Thirty-three years ago, George Engel (1) contended that all of medicine was in crisis. The crisis, he suggested, had its origin in medicine's adherence to a model of disease defined solely in terms of "somatic parameters"—a model that was no longer adequate for the "scientific tasks and social responsibilities" of the profession. Speaking of psychiatry, he stated that our specialty had been falsely polarized into those who held that psychiatry should concern itself with "problems of living" and, in contrast, those who held that the scope of psychiatry should be the identification, treatment, and cure of "biological brain dysfunctions, either biochemical or neurophysiological in nature." Engel summarized that modern medicine was "faced with the necessity and the challenge to broaden the approach to disease to include the psychosocial without sacrificing the enormous advantages of the biomedical model," which had become a "cultural imperative" in today's society (1).
Whether taken individually or together, the articles that make up this issue of Academic Psychiatry suggest that the biopsychosocial model has indeed emerged as a predominant paradigm in our field. It is clear that psychiatry concerns itself with problems of living as well as biologically driven conditions. It is clear that psychiatric educators concern themselves with preparing professional learners to provide pharmacotherapies as well as psychotherapies and to become astute scientists, teachers, clinicians, learners, advocates, and good citizens of the profession. Psychiatric educators work to help early career colleagues to serve in community-based programs and highly specialized academic centers and to be generalist-specialists as well as subspecialty experts. It is clear that psychiatrists-in-training have the courage to face tragedy, whether in caring for individual patients or seeking to help in truly catastrophic situations in our world, and they embrace their colleagues from many nations in their work.
So, what of 33 years from now? With transformative science occurring in and across all three domains that constitute the "bio-psycho-social" model, this paradigm will likely endure. Less certain, however, are how the field of psychiatry will fare and what mid-century academic psychiatry will look like.
The quiet message of one of the articles in this issue (2) is that the number of psychiatrists being produced in the United States is declining. In their excellent summary of the numbers of psychiatrists seeking and obtaining specialty/subspecialty certification, Faulkner et al. (2) indicate that in a 7-year period (from academic year 2000—2001 to 2007—2008), training programs in psychiatry decreased to 181 from 186, and the number of graduates decreased from 1,142 to 985. This is a decrement of nearly 14% in less than 1 decade. These data align with statistics reported previously by Rao (3), who noted that, according to the APA census, general psychiatric residency training programs (classes in postgraduate years 1—4) showed a 16.8% reduction in the total number of residents between 1995 and 2000.
Over a decade ago, Scully (4) stated that we need to train about 800 psychiatrists a year to maintain our current number of practitioners. In 2003, Scully and Wilk (5) cited that the number of general psychiatrists in the United States was approximately 39,457, and when including child and adolescent psychiatrists, the total number was 45,615. If we assume that the average "lifespan" of a working psychiatrist is about 40 years (i.e., graduating from residency training at age 30 and working until age 70), about 1,000 general psychiatrists (or 1,142 general and child and adolescent psychiatrists) will need to be graduated from psychiatric residency programs each year just to maintain these numbers. This figure is likely an underestimate, because it does not adjust for the emerging pattern of "controllable life styles" as a preference of younger physicians (6), the increasing proportion of women psychiatrists of childbearing age, and the desire of fathers to have adapted schedules to allow for greater parenting responsibilities (7). Thus, our field may actually be shrinking. These are observations with very real implications, given the increasing size of the U.S. population, the aging of the U.S. population, the increased lifespan of those living with chronic and co-occurring disorders, the small numbers of young people entering science-based and medical professions in comparison with other possible careers, and, above all else, the emerging demand for mental health services.
