Psychiatric DONALD
C.
Professor Department University Cincinnati,
LANGSLEY,
Chairman of Psychiatry of Cincinnati
Manpower:
M.D.
have conditions that require the specialized a psychiatrist, in addition to those whose emotional problems can be treated by the physician with consultative assistance (2).
and
College
An Overview
of Medicine
Children
Ohio
and the elderly
disorder
CAROLYN B. ROBINOWITZ, Deputy Medical Director and of Education American Psychiatric Washington, D.C.
M.D.
require
Director,
Office
Association
There in the
are approximately 25,000 to 30,Oi’YJ psychiatrists United States, some 1 7,000 of whom are in actual clinical practice. As part of an overview of psychiatric manpower, the authors show the distribution of psychiatrists by state and present population-per-psychiatrist ratios. In discussing the distribution of psychiatrists in various work settings, they note that the decreawtg percentages of psychiatrists in community mental health centers may be related to such factors as the large number of non-hospital-based centers, growing antimedical attitudes in centers, and psychiatrists’ inclination to work in a setting similar to their training site. They believe that federal and state support should be increased for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hOspitals, community mental health centers, and szmilar facilities. Such an approach would result in the recruitment and retention ofgreater numbers
ofpsychiatrists U
Between
conditions
These
in public 22 that
conditions
and
35
service million
require
mental
include
the
more
Americans health
suffer treatment
serious
from (1).
disorders
and do not necessarily
reflect
HOSPITAL
APA policy.
& COMMUNITY
PSYCHIATRY
higher
stages
services,
rates
mental
illness
requires
yet
than elaborate physical facilities there
test
are
people
of mental
proven
programs-85
giving
and
to 90 per
professionals
and
logical, fectious
prevention
services
cent-are
have
interdigitated
for
defined
product
and social disease
intervention
pre-
far less availgroups of all disorder, and that are not areas are no but are inreadily accesof rather
staff
They include the services of mental health als, nonpsychiatric physicians, paraprofessionals, cian-extenders, citizens, and volunteers (4). Health
and
treatment
equipment or technology. Although are a necessary part of treatment, and and promising uses for more technical the major direct costs of mental health
procedures,
plex
of and care
of development
ventive services for these age groups are able than for others. Members of minority ages are especially vulnerable to mental they often are surrounded by resources available to them. Those who live in rural less susceptible to mental disorders, adequately served because of the lack of sible services (3). The diagnosis and treatment as well as
factors. as well
necessary
illness of
services.
professionphysias the
biological,
This complexity holds as mental disorders.
to
assist
the
requiring removal with professionally
corn-
psycho-
return
to
of the cause conceived
for inThe health
is
of trouble plans for
appropriate intervention in a compassionate and helpful manner. For centuries physicians have been assigned the responsibility for treatment. But even with modern knowledge and skill, they cannot provide all the
help
The varying the
needed, role
and
and
collaboration
function
of
is essential. the
psychiatrist
situations; when mental problems with social factors (such as poverty
sociated
psychiatrist’s
ment Dr. Langsley is president-elect of the American Psychiatric Association. His address at the College of Medicine is 231 Bethesda Avenue, Cincinnati, Ohio 45267. The opinions expressed here are those of the
have
in other
complex
complex, when known,
such as schizophrenia (two million persons), clinical depressive illness (another two million), the organic brain disorders (at least one million), the serious complications of drug and alcohol abuse, and many other disabling problems. It has been estimated that at least 15 per cent of the patients seen by primary care physicians
authors
those
also
settings.
most
than
attention mental primary
role
of conditions
evident. The tal in treating phrenia, cations
VOLUME
in which
biomedical
affective of drug
is different
the
major
skills
in the
factors
of the
psychiatrist
illnesses
organic abuse,
NOVEMBER
differ more
in as-
or racism),
that
biological
mental
disorders, and alcohol
30 NUMBER!!
from
are
such
are
treatmore
are
vi-
as schizo-
syndromes, complior psychosomatic
1979
749
problems. chiatrist
Among is unique
mental health professionals in having the particular
the psyknowledge
skill
of the physician, and among physicians he is unique by virtue of his special knowledge and skills related to the psychosocial factors of illness.
and
At
a conference
sponsored
by
nient (5).
of the
education
American participants
multiple
Appendix
1.
made While what
the
of the
Psychiatric developed
and
varied
Association a detailed
functions
of the
and state-
Another
skills,
effort
and
the
Board
of Psychiatry
skills they
the
two
agreed
descriptions,
are
retired
time,
or
who
work
all
those
When ably
was
and Neurol-
on are very
similar.’
it is apparent
that
with
the past
cent
cent
tals psychi-
certain
role
need
der
to
sociocultural sequently practice.
include
uation illness diseases nervous hensive The
the
ability
to make
a comprehensive
eval-
second
area
relates
to treatment.
It includes
general
hospital.
functions
are
chosocial
factors
NUMBERS There
are
in the
United
American
related
Thus to
the
in health
OF
the
States.
interdigitation
and
formal
The
750
to 30,000
higher
Association
training
psychiatrists. Approximately members of the American D. G. Langsley
of
and
biopsy-
disease.
25,000
and M. Hollander,
HOSPITAL
estimate figures
designated psychiatrists: that selves psychiatrists whether completed
role
that
psychiatrists
is drawn
from
include
self-
is, persons who call themor not they have actually
or are
formally
25,000 Psychiatric unpublished
employed
physicians Association. data,
& COMMUNITY
are APA
1979.
PSYCHIATRY
prob(6). of
health
psy-
profession-
professionals
have
and
of state
This
in psychiatry
the
and
make
in-
up
county
as the
is complex.
language effectively
psychological may have both
and
culture
and
to
factors difficulties
educators
over
50
hospi-
the
brain from
quality
Psychia-
well
in or-
understand
the
of illness. Conin training or
and
legislators
have
drain
resulting
from
their
countries of origin, care and the numbers
of medical
available.
concern
in part
Assistance of its provisions who and
as well
led
as of medical
TABLE
1
workers,
and nurses
to
the
Health
Act of 1976 sets severe
in
Numbers per
States for resiof fluency in
knowledge
FMGs
in
Professions
(Public Law 94limits on the num-
may enter the United requires high standards
is a decrease
for entry.
psychiatry
of psychiatrists, psychologists, 100,000 population’
and
The other
social
Psychia-
Psycho-
Social
trists
logists
workers
Nurses
1960-61
7.7
10.3
8.0
10.7
1962-63
8.2
11.1
15.1 18.2 19.1
282
1961-62 1963-64 1964-65 1965-66 1966-67 1967-68 1968-69 1969-70 1970-71 1971-72 1972-73 1973-74 1974-75
8.6
1 1.5
12.1
20.3 21.4
306
9.0
Year
1975-76
as
are
practice
numbers
in 1975
staff
of physicians
Educational 484). One
result
PSYCHIATRISTS
approximately Medical
psychiatrists’
as well
English
ability to manage psychiatric emergencies, especially those in the emergency service of a general hospital; to use psychoactive medication competently; to use other physical treatments for mental illnesses, such as ECT, as appropriate; and to use laboratory tests, including those that demonstrate organic or systemic illness. The third area is the ability to provide medical consultation
in the
of FMGs
bers of FMGs dency training
that encompasses the organic causes of mental and the psychiatric accompaniments of organic of any part of the body (not just the central system) and the ability to arrive at a compretreatment plan for such organic disorders.
res;dents
Further,
of physicians
They
the
mental
health
physician
concerned
of complex
there are certain skills that are unique to and that fall in three general areas. general medical and neurological skills.
mental
and FMGs
agnosis
Nonetheless, psychiatrists First are
core
communicate
emigration
problems.
actual
part
practice.
there
in of
work
clinical
considered,
of other
to know
and others. Similarly, psychiaphysicians may be engaged in di-
biomedical
than
15 years.
