Must We Grieve End of Psychiatric Practice As We Know It?

Behold a tragic irony: as demand for psychiatrists expands, supply shrinks. Psychiatric practice as we currently experience it may disappear as a result.

Demand for psychiatric treatment has grown because of four converging realities: population growth, rising rates of depression and anxiety, improved public awareness and acceptance of psychiatric treatment, and increased access to health insurance through the Affordable Care Act and Medicaid expansion.

The supply of psychiatrists is not keeping up with the pace of population growth. According to the AMA, between 1995 and 2013 the total number of physicians rose by 45 percent, during which time the number of adult and child psychiatrists increased by only 12 percent. A 2009 study by Thomas and Holzer reported that 96 percent of counties in the United States had an unmet need for psychiatrists. Rural and low-income populations, which have a greater prevalence of mental health disorders, have an even more acute shortage of psychiatrists.

ACGME data for 2017-2018 show there were 5,907 psychiatry residents in training, including 1,157 residents in fellowships in the five ABPN-recognized specialty areas (addiction, child and adolescent, forensic, geriatric, and consultation-liaison psychiatry). Subtracting those in fellowship and dividing the remainder by three to arrive at an approximation of how many general adult psychiatry residents there are in each year of pre-fellowship training, there are about 1,583 residents a year. If 600 of those go into a fellowship-trained specialty (an approximate number because child and adolescent fellowship is two years, while the remaining fellowships are usually one year), it leaves around 980 graduates to enter the workforce each year as general adult psychiatrists.

Compounding the problem is the reality that two-thirds of practicing psychiatrists are over the age of 50, according to the AMA, and many are expected to retire in the next decade or two. Psychiatric practice is very different now compared with when these clinicians entered practice, and many of them struggle to adapt to complex electronic medical records and increased caseloads. One psychiatrist told me he is responsible for 700 patients in his community clinic.

Although demand for psychiatric treatment is increasing and medical students are interested in entering the field, a high number of applicants to residency programs are going unmatched (Psychiatric News, November 13, 2018. Why aren’t the number of residency slots increasing to meet this demand? It may be that academic medical centers are less interested in funding larger psychiatry residency classes because psychiatry departments are not profitable for the university. Alternatively, it may be that stigma continues to undermine our profession, reflected in inadequate funds to train the necessary workforce.

Collaboration with primary care physicians and pediatricians through integrated care models and telepsychiatry help stretch psychiatrist manpower by using psychiatrists as expert consultants rather than primary caregivers. Increased training of advance practice nurses with prescriptive authority is a parallel solution. Rather than training more psychiatrists, these approaches are offered as the solution to the psychiatrist shortage.

What do we lose if we shift our expertise to being consultants rather than primary providers of psychiatric treatment? Although advance practice nurses can also diagnose and treat patients, psychiatrists receive more extensive training in diagnosis, treatment planning, and skillful psychopharmacology. The art of combining medications with psychotherapy and knowing when to turn to which modality is something psychiatrists do best. Relegating psychotherapy services to other professions and becoming medication-management technicians, splitting the treatment, is a common solution but deprives patients of more holistic care. For many psychiatrists, meaningful relationships with patients are what bring us back to the office every day.

Psychiatrists in private practice are faced with daily phone calls from desperate prospective patients and their family members pleading to be added to already swamped practices. We risk taking on too many patients, working too many hours, taking too few days off. If we burn out and leave practice, either through early retirement or by working for an agency, the shortage of private practice psychiatrists grows.

For now, what shall we do? Professionalism demands that we at least return the calls of prospective patients and make referral suggestions. If we are aware of a colleague who is accepting patients, it is kind to pass that person’s name and number forward. If not, we can direct callers to the “Find a Psychiatrist” feature on the district branch and APA websites. The five minutes that these phone calls take are well worth the benefit of extending hope to patients and knowing we are behaving with courtesy and compassion.

Additionally, we may be able to accept another patient or two by encouraging our long-term, medication-management patients who are on stable and uncomplicated regimens to transfer their care to their primary care physician, with the assurance that if a consultation is required in the future, they are always welcome to come back. These patients don’t take up much time in our schedules, but if we transfer as many as is reasonable, we may have room for new patients who require our expertise more.

Is there another way? What if we trained more general adult psychiatrists? This would require a fundamental shift in priorities to make it fiscally possible for academic medical centers to increase class sizes, which itself would require a shift in how clinical services are valued and reimbursed. As long as procedural specialties are more valued than specialties that focus on primary treatment (internal medicine, family practice, pediatrics, and psychiatry), our field will remain devalued and our residency sizes inadequate to meet the needs of the population. ■