Since the mid-1970s, psychiatry has been concerned about the relatively low proportion of American medical school graduates (AMGs) choosing psychiatry compared to the proportion of students choosing it from 1944 to 1977 (1—4). The past 5 years have seen a change in the recruitment and workforce scene for most specialties, including psychiatry, which has enjoyed a modest increase in recruitment from 1998—2002 (Figure 1). We will a) present a rationale for focusing on AMG recruitment in this paper, b) discuss factors that make us cautiously optimistic about recruitment in the near future, c) comment on matters that might limit recruitment below what we perceive as ideal, and d) make recommendations for addressing these limiting factors.
A major reason to focus on AMGs choosing psychiatry is that their recruitment into psychiatry serves as an indicator of psychiatry's desirability, at least to U.S. medical graduates. Although some of the factors potentially contributing to low recruitment (1,2) since the 1970s, such as relatively low psychiatrist incomes coinciding with increasing debts of medical school graduates, are still operative, there are reasons for optimism about future AMG career choice of psychiatry.
Although interest of AMGs informs us about the standing or status of psychiatry, it is crucial to note that IMGs have an immense, pivotal role in U.S. psychiatry. Given the continual immigration to the U.S. from multiple and diverse nations, IMGs speaking the same national or regional languages or coming from the same cultures will have significant roles in caring for immigrant populations. And it is likely that IMGs will continue to be more willing than AMGs to care for medically underserved populations (5,6). Like others (7), we support selecting resident applicants based on their overall competency, not on their country of origin or where they obtained their medical education. Finally, IMGs have provided psychiatric care when there have been unfilled residency positions. Had this not occurred, psychiatry's "survival" might have been jeopardized, especially during its mid-1990s recruitment nadir.
It is unlikely that the percentage of U.S. graduates choosing psychiatry will ever fall below the proportion (2.9%) that chose it in 1998. This 2.9% proportion resembles the proportions (2%—3%) of students choosing psychiatry in published cross-sectional surveys conducted in other countries (8—10), and approximates the United Kingdom's 1978 recruitment nadir of 2.9%. Between 1974 and 1993, the percentage of UK students choosing psychiatry ranged from 2.9% to 4.2% (10).
Our reasons for optimism about future recruitment are a) inherent features of the specialty, b) accomplishments of psychiatry during the past decade, c) availability of jobs and increasing incomes for psychiatrists, d) peaking and current decline of the National Generalist Initiative, and e) an upward trend in recruitment during the past 5 years.
Inherent Features of the Specialty and Its Developments During the Past Decade
Psychiatry focuses on human behavior and the doctor-patient relationship, and our principal diagnostic and therapeutic strategies rely on interviewing and observing the patient. Even with increased demands for productivity and limitations on time imposed by third-party payers during the past decade, the average psychiatrist still spends significantly more time (39 minutes/visit) with patients than do other specialists (11). The second highest average minutes/visit is for internists, who spend a mean of 20.7 minutes with their patients. Additionally, psychiatry is a "controllable lifestyle" (i.e., control of work hours) specialty, along with anesthesiology, dermatology, emergency medicine, neurology, ophthalmology, otolaryngology, pathology, and radiology (12). During the past 6 years, there has been an increase in the proportion of graduates choosing controllable lifestyle specialties (13).
Making psychiatry yet more attractive is that the level of its scientific knowledge is at a point where the possibility of biopsychosocial understanding of our patients far exceeds what Engel (14) and our field "knew" in 1977 and 1981 when Engel wrote his classic papers. For example, reading Stahl's psychopharmacology text (15), one can now conceptualize behavioral neurochemistry on a cellular level.
Functional neuroimaging lets us map brain functions relating to behavior while the behaviors occur or while patients report what they are thinking and feeling. Functional neuroimaging has documented that psychotherapy's efficacy is associated with changes in brain function (16). Although some academicians remain critical about recent psychotherapy research, the evolving quality of empiric research on psychotherapy during the past 25 years moves psychotherapy from what was purely an art to an art with an improving evidence base (17—19).
