The National Center for Health Workforce Analysis predicts that between 2010 and 2025, the field of psychiatry will see a decrease of 1 to 2 full-time equivalents (FTEs) per 100,000 psychiatrists. Yet, the need for providers with expertise in treating psychiatric patients remains great, particularly in light of persistence of mental illness stigma.
As we begin a new year, we asked members of our Editorial Advisory Board how they’d like to see the specialty respond to these trends so that patients with mental illness will get the care that they need. Here are some of their responses:
Dr. Lee H. Beecher
“Ultimately, the answer to this question depends on creating and maintaining access to effective professional care and social supports for the true health care ‘customers’ we serve – for example, people with mental illnesses and their families. This will require changes in how psychiatric care is described, provided, and paid for. We are indeed witnessing a redefinition of the definition of a ‘health care provider.’ And we are not going out of business! Psychiatrists will be teachers, researchers, systems leaders, and expert providers in the future. Clinical psychiatrists grounded as medical specialists will collaborate with patients, family members, nurses, psychologists, social workers, alcohol/drug counselors, primary care physicians, and community advocates to the goal of enhancing patient-centered care, which is evaluated and controlled by patients and their families.
“In addition to learning and practicing interdisciplinary teamwork in their training and practice venues, psychiatrists will continue to evolve functional roles in both patient care and clinical systems. These new functions will spawn new definitions of subspecialties in psychiatry well beyond our current category. The needs of children and the elderly will be addressed.
“Some psychiatrists will choose to provide patients with specialized, therapeutic relationships, as I did for 42 years. And, for the past decade, I practiced addiction psychiatry with patients of different ages, races, nationalities, and economic circumstances. What a privilege!
“It is indeed good news that psychiatry is holding its own attracting new trainees in 2015. Continuing interest in psychiatry speaks to the dynamism and challenges of our profession and its appeal to medical students, by far the most going into psychiatry are female. When I meet with our Minnesota psychiatry residents, they tell me after residency they need a job that will allow them to have a family and pay off their training cost debt.
“In addition, here are a few more thoughts:
• ‘Cognitive specialties’ such as psychiatry do continue to face stiff competition from historically much-better-paying, procedurally oriented medical specialties.
• Participation in postgraduate medical school internships are fundamental to the training of psychiatrists so that we can understand the treatment and management of a wide range of patients and medical conditions.
• Learning patient care and clinical skills as physicians involves adhering to Hippocratic medical ethics. This is our basic training.
• That said, concepts of population disease management and associate cost rationing are worthy ethical issues that are often in conflict with Hippocratic patient-centeredness.
• The power and control of most physicians who provide patient care in the United States are superseded by private and governmental organizations, and most physicians nationwide are employees.
• Clinical psychiatric practice in large organizations and/or for psychiatrists who have insurance company provider contracts is governed by clinical guidelines, care algorithms, and pay-for-performance rules not under the control of physicians.
“Most independent, private psychiatrists in Minnesota doing direct clinical patient care have opted out of all provider contracts and Medicare. They have chosen to do direct pay practice because of obstacles to low pay for doing psychotherapy or conducting family meetings, disruptive and intrusive insurance company practices including prior authorizations, time-consuming coding requirements, mandated electronic medical records (concerns about checklists and privacy/confidentiality), stigma associated with data transfer, and interception of continuity of care between treatment settings. Many direct pay psychiatrists also have consultation jobs in mental health centers, the Department of Veterans Affairs, or are doing insurance reviews and like to manage their schedules.”
–Lee H. Beecher, M.D.
Dr. Carl C. Bell
“As a psychiatrist currently working in a general hospital and family medicine clinic setting, it seems to me that it would be wise for the specialty of psychiatry to more closely align itself with general medicine. There is a great deal of talk about co-locating mental health, substance abuse, and primary care in medical homes – but, with the exception of a few brave programs, not much has changed.
“I have been observing a trend that nurse practitioners are picking up the slack for the dearth of geriatric psychiatrist, and this is becoming the trend in several states. Another trend is for family practitioners to partner with a psychologist and to write the prescriptions the psychologists suggest to the physician – of course, they are just biding time until psychologists can prescribe. Unfortunately, it seems to me that it’s OK for these ‘psychiatrist extenders’ to prescribe and care for these patients, who unfortunately are seen as least desirable. I know of one context where a retired surgeon is nearly ubiquitous in caring for the geriatric nursing home population and, in my opinion, those specialists are not very learned in this area – as evidenced by their often inappropriate care of elderly patients with major neurocognitive disorder.