Signs of a Better Future

To be sure, reimbursements are down, inpatient units and clinics are closing, private practitioners are feeling squeezed, and managed care is grinding all of us down. Most affected of all are our patients, who wait for days in emergency rooms for inpatient beds to open up, and then for weeks on inpatient wards until a residential bed can be found. For those in need of outpatient care, they may confront waiting lists of several months and may find that the insurance coverage they thought would guarantee them reimbursement for care fails to cover its costs.

Our fellow citizens, I am afraid, are on the verge of learning the important lesson that if they are not willing to pay for psychiatric care, it won’t be there when they need it. Calling attention to this systematic defunding of the psychiatric system, in both the public and private sectors, will be a major theme of my presidential year. APA will work with other advocacy groups to come up with a set of strategies for beginning to turn this complex situation around. Those of you who were at the Opening Session of our 2002 annual meeting in Philadelphia heard me talk at greater length about this issue. (Coverage of the annual meeting will begin in the next issue of Psychiatric News.) And we will return to it in this column many times.

But now I want to call your attention to some of the truly good things that are going on in psychiatry today, things that are all too easy to overlook under the pressures of day-to-day practice. Start with residency training for one, the wellspring of our field. Beginning in the early 1990s, we began to see a drop in the number of American medical graduates entering psychiatry training, a number that plateaued in the range of 450 per year for much of the decade. Although international graduates from around the world came to these shores to make up the difference—and save more than one training program from extinction—the decline in interest among American graduates bespoke fundamental problems in persuading students of the appeal of a life in psychiatry.

Last year the number of American graduates entering our training programs edged up 9 percent—a good sign, but not quite a trend. This year, however, the number grew by another 8 percent, to reach a 10-year high of 564 new residents matching into training programs. Our experience at UMass and discussions with people in other programs indicate that their experience was similar and that the quality of these applicants as a whole was outstanding. Many of them were the very best people in their graduating classes. Although it’s too early to conclude that we have won this battle, this is an extremely encouraging sign.

What are our new residents seeing that we may be overlooking? For starters, despite all the travails of the field, it is still the only medical specialty that offers—to those who want it—an opportunity to work closely enough with patients over time to get to know them and their problems, and to watch them change. A decade’s worth of students lured into family medicine or other primary care specialties, only to endure the drudgery of 15-minute visits through the entire work day, have persuaded their successors that if humanistic medicine survives, it does so in psychiatry. Now, I know many of our colleagues feel chained to an endless string of 15-minute visits themselves, but many others have elected—often by sacrificing income—to structure their days so that the longer evaluation, follow-up, and psychotherapy sessions that bring them pleasure remain a part of their lives.

Moreover, there seems to be a change in public attitudes toward the importance of mental health as well. Part of this, of course, comes in the wake of the terrorist attacks of September 11, 2001, which have underscored the need to pay attention to the psychiatric impact of traumatic events. But the efforts of APA and other groups over the last decade and more to persuade the public that mental illnesses are diseases like all others, with excellent treatments available, seem slowly to be bearing fruit. As one state after another adopted some version of parity for insurance coverage of psychiatric disorders, the pressure grew on Congress to adopt national legislation. Last year, for the first time, a parity bill passed the Senate and had a majority of members of the House as cosponsors before the refusal of the House leadership to let it come to a vote doomed the bill. Progress, as they say, but no cigar.

Now, however, in the face of a renewed push for parity, President Bush has announced his administration’s support for the concept. This is an unprecedented action by our highest elected official that speaks volumes about our success in changing national attitudes about mental illness. It goes without saying that this isn’t the end of the battle. The specific contours of a parity bill can make the outcome meaningful or a useless gesture. And parity itself doesn’t guarantee fair decisions by insurers and managed care companies about patients’ coverage. But this is an important step nonetheless.

As we work together on the problems in our field, we ought not lose sight of the positive things that are happening, lest we become mistakenly discouraged about our overall prospects for success. I will use this column during the coming year to call your attention to the good news that deserves some applause, as well as the things that remain to be done. ▪