That Nobel Prizes were awarded last year to three behavioral neuroscientists, including a psychiatrist, is a huge achievement. A 1999 survey (20) demonstrated that medical students' attitudes toward psychiatry are, in many spheres, better than what they were in the 1970s and 1980s. With patient advocacy groups being more influential, with notable numbers of prominent persons discussing their mental illnesses unashamedly, and with some prominent legislators leading the "parity" fight (21), the stigma of mental illness may be declining. A decline in stigma has been demonstrated in the case of treatment of depression (22).
Availability of Jobs and Increasing Incomes for Psychiatrists
During the past 2 years, the number of jobs available to psychiatrists has increased (23): "Psychiatrists are in demand. After a six-year period during which primary care physicians were more sought-after than specialists, demand for all specialties—including psychiatry—has been on the increase over the last two years. In 2001, recruiters report difficulty in filling slots for psychiatrists in virtually every mental health care environment."
During the past 5 years, simultaneous to the increase in the number of medical students who chose psychiatry as a career, psychiatrists are earning higher incomes (24): "Over the years, compensation for psychiatrists has increased 14.66%, making it the seventh fastest-growing specialty. In 1999, the median compensation for psychiatrists was $151,903, up 6.42% from the previous year." Likely, much of this is attributable to more job availability for psychiatrists, in light of our graduating an essentially unchanging number of residents. Additionally, many psychiatrists are resigning from managed care plans—with their low autonomy, comparatively modest pay, and high bureaucratic obligations—refusing referrals from these plans and accepting more self-paying patients. In response, some managed care plans are making themselves more attractive to psychiatrists (24).
Peaking and Possible Decline of the National Generalist Initiative
The National Generalist Initiative, whereby nonpsychiatrist leaders of U.S. medical education and managed care organizations asserted that the greatest national needs are for family physicians, general internists, and general pediatricians, has probably peaked and seems to be losing its momentum. For each of the past 6 years, the proportion of U.S. medical graduates choosing family medicine has declined (Figure 2), and between 2000 and 2002, the proportion of graduates matching in general internal medicine declined (25). Of course, this may also represent a lack of attractiveness of generalist specialties rather than a decreased need for their practitioners.
Dwinnell and Adams (26) write, "In what seems like an eternity ago, one of the selling points for the expanding role of managed care in our health care system was that the role of the generalist would become more desirable. The primary care physician was to be the most prominent figure in the care of an individual patient, and with this expanded role would come improved financial incentives, which would work towards reducing the discrepancies between the incomes of generalists and specialists. Obviously, we have fallen well short of these predictions. In fact, generalist physicians are probably more dissatisfied than ever. Students in our medical school—and, we feel sure, at others as well—are savvy to this, and the sentiment toward primary care has become increasingly negative."
Schroeder (27) writes, "Rather than gaining stature by being at the center of managed care, primary care providers lost favor as the lynchpins of a system that many saw as denying necessary care. The last time I checked the polls, the only industry held in lower regard than managed care was the tobacco industry. And the difference was tiny." In a 1999 survey of 12,385 medical doctors, St. Peter et al. (28) reported that 24% of primary care physicians perceived that the scope of care that was expected of them was greater than it should be. This perception could apply to the treatment of depressive and anxiety disorders, where a national survey demonstrated that treatment of these disorders was much more likely to be inadequate when provided by primary care physicians than when provided by mental health professionals (29).
Cooper (30), an advocate since the 1980s for increasing the supply of specialists, writes, "Does anyone know that there's a specialist shortage? Or have our workforce receptors all been down-regulated by hearing for too long that there are surpluses of specialists, not shortages, and that what's really needed is more primary care physicians?"
Five-Year Upward Trend in AMG Recruitment
For the past 5 years, there has been an upward trend (Figure 1) in U.S. graduates choosing psychiatry (1,25,31), potentially presaging increased recruitment in the next decade. In 2002, 564 AMG seniors (3.9% of seniors) matched into psychiatry, compared to 524 (3.6%) in 2001, 481 (3.3%) in 1999, and 428 (2.9%) in 1998 (Figure 1). Including those seniors who matched directly into second-year psychiatry residencies or into combined internal medicine-psychiatry, pediatrics-psychiatry-child psychiatry, and family medicine-psychiatry, the figures are 4.4% in 2002, 4.2% in 2001, 3.9% in 2000, 3.8% in 1999, and 3.4% in 1998 (31). Figure 2 compares the trends for family medicine and psychiatry from 1998 to 2002 (25,31).
