Commentary How Many Psychiatrists Do We Need? Johan Verhulst, M.D. Gary Tucker, M.D. Projections of manpower needs based on population growth and possibly improving access are unconvincing because of rapid changes in psychiatric practice and because complex social and political forces are influencing the psychiatrist's role in the mental health system. Given this basic uncertainty, attempts at filling residency positions at all costs are less than responsible. To serve our field well, efforts should be focused on recruiting "the best and the brightest" of our medical students and on providing quality training that stays in tune with the developments of the field and the evolution of the role of the psychiatrist. (Academic Psychiatry 1995; 19:219-223)
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n light of the current decrease in American medical school graduates choosing psychiatry as a career, our first impulse is to reply, "we need to do something about this." However, before we do, psychiatry as a profession needs to examine future manpower needs. MORE PATIENTS FOR MORE PSYCHIATRISTS?
At first view, one would expect the need for· psychiatrists to increase dramatically because of two factors: 1) the growth of the population as a whole, and 2) improved access to psychiatric services promised by health care reform. Now a substantial segment of the population cannot afford to see a psychiatrist. If they are acutely and severely ill, or if they are afflicted with a disabling, chronic mental disorder, they quickly become dependent on the public health system, where access to physicians in general, and psychiatrists in particular, is severely limited. This should greatly improve if "universal access" were to become reality (a matter that is far from certain). Furthermore, there is a trend toward parity between mediAc·\m\llc
I~YCIIJ.\IRY
cal and psychiatric services, at least as far as the psychiatrist'S "medical management" is concerned. If so, psychiatrists might even "recapture" a number of patients who would otherwise seek help from nonphysician mental health practitioners. The conclusion seems clear: improved access and an expanding population base result in a need for more psychiatrists in the future. FEWER PSYCHIATRISTS FOR A LARGER POPULATION?
Manpower needs, however, are not determined by these two simple variables alone. The need for a particular kind of profeSSional service can be drastically altered by scientific and technological developments (for instance, the discovery of tuberculostatic drugs greatly reduced the need for tuberculosis Dr. Verhulst is associate professor and reSidency training director, and Dr. Tucker is professor and chairman; both are in the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Address reprint requests to Dr. Tucker, Department of Psychiatry, University of Washington School of Medicine, Seattle, WA 98195. Copyright © 1995 Academic Psychiatry.
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specialists in the 1960s and 1970s), by political decisions (such as health care reform), by sociocultural factors (the stigma attached to seeking mental health care, for instance), by economical imperatives (cost controls), or by unanticipated epidemiological events (AIDS, for instance). All these variables are interconnected, and they determine what role the professional is asked to play and what the scope of the professional practice will be. Consequently, predicting manpower needs will always be difficult and tentative, even for specialties that seem relatively stable with regard to most of these variables. Psychiatry, however, is undergoing profound change, and predicting manpower needs may be practically impossible. Conceivably, the role of the psychiatrist could expand in the future, leading to increased manpower needs. Laws could be passed that not only improve access to the mental health system in general, but also specifically to psychiatrists. Society could decide that psychiatrists should be reimbursed for their time, without specific rules about what that time needs to be spent on. Thus, long-term psychotherapy would be fully reimbursed, as would all consultation-liaison services. The length of inpatient stays could be left to the judgment of the attending psychiatrists. Public psychiatrists could be encouraged to implement all needed treatment. At the same time, there would be no disincentives for solo private practices either. None of this seems unreasonable per se. Yet the current trend is definitely in the opposite direction. Managed care companies, for instance, tend to staff their mental health programs with 0.4 to 0.8 psychiatrists per 10,000 subscribers, whereas the ratio of psychiatrists to the population as a whole is currently about 1.5 per 10,000. The question is: will the trend toward limiting the role and the scope of practice of the psychiatrist continue so as to more than offset the increased manpower needs due to population growth and potentially expanded access to care? We 221'
believe that it will. To illustrate this, we would like to focus on two mutually reinforcing developments: 1) changes in the practice of psychiatry toward brief and time-effective patient contacts, and 2) changes in the role of the psychiatrist as a result of health care reform. CHANGES IN PSYCHIATRIC PRACTICE In the 1960s and 1970s, psychiatric practice evolved around long-term psychotherapy. Inpatient treatment was focused on individual and "milieu" therapy, facilitated by new drug treatments. Outpatient practice was largely equivalent to doing psychotherapy. Since then, we have witnessed a shift in psychiatric practice toward spending an increasing amount of time doing diagnostic work, providing consultation to other medical and mental health professions, managing medication regimens, and doing individual work with only the most seriously mentally ill. These changes are also evident in our residency training programs, where the primary focus is no longer on long-term, psychoanalytical psychotherapy. Instead, more hours are allocated each year to the teaching of diagnostic skills, pharmacology, crisis intervention techniques, consultation-liaison duties, substance abuse treatment, geriatric psychiatry, child and adolescent psychiatry, and forensic psychiatry (1). Not only has our practice time changed, many conditions are approached differently than in the past. Conditions that required long-term psychotherapy are increasingly being treated with medications and/or brief, focused psychotherapeutic interventions. For example, obsessive-compulsive disorder was often treated as a deep-seated "personality" problem, requiring intensive and longterm psychotherapy. Now it is treated predominantly with pharmacology and behavioral approaches. In general, we believe that the field of psychiatry has made impressive strides toward time-effectiveness. Furthermore, specific treatments are be\ l ) 1 L \ II I')." l \ mil,
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I
n light of the current decrease in American medical school graduates choosing psychiatry as a career, our first impulse is to reply, "we need to do something about this." However, before we do, psychiatry as a profession needs to examine future manpower needs. MORE PATIENTS FOR MORE PSYCHIATRISTS?
