C. Edward Coffey, M.D.
C. Edward Coffey, M.D., understands how invaluable support is to patients struggling with mental health challenges. He has seen the impact firsthand in some of the country’s most successful treatment programs, and now lends his expertise as president and chief executive officer of the Menninger Clinic. Coffey sat down with Texas Medical Center Executive Vice President and Chief Strategy and Operating Officer William F. McKeon to discuss the perfect care model and how his team at Menninger—from nurses and physicians to housekeepers and administrative staff—rallies around patients in need.
Q | Tell us about your childhood in South Carolina and your formative years?
A | I grew up in a small South Carolina fishing village called Little River. My stepfather ran a small fishing boat and I was the mate on the boat. It was sport fishing in the summer so we typically took parties of six out on the weekends for day trips. We also did Gulf Stream trips where we go about 80 miles off the Carolina coast. It’s an eight-hour trek, so you go all night and then you start fishing at about two in the morning because you need to wrap up by eight or nine in the morning to get back. It is hard work. In the winter we would take the chairs off of the boat and attach traps for catching snapper, grouper and red snapper. It’s really back-breaking work. I lived in a trailer growing up and we ate what we caught that day. The good news was that we ate fresh fish five nights a week. The bad news is my mother deep-fried everything. But it was great. We had a very loving, very close family.
Q | Tell me about your education?
A | Being fortunate and lucky is absolutely my story over and over again. In 1970, my high school guidance counselor approached me early in my senior year and asked if I had plans to go to college. After I told him that I didn’t think my family would be able to afford college, he said, ‘Well, why don’t we see what we can do.’ That conversation resulted in a one-year scholarship to Wofford College. I remember this so vividly because there were only about 200 people in my high school, grades seven through 12. It was so small that athletes played every sport, both ways. I was the linebacker. I was very quick, but my stature probably wasn’t that of your typical linebacker. What is amazing about this is that I was a handful in high school and it would have been very easy for my guidance counselor to pick another student because of how ‘adventurous’ I was. I was so close to not going to college, but he picked me. I wasn’t the only one—I was one of not more than two from my high school class who actually went to college and graduated from college.
Because my original scholarship only covered a year, I did some work-study and other people helped with scholarships and that is how I paid my way through college. Wofford is where I became a person. It was just an incredible experience. Initially I was a pre-med major because I didn’t know what else I was going to do. College was challenging for me. My first test was a bomb. It was horrible. I was stunned because I had never gotten anything less than an A by just showing up and filling out the test. I didn’t learn how to study in high school, but one of the toughest biology professors offered to help me learn. I was all set to go to medical school to become a doctor, but then my sophomore year I took a psychology course from the chair of psychology and it changed my life. I realized I wanted to pursue a career in psychology because it’s all about human behavior—why we act, think and feel the way we do. What is more important? As you can tell, I am still ‘geeked’ about this. From that point, I changed plans and prepared for graduate school.
I began experimenting with psychology and the department chair pulled me aside in the summer before my senior year and said, ‘Look, if you really want to do research and are interested in human behavior, you are going to have much better access to that world if you have an M.D. instead of a Ph.D.’ Since I was not prepared for medical school, my senior year, I had to go back and take organic chemistry, physics and the like, all at the same time. I remember looking out the window of the lab on a Friday afternoon. The music is playing. All of the girls are coming to campus for the weekend, and we are up in the lab. Even though this change caused me to miss some campus activities, it was absolutely the right decision.
Then in a continuation of luck and good fortune, the dean of the college asked me to be one of two candidates from the school to apply for the Rhodes Scholarship. My friend from home claims that when he heard I was selected, he didn’t know whether to think more of Ed Coffey or less of the Rhodes Scholarship, so that helps me keep it in perspective. I went to England—a fantastic, phenomenal two years. The dean just comes and asks me to do this and the doors that open are just incredible.
Q | What was it like at Oxford University?
A | Unbelievable. I was sitting in a room with a kid from Uganda who was the president of the student body at the university when Idi Amin Dada came into power; he was describing his escape from Uganda. Amin was trying to kill him because students were opposed to the regime. Those experiences weren’t commonplace in South Carolina. So it was just unbelievable to be at Oxford.
