What Will Psychiatric Services Look Like in the Future?
Although some psychiatric practices will retain the “cottage industry,” individual office, independent-practice model, public, nonprofit, and private systems of care, as well as larger individual and group practices, will align practice patterns with the “Four A's”—core business values driving contemporary service industries, including medicine. These Four A's are Affordability (cost), Affability (patient satisfaction), Accessibility (ease of obtaining services), and Accountability (assuring quality outcomes)—paralleling business drivers euphemistically referred to as “FCB;” that is, “Faster, Cheaper, Better.” Under grinding social, financial, political, technological, and scientific pressures, systems of care and practices that optimize these core values are likely to succeed better than those that don't.
Individual patients (as well as institutional purchasers of healthcare plans) are, overall, becoming more informed and selective consumers. Contemporary media, the Internet, and direct-to-consumer advertising by pharmaceutical companies and healthcare systems have educated the general public's demands. Most Americans now routinely research health information online (1). Patients routinely google disorders, treatments, and clinicians. Expect that most of your patients will have googled you, to learn about your background, performance-, and malpractice-history.
What Does the Future Hold for Academic Health Centers in Which We Conduct Research, Offer Services, and Educate?
Academic health centers, saddled with complicated organizational structures, multipurposed mission statements, and arcane budgets, are besieged by external and internal pressures. Some do well financially, at least in specific pockets of activity, thanks to aggressive promotion of highly specialized tertiary-care programs that fill beds. These practices will not always necessarily be sustainable, as society inevitably attempts to contain medical costs. Other centers rely on wealthy donors or specific research expertise that garners windfall grants. However, even the most successful institutions struggle in some programs. Administrators constantly perform creative “financial finagles.”
Residency training transpiring within institutions must, in turn, accommodate to practice patterns shaped by the constraints and values these multiple forces impose.
Who Is Your Competition Likely to Be?
Behemoth institutions are not always capable of shifting nimbly in rapidly-changing environments. Some academic health centers and departments risk becoming big, ossified dinosaurs, incapable of adaptively dealing with competing models of research, services, and education. Although fundamental scientific findings often emanate from universities, remember that many of the most innovative and disruptive innovations more frequently originate from extra-university entrepreneurship. In fact, many innovators flee universities to free themselves from bureaucratic pressures that stifle creativity.
So, who might compete with tomorrow's academic psychiatric departments? Consider how the following missions might potentially be conducted efficiently, effectively, and cost-effectively:
Clinical services: As primary-care–based medical homes and “medical neighborhoods” more prominently occupy the healthcare landscape, many will design programs to manage psychiatric needs of patients and families (2). Primary-care providers with co-located mental health professionals, including psychiatrists, might provide for patients contending with medical and psychiatric comorbidities (3). Of course, who services these homes and neighborhoods will vary with funding and “zoning requirements.”
Disorder-focused models of care, including disease-management programs conducted by “Big Pharma,” already deployed for diabetes and for clozapine management, may well expand if they prove effective, user-friendly, and economically sound. Already, telephone and web-based monitoring and intervention programs for depression and anxiety have been shown to be viable and effective (4, 5). Measurement-based disease-management care will progress as even chronically ill psychiatric patients increasingly use computer-based tools in waiting rooms to rate their clinical status before office appointments (6).
As scope of practice expands for other professions, notably, advanced-practice psychiatric nurses with prescribing authority, competition by “psychiatroids” will increase for functions currently performed by psychiatrists (7, 8). Specialties utilizing advanced practice-nurses (e.g., family practice, pediatrics, and psychiatry), may see physicians increasingly undertaking additional subspecialty training to remain one step ahead. Furthermore, as routine aspects of care are increasingly assumed by master's-level therapists and paraprofessionals (e.g., case managers and “promotoras”), some psychiatrists may reshape their practices to incorporate additional patient services provided by teams.
Further affecting clinical services, consider the potential impacts of remote site consultation and treatment using telephone, videophone, e-mail, and Internet; that is, instantaneous global communication: “anyone, anywhere, 24/7.” Consultants can help every remote-dwelling practitioner diagnose and treat local patients. Using tele-medicine, psychiatrists already routinely assist rural primary-care physicians to manage psychiatric disorders (9). SmartPhone apps using HIPAA-compliant encrypted settings will permit SKYPE-like interactions between clinicians and patients located anywhere in the world.