Cooper and colleagues (8) in 2001 postulated that the United States would soon have a shortage of physicians and that if the pace of medical education remained unchanged, the shortage would become more severe. Contrary to previous predictions, Cooper (9) also warned about a progressively more severe shortage of specialists and cautioned against further dependence on international medical graduates to fill the gap. He suggested, "By 2025 the resulting shortfall could be as great as 200,000, requiring the training of as many as 10,000 additional physicians annually" (9). In his discussion of the shortage of physicians in various specialties, Cooper (10) also commented on psychiatry. Citing various authors, he wrote,
Added to these dire predictions is a serious concern about academic psychiatry itself. There are very few psychiatrist-researchers, and the number of physician-scientists continues to decline. Moreover, according to the AAMC, only about 9,100 academic psychiatrists currently serve on faculty of medical schools, and this number is also certain to decrease. Beyond the "head count," though, the financial stresses experienced by academic departments result in greater barriers to scholarly and educational endeavors, making many departments more closely resemble a private sector "group practice" rather than a true academic environment. These elements conspire to threaten the future of academic psychiatry.
Over the past few decades, psychiatry has worked—imperfectly and iteratively but with a measure of success—to resolve the tension between a hard, reductionist "disease" model and a soft, less-discernible perspective on the human condition. We have moved to a multidimensional paradigm that embraces, for lack of a better term, all of nature and nurture, encompasses molecules to populations, and affirms—using Engel's phrasing—the biological and psychosocial aspects of human experience. All of this is relevant to the work of psychiatry. And Engel would say, we believe, that resolution of this tension allows for the field of psychiatry to progress and not languish.
The new crisis that threatens the future of psychiatry is of a different sort. Neuropsychiatric disorders are the second leading cause of what is referred to as "disease burden" in the world, and the top cause in economically established countries according to WHO. Most of this need is unmet by appropriate health care services. The absolute number of specialist and subspecialist psychiatrists in the workforce is declining, which is especially a problem in low- and middle-income countries where a large migration of psychiatrists to economically established countries is potentially compromising the right to health care of the disadvantaged countries losing the critical resource of dedicated health professionals (11). The number of people entering academic psychiatry career paths and the number of psychiatrist-researchers has decreased dramatically. The engagement of international medical graduates has its own complexity and a comprehensive international approach is required to mitigate harm to countries that supply large numbers of psychiatrists to economically advantaged countries (11). And the "creation" of a psychiatrist takes many years and immense resources. Today's "solutions" may take 20 years to take hold.
Most of the solutions are clearly not in our hands. Cooper (8) presented several possible partial solutions to the overall physician shortage such as expanding existing medical schools, building new schools, increasing the number of medical school applicants, increasing the number of minorities who graduate from college and medical school, and bringing in more international medical graduates. Some of these "remedies" are already happening; several new medical schools are opening, and some schools have increased their number of medical students. But this is not helpful in addressing the immediate shortage of physicians.
An increased number of residency positions is required. A proposed bill (the Resident Physician Shortage Reduction Act of 2009) now pending in the United States Senate and House of Representatives would expand the number of residency positions by 15% (approximately by 15,000 positions). Preferences would be given to primary care, general surgery, nonhospital community-based settings, and other areas of need such as rural/primary care settings and areas in which "supervision" is critical, especially for more advanced learners, but funds previously committed to other areas may be freed up and reinvested. Thus, help may well be on its way. It will be essential for leaders and educators in psychiatry to advocate a resource shift to our field, however, because psychiatry has not been identified in the federal policy as an imperative area.
More psychiatrists are needed. It is critical that we in academic psychiatry work with our organizations and policy makers to ensure that the programs that train psychiatrists will survive and expand in the coming decades, that we continue to grow the resources to produce outstanding professionals to assume roles as specialists and subspecialists, scientists and educators. We should also continue to strive to understand and manage the full gamut of biopsychosocial factors that contribute to psychiatric illnesses and human suffering, and continue to serve in diverse settings and to indentify and treat unmet needs both nationally and internationally. Moreover, we should work to make our field more robust and attractive to prospective psychiatrists by clearly communicating our profession's value for individual patients, our communities, and the public health.
Disclosures of Academic Psychiatry editors are published in each January issue.