of the
mental health nurses, trists as well as other
and treatment
those
as psychia-
who
(7). The
been
psychologists,
are
of all psychiatric
per
other
workers,
as well
creased in number over the past 15 years, with psychologists having the greatest proportionate increase. The supply of psychiatrists, however, is more complicated than these figures might indicate. Since the early 1960s, foreign medical graduates have come to the United States in increasing numbers. They constituted 39 per
trists
social
other
a comparison
als over
the
in
psychiatrists
1 provides
of
residents
or incapacitated,
factors
17,000
chiatrists
atrists and other mental health professionals-as well as psychiatrists and other physician specialists-have overlapping areas of knowledge, skill, and activities. Psychotherapy is one such activity; psychotherapy of one type or another may be practiced by psychiatrists, physicians,
some
All
requisite
psychiatrist
include
who
psychi-
a survey of 500 teachers and practitioners. required knowledge was described in somedetail than in the APA statement, the spe-
cific clinical From
defining
of the
by the American through the more
at
attitudes
figures
trists
Table
psychiatrist
in the form of goals of basic residency training A condensed version of the statement appears in
knowledge, ogy
the
in 1975,
others
atrist,
on
membership
9.5
12.4
23.0
319
10.0
13.0
327
10.4 10.8
13.6 14.2
24.2 24.9
11.0 1 1.3 11.8 11.9 11.0 12.1
15.2 15.6 16.2 16.8 17.6 18.6
12.4
American
figures
19.5
are based
Psychiatric
on the numbers
24.6 24.2 26.0 27.3 26.9 28.7 30.2
32.2
Association
members,
of psychiatrists
335 345 356 366 376 390 407 427 449
are are American Psychological Association members, social workers who are members of the National Association of Social Workers, and data from the American Nurses’ Association. I
The
298
psychologists
who
who
medical
specialties,
the
been fully felt. At the same time,
impact
of which
there
has
been
a drop
American medical graduates 1970-71 a total of 1 1 per cent
In
school
graduates
number
dropped
cent.
per
The
not
yet
entered
psychiatry.
to 4 per
cent,
reasons
for
the
in the
num-
entering psychiatry. of American medical By
and
1975-76
by
decrease
this
1978-79
are
to
3.6
complex
and
include
issues of medical education and the role and function of psychiatrists as well as the attraction of family medicine and other primary care specialties. Consequently many residency positions are unfilled (8). In
1974-75
residency the
there
were
unaffiliated.
filled.
In the
tend
psychiatric
positions;
hundred
with
4370
ninety-six
universities,
affiliated
of
and
programs
29
FMGs, while in the were FMGs (9).
OF
Psychiatrists
One
affiliated
of the residents were programs 68 per cent
accredited of 5012
a total
were
LOCATIONS
256
with
positions
programs
were
were
programs
of these
60
per
cent
nonaffihiated
American
22,753
to
be
concentrated
in
Association
members
county, and their addresses
health on
living
metropolitan
survey
in
the
identified
U.S.
by
state,
systems agency region, based file in APA’s central office. Table
on 2
shows their distribution by state, the population per psychiatrist in the state, and the population per psychiatrist of the counties with the lowest and highest psychiatrist-to-population ratio. Eleven per cent of the U.S.
psychiatrists
centration
lation
are
distorts
ratios
The
figures
in metropolitan
variation
erable. at least
in academic
the
settings, for
areas
between
and
Carolina,
and
one
this
con-
(10).
Forty-eight of the 49 counties one psychiatrist. One county
in North
and
psychiatrist-to-popu-
within
states
is consid-
in California have in New York, one
in Massachusetts
have
a ra-
tio of one psychiatrist for less than a thousand population; at the same time, Virginia and Minnesota each have rural counties with more than 150,000 citizens per
psychiatrist. are
Although
not
many
regions
the of
psychiatrists. Nonetheless, counties have no psychiatrist rural
and
thinly
Koran
with tion
has
populated
underlying
largely WORK
the
attractions same (11).
AND
WORK
U.S.
is uneven, altogether
there without
more than 50 per cent at all; they include
of all many
areas.
compared
lawyer-population between the two.
distribution the
psychiatrist-population
ratios
ratios and found a high The correlation suggests for
both
professional
study
compared
the
treatment
of 2000
pa-
tients
PSYCHIATRISTS
Psychiatric
APA
private
A California
areas. In general, there are few data on practicing psychiatrists by county or smaller geographic area. In 1977 an
practice. We estimate that approximately psychiatrists are in public service, and many of them engage in part-time private practice. Psychiatrists as a group tend to be heavily involved in administrative activities and in such indirect services as teaching and consultation. Thus some psychiatrists who list their primary affiliation as private practice or fee-for-service may not actually spend the major percentage of their time in clinical work. Eighteen per cent of the psychiatrists in the survey work in areas in which the population is less than 100,000. Psychiatrists work long hours; 61 per cent of those reporting worked more than 45 hours per week, and only 33 per cent of those reporting saw less than 30 patients a month.2 It is a common belief that psychiatrists in private settings practice differently from those in public settings. in
15,000
of
her
has
correlathat the
groups
in private settings and 2000 patients in clinic settings. Both groups of patients had completed treatment and did not differ significantly in sex or diagnoses; more patients seen in private settings were married. The two groups of psychiatrists used similar amounts of medication, and they saw patients for similar lengths of time. However, clinic psychiatrists were more likely to see patients more than once a week when necessary, and they used group and family therapy approaches more often. Private-practice psychiatrists saw patients for approximately the same number of office visits as clinic psychiatrists, 12.8 and 10.2 visits, but kept patients in hospitals somewhat longer, 15 days compared with 5.9 days (12). Another survey found that in 1976 psychiatrists accounted for 5 per cent of the total staff positions of all mental health facilities or, more specifically, for 2 per cent of the full-time and 15 per cent of the part-time positions. Forty per cent of the full-time psychiatrists worked
in
state
and
county
mental
hospitals,
16
per
cent in community mental health centers, and 15 per cent in general hospital psychiatric units. The percentage of full-time-equivalent positions of psychiatrists in community mental health centers has decreased continuously, from 12.8 per cent of the total professional positions in 1972 to 10.7 per cent in 1976 (13). Since the number of psychiatrists trained has remained stable or even decreased while the numbers of patients and staff as well as of centers have increased, it is not surprising that the gap has been filled in part by other mental health professionals. MENTAL
COMMUNITY
HEALTH
CENTERS
are
Since opened
SETFINGS
In 1977 the American Psychiatric Association surveyed 20 per cent of its members about their professional activities as part of a study of the use of electroconvulsive therapy; 3000 psychiatrists responded. Almost half the respondents (49 per cent) indicated they were primarily
the first community mental health center was in 1964, the number of centers grew to 164 in 1968 and 528 in 1976. Nonetheless, only 43 per cent of the catchment areas in the United States have developed centers to meet federal standards. CMHCs serve an estimated 77.6 million persons, 35 per cent of whom 2Tk Association,
VOLUME
Force
on Electroconvulsive
Washington,
30 NUMBER
D.C.,
Therapy, report
11 NOVEMBER
American
of questionnaire,
1979
Psychiatric 1978.
751
TABLE
2
Geographic
distribution
of psychiatrists
of
Number
State
133
1,923,322 19,969,175 2,209,596
578
3,032,217
58
D.C.
