Academic Psychiatry 27:229-234, December 2003
© 2003 Academic Psychiatry
Where Is Psychiatry Going and Who Is Going There?
Richard A. Cooper, M.D.
Dr. Cooper is with the Division of Health Care Planning, Health Policy Institute at the Medical College of Wisconsin, Milwaukee, Wisconsin. Address correspondence to Dr. Cooper, Health Policy Institute, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin 53226, rcooper{at}mcw.edu (E-mail).
The articles in this issue cover important ground in their examination of workforce concerns in psychiatry. While bearing many similarities to analogous concerns that exist in other medical specialties, they take on an additional layer of complexity in psychiatry because of two unusual, if not unique, characteristics. The first has to do with psychiatry's shifting jurisdictional boundaries and the second with its evolutionary conceptual basis—its defining abstraction (1). It is from this frame of reference that I will attempt to shed light on where psychiatry is going and how recruitment and training might best take place.
Abstract Identity
Freud never made it into my medical school curriculum. I learned biological psychiatry in the late 1950s at the feet of Robins and Guze, who were not only leading the revolution away from dynamic psychiatry but preparing us for the coming era of psychopharmacology (2,3). We sensed the winds of change, not realizing that change had been the rule. From a 19th-century focus on "moral therapy" for insanity, the profession had progressively enlarged its identity around issues of social adjustment and personality structure, thus paving the way for the link between physical and emotional well-being and laying the groundwork for the mid-20th-century explosion of outpatient psychotherapy. The authority of psychiatrists was strengthened by their attachment to Freudian concepts of blocked emotional conflicts, matters that they insisted only physicians could resolve, although Freud saw no reason for this to be the case. Nonetheless, their primacy in these matters was embraced widely enough that they were able to subordinate psychiatric social workers, psychologists, and others whom the public had previously accepted, a situation that persisted well into the 1970s (1).
The biological framework that evolved from the work of Robins, Guze, Engel, and others (2–4) grew to dominate psychiatric education (5). One of its benefits has been to bring psychiatry into the mainstream of medicine, which has proven to be an important factor in attracting residents (5,6). But this unification no longer satisfied those who preferred to see mind and body as separate, opening the way for other therapeutic paradigms, nor did it persuade most health plans to provide parity in mental health coverage. More importantly, the stature of psychiatrists was no longer a product of their association with a unique psychodynamic abstraction. Rather, they were differentiated by their particular operational roles as medical practitioners for severe mental illness and as principal gatekeepers for psychopharmacologic therapy, roles that have counterparts in other specialties but that are quite limited in comparison with the breadth that psychiatry had acquired over the previous half century.
The sociologist, Andrew Abbott, has observed that the control that professions have over their abstract body of knowledge allows them to seize new problems, redefine their scope of interest, and defend their jurisdictions against interlopers (1). This phenomenon is expressed within most medical specialties as an evolution of diagnosis or treatment to progressively more complex levels as the specialty's knowledge base expands. Psychiatry is an exception. Rather than seizing new problems that emerge from technological progress or conceptual growth, it has expanded its scope of interest by medicalizing what are often referred to as "problems of living" (7). Recent examples include posttraumatic stress syndrome, social anxiety disorder, and attention deficit hyperactivity disorder, a malady in which three-fourths of those affected are little boys (8). But these merely continue the tradition of medicalizing socially objectionable behaviors, such as criminality, juvenile delinquency, and alcoholism, which continue to be outside of societal norms, or homosexuality and (e.g., in the Soviet Union) political dissent, which are no longer. No doubt, some who are so labeled harbor true psychiatric disease—certainly many criminals do. But medicalization is a tenuous use of systems of knowledge, one that is open to reinterpretation and redefinition (8). More germane to the present discussion, it is very difficult to integrate into workforce planning.
