Psychiatry: Composition & Trends

During the weekend of February 9 to 11, I attended a meeting of the APA Council on Medical Education and Career Development. The topic for the meeting was the psychiatric workforce. The council and its knowledgeable invited guests from the APA Committee on Workforce Issues and representatives from other academic and professional organizations shared their perspectives about our field. The presentations were stimulating and illuminating for me.

The basic question is, How many psychiatrists does the country require to provide the treatment needed by our population? Managed care took the position that 25 percent of the existing workforce was all that is required. Depending upon which assumptions are made, estimates of the number of psychiatrists needed per 100,000 population can vary from practically none to thousands. Other countries have wide variations in the number of psychiatrists per 100,000 of population: Canada 12, Australia 10.6, New Zealand 4.3, Holland 12, and Great Britain 4. Currently, we have about 14 psychiatrists per 100,000 in the U.S., 16 if child psychiatrists are included.

New York has the largest number of psychiatrists (6,119), followed by California, Massachusetts, Pennsylvania, and Texas. Wyoming has the fewest psychiatrists (35), followed in ascending order by South Dakota, Alaska, Idaho, and North Dakota. Washington, D.C., has the highest number of psychiatrists per capita, while Alaska has the lowest.

The total number of psychiatrists in the U.S. has grown very little, while the three largest specialty fields—internal medicine, family practice, and pediatrics—have grown significantly. There are approximately 39,000 psychiatrists and another 6,000 child psychiatrists for a total of 45,000, making psychiatry the fourth largest medical specialty.

Psychiatry also has the fourth highest number of women specialists. For a number of years, half or more of the students entering U.S. medical schools have been women. Between 45 percent and 50 percent of first-year residents in psychiatry are women. While 24 percent of men psychiatrists are over age 65, only 10 percent of women psychiatrists fall into this age group. As might be expected, 25 percent of men psychiatrists are under age 45, compared with 47 percent of women psychiatrists.

The AMA database lists the race/ethnicity for 72.5 percent of the physicians in the U.S. These data indicate that 54.6 percent of physicians are white, 9.1 percent Asian, 3.5 percent Hispanic, and 2.6 percent black. The proportions are about the same across other specialties, with the exception of anesthesiology, which has a higher percentage of Asian physicians.

The number of U.S. medical graduates (USMGs) entering psychiatry residencies has varied from a high of 844 in 1988 to a low of 463 in 1998. In 1999 the number was 505 and rose last year to 516. The number of qualified USMGs selecting psychiatry residencies is insufficient to fill all of the positions. This has opened the door to a surge of interest from well-qualified medical graduates from around the world. In the 1980s IMGs constituted approximately 25 percent of psychiatry trainees. Currently, IMGs are filling about 44 percent of the 800 first-year U.S. psychiatry residency positions. How does this compare with the rest of medicine in the United States? Between 1970 and 1999, the total number of physicians increased by 463,000, or 139 percent. IMG physicians in the U.S. increased by 235 percent during the same period, constituting 24 percent of the total physician population and 26 percent of all medical trainees. The largest specialties have the highest numbers of IMGs, with psychiatry ranked fourth. However, the percentage of USMGs entering psychiatry is much lower than the percentage entering other specialties.

Two external factors have significantly contributed to USMG's diminished interest in psychiatry. First is the shift from psychodynamic departments of psychiatry and training programs to biologically oriented programs. Decreased and, at times, complete loss of psychodynamic considerations and psychotherapy training removed an intellectually interesting aspect of psychiatry that differentiated it from other fields. Second, the economic pressures imposed disproportionately on our profession by managed care made it less attractive, especially to medical students with large debts. Providing a better learning experience for U.S. medical students during psychiatry clerkships will help restore their interest in our exciting specialty. ▪