400
548,104 756,668
Florida
816
6,791,418
Georgia Hawaii Idaho
331
4,587,930
Illinois
997 248 134 222 196 241
111 26
Kansas
Kentucky Louisiana Maine Maryland
8,296 17,645
20,950 21,085
84,927
1,347
4,871
46,527 119,215 154,712 49,700 123,702 33,281 66,200
892 1,709 2,713
694,409
23,147
100
33
857,756 488,738
14,810
74
737,681
9,968
732 93 4,007
7,171,112 1,017,055 18,241,584 5,084,411 617,792
9,796 10,936 4,552 12,872 32,515
131 186
Oregon
Pennsylvania Rhode Island
1,177 1 13
8,578
1 1,245 10,026
949,723
8,405
2,590,835 666,257
17,685
38,696
18,118
58,956
3,248
28,968
36,920
4,255 5,609
4,417,821 332,416
22,161
752
HOSPITAL
Data
on APA
& COMMUNITY
Member
Psychiatrists,
12,485 11,901 6,176 9,303
PSYCHIATRY
2,314 7,167
26,318 154,364
2,789 1,738
41,103 39,749 69,004 51,264
14,875
American
49,514
108,312
10,158
1977,
4,283 3,912 937 834 5,888
2,303 7,178
297
Distribution
7,122
2,496
99,190 21,426
Wisconsin
on S. Muszynski,
2,248
3,130 4,567
52,640
29,563
Based
4,881
6,521 3,681 5,778
1,744,237
‘
95,627 58,560 125,868 108,144
2,091,533 11,800,766
444,732
15
110,828
15,930
4,851,448 3,413,244
Wyoming
49,554
19,843
3,926,018 1 1,199,385 1,059,273
72
60,687
2,599,463
500 336 59
23 222 897 89
18,219 23,477
10,657,423
South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia
143
2,671
4,374
30
395 20 675
62,783 60,765
5,689,170
27,037 12,540
York
7,692 8,645 6,712 1,524
3,923,897
2,216,994 4,677,623
North Carolina North Dakota Ohio Oklahoma
1,556
15,867 29,167 111,409 48,127
118,078 94,078
3,806,103
New
50,691
15,114 10,240
82 381
Mexico
1,892 1,306
1,523 2,766 1,455 4,144
268
Jersey
7,016
129,440
Mississippi
New
7,735
3,798 6,024 4,103 1,681 2,548 3,485
10,731 16,432
Minnesota
New
14,490 80,356 31,035
13,861 6,936 27,423 11,147
11,337 14,202
Hampshire
40,046
74,492
8,881,826
New
with lowest population-perpsychiatrist ratio
29,967
780
Montana Nebraska Nevada
with highest population-perpsychiatrist ratio
6,368 5,246
Michigan
Missouri
Population of county
5,889
9,450 1,892 8,322
3,220,711 3,642,463 993,722
897
Population of county
61,268 17,100 61,918
11,638
2,249,071
1,168
per
25,897
2,825,368
ratios’
population-per-psychiatrist
Population psychiatrist
769,913 713,015 11,113,141 5,195,610
99
Massachusetts
and
1,775,399
109 3,391 347
Indiana Iowa
22,753)
3,444,354 302,583
26 214
Delaware
=
Population of state, 1970
psychiatrists
Alabama Alaska Arizona Arkansas California Colorado Connecticut
(N
Psychiatric
Association,Washington,
5,601 4,248
3,770 1,775 D.C.,1977
are in metropolitan
areas. The centers now account for 4 per cent of the episodes of inpatient care and 25 per cent of the episodes of outpatient care, excluding the care provided by other non-VA federal programs and psychiatrists in private practice. Personnel patterns in community mental health centers show a diminishing proportion of psychiatric staff in spite of increases in the total number of psychiatrists. Although the total staff of the centers almost tripled in the six years between 1970 and 1976, the number of FTE psychiatric positions per center dropped from 6.8 to 4.3, while nonpsychiatrist-physician positions remained stable at .5 per center. Fifty per cent of the centers reported having less than 2.3 psychiatrists on the staff in 1976. In the same time period, the number of VfE psychologists nearly doubled (from 4.9 to 8.6), and social workers increased by 35 per cent (from 9.7 to 12.8). Psychiatric residents constituted 29 per cent of the total trainees in centers in 1970 but dropped to 14 per cent of all trainees in 1976, although the residents’ absolute numbers increased from 432 to 659. In the same period psychology trainees increased from 10 to 19 per cent, and social work students increased from 17 to 25 per cent (13,14). If the staffing of community mental health centers is to depend in part on psychiatrists’ services, it is clear that not enough psychiatrists are trained in such settings to staff them. These changes are related to a number of issues. They may reflect the fact that more non-hospital-based than hospital-based community mental health centers are being funded. Many programs are moving from treating the most seriously and chronically mentally ill to providing care more oriented to social services-that is, care for patients with less serious illnesses and also assistance with their housing and sociocultural problems-although that may be a result as well as a cause of the decrease in psychiatric personnel. The decrease may also be related to the growing antiprofessional and especially antimedical attitudes in centers. While there are claims that psychiatrists do not remain in centers for economic reasons, surveys have demonstrated that job satisfaction and work in a setting similar to one’s own training site are more relevant determinants. Graduates of university psychiatric training programs that are located in community mental health centets are more likely to work in a center after graduation. Ninety-five per cent of the graduates of the residency training program at the University of California at Davis, where all training took place in three community mental health centers staffed by university faculty, accepted full-time staff positions in CMHCs during the first eight years of the residency program.3 In many centers, psychiatrists are used only to prescribe medication. Many report the existence of antiprofessional attitudes that undervalue direct treatment and overvalue consultation directed toward impossible solutions of social problems (15). Psychiatrists are more 3D. G. Langsley,
unpublished
data,
1978.
likely to remain in a community mental health they experience job satisfaction and feel they forming useful and valued services.
STATE
center if are per-
HOSPITALS
State hospitals have had constant difficulties in retaining qualified psychiatrists. A telephone survey in 1976 confirmed the shortage of psychiatrists in those facilities and found that hospitals with residency training programs, especially those affiliated with universities, employed more psychiatrists. The nine states that employed more psychiatrists and had significantly smaller proportions of foreign medical graduates were those with university-affiliated residency training programs (16). Another telephone survey, in August 1977, demonstrated that of 3480 psychiatrists in state mental hospitals, 13 per cent were FMGs unlicensed in the state in which they practiced, while another 17 per cent were FMGs in residency training. In addition, since state hospitals cannot recruit enough psychiatrists, general physicians often fill staff positions. Of these additional 21 12 physicians, the survey showed, 24 per cent were FMGs unlicensed in the state in which they practiced. Thus of the total of 5592 physicians, 54 per cent were unlicensed FMGs (17). In a landmark decision that established standards for psychiatrists and other physicians working in state hospitals, Wyatt v. Stickney, Judge Frank Johnson of Alabama ruled that two board-eligible psychiatrists and four other physicians were required for each 250 patients (18). This ratio translates to a caseload of 125 patients per psychiatrist and 62.5 patients per each other physician-hardly a standard that could be called overgenerous-and it suggests that psychiatrists are mainly involved in initial diagnosis and case management, leaving much of the therapeutic interactions and ongoing contact to other mental health professionals. A July 1977 report from the Health Resources Administration suggested that state mental hospitals are in immediate need of approximately 1700 psychiatrists to bring the number of psychiatrists to a reasonable level (19). CHILDREN
AND
THE
ELDERLY
Of the 88 million children 18 years old or under, approximately 9 to 13 million need mental health services. The National Institute of Mental Health’s Division of Biometry reported that although 40 per cent of the U.S. population was under age 18 in 1971, only 25 per cent of new patients in community mental health centers were under 18 (20). It was so evident that the centers had failed to serve children that in 1971 Congress developed a special program for children (part F grants under the community mental health centers legislation), but it appropriated only $10 million a year for these services. Child and adolescent services have now been mandated for all community mental health center pro-
VOLUME
30 NUMBER
11 NOVEMBER
1979
753
grams; however, legislated mandates cannot solve the problems of mental health services for children because of the serious shortages of personnel, lack of funds, and poor commitment. In 1974 the federal budget for direct services for all mental illness was only 3.4 per cent of the appropriated health care funds. There are only about 2800 child psychiatrists in the United States. One estimate of need is that if child psychiatrists spent one hour yearly in the evaluation of each child initially entering school (of whom at least 10 per cent are estimated to need specialized mental health care), 500,000 hours yearly or 250 FTE child psychiatrists would be needed for this task alone. Most diagnostic interventions for children require a highly complex and specialized set of skills for the understanding of psychological, social, cognitive, developmental, and neurological and other physical parameters. In fact, if 40 per cent of all psychiatrists were trained in child and adolescent work (to match the proportion of children and adolescents in the population), there would be 1 1,000 child psychiatrists instead of 2800. Nonetheless, only about 200 child psychiatrists complete residency training each year, certainly not enough to increase their numbers. By the year 2000, a total of 25 per cent of the population will be over 65. The mental health problems of this age group are specialized, just as are those of children. Many of the elderly are institutionalized as “senile” when they suffer from a treatable condition. Diagnosis and treatment of the elderly is complicated and demands close interdigitation of biological factors (especially those related to physical conditions and drug interactions) with developmental and psychosocial features. There are only a handful of psychiatrists who specialize in the mental health problems of the aged. Residency programs are just beginning to incorporate information about this age group. In view of the lack of almost any specialized manpower and the size of the problem, accurate estimates of need cannot be made. Based on population figures, psychiatrists knowledgeable in geriatric psychiatry should constitute 25 per cent of the field, or 6800, a logarithmic increase.
ACADEMIC
SETTINGS
As noted above, 1 1 per cent of all psychiatrists work in academic settings. There are more than 120 fully accredited medical schools in the United States and another ten in stages of development. Besides operating education programs for medical students, physicians, and other health and mental health workers, departments of psychiatry in these schools operate patient care services and are the backbone of research programs in the broad field of mental health. They represent a national resource in the development of mental health manpower and the new knowledge needed to prevent mental illness or treat it more effectively. There is some information about the significant proportion of time residents spend in community mental
754
HOSPITAL
& COMMUNITY
PSYCHIATRY
health centers, state hospitals, VA hospitals, and similar facilities that negates the myth of the distant ivory towers of academia whose inhabitants have little involvement in public service settings. Reports from 64 departments of psychiatry (half the total) indicate that each year they deliver 1.3 million inpatient days of care, see patients in 1.4 million outpatient visits and 125,000 emergency service visits, and provide 57,000 consultations to other medical services (21). Many of those services have been provided by residents (under supervision) to otherwise underserved population groups. Yet funding for services and training has diminished significantly; federal dollars for total mental health manpower training decreased 50 per cent since 1970 through actual dollar decrease and diminished purchasing power (22). Psychiatric training has borne the brunt of these cuts, and funding has been a major factor in limiting activities of departments of psychiatry and limiting the numbers of American medical graduates entering psychiatry.