Given that psychiatroids anywhere can virtually manage many psychiatric patients located anywhere, “outsourcing” assessment and even psychotherapy is constrained only by regulatory statutes governing licensing, any of which might be modified in “free-trade agreements” if health systems think they can offer sufficient quality at the right price and manage the political processes and the outcry. With increasing globalization and falling trade barriers, if a strong business case can be made for the economic advantages, couldn't we outsource elements of psychiatric diagnostic and management? If Walmart and Dell do it, why can't Humana or Kaiser-Permanente?
Medical education: As Einstein showed, time and space are malleable.
First, space: Almost anything that can be taught in a classroom can now be taught through web-based, distance-learning, permitting great latitude regarding where teaching programs originate and are transacted. “Virtualized” laboratory and clinical demonstrations enable students to participate at a distance. And, although hands-on and “eyes-on” clinical supervision benefit from on-site, live teachers, tele-supervision can go a long way toward providing acceptable substitutes. Even for physical examinations, faculty working at a distance can lead trainees through the mechanics with sufficient “HD” fidelity to satisfy some quality concerns. Compared with tele-surgery via robotics, tele-psychiatry is easy.
Second, time: “24/7”environments offer students educational programming to custom fit their temporal needs: evenings, nights, weekends, summers, part-time. The popularity and successes of the University of Phoenix models, designed as “no-frills” learning venues for working adults seeking off-hours education, exemplify these trends. Which aspects of psychiatric education might utilize these delivery systems?
The web permits student–faculty and patient–provider interactions to become increasingly asynchronous. Complex verbal and nonverbal communications can transact in HD whenever times work best for You and—independently—for Me. You leave a message/question, or send a (confidentiality encrypted) video-clip of a patient interaction, and I respond whenever it's convenient.
Clinical research: Certain types of “translational” research favor extra-university settings. Non-academic, clinical-trials organizations, utilizing community practices, have increasingly replaced academic centers for industry-sponsored clinical trials (accounting for more than half of such studies). Pharmaceutical and medical-device companies increasingly sidestep delays and hassles imposed by universities' Institutional Review Boards by employing time-efficient private IRBs. Parenthetically, today's increasingly restrictive academic zeitgeist regarding Pharma might discourage some excellent clinical researcher-teachers from academic careers and, instead, lead some of the brightest to private practices or industry positions with better financial rewards.
How Might Technological and Scientific Advances Shape Practice?
Before considering the following futuristic scenarios (although everything I cite is already happening), please recall that scientific advances are implemented only at the pace that social-cultural shifts and economic realities permit. Today's marvelous discoveries may take decades to work into common practice, depending on provider and practitioner acceptance, utility, and financing—the Four A's. For example, disseminating electronic medical records has been comparatively sluggish. Prototypes abound that are never adopted.
That said, the phenomenal speeds with which the web, videogames, smart-phones, and social networking have disseminated illustrate how “hot” advances can be disruptive, often in little-foreseen ways. Consider how the following emerging advances, each already available at least in prototype, might shape psychiatric beliefs and practices; and these represent only a small fraction of what's now on the drawing board. All have implication for curriculum development:
We already see ever-improving virtual-reality technologies morphing with game simulations, as in the “Sims.” Some are proving to be psychotherapeutically adept (30). Consider, for example, adjunctive psychotherapies based on virtual-reality games confronting cognitive and emotional biases and distortions, as well as dysfunctional interpersonal patterns (31). Internet avatars and virtual relationships might provide laboratories in which patients work out interpersonal difficulties before “taking them live,” and, in some instances, provide adjunctive lifelong comforting companions; and, of course, we may next have sex therapies via virtual reality-style “tele-dildonics” (32).
Shall we expect personalized matchmaking of patients and therapists? Trainees and mentors? Consider mash-ups where e-Harmony.com meets amplified Facebook profiles, based on ever-more-sophisticated data-mining of personal habits and characteristics.
“Back-engineering” the brain may yield “neuromorphing,“ leading ultimately to neuroprosthetics (33) and even mind-prosthetics.
Robotics, leading to individually-programmed psychologically-supportive “rescue robots,” analogous to rescue pets. Combine a Roomba, current Japanese and MIT robot technology, and the SmartPhone personal psychologist, and R2D2 isn't very far off. How might clinicians employ empathic, nonhuman, countertransference-generating computer and robotherapists in practice?