Despite the laudable developments of our field, some recent data and events suggest that unless we identify, understand, and resolve certain problems in psychiatry in general and psychiatric education in particular, recruitment might not improve as much as we would like. Sources of concern are a) low "overt" interest in psychiatry among entering first-year medical students, b) concerns of psychiatry clerkship directors about the impact of managed care on the educational climate, c) suboptimal satisfaction of graduating seniors about their psychiatry clerkships, and d) the potential impact of New Mexico legislation that would develop a program to educate a small number of state psychologists to acquire privileges for prescribing psychotropic medications.
Low "Overt" Interest in Psychiatry Among Entering First-Year Medical Students
In the late 1990s, Feifel et al. (32) surveyed 223 newly matriculated first-year medical students at three southwestern schools and found that psychiatry was the career choice for only one student (0.5% of the sample), strongly suggesting a prematriculation bias against psychiatry that cannot readily be explained by medical school factors. Feifel et al. did not report what proportion of their sample eventually chose psychiatry, but if the figure is near the 3% national average at the time of their survey, another way to view the results (i.e., the glass is half full) is that, as a result of varied factors, potentially including good psychiatric education at these three schools, student preference for psychiatry increased sixfold.
Concerns of Psychiatry Clerkship Directors About the Impact of Managed Care on the Educational Climate and Suboptimal Satisfaction of First-Year Psychiatry Residents
In another area of concern that merits further study, Brodkey et al. (33) found that compared to clerkship directors in other core specialties in 1997 to 1998, clerkship directors in psychiatry were significantly more apt to perceive that managed care reduced the quality of clinical medical education. Brodkey et al. did not explain why this discrepancy existed. Since, as discussed above (26—28), the managed care scene has recently changed to the disadvantage of primary care physicians, the differences in concerns about managed care between psychiatrists and other specialists may also have changed.
Suboptimal Graduating Medical School Seniors' (Retrospective) Perceptions About Their Psychiatry Clerkships
Although we do not know how to connect recruitment with clerkship ratings, there is intriguing data about clerkships from 1999 to 2000 and from 2000 to 2001 (before 2000, specific data about clerkship "performance" was not gathered) from the Graduating Seniors Questionnaire of the Association of American Medical Colleges (AAMC), a survey completed by approximately 80% of the 16,000 graduating senior medical students nationally (34). The data indicated that seniors graduating in 2001 were more apt to rate their neurology, obstetrics, and psychiatry clerkships as having been "inadequate" and less likely to rate these clerkships as excellent (Figure 3) than clerkships in internal medicine (the highest rated), pediatrics, family medicine, and emergency medicine (34).
There is an unusually high correlation (Pearson's r = 0.95, p = < 0.001) between these senior students' post hoc ratings of these clerkships and the proportion of U.S. graduates who matched into these specialties (Figure 3). The correlation is imperfect (i.e., not 1.0) because, although obstetrics clerkships are rated lower than psychiatry clerkships, obstetrics recruits better than does psychiatry.
Unfortunately, the data on student perceptions of specialties, gathered from this graduating seniors questionnaire, are retrospective, cross-sectional, and univariate and failed to consider the possibility that students choosing the more-often-selected specialties (e.g., internal medicine, pediatrics, family medicine) were retrospectively misperceiving that such clerkships were more useful to their chosen careers (i.e., a retrospective falsification). Indeed, it sometimes seems that medical school itself focuses on training students to become internists—internal medicine is the most frequently selected specialty—although medical schools understand that not all students will become internists. To shed more light on how clerkship ratings are connected to recruitment, we should use AAMC data, at each school, to longitudinally track student prematriculation and pregraduation specialty preferences and pregraduation post hoc clerkship ratings for each specialty.