INCOME
OF
PSYCHIATRISTS
Psychiatrists are the most poorly paid group of all medical specialists. Data from Medical Economics surveys indicate that psychiatrists constitute 5.4 per cent of all private practitioners. As a group they have a net income significantly less than the average medical specialist, and even psychiatrists in private practice have incomes far lower than is usually assumed (23,24). Because psychiatrists’ fees are based on length of time of patient contact, because they use few technological procedures (compared with the plethora of laboratory tests and procedures available for other physicians), and because they spend more time with each patient than other physicians, psychiatrists’ fees are more limited and are not rising as fast as those of other specialists. CURRENT
NEEDS
Psychiatrists work in a number of settings providing urgently needed services. A current study indicates that psychiatrists are spending increasing proportions of time in public service settings, caring for the more seriously ill and heretofore underserved (25). Yet the federal government’s support of manpower training has not produced enough psychiatrists to meet the needs of the population. The frequently repeated statement that psychiatrists are maldistributed is correct, but it must be reconsidered in the light of a clear shortage of psychiatric manpower. There cannot be appropriate distribution without a sufficient number. Location of practice is often related to psychiatrists’ training experiences and job satisfaction during training. Thus problems in distribution suggest the need for appropriate changes in psychiatric education programs. Recruitment is a key issue. A conference to discuss the facets of recruitment will be held March 7-8, 1980;
it will be sponsored by the American Psychiatric Association’s council on medical education and career development, the APA office of education, and a consortium of psychiatric education and service organizations and funded in part by NIMH. This conference should lead to specific efforts at remediation. There is a clear need for increased federal and state support for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hospitals, community mental health centers, and similar facilities. Such an approach would result in the recruitment and retention of greater numbers of psychiatrists in public service settings. Then the unique knowledge, skills, and abilities of psychiatrists could be more appropriately used in a total health and mental health care system, with increased benefits for patients and their families.#{149} REFERENCES 1) Report tal Health,
to the
President
From
the President’s
Commission
Vol. 1, Washington, D.C., 1978, pp. 2) National Institute of Mental Health, The
and
Quality
Maryland,
of 1976,
Mental
Health
Care
in the
on Men-
8-10. Financing,
United
States,
Rockville,
p. 27.
American Psychiatric Association, Washington, D.C., 1976, pp. 1931. 6) C. B. Robinowitz, Psychiatric Manpower, report prepared for the Manpower Policy Analysis Task Force, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland, 1978. 7) J. J. Jenkins and M. J. Witkin, Foreign Medical Graduates Employed in State and County Mental Hospitals, Mental Health Statistical Note 131, National Institute of Mental Health, Rockville, Maryland, July 1976. American
Psychiatric
Association,
Resident
Census,
Washing-
ton, D.C., yearly reports, 1970 through 1978. 9) American Medical Association, Directory of Accredited Residencies, Chicago, 1976. 10) 5. Muszynski, Distribution Data on APA Member Psychiatrists. 1977, American Psychiatric Association, Washington, D.C., 1977. 11) L. Koran, “Psychiatric Manpower Ratios: A Beguiling Numbers Game,” Archives ofGeneral Psychiatry, in press. 12) D. G. Langsley, “Comparing Clinic and Private Practice of Psychiatry,” American Journal ofPsychiatry, Vol. 135, June 1978, pp. 702-706.
13) R. D. Bass, CMHC stitute
of Mental
Health,
Staffing: Rockville,
Who Minds Maryland,
the Store? 1979.
National
In-
14) W. W. Winslow, munity Mental Health
“The Changing Role of Psychiatrists in CornCenters,” A,nerican Journal of Psychiatry,
Vol.
pp.
136,
January
1979,
24-27.
15) P. J. Fink and S. P. Weinstein, “Whatever Happened to PsychiThe Deprofessionalization of Community Mental Health CenAmerican Journal of Psychiatry, Vol. 136, April 1979, pp. 406409. 16) D. J. Knesper, “Psychiatric Manpower for State Mental Hospitals: A Continuing Dilemma,” Archives of General Psychiatry, Vol. 35, January 1978, pp. 19-24. 17) D. J. Knesper, Career Decisions Made by Psychiatrists: A Multistate Survey, Mental Health Research Institute, University of Michigan, Ann Arbor, 1978. 18) S. Stickney, ‘Wyatt vs. Stickney: The Right to Treatment,” Psychiatric Annals, Vol.4, August 1974, pp. 32-45. 19) “Health Manpower Shortage Areas: Criteria for Designation,” Federal Register, Vol. 43, January 10, 1978, pp. 1586-1596. atry? ters,”
Institute 1971,
of
Mental
Health,
of Mental
Utilization
Rockville, Maryland, 1973. 21) American Association of Chairmen of Departments try, The Crisis in Psychiatric Manpower: Toward a National ric Manpower
Policy, D.C., January 1977.
22) B. Brown,
American
Psychiatric
Association,
of PsychiaPsychiatWashington,
of the NIMH Director to the National AdviCouncil, National Institute of Mental Health, December 1977. 23) “Earnings Survey: Which Specialties Are Staying Ahead of Inflation,” Medical Economics, October 18, 1976, Pp. 146-159. 24) “Doctors’ Earnings: Inflation Edges Ahead,” Medical Economics, September 18, 1978, pp. 226-246. 25) P. E. Dietz, “Psychiatrists Young and Old: A Comparative Survey,” paper presented at the annual meeting of the American Psychiatric Association, May 8-12, 1978, Atlanta. Report
sory Mental Health Rockville, Maryland,
APPENDIX
1
Functions
the psychiatrist’
of
1) Demonstrate general medical skills, including the abildiagnose and plan for the treatment of illness, the judgment and skill to deal with medical emergencies, and the ability
to
ity to deal with medical 2) Demonstrate the
Utilization,
3) Report to the President From the Presidents Commission on Mental Health, Vol. 1, Washington, D.C., 1978, pp. 4-8. 4) National Institute of Mental Health, Staffing of Mental Health Facilities, U.S., 1976, Rockville, Maryland, 1977. 5) A. H. Rosenfeld, Psychiatric Education: Prologue to the 198ffs,
8)
National Facilities,
20)
Health
problems neurological
of the mentally skills needed
ill. to make
a
presumptive diagnosis based on the patient’s history and a neurological examination and to understand specialized neurological diagnostic procedures. 3) Obtain a psychiatric history and perform a thorough physical examination using interviewing nation skills, and appropriate tests. 4) Arrive at a diagnosis and treatment 5) Manage psychiatric emergencies.
6) Provide ing individual, appropriate
physical
Deal
mental
plan.
therapies
with
and
behavioral
medication
therapies.
competently.
developmental
and
aging
processes
early life to aging and death, based on knowledge of children and adolescents as well as the elderly. 9) Keep adequate medical records. 10) spective
exami-
treatment appropriate to the patient, includgroup, and family therapies; be familiar with
7) Use psychoactive 8)
skills,
View patients from using biopsychosocial
a holistic, data and
from
of problems
developmental their interaction.
per-
1 1) Serve as a medical consultant in the general and as a mental health consultant in various agencies. 12) Demonstrate consistent awareness social aspects of medical practice, the tionship,
and
the
distribution
health care system. 13) Critically assess ical practice.
14) Demonstrate ued
and
ability
17) Be able
to apply
of complex
clinical
18) Demonstrate
VOLUME
research
within
information
capacity,
and relathe
in din-
and skills for continand
to communicate role with fellow
supervise
treat-
comfortably psychiatrists
.
and and
general
personal
for
Education:
skills
in a va-
maturity, self-awareness, and as a psychiatric specialist.
the
identity
basic residency Prologue to the
Washington,
30 NUMBER
problem-solving
situations.
of professional
‘Based on goals Association,
responsibility
legal,
alike.
nonpsychiatrists
Psychiatric
of ethical, physician-patient
to organize
ment given by others. 16) Demonstrate ability effectively in a teaching
possession
apply
motivation,
self-education. 15) Demonstrate
riety
of
hospital
training, 1980’s, D.C., 1976, pp. 19-31.
11 NOVEMBER
1979
in A. H.
American
Rosenfeld,
Psychiatric
755
C.