Mega data-mining: Huge data-mining capacities should produce better evidence-based outcomes research. Data drawn from forests of electronic medical records might frequently update comparative benefits and risks of various interventions. As federally-mandated and financially-incentivized “performance indicators” steadily nudge practitioners toward measurement-based care, such data should—in theory—better inform clinical practice. More discriminating meta-analyses of increasingly transparent industry-designed clinical-trials data should generate a more discerning “evidence-base” (34, 35).
Future possibilities for psychotherapy: As mentioned above, advances in virtual-reality and computer-based “games” might help patients improve their problem-solving skills and deal with emotional sensitivities (36). Conceivably, psychotherapies might be prescribed according to individual nervous-system and information-processing characteristics, perhaps based on patient (and therapist) polymorphism variants. This isn't overly far-fetched, since genetically mediated personality factors such as “interpersonal sensitivity” and “empathic capacity” have been shown to predict better outcomes in psychotherapy, regardless of specific psychiatric diagnoses. How might these advances inform treatment algorithms or manuals? Furthermore, how might psychotherapy supervision use “smart programs” applied to digitized audio and video recordings to assess treatment compliance?
What Exactly Will Psychiatrists Be Doing?
Just as today, no single role definition for tomorrow's psychiatrist will suffice. Future general-residency psychiatrists are likely to diversify increasingly into a proliferating array of subspecialty eco-niches via formal fellowships leading to added qualifications/board certifications, other postgraduate studies, and assorted “on the job” training agendas. Darwinian experiments conducted by healthcare systems and competing psychiatroid professions will determine which types of individual, group, private, public, and tele-practice treatment, administrative, and academic activities will thrive in which sorts of environments, and which are at risk of withering. Psychiatrists are already shifting away from practicing psychotherapy in many areas (37). Certainly, psychiatrists devoted to orthodox psychoanalytic practice represent a dying breed, and other archetypes may go the way of the archeopteryx.
Careers: New Areas of Psychiatric Specialization
Emerging technological and scientific advances are likely to generate demands for new psychiatric subspecialties. Consider clinical “computerologists” and informaticists to deal with all manner of computer-associated practice, from web-based disease management through electronic medical records. Medical Informatics graduate programs are busily enrolling all physician specialties. Although psychiatry departments have traditionally relied on their “geekiest” faculty to devote hours of avocational passion to informatics infrastructure (and/or have increasingly hired nonphysician information-technology [IT] specialists), formalized training and official job roles are likely to blossom for psychiatrists. Psychiatrists trained in virtual-reality game design might specify scenarios to assess and treat a wide assortments of psychiatric dysfunctions, as already demonstrated with phobias, posttraumatic stress disorder, and Asperger's syndrome. Therapies for “quirky personalities” are in the works.
New imaging technologies will demand experts to administer and interpret, and to apply increasingly localized interventions involving deep brain stimulation or gamma knife surgery, such as for treatment-resistant obsessive-compulsive disorder. Some neuroradiology and nuclear medicine fellowships already accept psychiatrists for advanced training. Will we see an ABPN added-qualifications certificate for “psychiatric diagnostic and interventional neuroimaging”? Other somatic interventions will evolve from brain and nerve stimulations and research in neuronal neogenesis, involving injected stem cells, or gene therapy to treat depression (38) and other psychiatric disorders, or be based on optogenetically-mediated neural reengineering (39).
Combine genomics, proteinomics, epigenetics, and personalized medicine with pharmaceutical advances, and we have tomorrow's psychopharmacologists. Focus on cognitive-enhancers, including “nootropic agents” (intelligence- and memory-enhancing drugs); “empathogens;” and other “hedonics;” work out the ethical practice boundaries; and you might produce cosmetic psychopharmcologists (not just drug-pushers).
Expect computational cognitive neurobiologists (17), modeling CNS nuclei and networks, to derive new hypotheses regarding psychiatric phenomenology and interventions.
And, as now, careers combining clinical practice with administration, entrepreneurialism, health services, and complex organization perspectives will produce Executive-Manager Psychiatrists. MD-MBA, MD-MPH, and MD-LLB fusions, already offered as organized curricula by some universities, will flourish. Many executives will experiment with “faster-better-cheaper” models, employing nondoctoral-level therapists for assessment, therapy, and “disease management” (in-vivo and via tele-medicine). Some entrepreneurs might consider the idea of “spot-market” pricing underutilized psychiatric beds and services (think PriceLine during low-occupancy periods). Some might “package” traveling mental health teams to manage psychiatric aftermaths of man-made terror and natural disasters.