Psychiatry's Jurisdictional Boundaries
The conflict between dynamic and biological psychiatry was not the only battle being waged in the 1960s. Another was for patients' rights to treatment. This battle culminated in the Community Mental Health Act of 1963, which emptied most mental hospitals and relocated psychiatry's locus of power from public institutions to the community. And psychiatry's power was substantial. Based on an acceptance of the profession's unique body of knowledge, psychiatrists had not only won their earlier jurisdictional contests with psychologists and social workers, whose limited domains were brought under psychiatry's control, but they had taken counseling from the clergy and criminal behavior from the legal system. Psychiatrists owned the turf, and as the 1970s progressed, an educated populace demanded more of what they had to offer. This was a high watermark for the profession, perhaps too high. With fewer than 25,000 practitioners in 1975, psychiatry simply could not meet either the public's demand for individual psychotherapy or the community's needs for mental health services.
What followed was a massive outpouring of mental health providers, in large part fueled by grants from the National Institute of Mental Health (NIMH) for purposes of making low-cost psychotherapy more widely available. Initially aimed at training more psychologists, these grants later supported the training of clinical social workers, counselors, and therapists. Over the next 25 years, psychiatry's ranks barely doubled to 48,000 (9), while psychology's more than tripled to 75,000, the number of clinical social workers grew to more than 200,000, and 100,000 counselors and therapists emerged from disciplines that were virtually nonexistent in the 1960s. Reimbursement of nonphysician therapists by Medicaid and other insurers quickly followed. And in the 1990s, a second wave of nonphysicians appeared, this time composed of practitioners of alternative and complementary medicine offering a range of mind-body interventions and natural remedies.
It was not only from outside of medicine that additional mental health providers emerged. The period after 1970 also marked the birth of family practice, which, like general practice that it replaced, saw mental health as within its domain and readily adopted psychiatry's biological perspective. While the effectiveness of primary care physicians in this arena has been questioned (10,11), they now care for a greater volume of anxiety, mood disorders, and other common psychiatric conditions than do psychiatrists, and like psychiatrists, prescribe a wide range of psychotropic agents. Clearly, the practices of psychiatrists extend well beyond these common conditions to encompass more severe disorders, often among patients who are institutionalized, and psychiatrists have a much wider set of skills and the ability to use a more extensive pharmacopeia. However, they spend less than 20% of their time treating institutionalized patients, and fewer than 15% of their patients are psychotic, whereas more than one-half carry diagnoses that family physicians also treat (12).
Despite this overlap with family practice, psychiatrists dominate psychopharmacologic therapy. Yet, even this has come under attack by psychologists who are seeking their own prescriptive privileges. Although as recently as 10 years ago, many leaders in psychology looked with disdain upon prescriptive authority, a pilot program for prescribing psychologists in the military in the mid-1990s yielded good clinical results, and such privileges were recently granted in New Mexico. Although past efforts to obtain similar privileges in more than a dozen other states repeatedly failed, attempts at the state level are now proceeding with renewed vigor in Texas, Nebraska, and elsewhere. Even without state sanction, the authority to prescribe psychotropic medications has existed for some time among a small group of psychologists who are also nurse practitioners and who prescribe under their nursing license, and it exists de facto for many psychologists through their relationships with family physicians. Nonetheless, psychiatrists protest that psychologists are not adequately prepared for this role, and many psychologists agree, but psychology training programs are ramping up their capacity to compensate for any deficiencies. It is worthwhile noting that the concerns of psychiatrists about psychologists echo ones that were voiced when nurse practitioners first obtained prescriptive authority, but nurse practitioners now have such privileges independent of physician supervision in 10 states and there are no indications that the public is being harmed. Moreover, as occurred on behalf of nurse practitioners, much of the political pressure in support of prescriptive privileges for psychologists is emanating from underserved rural communities, which psychiatrists tend to shun.
The consequence of psychiatry's loss of jurisdictional control has been a diffusion of mental health treatment among a range of professionals whose stature and authority are both substantial and growing. This is very different from the scene that psychiatry residents entered 30 years ago, and it foreshadows a still different one 30 years from now (8), an issue that planners need to contemplate when trying to discern the necessary size and characteristics of tomorrow's psychiatric workforce and that students need to consider in making their long-term career decisions.