Professor Department University Cincinnati,
LANGSLEY,
Chairman of Psychiatry of Cincinnati
Manpower:
M.D.
have conditions that require the specialized a psychiatrist, in addition to those whose emotional problems can be treated by the physician with consultative assistance (2).
and
College
An Overview
of Medicine
Children
Ohio
and the elderly
disorder
CAROLYN B. ROBINOWITZ, Deputy Medical Director and of Education American Psychiatric Washington, D.C.
M.D.
require
Director,
Office
Association
There in the
are approximately 25,000 to 30,Oi’YJ psychiatrists United States, some 1 7,000 of whom are in actual clinical practice. As part of an overview of psychiatric manpower, the authors show the distribution of psychiatrists by state and present population-per-psychiatrist ratios. In discussing the distribution of psychiatrists in various work settings, they note that the decreawtg percentages of psychiatrists in community mental health centers may be related to such factors as the large number of non-hospital-based centers, growing antimedical attitudes in centers, and psychiatrists’ inclination to work in a setting similar to their training site. They believe that federal and state support should be increased for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hOspitals, community mental health centers, and szmilar facilities. Such an approach would result in the recruitment and retention ofgreater numbers
ofpsychiatrists U
Between
conditions
These
in public 22 that
conditions
and
35
service million
require
mental
include
the
more
Americans health
suffer treatment
serious
from (1).
disorders
and do not necessarily
reflect
HOSPITAL
APA policy.
& COMMUNITY
PSYCHIATRY
higher
stages
services,
rates
mental
illness
requires
yet
than elaborate physical facilities there
test
are
people
of mental
proven
programs-85
giving
and
to 90 per
professionals
and
logical, fectious
prevention
services
cent-are
have
interdigitated
for
defined
product
and social disease
intervention
pre-
far less availgroups of all disorder, and that are not areas are no but are inreadily accesof rather
staff
They include the services of mental health als, nonpsychiatric physicians, paraprofessionals, cian-extenders, citizens, and volunteers (4). Health
and
treatment
equipment or technology. Although are a necessary part of treatment, and and promising uses for more technical the major direct costs of mental health
procedures,
plex
of and care
of development
ventive services for these age groups are able than for others. Members of minority ages are especially vulnerable to mental they often are surrounded by resources available to them. Those who live in rural less susceptible to mental disorders, adequately served because of the lack of sible services (3). The diagnosis and treatment as well as
factors. as well
necessary
illness of
services.
professionphysias the
biological,
This complexity holds as mental disorders.
to
assist
the
requiring removal with professionally
corn-
psycho-
return
to
of the cause conceived
for inThe health
is
of trouble plans for
appropriate intervention in a compassionate and helpful manner. For centuries physicians have been assigned the responsibility for treatment. But even with modern knowledge and skill, they cannot provide all the
help
The varying the
needed, role
and
and
collaboration
function
of
is essential. the
psychiatrist
situations; when mental problems with social factors (such as poverty
sociated
psychiatrist’s
ment Dr. Langsley is president-elect of the American Psychiatric Association. His address at the College of Medicine is 231 Bethesda Avenue, Cincinnati, Ohio 45267. The opinions expressed here are those of the
have
in other
complex
complex, when known,
such as schizophrenia (two million persons), clinical depressive illness (another two million), the organic brain disorders (at least one million), the serious complications of drug and alcohol abuse, and many other disabling problems. It has been estimated that at least 15 per cent of the patients seen by primary care physicians
authors
those
also
settings.
most
than
attention mental primary
role
of conditions
evident. The tal in treating phrenia, cations
VOLUME
in which
biomedical
affective of drug
is different
the
major
skills
in the
factors
of the
psychiatrist
illnesses
organic abuse,
NOVEMBER
differ more
in as-
or racism),
that
biological
mental
disorders, and alcohol
30 NUMBER!!
from
are
such
are
treatmore
are
vi-
as schizo-
syndromes, complior psychosomatic
1979
749
problems. chiatrist
Among is unique
mental health professionals in having the particular
the psyknowledge
skill
of the physician, and among physicians he is unique by virtue of his special knowledge and skills related to the psychosocial factors of illness.
and
At
a conference
sponsored
by
nient (5).
of the
education
American participants
multiple
Appendix
1.
made While what
the
of the
Psychiatric developed
and
varied
Association a detailed
functions
of the
and state-
Another
skills,
effort
and
the
Board
of Psychiatry
skills they
the
two
agreed
descriptions,
are
retired
time,
or
who
work
all
those
When ably
was
and Neurol-
on are very
similar.’
it is apparent
that
with
the past
cent
cent
tals psychi-
certain
role
need
der
to
sociocultural sequently practice.
include
uation illness diseases nervous hensive The
the
ability
to make
a comprehensive
eval-
second
area
relates
to treatment.
It includes
general
hospital.
functions
are
chosocial
factors
NUMBERS There
are
in the
United
American
related
Thus to
the
in health
OF
the
States.
interdigitation
and
formal
The
750
to 30,000
higher
Association
training
psychiatrists. Approximately members of the American D. G. Langsley
of
and
biopsy-
disease.
25,000
and M. Hollander,
HOSPITAL
estimate figures
designated psychiatrists: that selves psychiatrists whether completed
role
that
psychiatrists
is drawn
from
include
self-
is, persons who call themor not they have actually
or are
formally
25,000 Psychiatric unpublished
employed
physicians Association. data,
& COMMUNITY
are APA
1979.
PSYCHIATRY
prob(6). of
health
psy-
profession-
professionals
have
and
of state
This
in psychiatry
the
and
make
in-
up
county
as the
is complex.
language effectively
psychological may have both
and
culture
and
to
factors difficulties
educators
over
50
hospi-
the
brain from
quality
Psychia-
well
in or-
understand
the
of illness. Conin training or
and
legislators
have
drain
resulting
from
their
countries of origin, care and the numbers
of medical
available.
concern
in part
Assistance of its provisions who and
as well
led
as of medical
TABLE
1
workers,
and nurses
to
the
Health
Act of 1976 sets severe
in
Numbers per
States for resiof fluency in
knowledge
FMGs
in
Professions
(Public Law 94limits on the num-
may enter the United requires high standards
is a decrease
for entry.
psychiatry
of psychiatrists, psychologists, 100,000 population’
and
The other
social
Psychia-
Psycho-
Social
trists
logists
workers
Nurses
1960-61
7.7
10.3
8.0
10.7
1962-63
8.2
11.1
15.1 18.2 19.1
282
1961-62 1963-64 1964-65 1965-66 1966-67 1967-68 1968-69 1969-70 1970-71 1971-72 1972-73 1973-74 1974-75
8.6
1 1.5
12.1
20.3 21.4
306
9.0
Year
1975-76
as
are
practice
numbers
in 1975
staff
of physicians
Educational 484). One
result
PSYCHIATRISTS
approximately Medical
psychiatrists’
as well
English
ability to manage psychiatric emergencies, especially those in the emergency service of a general hospital; to use psychoactive medication competently; to use other physical treatments for mental illnesses, such as ECT, as appropriate; and to use laboratory tests, including those that demonstrate organic or systemic illness. The third area is the ability to provide medical consultation
in the
of FMGs
bers of FMGs dency training
that encompasses the organic causes of mental and the psychiatric accompaniments of organic of any part of the body (not just the central system) and the ability to arrive at a compretreatment plan for such organic disorders.
res;dents
Further,
of physicians
They
the
mental
health
physician
concerned
of complex
there are certain skills that are unique to and that fall in three general areas. general medical and neurological skills.
mental
and FMGs
agnosis
Nonetheless, psychiatrists First are
core
communicate
emigration
problems.
actual
part
practice.
there
in of
work
clinical
considered,
of other
to know
and others. Similarly, psychiaphysicians may be engaged in di-
biomedical
than
15 years.
