. Eli Ginzberg, Director, Resources Analysis Division, the Surgeon General's Office:
There were available on V-E Day a total of 2,402 Medical Corps officers with a military occupational classification 'neuropsychiatrist,' to treat and dispose of this patient load. This disregards for the moment the many who were not available to treat patients because their work was concerned with processing personnel, courts-martial, and training. The foregoing wording is cautious and deliberately so, because it is important to realize that about half of the total group were '90-day wonders'-mostly young doctors who volunteered for or were assigned to an intensive 90-day course after which they were reclassified as psychiatrists.
The 1,200 doctors who were classified as psychiatrists at the time when they were commissioned warrant further analysis. For the most part, these psychiatrists had been employed in State institutions where they were concerned primarily with the care of psychotic patients. The Army always has some psychotic patients-about 10 percent of the total psychiatric load-but the center of gravity in the military is the patient suffering from neurotic and other personality difficulties. Hence, most psychiatrists commissioned directly from civilian life had much to adjust to, when they went into uniform. The scale of the Army's training program for psychiatrists which resulted in doubling the available supply-at least statistically-was an achievement without parallel in medical training during World War II.
If all of the 2,400 psychiatrists were treating patients on V-E Day, a doctor-patient ratio of approximately 1 to 23 would have existed.
For contrast, the following figures will prove helpful. At the time when there were 55,000 psychiatric patients in Army hospitals, there were approximately 250,000 surgical patients. To handle this surgical load, the Army had available about 10,000 surgical specialists, most of whom had been specialists in civilian life. In addition, there were assigned large numbers of 'general duty' officers, many of whom had completed surgical internships. The ratio of surgeons to surgical patients was probably 1 to 10.
On the medical side there were on V-E Day about 240,000 medical patients. Available to treat these patients were 6,000 specialists in internal medicine, cardiology, gastroenterology, and allied specialties, and a sufficiently large number of 'general duty' medical officers to establish a ratio of approximately 1 to 15, perhaps 1 to 12.
The foregoing ratios understate psychiatry's handicap because psychiatric patients usually require more doctor's time than medical or surgical patients. However, a smaller percentage of neuropsychiatrists were engaged in patient treatment than surgeons and internists; large numbers were occupied in other essential work.
During the first 6 months of 1945 when patients evacuated from overseas reached a wartime peak, there were actually more neuropsychiatric patients than medical patients returned from the Pacific. The significance of this statement is highlighted when one realized that the Pacific evacuated a larger percentage of patients for disease than any other theater. During this same period the number of patients evacuated for neuropsychiatric disorders from the European theater almost equaled the number evacuated for disease.
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The most startling figures are those becoming available with the publication of the medical histories of the field armies. The experiences of the First U.S. Army-which accounted for most of the American fighting strength during the first 2 months after D-day in France-have been published. During these 2 months, nine divisions can be considered to have been actively engaged. The records of these divisions reveal that there was one neuropsychiatric admission out of every two medical admissions. In certain divisions, the admissions for neuropsychiatric causes swamped all other medical admissions. This can be illustrated by pointing to one division which had a per annum rate of 944 neuropsychiatric admissions out of 1,100 total medical admissions. In nonstatistical terms, this means that the entire strength of the division would have been dissipated within a year as a result of psychiatric casualties if men had not been treated and returned to duty.
In the other light divisions, neuropsychiatric admissions amounted to 200 out of a total of 482 medical admissions per annum or approximately 40 percent. If these psychiatric casualties had not been effectively treated, one-fifth of the entire divisional strength would have been lost during the course of a year.
What about surgery? In these nine fighting divisions there were 5.4 battle casualties for one neuropsychiatric casualty. It must be emphasized that many men classified as casualties were lightly wounded casualties.
Shifting from rates to absolute figures, the First U.S. Army reported, during June and July, 11,000 neuropsychiatric admissions, 16,000 admissions for disease, and 60,000 battle casualties, half of whom were classified as serious.
If D-day had come earlier, at a time when the Army had no detailed plans for the prevention, treatment, and assessment of psychiatric patients, the First U.S. Army would probably have lost most of these 11,000 admissions. Actually only 4,000 were lost. This means that approximately 60 percent of the men admitted for neuropsychiatric disorders were treated and returned to duty within the army area. The remaining 35 percent were evacuated to the rear. They were lost for combat but only 10 percent were lost for service in the theater. In contrast, medicine was able to salvage about 60 percent of its admissions while surgery succeeded in returning within the army area only 5,000 of the 60,000 wounded, or 9 percent.
In light of this experience, it should prove profitable to review the War Department planning for the distribution of medical means. Based upon current tables of organization, a field army composed of three corps with supporting troops is assigned approximately 1,500 Medical Corps officers. Of this number, the tables provide for 62 specialists in medicine. Experience indicates that approximately three 'general duty' officers were assigned to medical work for each specialist or a total of 250 doctors in an army area. In the First U.S. Army, this group had to care for 16,000 disease admissions. The surgical staff amounted to 370 surgical specialists and about 600 'general duty' officers. The surgical workload totaled 60,000 patients. The remaining medical officers in the army area were assigned to evacuation, planning, and other operational work.
These same tables of organization provided for 26 neuropsychiatrists. In the First U.S. Army, their workload amounted to 11,000 admissions. Theater surgeons, recognizing on the basis of past experience the gross discrepancy between means and requirements, rose to the challenge as best they could by training battalion surgeons and by scraping together psychiatrists who could be spared from duties in the Communications Zone and bringing them forward to the army area where the challenge was greatest.
By improvisation, by hard work, by careful control over the evacuation system, the 26 Army psychiatrists, assisted by whatever the theater surgeon was able to spare, succeeded in returning to duty 40 percent of all admissions directly from the clearing stations and other forward units. Another 25 percent was returned to duty from evacuation and convalescent hospitals in the army area. As had been pointed out
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before, 35 percent of the original admissions had to be evacuated to the Communications Zone, but only 1 man in 10 was lost to the theater.
CONCLUSION
The defeat of Germany in 1945, making possible the return of a number of capable, experienced personnel to the Zone of Interior for duty, permitted the release of a number of like officers from the Zone of Interior to the Pacific theaters, so that by V-J Day, the personnel requirements had been nearly approximated by the available men.
While the lack of preparation, along with inadequate numbers of personnel and facilities, makes this chapter a recital of work performed under severe handicaps, it is also apparent from the psychiatric manpower analysis, presented by Ginzberg, that surprisingly good results were obtained by a limited number of psychiatric personnel utilizing appropriate methods of management and treatment.