At first view, one would expect the need for· psychiatrists to increase dramatically because of two factors: 1) the growth of the population as a whole, and 2) improved access to psychiatric services promised by health care reform. Now a substantial segment of the population cannot afford to see a psychiatrist. If they are acutely and severely ill, or if they are afflicted with a disabling, chronic mental disorder, they quickly become dependent on the public health system, where access to physicians in general, and psychiatrists in particular, is severely limited. This should greatly improve if "universal access" were to become reality (a matter that is far from certain). Furthermore, there is a trend toward parity between mediAc·\m\llc
I~YCIIJ.\IRY
cal and psychiatric services, at least as far as the psychiatrist'S "medical management" is concerned. If so, psychiatrists might even "recapture" a number of patients who would otherwise seek help from nonphysician mental health practitioners. The conclusion seems clear: improved access and an expanding population base result in a need for more psychiatrists in the future. FEWER PSYCHIATRISTS FOR A LARGER POPULATION?
Manpower needs, however, are not determined by these two simple variables alone. The need for a particular kind of profeSSional service can be drastically altered by scientific and technological developments (for instance, the discovery of tuberculostatic drugs greatly reduced the need for tuberculosis Dr. Verhulst is associate professor and reSidency training director, and Dr. Tucker is professor and chairman; both are in the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Address reprint requests to Dr. Tucker, Department of Psychiatry, University of Washington School of Medicine, Seattle, WA 98195. Copyright © 1995 Academic Psychiatry.
2l LJ
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specialists in the 1960s and 1970s), by political decisions (such as health care reform), by sociocultural factors (the stigma attached to seeking mental health care, for instance), by economical imperatives (cost controls), or by unanticipated epidemiological events (AIDS, for instance). All these variables are interconnected, and they determine what role the professional is asked to play and what the scope of the professional practice will be. Consequently, predicting manpower needs will always be difficult and tentative, even for specialties that seem relatively stable with regard to most of these variables. Psychiatry, however, is undergoing profound change, and predicting manpower needs may be practically impossible. Conceivably, the role of the psychiatrist could expand in the future, leading to increased manpower needs. Laws could be passed that not only improve access to the mental health system in general, but also specifically to psychiatrists. Society could decide that psychiatrists should be reimbursed for their time, without specific rules about what that time needs to be spent on. Thus, long-term psychotherapy would be fully reimbursed, as would all consultation-liaison services. The length of inpatient stays could be left to the judgment of the attending psychiatrists. Public psychiatrists could be encouraged to implement all needed treatment. At the same time, there would be no disincentives for solo private practices either. None of this seems unreasonable per se. Yet the current trend is definitely in the opposite direction. Managed care companies, for instance, tend to staff their mental health programs with 0.4 to 0.8 psychiatrists per 10,000 subscribers, whereas the ratio of psychiatrists to the population as a whole is currently about 1.5 per 10,000. The question is: will the trend toward limiting the role and the scope of practice of the psychiatrist continue so as to more than offset the increased manpower needs due to population growth and potentially expanded access to care? We 221'
believe that it will. To illustrate this, we would like to focus on two mutually reinforcing developments: 1) changes in the practice of psychiatry toward brief and time-effective patient contacts, and 2) changes in the role of the psychiatrist as a result of health care reform. CHANGES IN PSYCHIATRIC PRACTICE In the 1960s and 1970s, psychiatric practice evolved around long-term psychotherapy. Inpatient treatment was focused on individual and "milieu" therapy, facilitated by new drug treatments. Outpatient practice was largely equivalent to doing psychotherapy. Since then, we have witnessed a shift in psychiatric practice toward spending an increasing amount of time doing diagnostic work, providing consultation to other medical and mental health professions, managing medication regimens, and doing individual work with only the most seriously mentally ill. These changes are also evident in our residency training programs, where the primary focus is no longer on long-term, psychoanalytical psychotherapy. Instead, more hours are allocated each year to the teaching of diagnostic skills, pharmacology, crisis intervention techniques, consultation-liaison duties, substance abuse treatment, geriatric psychiatry, child and adolescent psychiatry, and forensic psychiatry (1). Not only has our practice time changed, many conditions are approached differently than in the past. Conditions that required long-term psychotherapy are increasingly being treated with medications and/or brief, focused psychotherapeutic interventions. For example, obsessive-compulsive disorder was often treated as a deep-seated "personality" problem, requiring intensive and longterm psychotherapy. Now it is treated predominantly with pharmacology and behavioral approaches. In general, we believe that the field of psychiatry has made impressive strides toward time-effectiveness. Furthermore, specific treatments are be\ l ) 1 L \ II I')." l \ mil,
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