of the
mental health nurses, trists as well as other
and treatment
those
as psychia-
who
(7). The
been
psychologists,
are
of all psychiatric
per
other
workers,
as well
creased in number over the past 15 years, with psychologists having the greatest proportionate increase. The supply of psychiatrists, however, is more complicated than these figures might indicate. Since the early 1960s, foreign medical graduates have come to the United States in increasing numbers. They constituted 39 per
trists
social
other
a comparison
als over
the
in
psychiatrists
1 provides
of
residents
or incapacitated,
factors
17,000
chiatrists
atrists and other mental health professionals-as well as psychiatrists and other physician specialists-have overlapping areas of knowledge, skill, and activities. Psychotherapy is one such activity; psychotherapy of one type or another may be practiced by psychiatrists, physicians,
some
All
requisite
psychiatrist
include
who
psychi-
a survey of 500 teachers and practitioners. required knowledge was described in somedetail than in the APA statement, the spe-
cific clinical From
defining
of the
by the American through the more
at
attitudes
figures
trists
Table
psychiatrist
in the form of goals of basic residency training A condensed version of the statement appears in
knowledge, ogy
the
in 1975,
others
atrist,
on
membership
9.5
12.4
23.0
319
10.0
13.0
327
10.4 10.8
13.6 14.2
24.2 24.9
11.0 1 1.3 11.8 11.9 11.0 12.1
15.2 15.6 16.2 16.8 17.6 18.6
12.4
American
figures
19.5
are based
Psychiatric
on the numbers
24.6 24.2 26.0 27.3 26.9 28.7 30.2
32.2
Association
members,
of psychiatrists
335 345 356 366 376 390 407 427 449
are are American Psychological Association members, social workers who are members of the National Association of Social Workers, and data from the American Nurses’ Association. I
The
298
psychologists
who
who
medical
specialties,
the
been fully felt. At the same time,
impact
of which
there
has
been
a drop
American medical graduates 1970-71 a total of 1 1 per cent
In
school
graduates
number
dropped
cent.
per
The
not
yet
entered
psychiatry.
to 4 per
cent,
reasons
for
the
in the
num-
entering psychiatry. of American medical By
and
1975-76
by
decrease
this
1978-79
are
to
3.6
complex
and
include
issues of medical education and the role and function of psychiatrists as well as the attraction of family medicine and other primary care specialties. Consequently many residency positions are unfilled (8). In
1974-75
residency the
there
were
unaffiliated.
filled.
In the
tend
psychiatric
positions;
hundred
with
4370
ninety-six
universities,
affiliated
of
and
programs
29
FMGs, while in the were FMGs (9).
OF
Psychiatrists
One
affiliated
of the residents were programs 68 per cent
accredited of 5012
a total
were
LOCATIONS
256
with
positions
programs
were
were
programs
of these
60
per
cent
nonaffihiated
American
22,753
to
be
concentrated
in
Association
members
county, and their addresses
health on
living
metropolitan
survey
in
the
identified
U.S.
by
state,
systems agency region, based file in APA’s central office. Table
on 2
shows their distribution by state, the population per psychiatrist in the state, and the population per psychiatrist of the counties with the lowest and highest psychiatrist-to-population ratio. Eleven per cent of the U.S.
psychiatrists
centration
lation
are
distorts
ratios
The
figures
in metropolitan
variation
erable. at least
in academic
the
settings, for
areas
between
and
Carolina,
and
one
this
con-
(10).
Forty-eight of the 49 counties one psychiatrist. One county
in North
and
psychiatrist-to-popu-
within
states
is consid-
in California have in New York, one
in Massachusetts
have
a ra-
tio of one psychiatrist for less than a thousand population; at the same time, Virginia and Minnesota each have rural counties with more than 150,000 citizens per
psychiatrist. are
Although
not
many
regions
the of
psychiatrists. Nonetheless, counties have no psychiatrist rural
and
thinly
Koran
with tion
has
populated
underlying
largely WORK
the
attractions same (11).
AND
WORK
U.S.
is uneven, altogether
there without
more than 50 per cent at all; they include
of all many
areas.
compared
lawyer-population between the two.
distribution the
psychiatrist-population
ratios
ratios and found a high The correlation suggests for
both
professional
study
compared
the
treatment
of 2000
pa-
tients
PSYCHIATRISTS
Psychiatric
APA
private
A California
areas. In general, there are few data on practicing psychiatrists by county or smaller geographic area. In 1977 an
practice. We estimate that approximately psychiatrists are in public service, and many of them engage in part-time private practice. Psychiatrists as a group tend to be heavily involved in administrative activities and in such indirect services as teaching and consultation. Thus some psychiatrists who list their primary affiliation as private practice or fee-for-service may not actually spend the major percentage of their time in clinical work. Eighteen per cent of the psychiatrists in the survey work in areas in which the population is less than 100,000. Psychiatrists work long hours; 61 per cent of those reporting worked more than 45 hours per week, and only 33 per cent of those reporting saw less than 30 patients a month.2 It is a common belief that psychiatrists in private settings practice differently from those in public settings. in
15,000
of
her
has
correlathat the
groups
in private settings and 2000 patients in clinic settings. Both groups of patients had completed treatment and did not differ significantly in sex or diagnoses; more patients seen in private settings were married. The two groups of psychiatrists used similar amounts of medication, and they saw patients for similar lengths of time. However, clinic psychiatrists were more likely to see patients more than once a week when necessary, and they used group and family therapy approaches more often. Private-practice psychiatrists saw patients for approximately the same number of office visits as clinic psychiatrists, 12.8 and 10.2 visits, but kept patients in hospitals somewhat longer, 15 days compared with 5.9 days (12). Another survey found that in 1976 psychiatrists accounted for 5 per cent of the total staff positions of all mental health facilities or, more specifically, for 2 per cent of the full-time and 15 per cent of the part-time positions. Forty per cent of the full-time psychiatrists worked
in
state
and
county
mental
hospitals,
16
per
cent in community mental health centers, and 15 per cent in general hospital psychiatric units. The percentage of full-time-equivalent positions of psychiatrists in community mental health centers has decreased continuously, from 12.8 per cent of the total professional positions in 1972 to 10.7 per cent in 1976 (13). Since the number of psychiatrists trained has remained stable or even decreased while the numbers of patients and staff as well as of centers have increased, it is not surprising that the gap has been filled in part by other mental health professionals. MENTAL
COMMUNITY
HEALTH
CENTERS
are
Since opened
SETFINGS
In 1977 the American Psychiatric Association surveyed 20 per cent of its members about their professional activities as part of a study of the use of electroconvulsive therapy; 3000 psychiatrists responded. Almost half the respondents (49 per cent) indicated they were primarily
the first community mental health center was in 1964, the number of centers grew to 164 in 1968 and 528 in 1976. Nonetheless, only 43 per cent of the catchment areas in the United States have developed centers to meet federal standards. CMHCs serve an estimated 77.6 million persons, 35 per cent of whom 2Tk Association,
VOLUME
Force
on Electroconvulsive
Washington,
30 NUMBER
D.C.,
Therapy, report
11 NOVEMBER
American
of questionnaire,
1979
Psychiatric 1978.
751
TABLE
2
Geographic
distribution
of psychiatrists
of
Number
State
133
1,923,322 19,969,175 2,209,596
578
3,032,217
58
D.C.