What Will Psychiatrists Need to Know?
For the foreseeable future, general-psychiatry residents will still be expected to master all the usual subjects near and dear to the hearts of the Residency Review Committee: broad bio-psycho-social medical knowledge, clinical skills, professionalism, communication, and systems-based competencies. These and other curriculum elements for the 21st Century are noted in Table 1. Residents will continue to require working knowledge in clinical neuroscience and biological psychiatry, including advances in genetics, proteonomics, epigenetics, neuroimmunology, and imaging; multiple perspectives on developmental and adult psychology, psychopathology, and phenomenology, including, for example, perspectives from evolutionary psychology and psychiatry (40–43); social psychology; family system and transactional perspectives (both functional and dysfunctional), as well as epidemiology, cultural anthropology, and knowledge of pertinent local and national health systems.
TABLE 1.Curriculum Elements for 21st-Century Psychiatry
Teaching the art of diagnosis will require some shape-shifting: DSM-5, due in 2013, will differ moderately from previous DSM systems, with added attention to dimensional “cross-cutting,” and, perhaps, cultural issues. With DSM's anticipated integration into the ICD (World Health Organization's International Classification of Diseases) system, future diagnoses may be individually modified “online” as merited by changing data. Or, at the least, the entire DSM may be revised roughly every decade or two. In any event, the average psychiatrist's career may span three or four editions. The bottom line may be, “don't get too attached to your diagnoses” (44, 45). The curriculum challenge will be teaching how to think about diagnosis. Our accelerating world may provoke disorders related to new technologies (such as Internet addictions), rapid and premature vocational obsolescence, multiple role strains, and adult attentional-overload syndromes; and, as mentioned, NIMH's RDoCs project anticipates newer ways to slice diagnostic pies.
Consistent with the Four A's, clinical skills will include fundamentals required to ensure high patient satisfaction. Foremost are those consistent with “giving good face:” therapeutic listening, inquiring, and interacting, all “common elements” across all psychotherapies. We're now seeing trans-theoretical psychotherapies, where separate schools are replaced by increasingly practical, outcomes-oriented, and evidence-based deconstructions of psychotherapies into their effective elements: the psychotherapy toolbox (46, 47). Toolbox elements mined from psychodynamic, supportive, cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), interpersonal, couples, family, group, and other approaches might become the focus of education and training: empathic and nuanced listening to what is being said and to what is unspoken and avoided; focused inquiry; grappling with interpersonal and intrapersonal conflicts, dysfunctional attitudes, schemas and behaviors; working with families and significant others; and even educating and counseling. Using the toolbox, psychotherapy training may focus on how best to combine elements, align patient–therapist match-ups, and integrate increasingly-available virtual, computer-mediated, and in-vivo psychotherapeutic adjuncts.
Given that psychiatrists increasingly work in clinical and administrative teams and in positions of authority, suitable instruction and competencies in group and organizational dynamics will be increasingly important for successful careers, particularly for chief residents and “transition to practice” seminars (48, 49).
Most importantly, trainees will require skills in lifelong learning, deaaling with constantly accelerating database versions, increasingly utilizing web-based resources, professional social networking, and participating as contributors to and benefactors from “survey monkeys,” gathering and distributing frequent updates on medication effectiveness and adversities, data-mining the wisdom of crowds.
Key to lifelong-learning is “critical thinking.” Educators must ignite and nurture trainees' “crap-detectors” (50), specifically, their abilities to discern and deconstruct all sorts of propaganda: deceptive research and marketing studies from the “pharmaceutical-industrial complex,” the “psychoanalytic-industrial complex,” the “CBT-industrial complex,” and other special-interest groups. Trainees require proficiency in separating facts from “factoids” and “spin” (51).
No Small Order: How Should Psychiatrists Be Educated?
Traditional training has relied on time-based immersion. In competency- and outcomes-based models, trainees graduate after demonstrating mastery of competencies, regardless of the time to mastery. For practical work-force reasons, time-based scheduling is likely to prevail. But where individual learning programs, portfolios, and competencies can be cultivated, outcomes and trainee satisfaction are likely to improve. Most clinical learning will undoubtedly continue via “apprenticeships,” relying on modeling, coaching, scaffolding, articulation, reflection, and exploration of new possibilities (52).
