In a provocative editorial in The American Journal of Psychiatry titled "Why Be Concerned About Recruitment?," James Scully, M.D. (1) stated, "Whatever the right number (of psychiatrists) turns out to be, we'll still need to recruit new psychiatrists. To fail to do so is to abandon our profession and our patients." (1). These words of admonition by a leader in the profession have provided the rationale for this special issue of Academic Psychiatry devoted to psychiatric workforce as well as the retreat conducted by the Council on Medical Education and Career Development of the American Psychiatric Association (APA) that took place February 9—11 of 2001 in Washington.
The backdrop of the retreat was provided by several developments pertaining to physician workforce that occurred in the preceding decade. The late 1980s and 1990s were marked by publication of a flurry of reports by think tanks and governmental agencies expressing deep concerns that the United States was heading toward a major physician surplus and that this physician excess—especially that of specialists—was fuelling an escalation of health care costs. Unless this excess was curtailed, so went the argument, escalating health care costs would have adverse consequences for the economy as a whole.
These concerns regarding health care costs and delivery led to the failed attempt by the Clinton administration to reform health care with one bold stroke. In addition, the same concerns resulted in the evolution of managed care, which called for training of more generalists to act as gatekeepers to contain health care costs and reduce the number of specialists being trained. With major shifts in graduate medical education (GME) financing by Medicare, medicine began to downsize its GME workforce.
Closer to home, psychiatry was seen by managed care as having far too many practitioners than was needed to deliver cost-effective mental health services. Consequently, the scope of psychiatric practice shifted in favor of psychopharmacological management and less psychotherapy. Mental health professionals of other disciplines began to fill the void in providing psychotherapy. As these paradigmatic changes were occurring in the field, fewer U.S. medical graduates (USMGs) were choosing psychiatry as a career. As fewer USMGs entered psychiatry, international medical graduates (IMGs) rushed in to correct the shortfall.
As the 1990s came to an end, reports began to appear that other Western nations, such as Canada and the United Kingdom, that carefully planned their physician workforces, were confronting major physician shortages as well as physician maldistribution. Here in the United States, the Education Council for Foreign Medical Graduates (ECFMG) introduced an additional qualifying exam called the Clinical Skill Assessment Examination (CSA) for IMGs that was administered only in the United States, which hindered access to ECFMG certification for many otherwise qualified IMGs for pecuniary reasons. In addition, several immigration-related changes occurred that further restricted IMG entrance into U.S. medicine. Ironically, this time, concerns were raised that a reduced number of IMGs would have severe impact on residency training programs that depended on them as their trainees. Finally, secondary to managed care's emphasis on quality of care, the field became justifiably concerned about the competency of its practitioners and the ensuing debate over core competencies, which added further complexity to the workforce examination.
Thus, workforce studies in psychiatry, which in earlier times used to be narrowly focused on residency recruitment issues, began to include more complex ones such as the scope of practice, access to care, the economics of health care delivery, practitioner's competence, etc. Against this backdrop, the Council on Medical Education and Career Development held a meeting where experts in the field of workforce studies shared their perspectives on various aspects of the psychiatric workforce. There were presentations about the supply and maldistribution of psychiatrists, factors affecting USMGs' interest in psychiatry, the gap-filling role of IMGs, the scope of psychiatric practice, and the workforce needs of subspecialties. A representative of the ECFMG and an immigration lawyer shared their views on changes affecting IMGs. In addition, there was a presentation regarding Canada's experiences with its workforce reforms. After 2 days of deliberations, a strategic action plan that was supported by Daniel Borenstein, M.D., then president of the APA, and Richard Harding, M.D., then president-elect, was developed. The APA's board of trustees also took on this action plan. A decision was made to share with the field some of the important findings from the retreat, and hence this special issue of Academic Psychiatry.