400
548,104 756,668
Florida
816
6,791,418
Georgia Hawaii Idaho
331
4,587,930
Illinois
997 248 134 222 196 241
111 26
Kansas
Kentucky Louisiana Maine Maryland
8,296 17,645
20,950 21,085
84,927
1,347
4,871
46,527 119,215 154,712 49,700 123,702 33,281 66,200
892 1,709 2,713
694,409
23,147
100
33
857,756 488,738
14,810
74
737,681
9,968
732 93 4,007
7,171,112 1,017,055 18,241,584 5,084,411 617,792
9,796 10,936 4,552 12,872 32,515
131 186
Oregon
Pennsylvania Rhode Island
1,177 1 13
8,578
1 1,245 10,026
949,723
8,405
2,590,835 666,257
17,685
38,696
18,118
58,956
3,248
28,968
36,920
4,255 5,609
4,417,821 332,416
22,161
752
HOSPITAL
Data
on APA
& COMMUNITY
Member
Psychiatrists,
12,485 11,901 6,176 9,303
PSYCHIATRY
2,314 7,167
26,318 154,364
2,789 1,738
41,103 39,749 69,004 51,264
14,875
American
49,514
108,312
10,158
1977,
4,283 3,912 937 834 5,888
2,303 7,178
297
Distribution
7,122
2,496
99,190 21,426
Wisconsin
on S. Muszynski,
2,248
3,130 4,567
52,640
29,563
Based
4,881
6,521 3,681 5,778
1,744,237
‘
95,627 58,560 125,868 108,144
2,091,533 11,800,766
444,732
15
110,828
15,930
4,851,448 3,413,244
Wyoming
49,554
19,843
3,926,018 1 1,199,385 1,059,273
72
60,687
2,599,463
500 336 59
23 222 897 89
18,219 23,477
10,657,423
South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia
143
2,671
4,374
30
395 20 675
62,783 60,765
5,689,170
27,037 12,540
York
7,692 8,645 6,712 1,524
3,923,897
2,216,994 4,677,623
North Carolina North Dakota Ohio Oklahoma
1,556
15,867 29,167 111,409 48,127
118,078 94,078
3,806,103
New
50,691
15,114 10,240
82 381
Mexico
1,892 1,306
1,523 2,766 1,455 4,144
268
Jersey
7,016
129,440
Mississippi
New
7,735
3,798 6,024 4,103 1,681 2,548 3,485
10,731 16,432
Minnesota
New
14,490 80,356 31,035
13,861 6,936 27,423 11,147
11,337 14,202
Hampshire
40,046
74,492
8,881,826
New
with lowest population-perpsychiatrist ratio
29,967
780
Montana Nebraska Nevada
with highest population-perpsychiatrist ratio
6,368 5,246
Michigan
Missouri
Population of county
5,889
9,450 1,892 8,322
3,220,711 3,642,463 993,722
897
Population of county
61,268 17,100 61,918
11,638
2,249,071
1,168
per
25,897
2,825,368
ratios’
population-per-psychiatrist
Population psychiatrist
769,913 713,015 11,113,141 5,195,610
99
Massachusetts
and
1,775,399
109 3,391 347
Indiana Iowa
22,753)
3,444,354 302,583
26 214
Delaware
=
Population of state, 1970
psychiatrists
Alabama Alaska Arizona Arkansas California Colorado Connecticut
(N
Psychiatric
Association,Washington,
5,601 4,248
3,770 1,775 D.C.,1977
are in metropolitan
areas. The centers now account for 4 per cent of the episodes of inpatient care and 25 per cent of the episodes of outpatient care, excluding the care provided by other non-VA federal programs and psychiatrists in private practice. Personnel patterns in community mental health centers show a diminishing proportion of psychiatric staff in spite of increases in the total number of psychiatrists. Although the total staff of the centers almost tripled in the six years between 1970 and 1976, the number of FTE psychiatric positions per center dropped from 6.8 to 4.3, while nonpsychiatrist-physician positions remained stable at .5 per center. Fifty per cent of the centers reported having less than 2.3 psychiatrists on the staff in 1976. In the same time period, the number of VfE psychologists nearly doubled (from 4.9 to 8.6), and social workers increased by 35 per cent (from 9.7 to 12.8). Psychiatric residents constituted 29 per cent of the total trainees in centers in 1970 but dropped to 14 per cent of all trainees in 1976, although the residents’ absolute numbers increased from 432 to 659. In the same period psychology trainees increased from 10 to 19 per cent, and social work students increased from 17 to 25 per cent (13,14). If the staffing of community mental health centers is to depend in part on psychiatrists’ services, it is clear that not enough psychiatrists are trained in such settings to staff them. These changes are related to a number of issues. They may reflect the fact that more non-hospital-based than hospital-based community mental health centers are being funded. Many programs are moving from treating the most seriously and chronically mentally ill to providing care more oriented to social services-that is, care for patients with less serious illnesses and also assistance with their housing and sociocultural problems-although that may be a result as well as a cause of the decrease in psychiatric personnel. The decrease may also be related to the growing antiprofessional and especially antimedical attitudes in centers. While there are claims that psychiatrists do not remain in centers for economic reasons, surveys have demonstrated that job satisfaction and work in a setting similar to one’s own training site are more relevant determinants. Graduates of university psychiatric training programs that are located in community mental health centets are more likely to work in a center after graduation. Ninety-five per cent of the graduates of the residency training program at the University of California at Davis, where all training took place in three community mental health centers staffed by university faculty, accepted full-time staff positions in CMHCs during the first eight years of the residency program.3 In many centers, psychiatrists are used only to prescribe medication. Many report the existence of antiprofessional attitudes that undervalue direct treatment and overvalue consultation directed toward impossible solutions of social problems (15). Psychiatrists are more 3D. G. Langsley,
unpublished
data,
1978.
likely to remain in a community mental health they experience job satisfaction and feel they forming useful and valued services.
STATE
center if are per-
HOSPITALS
State hospitals have had constant difficulties in retaining qualified psychiatrists. A telephone survey in 1976 confirmed the shortage of psychiatrists in those facilities and found that hospitals with residency training programs, especially those affiliated with universities, employed more psychiatrists. The nine states that employed more psychiatrists and had significantly smaller proportions of foreign medical graduates were those with university-affiliated residency training programs (16). Another telephone survey, in August 1977, demonstrated that of 3480 psychiatrists in state mental hospitals, 13 per cent were FMGs unlicensed in the state in which they practiced, while another 17 per cent were FMGs in residency training. In addition, since state hospitals cannot recruit enough psychiatrists, general physicians often fill staff positions. Of these additional 21 12 physicians, the survey showed, 24 per cent were FMGs unlicensed in the state in which they practiced. Thus of the total of 5592 physicians, 54 per cent were unlicensed FMGs (17). In a landmark decision that established standards for psychiatrists and other physicians working in state hospitals, Wyatt v. Stickney, Judge Frank Johnson of Alabama ruled that two board-eligible psychiatrists and four other physicians were required for each 250 patients (18). This ratio translates to a caseload of 125 patients per psychiatrist and 62.5 patients per each other physician-hardly a standard that could be called overgenerous-and it suggests that psychiatrists are mainly involved in initial diagnosis and case management, leaving much of the therapeutic interactions and ongoing contact to other mental health professionals. A July 1977 report from the Health Resources Administration suggested that state mental hospitals are in immediate need of approximately 1700 psychiatrists to bring the number of psychiatrists to a reasonable level (19). CHILDREN
AND
THE
ELDERLY
Of the 88 million children 18 years old or under, approximately 9 to 13 million need mental health services. The National Institute of Mental Health’s Division of Biometry reported that although 40 per cent of the U.S. population was under age 18 in 1971, only 25 per cent of new patients in community mental health centers were under 18 (20). It was so evident that the centers had failed to serve children that in 1971 Congress developed a special program for children (part F grants under the community mental health centers legislation), but it appropriated only $10 million a year for these services. Child and adolescent services have now been mandated for all community mental health center pro-
VOLUME
30 NUMBER
11 NOVEMBER
1979
753
grams; however, legislated mandates cannot solve the problems of mental health services for children because of the serious shortages of personnel, lack of funds, and poor commitment. In 1974 the federal budget for direct services for all mental illness was only 3.4 per cent of the appropriated health care funds. There are only about 2800 child psychiatrists in the United States. One estimate of need is that if child psychiatrists spent one hour yearly in the evaluation of each child initially entering school (of whom at least 10 per cent are estimated to need specialized mental health care), 500,000 hours yearly or 250 FTE child psychiatrists would be needed for this task alone. Most diagnostic interventions for children require a highly complex and specialized set of skills for the understanding of psychological, social, cognitive, developmental, and neurological and other physical parameters. In fact, if 40 per cent of all psychiatrists were trained in child and adolescent work (to match the proportion of children and adolescents in the population), there would be 1 1,000 child psychiatrists instead of 2800. Nonetheless, only about 200 child psychiatrists complete residency training each year, certainly not enough to increase their numbers. By the year 2000, a total of 25 per cent of the population will be over 65. The mental health problems of this age group are specialized, just as are those of children. Many of the elderly are institutionalized as “senile” when they suffer from a treatable condition. Diagnosis and treatment of the elderly is complicated and demands close interdigitation of biological factors (especially those related to physical conditions and drug interactions) with developmental and psychosocial features. There are only a handful of psychiatrists who specialize in the mental health problems of the aged. Residency programs are just beginning to incorporate information about this age group. In view of the lack of almost any specialized manpower and the size of the problem, accurate estimates of need cannot be made. Based on population figures, psychiatrists knowledgeable in geriatric psychiatry should constitute 25 per cent of the field, or 6800, a logarithmic increase.
ACADEMIC
SETTINGS
As noted above, 1 1 per cent of all psychiatrists work in academic settings. There are more than 120 fully accredited medical schools in the United States and another ten in stages of development. Besides operating education programs for medical students, physicians, and other health and mental health workers, departments of psychiatry in these schools operate patient care services and are the backbone of research programs in the broad field of mental health. They represent a national resource in the development of mental health manpower and the new knowledge needed to prevent mental illness or treat it more effectively. There is some information about the significant proportion of time residents spend in community mental
754
HOSPITAL
& COMMUNITY
PSYCHIATRY
health centers, state hospitals, VA hospitals, and similar facilities that negates the myth of the distant ivory towers of academia whose inhabitants have little involvement in public service settings. Reports from 64 departments of psychiatry (half the total) indicate that each year they deliver 1.3 million inpatient days of care, see patients in 1.4 million outpatient visits and 125,000 emergency service visits, and provide 57,000 consultations to other medical services (21). Many of those services have been provided by residents (under supervision) to otherwise underserved population groups. Yet funding for services and training has diminished significantly; federal dollars for total mental health manpower training decreased 50 per cent since 1970 through actual dollar decrease and diminished purchasing power (22). Psychiatric training has borne the brunt of these cuts, and funding has been a major factor in limiting activities of departments of psychiatry and limiting the numbers of American medical graduates entering psychiatry.
