John Gardner said, "If the modern leader doesn't know the facts, he is in grave trouble, but rarely do the facts provide unqualified guidance" (1). Anyone considering medical workforce issues quickly comes to realize how apt Gardner's words are. For there is much more to the medical workforce debate than merely counting physicians (2). Any reasonable analysis of the medical workforce must consider many complicated issues with interrelated social, political, and economic facets (3,4). While considerable disagreement exists about any conclusions that might be drawn concerning the medical workforce in the United States, there does appear to be a consensus of opinion that our country has major problems with geographic and sociocultural maldistribution of the physician workforce and significant deficiencies in the training of physicians to practice in modern medical delivery systems (5,6). Partly as a result of these impressions, medicine has come under increased pressure to demonstrate that its diagnostic and treatment systems are effective and efficient, its patients have reasonable access to competent care, and its physicians are trained adequately for the scope of practice they provide (7). The manner in which a specific specialty responds to each of these issues will obviously have a significant impact on that specialty's workforce requirements.

My colleagues and I have suggested that the only rational method for estimating psychiatric workforce requirements is a strategy based upon the needs of patients (8,9). Such an approach is patient centered, and it helps to clarify the basic assumptions that underlie the estimation of psychiatric workforce requirements. I believe the needs-based method also provides a useful framework for understanding and managing other important factors that affect psychiatric workforce requirements. Specifically, I believe the needs-based method can help to identify and address important diagnosis and treatment, access to care, and scope of practice questions and issues that must be clarified in any comprehensive psychiatric workforce analysis. In this paper, I will briefly review our five-step needs-based approach, outline some of the questions and issues it raises, and suggest several strategies that organized psychiatry might pursue to begin to address them.

Our five-step needs-based approach to estimating psychiatric workforce requirements (9) mandates that the following determinations be made for any geographic area under consideration (e.g., community mental health center, state, region, nation):

The number of people with mental health problems.

The number of people who need mental health treatment.

The number of people who need psychiatric treatment.

The amount of psychiatric time required to meet patient needs.

The amount of time psychiatrists have available to provide direct patient care.

As shown in F1, once these five determinations are made, the calculation of the estimated psychiatric workforce requirements is straightforward. The first four determinations provide an estimate of the total amount of psychiatric time required to provide adequate treatment to patients in the area under study. Dividing this total time required by the time available per psychiatrist from the fifth determination yields an estimate of the total number of psychiatrists required in the area.

It must be emphasized that obtaining the specific data to complete the formula in F1 is far from an easy task. There is also considerable disagreement among professions and organizations about the validity and meaning of much of the data that exist concerning each determination in the formula. Despite these difficulties, however, we have found that it is possible to overcome them and gather the type of information necessary to estimate psychiatric workforce requirements (8,9).

Another way to conceptualize the needs-based approach described above is to recognize that it raises specific questions that must be answered in order to make a final estimate of psychiatric workforce requirements in any area. As shown in t1, these questions can be grouped into the three categories I have designated: clinical science, access to care, and scope of practice. Clinical science questions concern the fundamental processes of mental illness diagnosis and treatment; access to care questions focus on the treatment needs of specific patients with mental illnesses; and scope of practice questions pertain to the specific professional roles to be performed by psychiatrists.

t2 lists some of the issues pertinent to the questions raised by a needs-based approach to estimating psychiatric workforce requirements. For example, in order to answer the clinical science questions concerning psychiatric workforce requirements, it will be necessary to continually refine the diagnostic classification system for mental illnesses; elucidate the prevalence of significant, treatable mental illnesses; and clarify which treatments are acceptable for which significant, treatable mental illnesses. This information provides a basic understanding of the totality of the work to be done in treating the mentally ill by psychiatrists and all other professionals.

In order to answer the access to care questions concerning psychiatric workforce requirements, the needs of specific types of patients must be addressed. This will entail the development of practice guidelines and clinical pathways; adoption of a multidisciplinary, biopsychosocial approach to treatment; and clarification of the rolesof other medical specialties in the treatment of the mentally ill. Specific clinician competencies required to provide treatment for different types of patients must be identified. Access to care also entails ensuring that adequate insurance coverage is available for specific patients, sociocultural and geographic barriers to treatment are analyzed and eliminated, and trainees are educated in adequate numbers and with the appropriate characteristics and attitudes to provide competent treatment. All of this is necessary to underscore that the only legitimate access to care is adequate and timely access to competent care provided by an appropriately trained professional.

Answering scope of practice questions that pertain to psychiatric workforce requirements demands a clear understanding of the definition of a psychiatrist and the extent to which psychiatrists are prepared to: practice primary care psychiatry or one of its subspecialties; provide psychotherapy to specific types of patients; and participate in indirect, nonpatient care roles in medical education, research, and administration. Some aspects of scope of practice, such as medication management, will be determined by state statutes as well as professional standards, and studies of psychiatric effectiveness and efficiency must help clarify the parameters of these issues. Effective recruitment and educational initiatives can be developed and implemented only by understanding what the scope of practice for psychiatrists should be.

As shown in t2, one of the values of a needs-based approach is that it clearly illustrates the complexity of the psychiatric workforce debate. Each of the psychiatric workforce question categories raises complicated, interrelated issues, and addressing any of them effectively will be no easy task. Another side to this type of analysis, however, is that it also clearly lays out the work to be done. It suggests specific strategies that might be pursued and how they fit into the overall psychiatric workforce discussion. It is well to remember that psychiatric workforce issues are dynamic and capable of being influenced by forces internal and external to psychiatry. The question is not whether forces will be brought to bear to determine the size and characteristics of the psychiatric workforce of the future. This will surely happen. The only question is: To what extent will psychiatry itself play an active role in determining its own destiny? In this section, I will review briefly 10 specific strategies, suggested by the issues in t2, that psychiatry might pursue in order to influence the nature of its future workforce. There is some overlap among these strategies, and they are not presented in any particular order of priority. I believe they are all crucial to the psychiatric workforce debate.

The scope and complexity of these 10 strategies mandate their implementation at the state and national level by psychiatric organizations with the resources and influence to do so. While the American Psychiatric Association must play a leadership role, it cannot succeed without the active involvement of other important organizations such as the American Association of Directors of Psychiatric Residency Training, the American Association of Chairs of Departments of Psychiatry, the American Board of Psychiatry and Neurology, the Psychiatric Residency Review Committee, the American College of Psychiatrists, and the subspecialty societies. Only a carefully orchestrated, coordinated effort on the part of these organizations will ensure that the future psychiatric workforce is adequate to meet the needs of the mentally ill.

Many aspects of psychiatric workforce requirements are complicated and controversial. A needs-based approach to estimating these requirements can be helpful in clarifying the questions, issues, and strategies that must be addressed. These processes will not succeed without the support and active involvement of organized psychiatry at the state and national levels. Tremendous effort and considerable expense will be necessary over many years to ensure that the psychiatric workforce of the future is adequate to meet the demands of patients with mental illness. Perhaps this is as it should be, for as Robert Lauer reminds us, "Nothing worthwhile ever happens quickly and easily. You achieve only as you are determined to achieve … and as you keep at it until you have achieved" (10).