After completing additional bachelor’s degrees at Oxford, I went on to Duke medical school. Because I was now two years behind in school, I didn’t take any summer breaks and completed medical school in three years. Duke was great. Looking back on it, that was such an incredible time to be in medical school. I rounded with my professors on Friday afternoons and then went back to his or her office and talked about how ‘this is what you’ve got to do and this is how you respond to this kind of situation.’ That is where the learning took place, because all of the stuff you learned from the book is going to be incorrect next year anyway. It was an amazing place, and those were the most important experiences.
Q | What led you to Detroit?
A | I am board certified in both neurology and psychology because I am interested in brain behavior relations. That is the sweet spot for me. Professionally, my interest has been neuropsychiatry, and there are many definitions of that, but in general, it is taking care of patients with a psychiatric disturbance that is somehow related to an underlying neurological problem. It might be a person with a stroke who is now depressed. It might be a person with a head injury who now has a personality change. It could be a person with Alzheimer’s disease who is now hearing voices.
At Duke, I became director of the neuropsychiatry/electroconvulsive therapy program before being recruited to the Allegheny System in Pittsburgh by Dr. Stuart Yudofsky, who is now at Baylor. Dr. Yudofsky convinced the leadership at Allegheny to buy a free-standing, 94-bed, neuropsychiatry facility and then hired me to run it. After being in Philadelphia for six years, the Henry Ford Health System in Detroit had a position open and I knew many, many people there, including the former chair who had risen to the dean’s position. The leaders were and are phenomenal—Henry Ford is an incredible, world-class health care system. I thought I would only be there five years, but my family and I fell in love with Detroit and there were plenty of great learning opportunities there. We created an integrated mental health service line for the system—it was a $4 billion system and we had the oppor- tunity to create this notion of Perfect Depression Care and Zero Suicide.
Q | I know the Perfect Depression Care and Zero Suicide program was a Malcolm Bladridge Award-winning program. What was the standard of care before and after the program?
A | A couple years after I arrived in Detroit, health care financing underwent a major change. Our system, like many others, was struggling. We had to recalibrate after a round of layoffs that sank morale. At the same time, the Institute of Medicine convened a committee to evaluate the American health care system. What resulted was an Institute of Medicine Report called Crossing the Quality Chasm. I was tasked with studying the report and presenting findings that were applicable to Henry Ford. The report revealed that despite the great people in the American health care system, despite the advances in knowledge in this country, the care that people are getting at bedside is mediocre. The gap that exists between what is possible with health care professionals and what is happening at bedside is the chasm.
The report also yielded a model of how to fix the chasm. When this was published, the Robert Wood Johnson Foundation got behind the report and partnered with Don Berwick at the Institute for Healthcare Improvement to launch the ‘pursuing perfect initiative.’ The idea was, if you can take this document as a road map to transform your system, they would give you a few million dollars to get started.
I spearheaded Henry Ford Health System’s application to the ‘pursuing perfection initiative.’ There were about 3,000 applications downloaded, 25 semifinalists and eventually 12 finalists. We were one of the 12 finalists and the only mental health application in the group. Our application was Perfect Depression Care. Each applicant was required to outline six dimensions of care—safe, effective, patient-centered, timely, efficient and equitable—and define how to achieve perfection in all six dimensions. We had five of the six nailed, but we couldn’t get something around effective care. We initially thought we’d do the same thing that the FDA does to approve drugs and say effective care is lowering depression scores by 50 percent with our treatment. While this was good enough for the FDA, it did not meet the standards for this initiative.
We regrouped around a conference table, and a nurse raised her hand to suggest that doing perfect depression care would mean that people wouldn’t kill themselves. The room went still and no one said anything for what seemed like an hour. Her idea was met with resistance as some clinicians were under the impression that we couldn’t stop people from killing themselves
if that’s what they wanted to do. To be honest, that was kind of the attitude back then in psychiatry—suicide is inevitable and you can’t do anything about it. That nurse’s suggestion, however, transformed our department. We went back and forth among our team, asking ourselves if zero isn’t the right number for our goal, what is? Is it 12 suicides a year? Does that include my sister? Your mother? What does our billboard say? ‘Come to Henry Ford, only 12 of you will commit suicide this year.’ No, it has to be zero. You would think that is common sense, but even today, this is still very difficult for people to embrace. That is how we got into Perfect Depression Care. We drove the suicide rate down in two years and maintained it for over a decade.
