If you care about psychiatric education, you probably already know everything we are going to mention in this introduction. If you care about child and adolescent psychiatry, you probably already know this introduction even better. And if you have ever been asked to teach child and adolescent psychiatry at a medical school, you probably could sit down and write with passion and not a little frustration the very arguments we hope to stress in this commentary.
Many of the articles in this issue seem to begin with the same set of data. They make clear their case for more education in child psychiatry throughout every stage of medical teaching by noting the crises facing psychiatrically ill children and adolescents. We have heard these alarms before (1), and they help us appreciate something deceptively obvious and of paramount importance: the data alone are not enough.
We must add even more passion to our purpose. As virtually every article on this topic shows, child and adolescent psychiatrists are needed now more than ever, yet we are forced now more than ever to compete with an ever-growing set of curricular demands in the seemingly shrinking space currently available for a well-rounded medical education. The arguments for more child and adolescent psychiatry across all realms of medical education seem to rest on a relentless Mobius strip. We keep coming back to the same dire statistics and predictions for need and the same desire and firmly held belief, especially among child psychiatrists themselves, that if only we could show students what we know and do, and generally how happy we are in our work, they would gravitate with relative ease toward our field.
And yet, as the articles in this issue show, these arguments have not materialized into large-scale changes across medical schools.
Here are some points to put the problems into perspective:
The U.S. Bureau of Health Professions (2) projected in 2000 that by 2020 there would be a need for roughly 12,000 child psychiatrists but a supply of just over 8,000.
In 2000, the Surgeon General reported a serious “dearth of child psychiatrists.” That report (3) went on to loudly and without reservation instruct the medical educational infrastructure to address what would soon be a costly and ironically eminently fixable crisis. No such changes in educational endeavors have occurred on anywhere near the scale that the Surgeon General’s report recommended.
As reported in great detail in the Journal of the American Academy of Child and Adolescent Psychiatry in 2006 (4), there is a severe and at times overwhelming lack of child psychiatry expertise in rural America.
We could go on. All of this translates into our most vulnerable patients fighting to see doctors who simply are not there because there are not enough child and adolescent psychiatrists to go around. Even those practicing in urban centers are overwhelmed. Tough economic times do not help—reimbursement falters and state and federal budgets recurrently cut child and adolescent mental health services when times are financially difficult. These problems might very well scare our students and our deans away from adding more child psychiatry to medical education.
In addition to accentuating the crises in our field, the articles in this issue also wonderfully celebrate the pleasurable challenges (and the challenging pleasures) of providing care to psychiatrically ill children and adolescents. What other field in medicine allows one to discuss, in the same formulation, a patient’s proclivity for video games as well as his or her difficulties with social connectedness? What other field brings to light the inextricable interweaving of culture and phenomenology that is the rule, not the exception, of good child psychiatric care? What other field is continually steeped in the intellectual challenges of turning sometimes acrimonious debate—consider the issues surrounding the diagnosis of bipolar disorder in children—into a collegial, stimulating, and therapeutically helpful discussion of what is best for our children and our society? What other field requires participation of the entire family and community system in its care of the child, or allows the physician to follow a child over an extended period of time, thus actively participating in the steeply moving targets of human development?
In other words, what other field so completely immerses its practitioners into the culture of its patients?
Child and adolescent psychiatry is wonderful fun precisely because it allows one to discuss video games and the amygdala in the same sentence. And although child and adolescent psychiatry is dogged by the misconception that it is underpaid and underappreciated, few fields provide work-family balance in concert with the relatively attractive financial and social attributes as this field does.
Ironically, the seemingly positive aspects of child psychiatry match remarkably well with the explicitly stated reasons that many students decide to become physicians. But something happens during medical school and psychiatric residency, because these students and residents are not becoming child psychiatrists.
Of vital importance is a better understanding of perceptions and feelings regarding child and adolescent psychiatry among medical students and general psychiatric residents. In their 1986 studies, Weissman and Bashook (5, 6) found that initial interest in the field dropped by nearly 50% between medical school and postgraduate year 4. From APA 2008–2009 census data (7) and the experience of many psychiatric educators over the years, we believe that this trend has been fairly consistent since 1982.
Additionally, Weissman and Bashook (5, 6) noted that many students who initially expressed interest in child and adolescent psychiatry were drawn to the field by their interest in psychoanalysis and pediatrics. The relationship is obvious: both psychoanalytic studies and pediatrics are steeped in developmental inquiry. Is it possible that students and residents do not experience a strong focus in human development throughout their formative years? Have we neglected a real emphasis on the human condition that places growth and change in children, families, and communities on the back burner? One would expect that the basic and clinical research on brain plasticity, attachment theory, developmental psychopathology, family systems, evidence-based psychotherapies, psychopharmacology, and the environmental, community, and cultural influences on health and illness would provide a newfound excitement in child and adolescent psychiatry.
These observations call for an important series of questions: What influences may mitigate migration into the field? Is it the perceived excessive workload, fear of dealing with uncertainty, concerns about the limitations of the evidence base of the treatments, or worries about endless calls, e-mails, pages, and reports? Or is it simply lack of experience working with children, adolescents, and families; lack of exposure to sufficiently talented and passionate role models; and difficulties in carrying cases over time to witness the joys of change and deep gratitude of parents, teachers, and the children themselves? Could it be that sheer lack of exposure to sound teaching in medical schools and residencies focusing specifically on child and adolescent psychiatry is responsible for lack of recruitment into the field?
As educators, it sounds as if we need to do more. We need to push without reservation and perhaps even with a bit of righteous indignation for our field to be better represented in medical student and residency education. After all, the Surgeon General has done just that, yet the results have not been forthcoming. We need to be more proactive. And yes, the irony of this call to action is that the very crisis about which we write makes it that much more difficult to make the time and create the energy to push for these pedagogic changes.
But that does not mean we should not push. This issue shows us data that when we invest ourselves in these educational efforts, we can get results. We can create interest, enthusiasm, intellectual curiosity, and, it is hoped, like-minded clinicians who will choose child psychiatry as their career. Then we can start reading some new, more optimistic statistics at the beginnings of these articles. That would be a welcome change.
At the time of submission, Dr. Schlozman reported no competing interests. Disclosures of editors are published in each January issue.