Parallels in Other Medical Specialties
These professional conundrums are not shared by most of the other specialties of medicine. For example, with the possible exception of family practice, which has attached itself to the elusive concept of primary care, there is no other specialty that has any ambiguity over its abstract identity, and none of the others confronts any structural barriers to reimbursement, although all are constantly fighting for more. Indeed, it is only psychiatry and primary care that have fostered a literature that examines the conceptual basis of their professional roots and directions (13,14). Even in the arena of jurisdictional conflict, few face significant issues, and none has issues that are as profound as psychiatry's. In fact, other than psychiatry, there are only three specialties in which substantial jurisdictional issues exist (15,16).
One such instance involves ophthalmology and optometry. In the past, busy ophthalmologists gladly ceded refraction and other low-level eye care to optometrists, but they now are regretting the entrée that this has given to optometrists for the delivery of more advanced care, such as the treatment of glaucoma with prescription medications. Anesthesiologists and nurse anesthetists have a somewhat similar history. Nurse anesthetists provided most of the anesthesia in the early 1900s, principally because anesthesia was poorly rewarded and looked upon by doctors as "nurse's work." Even today, anesthesiologists gladly delegate much of it to nurse anesthetists, albeit with physician supervision and financial participation, but they wince over the independence that nurse anesthetists have garnered in some states. The same story is unfolding in family practice, as physicians gladly off-load routine care to nurse practitioners, particularly under circumstances that are financially rewarding to physician practices. However, nurse practitioners have gained prescriptive authority in all states and the right to exercise it independently in 10, and Medicare has given them direct access to reimbursement. As a result, many have discovered that they can do it alone. Indeed, a new breed of doctoral level training programs is preparing nurse practitioners to compete head-on with family physicians (17).
In each of these specialties, as in psychiatry, there is a core of severity and complexity that cannot easily be shared or delegated, but the margins are often blurred, and the question ultimately becomes a quantitative one—how much will be done by whom and with what degree of independence? And that, inevitably, leads to a workforce question—how many will be needed? Anesthesiology is spared most of this because there are not enough of either anesthesiologists or nurse anesthetists, but ophthalmology, family practice, and psychiatry are strongly affected by their interfaces with nonphysician clinicians. The shifting jurisdictional boundaries that result are certain to redefine the content of each specialty and impact on the necessary number of its future practitioners.
No Need for Needs-Based Planning
How, then, does one plan for psychiatry's future? It might be best to start with how not to. Don't do needs-based planning. This approach, which is described in this issue of the Journal by Faulkner (18), was popularized by the Graduate Medical Education National Advisory Committee (GMENAC) in the 1980s (19) but now lies on the rubble heap of health care policy (20,21). It just doesn't work, not only in psychiatry, where fundamental questions of definition exist, but even in specialties such as orthopedic surgery and medical oncology, which have no such ambiguities (21). First, it's impossible to project how many people will have health problems. It becomes particularly difficult in psychiatry because the definition of mental health vis-à-vis a host of behavior patterns and societal norms is constantly in flux. Even if the range of disorders that psychiatrists will care for in the future could be projected, it is illusory to estimate how much time each element of care would require in the future. Tiny errors multiplied through hundreds of disorders and encounters have a huge effect on the resulting demand projections. All of this is fodder for manipulation, or, by analogy to the old accounting joke, "What's the bottom line? What do you want it to be?"
Past estimates of workforce requirements in child and adolescent psychiatry are good examples of the folly of needs-based planning. Most observers would agree with Kim that the nation has too few psychiatrists in this subspecialty (22), but it isn't clear from planners just how many too few there are. In 1981, GMENAC's consensus process concluded that 17.1% of the children in 1990 would have mental problems requiring some kind of intervention and that 5.4% would need psychiatrists (19). That translates into 26,100 child psychiatrists, far in excess of the 6,300 who are now in the workforce. However, with the flip of a number here and an assumption there, GMENAC's Modeling Panel (whose figures were used in the final report) decided, quite arbitrarily, that only 8.6% of children would need mental health treatment, and only 3.0% would need psychiatrists. So presto, only 8,000 to 10,000 child psychiatrists would be necessary (19). Why not 6,000, or 60,000?