The Possibility of Some New Mexico Psychologists Eventually Obtaining Prescribing Privileges
Recently, the state of New Mexico enacted legislation that ultimately may permit psychologists to prescribe psychotropic medications, after completing an as-yet-to-be-approved course of at least 450 hours of classroom training in pharmacology, neuroscience, physiology, pathophysiology, and clinical pharmacotherapeutics, followed by a practicum of at least 400 hours treating at least 100 persons with mental disorders under a physician's supervision, and receipt of a 2-year conditional supervised prescription certificate (35). It is conceivable, but by no means certain, that despite strong opposition by the American Psychiatric Association (APA), the American Medical Association, and other groups (36—38), similar legislation could eventually be adopted in other states, and this could blur distinctions between psychologists and psychiatrists and affect recruitment adversely. But in other disciplines (e.g., anesthesiology, ophthalmology) where similar competition exists, there has been no decline in status or medical student interest. The uniqueness of psychiatry as a branch of medicine will likely bring the same results.
What can we do to reach our recruitment potential? To help improve the quality of medical student clerkships, psychiatry chairs must take steps to ensure that their departmental directors of medical student and residency education and their core clinical and classroom teachers have sufficient amounts of protected time to teach and are rewarded for teaching effectively.
The obligation of ensuring protected time for medical education rests primarily on the shoulders of top medical school management, including chairs, deans, presidents, and boards of trustees, since it is unlikely that government funding for medical student clinical education will increase in the next decade. As Friedman (39) so caustically wrote, "What if I asked why a $13,000-a-year uninsured janitor, who pays taxes and is trying to raise a family of four on that income, should subsidize the education of someone who will become a $300,000-a-year cardiologist (or—our words—a $150,000-a-year psychiatrist) who will refuse to provide care to that janitor because he is uninsured and can't pay for it?"
In their article on expectations of and for the psychiatry clerkship director, Kuhn et al. (40) specify what it takes to support a psychiatry clerkship director effectively, including protecting 55% of a director's time for clerkship-related activities, regular access to the chair, secretarial and administrative support for the program, and support for educational research and travel to educational meetings. In addition to the clerkship and residency directors having this amount of support, at least several other key educators should also be supported as well.
Second, more attention should be paid to medical student career choice of psychiatry and psychiatric recruitment and to psychiatric education in general. Although valuable articles on psychiatric recruitment have appeared since 1995 (7,8,10,20,29,32,40—48), this literature has been relatively quiescent from that time until now (48), perhaps due to reduced interest in the subject.
New research should include multivariate (and as much as possible, longitudinal) studies of career choice, including a) studies of the interactions between medical student personality as measured by personality instruments, sociodemographic factors, and medical school experiences; b) surveys of contemporary trends in psychiatric recruitment; c) studies of the association between managed care penetration, job availability, and recruitment; d) examinations of factors influencing specialty choice among Asian Americans, who comprise 18% of medical students but who are less likely than other students to select psychiatry (1), and among underserved minorities or persons reared in rural areas, who are more likely to practice their specialties in underserved communities; and e) studies of the extent to which psychiatrist participation on medical school admissions committees influences recruitment. Also, faculty at high-recruiting schools should keep the rest of the field fully informed about their programs (49). Some of these efforts are already under way.
Because some leaders in medical education are dissatisfied (50) with the structure and methodology of clerkships in all specialties (e.g., not enough ambulatory education, inadequacy of short-patient-stay inpatient education), the AAMC recently began a Project on the Clinical Education of Medical Students (50). The APA, the Association of Directors of Medical Student Education in Psychiatry, the Alliance for Clinical Education, and the American Association of Chairs of Departments of Psychiatry should assert and maintain a "seat at the table" for this project.
Psychiatry's contribution should include understanding and explaining why the psychiatry clerkship ratings on the Graduating Seniors' Questionnaire are lower than desirable (including reporting biases) and the extent to which factors such as student assignments to high-acuity, high-turnover inpatient services from which patients are discharged before their acute symptoms resolve, the high expense and administrative complexity of teaching students in ambulatory settings (50), and the inadequate protected time for teachers (33,40) contribute to suboptimal ratings.
Most of the recommendations from prior national recruitment conferences (3,4) are as applicable today as they were in 1981 and 1993.
Although the challenges are real, so too are the causes for optimism. If psychiatry addresses these concerns skillfully and energetically, we believe that recruitment of AMGs into psychiatry is likely to continue to increase.