It was unprecedented. People around the world told me that we were crazy for doing this, and that I was going to embarrass myself and ruin my career. As my senior leadership team at Menninger now knows, I am stubborn and hardheaded and so I said, ‘We’re going to do it.’ What is neat about this notion of perfection is that it is absolutely galvanizing. Most people don’t want to get up in the morning, go to work and be average. Most people have the notion of doing something spectacular, but it is not for everybody. You have to adjust an organization’s culture. Now others have signed on to this movement—Great Britain, Northern Ireland and other states here in the U.S.
Q | In the perfect care model, what was the di erence? Was there more intense communication with the patient? Was it the focus on the patient to not let them wander o alone and feel lost within the spiral of depression that leads to suicide?
A | You are absolutely right. There are two evidence-based approaches to reducing suicide: rapid access to definitive diagnosis and treatment of the underlying disorder—depression, anxiety disorder, substance abuse, etc. The other is ‘means restriction’—you make it hard for the person to carry out the act. Patients who have survived suicide attempts will tell you that it is purely impulsive. The thought is maybe always there, but most of the time it is in the background. But when the person is experiencing stress or maybe when they are drinking, the impulse bubbles to the top.If it is easy to do it right then—if you have a gun that is loaded in your car’s glove box and it doesn’t take any thought or planning to do it, then it happens. Means restriction means getting rid of that stuff.
We had very intentional conversations every time we interacted with the patient, not just in person, but on the phone, email whatever and every interaction began and ended with, ‘What is the status of your gun at home? Your plan?’ If it wasn’t a gun, but hanging, ‘Tell me about how you have thought this would happen? What do you imagine is the means?’ If the patient told us they were planning to hang themselves in the garage using a ladder and a cord, we would tell them to go home and get rid of the ladder and the cord. The most incredible thing we learned from doing this is that the patient will not go buy a new ladder. Another fascinating thing is people who have chosen the ladder and cord in their suicide plan don’t typically go and replace those with a gun after they’ve gotten rid of them. The goal here is to put some time between the impulse, so that the impulse will subside. Michigan is a big gun state like Texas, so we negotiated with patients to have them put the ammunition in one safe on one side of the house and the gun in another safe on the other side of the house. We also got the gun clubs in Michigan to get on board with this. A lot of patients didn’t want to give up their guns, so the gun clubs said, ‘We’ll hold it for you. Whenever you want to come practice you can, but we will keep it here.’ We got really good at means restriction.
Q | What was the driving force behind you taking the CEO position at Menninger?
A | There are several factors. My family is from the South, so there was an appeal to get back to our cultural roots. I’ve since learned that there’s the South and then there’s Texas, and those aren’t identical. I’m not saying there’s anything negative here. I’m just saying they’re different, and I didn’t fully appreciate that. And we love Texas. Additionally, there is no brand in mental health like Menninger. It is just an amazing brand. That’s, of course, due to leaders here in Houston and people like Dr. Yudofsky who were so keen on bringing Menninger here over a decade ago. They knew it had the potential to be the MD Anderson of mental health. In fact, I think that analogy has been used by many here in the Texas Medical Center.
Q | The Menninger program is very unique and has changed over time. How would you define Menninger?
A | I would say the essence, part of the secret sauce, is the unbelievable commitment on the part of the entire team here at Menninger. I don’t mean just the nurse, just the therapist and just the doctor, but everyone, including the housekeeping staff, facilities, security, finance, etc. There is an incredible commitment to patients’ welfare and their healing. The idea of restoring hope is not just lip service. It’s real. I take no credit for that. That culture was here when I got here. I think it’s been here for decades.