The second reason that needs-based planning doesn't work is that, in most circumstances, the demand for care is not a function of "medical need," however defined. Society's needs are never met. Rather, need translates into demand through the keyhole of economic capacity (23). In the last analysis, we need, or demand, what we can pay for, individually and collectively. For example, the prescription needs of the elderly are well recognized, but they will not be met through Medicare until the country decides that it can afford the costs. Or look beyond the United States. The mental health needs in sub-Saharan Africa are at least as great as those of the United States—millions of children have been orphaned. But there are virtually no resources for psychiatrists, so the demand is low. While it is important to lobby on behalf of mental health services, both here and there, workforce planning must be based not on what is optimal but on what is likely, and what is likely can best be inferred from the trajectory of economic growth.
The Physician Shortage
That brings us to the supply side of the equation and to two realities that weigh on future training decisions, not only in psychiatry but in other specialties, as well. The first is that there won't be enough trainees to meet the demand for physicians overall. Based on long-term economic and demographic trends—not on microanalyses of "need"—our nation is headed for a serious shortage (22,24). The second reality is that the trainees of today are different from those of the past. More are women, many are international medical graduates (IMGs), and most want what has come to be called a "controllable lifestyle" (25). While some planners saw these issues on the horizon (26–28), most did not (29), and our nation is now unprepared to deal with them. There is limited potential to ramp up undergraduate medical education in time to avert the coming shortages. Even opening the gates to more IMGs will do little to help near term. And in both cases, substantial political obstacles will be encountered in creating the necessary additional residency positions.
With insufficient numbers of students in the pipeline, the competition for residents will be brisk. Some medical specialties are already looking for ways to increase their training capacity, either by attempting to roll back the restrictions in the Balanced Budget Act of 1997 or by decreasing the duration of residency training and thereby increasing the number of residents who can be trained (30). As students search for the best path to their future, it seems inevitable that most will gravitate to specialties that demand their level of education. While some may be dissuaded from choosing psychiatry because of its strong overlap with nonphysician therapists, or because of managed care's strictures (31), or simply because psychiatry is seen as too distant from "real" medicine (25), others will be attracted to psychiatry because of its biological paradigm and the intensity of patient contact that it affords (5). Yet some may wonder what became of the profession's antecedent paradigms and of the practitioners who trained under them—and what might be its next (8).
These concerns do not appear as great for IMGs, who in 1975, accounted for 25% of psychiatrists but who now account for more than 30% and who fill 40% of psychiatry's current residency positions. Cultural differences may exist, but IMGs contribute a great deal to the profession, often in ways that differentiate them from U.S. medical graduates. When assessed in 1996, IMG psychiatry residents tended to be older than U.S. graduates, and many more were women. After residency, they practiced more hours, worked more often in public institutions, and cared for more psychotic patients than their U.S.-educated peers (9). Indeed, in 2000, one-third of IMG psychiatrists who were involved in patient care worked as staff physicians, double the percentage of U.S. grads, and they accounted for almost one-half of these positions. That such differences should exist between U.S. and international grads tells something of the priorities and expectations that U.S. students have upon entering the profession—and of the jurisdictional boundaries that they are most likely to defend.
As potential residents look to psychiatry, one of its most visible strengths is its rich intellectual milieu, which, in combination with a controllable lifestyle, creates the basis for a satisfying career. These characteristics may draw more attention than either the profession's current travails with managed care and competing providers or the ambiguities that exist over its jurisdictional boundaries and its "overarching conceptual framework" (32). Yet, it is these latter issues that have generally proven to be the most important ones over time. The art is long, life is short, but psychiatry will surely endure. It simply isn't clear in what form or with whom that is most likely to occur.
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D. J. Vernon, E. Salsberg, C. Erikson, and D. G. Kirch
Planning the Future Mental Health Workforce: With Progress on Coverage, What Role Will Psychiatrists Play?
Acad Psychiatry,
May 1, 2009;
33(3):
187 - 192.
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