Educators will increasingly utilize principles of adult learning:
Increased knowledge integration into workflow: Medical record templates will increasingly link to decision-algorithms, practice guidelines, UpToDate, MicroMedix, and other current evidence sources, facilitating “just-in-time learning,” where information appears at point of use.
Active learning and self-instruction trumps passive learning: Problem-based and scenario-based learning (focusing on specific cases and instances), including team-based learning, seem more effective than traditional lectures at imparting knowledge and skills.
Web-based instruction: Web-based learning laboratories can demonstrate anything from psychopathology video-clips to entire treatments. Clinicians may be “lured” into learning pertinent basic sciences via the so-called “Trojan Horse” approach (53), starting with clinical cases and working down to basic science presentations. Recent innovations are available through Science Magazine's SPORE awards (Science Prize for Online Resources in Education) (54). Web-based classroom programs such as “Blackboard” host web-based courses permitting participants to engage in synchronous and/or asynchronous group-format discussions. Groups of training programs, combining resources to develop critical masses of educators and trainees, can easily organize web-based trans-university courses.
A small-group, problem-based project for educators:
Which curriculum components best lend themselves to web-based learning? Which do better with traditional face-to-face methods? What hybrids are most sensible and cost-effective?
Evaluating Psychiatric Competencies
Residency Review Committees will continue to keep raising the bar for assessing professional competencies, and the American Boards may well do the same regarding Maintenance of Certification. The challenge is to ascertain how meaningful, reliable, valid, and non–game-able the proposed requirements are, so that they don't simply represent hollow bureaucratic exercises. Assessment methods (55) will include simulation-interactive videos. During residency, the “process-folio” method may be most practical for documenting psychotherapy and other competencies (56).
Financing educational mandates will remain problematic. The future of graduate medical education funding via the Centers for Medicare and Medicaid Services (CMS) is uncertain. Some Federal funding may become available through health-finance reform, for improving electronic medical records, comparative-effectiveness research, and informatics, for example, through the National Library of Medicine. Private foundations may fund projects aligned with their missions. Small grants are available through many Dean's Office initiatives in educational development. As usual, considerable efforts for educational innovation will come from volunteerism among individual faculty and via collaborations developed through such organizations as AADPRT, AAP, and ADMSEP.
How Will We Maintain Professional Satisfaction?
Psychiatry has traditionally enjoyed high career satisfaction, as compared with other medical specialties, although its relative satisfaction has dropped in recent years. With increasing pressures resulting in decreased autonomy in institutional settings, how will the professional satisfaction of psychiatrists measure up in the future? Although challenges are clear, in my view, psychiatry's satisfactions will remain considerable.
First, psychiatry is intrinsically hugely satisfying, offering sustained doctor–patient relationships and deep, comprehensive understandings of humanity, plus attractive lifestyles, regular hours, and a relatively low call-burden.
Second, psychiatry's treatments are increasingly effective. We have more to offer regarding accountability.
Finally, one of psychiatry's central contributions, more than many other medical specialties, is to offer meaning. Psychiatry contributes substantially to generating and sustaining the culture's significant narratives (and myths) regarding human nature. Thanks to phenomenal knowledge growth in neuroscience, developmental psychology, and other bio-psycho-social domains, as our sciences get better, so do our stories. The deep professional satisfactions of psychiatric educators have always included, and will continue to include, helping to synthesize and disseminate the cutting-edge, evidence-based cultural narratives for our trainees and for society.
For psychiatric educators and practitioners, professional satisfaction correlates with such activities as keeping up with professional advances, helping grow the profession by contributing to new knowledge, participating in professional and political organizations to benefit patients and families, and improving the work environment in small ways on a daily basis,. All these activities are easily achievable by tomorrow's psychiatrists.
Psychiatric educators will continuously upgrade their own pedagogical skills, using resources that include medical school-wide programs for “teaching scholars” and organizations focusing on medical education; these include AADPRT, AAP, AATP, ADMSEP, APA, AAMC, and others.
At the end of the day, professional satisfaction and self-esteem depend on the daily “mirror test” (57)—how well we can look ourselves in the eye and call our efforts honest, heartfelt, professionally interesting and worthwhile—contributing in some manner to the general good and to others' well-being.
Psychiatry's core values of honesty, integrity, compassionate caring, and respect for patients will endure and be valued.
Psychiatry's ideas and interventions are better than ever, and will only improve further.
Fostering career satisfaction in trainees and in ourselves will require increasing paradigm and career flexibility.
The tools we require to do the job are now available.