INCOME
OF
PSYCHIATRISTS
Psychiatrists are the most poorly paid group of all medical specialists. Data from Medical Economics surveys indicate that psychiatrists constitute 5.4 per cent of all private practitioners. As a group they have a net income significantly less than the average medical specialist, and even psychiatrists in private practice have incomes far lower than is usually assumed (23,24). Because psychiatrists’ fees are based on length of time of patient contact, because they use few technological procedures (compared with the plethora of laboratory tests and procedures available for other physicians), and because they spend more time with each patient than other physicians, psychiatrists’ fees are more limited and are not rising as fast as those of other specialists. CURRENT
NEEDS
Psychiatrists work in a number of settings providing urgently needed services. A current study indicates that psychiatrists are spending increasing proportions of time in public service settings, caring for the more seriously ill and heretofore underserved (25). Yet the federal government’s support of manpower training has not produced enough psychiatrists to meet the needs of the population. The frequently repeated statement that psychiatrists are maldistributed is correct, but it must be reconsidered in the light of a clear shortage of psychiatric manpower. There cannot be appropriate distribution without a sufficient number. Location of practice is often related to psychiatrists’ training experiences and job satisfaction during training. Thus problems in distribution suggest the need for appropriate changes in psychiatric education programs. Recruitment is a key issue. A conference to discuss the facets of recruitment will be held March 7-8, 1980;
it will be sponsored by the American Psychiatric Association’s council on medical education and career development, the APA office of education, and a consortium of psychiatric education and service organizations and funded in part by NIMH. This conference should lead to specific efforts at remediation. There is a clear need for increased federal and state support for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hospitals, community mental health centers, and similar facilities. Such an approach would result in the recruitment and retention of greater numbers of psychiatrists in public service settings. Then the unique knowledge, skills, and abilities of psychiatrists could be more appropriately used in a total health and mental health care system, with increased benefits for patients and their families.#{149} REFERENCES 1) Report tal Health,
to the
President
From
the President’s
Commission
Vol. 1, Washington, D.C., 1978, pp. 2) National Institute of Mental Health, The
and
Quality
Maryland,
of 1976,
Mental
Health
Care
in the
on Men-
8-10. Financing,
United
States,
Rockville,
p. 27.
American Psychiatric Association, Washington, D.C., 1976, pp. 1931. 6) C. B. Robinowitz, Psychiatric Manpower, report prepared for the Manpower Policy Analysis Task Force, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland, 1978. 7) J. J. Jenkins and M. J. Witkin, Foreign Medical Graduates Employed in State and County Mental Hospitals, Mental Health Statistical Note 131, National Institute of Mental Health, Rockville, Maryland, July 1976. American
Psychiatric
Association,
Resident
Census,
Washing-
ton, D.C., yearly reports, 1970 through 1978. 9) American Medical Association, Directory of Accredited Residencies, Chicago, 1976. 10) 5. Muszynski, Distribution Data on APA Member Psychiatrists. 1977, American Psychiatric Association, Washington, D.C., 1977. 11) L. Koran, “Psychiatric Manpower Ratios: A Beguiling Numbers Game,” Archives ofGeneral Psychiatry, in press. 12) D. G. Langsley, “Comparing Clinic and Private Practice of Psychiatry,” American Journal ofPsychiatry, Vol. 135, June 1978, pp. 702-706.
13) R. D. Bass, CMHC stitute
of Mental
Health,
Staffing: Rockville,
Who Minds Maryland,
the Store? 1979.
National
In-
14) W. W. Winslow, munity Mental Health
“The Changing Role of Psychiatrists in CornCenters,” A,nerican Journal of Psychiatry,
Vol.
pp.
136,
January
1979,
24-27.
15) P. J. Fink and S. P. Weinstein, “Whatever Happened to PsychiThe Deprofessionalization of Community Mental Health CenAmerican Journal of Psychiatry, Vol. 136, April 1979, pp. 406409. 16) D. J. Knesper, “Psychiatric Manpower for State Mental Hospitals: A Continuing Dilemma,” Archives of General Psychiatry, Vol. 35, January 1978, pp. 19-24. 17) D. J. Knesper, Career Decisions Made by Psychiatrists: A Multistate Survey, Mental Health Research Institute, University of Michigan, Ann Arbor, 1978. 18) S. Stickney, ‘Wyatt vs. Stickney: The Right to Treatment,” Psychiatric Annals, Vol.4, August 1974, pp. 32-45. 19) “Health Manpower Shortage Areas: Criteria for Designation,” Federal Register, Vol. 43, January 10, 1978, pp. 1586-1596. atry? ters,”
Institute 1971,
of
Mental
Health,
of Mental
Utilization
Rockville, Maryland, 1973. 21) American Association of Chairmen of Departments try, The Crisis in Psychiatric Manpower: Toward a National ric Manpower
Policy, D.C., January 1977.
22) B. Brown,
American
Psychiatric
Association,
of PsychiaPsychiatWashington,
of the NIMH Director to the National AdviCouncil, National Institute of Mental Health, December 1977. 23) “Earnings Survey: Which Specialties Are Staying Ahead of Inflation,” Medical Economics, October 18, 1976, Pp. 146-159. 24) “Doctors’ Earnings: Inflation Edges Ahead,” Medical Economics, September 18, 1978, pp. 226-246. 25) P. E. Dietz, “Psychiatrists Young and Old: A Comparative Survey,” paper presented at the annual meeting of the American Psychiatric Association, May 8-12, 1978, Atlanta. Report
sory Mental Health Rockville, Maryland,
APPENDIX
1
Functions
the psychiatrist’
of
1) Demonstrate general medical skills, including the abildiagnose and plan for the treatment of illness, the judgment and skill to deal with medical emergencies, and the ability
to
ity to deal with medical 2) Demonstrate the
Utilization,
3) Report to the President From the Presidents Commission on Mental Health, Vol. 1, Washington, D.C., 1978, pp. 4-8. 4) National Institute of Mental Health, Staffing of Mental Health Facilities, U.S., 1976, Rockville, Maryland, 1977. 5) A. H. Rosenfeld, Psychiatric Education: Prologue to the 198ffs,
8)
National Facilities,
20)
Health
problems neurological
of the mentally skills needed
ill. to make
a
presumptive diagnosis based on the patient’s history and a neurological examination and to understand specialized neurological diagnostic procedures. 3) Obtain a psychiatric history and perform a thorough physical examination using interviewing nation skills, and appropriate tests. 4) Arrive at a diagnosis and treatment 5) Manage psychiatric emergencies.
6) Provide ing individual, appropriate
physical
Deal
mental
plan.
therapies
with
and
behavioral
medication
therapies.
competently.
developmental
and
aging
processes
early life to aging and death, based on knowledge of children and adolescents as well as the elderly. 9) Keep adequate medical records. 10) spective
exami-
treatment appropriate to the patient, includgroup, and family therapies; be familiar with
7) Use psychoactive 8)
skills,
View patients from using biopsychosocial
a holistic, data and
from
of problems
developmental their interaction.
per-
1 1) Serve as a medical consultant in the general and as a mental health consultant in various agencies. 12) Demonstrate consistent awareness social aspects of medical practice, the tionship,
and
the
distribution
health care system. 13) Critically assess ical practice.
14) Demonstrate ued
and
ability
17) Be able
to apply
of complex
clinical
18) Demonstrate
VOLUME
research
within
information
capacity,
and relathe
in din-
and skills for continand
to communicate role with fellow
supervise
treat-
comfortably psychiatrists
.
and and
general
personal
for
Education:
skills
in a va-
maturity, self-awareness, and as a psychiatric specialist.
the
identity
basic residency Prologue to the
Washington,
30 NUMBER
problem-solving
situations.
of professional
‘Based on goals Association,
responsibility
legal,
alike.
nonpsychiatrists
Psychiatric
of ethical, physician-patient
to organize
ment given by others. 16) Demonstrate ability effectively in a teaching
possession
apply
motivation,
self-education. 15) Demonstrate
riety
of
hospital
training, 1980’s, D.C., 1976, pp. 19-31.
11 NOVEMBER
1979
in A. H.
American
Rosenfeld,
Psychiatric
755