This special issue has had a prolonged gestational period, spanning more than 2 years. All the presenters at the APA's retreat were encouraged to submit their presentations to this issue. The papers were reviewed internally in the Council before being submitted to the editor, Laura Roberts, M.D., for the journal's peer review process. Many of these papers are data-based, and others provide thoughtful commentaries on the current status of the psychiatric workforce in the United States and offer prognostications on their future course. This special issue cannot fully capture the excitement and the depth of discussions that were in evidence at the retreat. We are fortunate to have expert commentary on the issues raised in this publication. In his insightful commentary entitled "Where Is Psychiatry Going and Who Is Going There?," Richard Cooper, M.D. confronts psychiatry's predicament with workforce identity, along with other issues, as a sharp-eyed analyst would zero in on the narcissistic and identity conflicts of his analysand. In his compelling commentary entitled "Bullish on Psychiatry," Craig Van Dyke, M.D. presents a careful analysis of historical and current factors influencing medical student choice of specialty residency training in psychiatry.
In his paper entitled "Implications of a Needs-Based Approach to Estimating Psychiatric Workforce Requirements," Larry Faulkner, M.D., elucidates a needs-based approach to understanding how many psychiatrists the nation requires. His takes a complex, methodical, and cogent approach to a befuddling area of physician workforce projection. In "Selected Characteristics and Data of Psychiatrists in the United States, 2001—2002," James Scully, M.D. and Joshua Wilk, Ph.D., provide basic data about the physician workforce in the United States and the relative place of psychiatrists in the total workforce. They also present data on characteristics of psychiatrists' work activities in routine psychiatric practice.
In a reflective paper entitled "Recruitment of U.S. Medical Graduates Into Psychiatry: Reasons for Optimism, Sources of Concern," Frederick S. Sierles, M.D., Joel Yager, M.D., and Sidney H. Weissman, M.D. make a case for recruiting USMGs into psychiatry and share their optimism about future recruitment as well as their concerns about problems that could hinder it. While not part of the original set of papers presented at the APA's retreat, the second paper by Frederick S. Sierles, M.D. et al. entitled "Factors Affecting Medical Student Career Choice of Psychiatry From 1999 to 2001" fits appropriately into this issue. In their study, students from a wide variety of medical schools were asked a series of questions in order to assess the extent to which regional and local extrinsic and intrinsic factors determine the choice of psychiatry as a specialty. Sierles et al. found that, while extrinsic factors did not influence the choice of psychiatry as a career, the proportions of IMGs in one particular psychiatric residency did impact specialty residency choice.
In my paper, entitled "Recent Trends in Psychiatry Residency Workforce With Special Reference to International Medical Graduates," I point out that there was substantial reduction in the number of residents in psychiatry in the 1990s and that IMGs made significant inroads into medical school and nonmedical school-based residency programs located in all regions of the United States. Finally, in a paper entitled "Child and Adolescent Psychiatry Workforce: A Critical Shortage and a National Challenge," Wun Jung Kim, M.D., M.P.H. and the American Academy of Child and Adolescent Psychiatry (AACAP) Task Force on Workforce Needs present a sobering assessment of the current acute shortage of child psychiatrists and its impact on our nation’s ability to care for the mental health needs of our children.
In presenting this special issue of Academic Psychiatry, devoted to workforce issues, I thank many who have contributed to this effort by writing articles and many more by reviewing them. Personally, shepherding the process has been both an exhilarating and, at times, a demanding experience for me. I am especially grateful to Laura Roberts and her capable team for their support, encouragement, and commitment to producing a quality product.
In conclusion, any serious student of psychiatric workforce studies is impressed by the appearance of recurring themes, resulting in a sense of déjá vu. One major preoccupation of the field in the past three decades has understandably been on how to increase USMGs' interest in psychiatry. Psychiatry exulted when their numbers in the field increased and became despondent when their numbers declined. However, the world has dramatically changed with the phenomenon of globalization and its emphasis on free movement of goods and labor across national boundaries. Our nation's demographics have changed as well, in favor of a more racial heterogeneity. I hope we will adapt and move on to more enlightened workforce policies that will keep psychiatry vibrant. Not doing so will be tantamount to abandoning our profession and our patients.