These patients have some of the most difficult illnesses in all of general medicine, not just psychiatry. The mortality rates are higher than cancer or heart disease for these people. It’s not just suicide; it’s also death from certain general medical illnesses that’s elevated in this population. In addition, there’s a long history and a culture of studying and learning from what we do. This notion of learning has been my theme in life. As long as I’m learning, I’m happy. When that curve levels off, I get restless. We’ve created a culture of learning and improving here at Menninger. We’re now formally studying patients not just through the course of hospitalization, but for up to a year after they’ve left. This is unique to Menninger for a couple of reasons. One, it takes time to create relationships with patients and families, such that they’d be willing to stay in touch with you and let you know how it’s going, good or bad, post-treatment. Another reason is we’re the only organization in the world that I know of that is doing these types of outcomes studies because we have the philanthropic resources needed to support such intense research. In fact, the bulk of Menninger’s research is supported through Houston’s generous philanthropic-minded community.
Q | What is the cohort of patients you see here?
A | It’s surprisingly consistent in its inconsistency, but the typical patient will have a severe mood disorder—depression, bipolar disorder—often with a co-occurring substance use disturbance.
Q | What is the average length of stay for patients?
A | The average is 45 days. We have five inpatient programs at Menninger, so the length of stay varies. For example, the average stay of our Adolescent Treatment Program patients (ages 12 – 17) is a couple of weeks. Patients on the Comprehensive Psychiatric Assessment and Service are here for an intensive two-week diagnostic assessment after which they receive a detailed treatment plan to take their treatment provider of choice. The Professionals in Crisis Program, Hope Program for Adults and the Compass Program for Young Adults are our more standard programs where the length of treatment is six to eight weeks.
Q | What is the new diagnostic strategy? What’s the state of the art now compared to 10 or 20 years ago?
A | Since we don’t conceptualize these illnesses as either environmental or psychological or biological, the magic here and the art of this is trying to understand what is the relevant contribution of each of those influences. It can be biological, genetic or a patient’s brain chemistry. That then can be complicated by substance abuse, hypothyroidism, or a pregnancy a year ago. Then you add in environmental factors, plus psychology, plus spiritualization. Assessment is an explorative journey. All of those factor in and they factor in to every illness in general medicine, not just mental health. Is cancer not a psychological condition and an environmental and spiritual one? Of course it is.
Q | What excites you most about what happens here every day?
A | It’s the care we provide. The tagline: ‘Advancing treatment and transforming lives.’ That isn’t just talk. It really is what goes on here. It’s incredible.
Q | What would be the typical team you’d assign to a patient?
A | Menninger patients are fortunate to receive care from some of the best mental health professionals in the world, including many who are also affiliated with Baylor College of Medicine. The expertise level here is very high. The clinical team is often comprised of multiple physicians—many of whom are double- and triple-boarded. Then you have nursing, social work, psychology and other specialties as needed. The exact mix depends on the nature of the patient’s issues. If those are heavy on the medical side, then the team will include more psychiatry and nursing expertise. Menninger also offers rehabilitation services through our outpatient services division and our adult clubhouse, The Gathering Place.
Q | How far have we come with social opinion toward mental illness?
A | There’s no question, it’s better. It’s not where it needs to be because shame still gets in the way. Shame has a double meaning in the area of mental health. There’s stigma, and shame related to stigma, but there’s also shame related to, ‘My life’s a mess. I’m the son that just can’t get it together.’ ‘I’m the person that’s had four affairs.’ ‘I’m the CEO that’s falling apart.’ There’s tremendous shame around that. In our work, unconditional acceptance has been shown to be a core of the effectiveness of therapy, whatever kind of therapy is being done. We give it all kinds of labels, but it turns out that there are commonalities to being successful and that’s one of them—this unconditional acceptance.
Q | Anything you would like to add?
A | I’m so happy to be at Menninger and to be a part of the Texas Medical Center. My wife, Kathy, and I are so happy to be in this city. We have been welcomed with open arms and everything I learn about Texas just makes me smile. It’s so different than I imagined and I think Houston is unique within Texas. It’s an open, accepting place. I’ve always valued diversity, and as best I can tell about Houston, if you’re just willing to roll up your sleeves and contribute in some way, you’re in.