Child and Adolescent Psychiatry Work Force; A Critical Shortage

and National Challenge

AACAP

Steering Committee for Workforce Issues

2

“There is a dearth of child psychiatrists… Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals... This places a burden on pediatricians, family physicians, and other gatekeepers to identify children for referral and treatment decisions.” (Mental Health: A Report of the Surgeon General, 1999)

3

Prevalence and Magnitude of Child and Adolescent Psychiatric Problems

• About 20 percent of U.S. children and adolescents (15 million), ages 9 to 17, have diagnosable psychiatric disorders (MECA, 1996, the Surgeon General, 1999)

• The Center for Mental Health Services (1998) estimated that 9 to 13 percent of U.S. children and adolescents, ages 9 to 17, meet the definition of “serious emotional disturbance” and 5 to 9 percent of U.S. children and adolescents, “extreme functional impairment.”

• Only about 20 percent of emotionally disturbed children and adolescents receive some kind of mental health services (the Surgeon General, 1999), and only a small fraction of them receive evaluation and treatment by child and adolescent psychiatrists.

• The demand for the services of child and adolescent psychiatry is projected to increase by 100 percent between 1995 and 2020, and for general psychiatry, by 19 percent (U.S. Bureau of Health Professions, DHHS, 2000).

• The population of children and adolescents under age 18 is projected to grow by more than 40 percent in the next 50 years from the current 70 million to more than 100 million by 2050 (U.S. Bureau of the Census,2000).

4

Prevalence and Magnitude of Child and Adolescent Psychiatric

Problems About 20 percent of U.S. children and

adolescents (15 million), ages 9 to 17, have diagnosable psychiatric disorders (MECA, 1996, the Surgeon General, 1999)

5

Prevalence and Magnitude of Child and Adolescent Psychiatric

Problems (continued)• The Center for Mental Health Services

(1998) estimated that 9 to 13 percent of U.S. children and adolescents, ages 9 to 17, meet the definition of “serious emotional disturbance” and 5 to 9 percent of U.S. children and adolescents, “extreme functional impairment.”

6

Prevalence and Magnitude of Child and Adolescent Psychiatric Problems

(continued)• Only about 20 percent of emotionally

disturbed children and adolescents receive some kind of mental health services (the Surgeon General, 1999), and only a small fraction of them receive evaluation and treatment by child and adolescent psychiatrists.

7

Prevalence and Magnitude of Child and Adolescent Psychiatric Problems

(continued)• The demand for the services of child and

adolescent psychiatry is projected to increase by 100 percent between 1995 and 2020, and for general psychiatry, by 19 percent (U.S. Bureau of Health Professions, DHHS, 2000).

8

Prevalence and Magnitude of Child and Adolescent Psychiatric Problems

(continued)• The population of children and adolescents

under age 18 is projected to grow by more than 40 percent in the next 50 years from the current 70 million to more than 100 million by 2050 (U.S. Bureau of the Census, 2000).

9

Supply of Child and Adolescent Psychiatrists

• There are currently about 7,000 and adolescent psychiatrists practicing in the U.S. (AMA, 2006).

• In 1980, GMENAC recommended that the number of child and adolescent psychiatrists be increased to 8,000 - 10,000 by 1990 in order to meet the projected needs for treatment of child mental disorders.

• In 1990, COGME reported that the nation would need more than 30,000 child and adolescent psychiatrists by 2000, based on increasing rates of child mental illnesses and managed care staffing models.

• There is a severe maldistribution of child psychiatric services in the U.S., with children in rural areas and areas of low SES having significantly reduced access. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts with an average of 8.7 (Thomas and Holzer, 2006).

• While the U.S. Bureau of Health Professions (2000) projects that the number of child and adolescent psychiatrists will increase by about 30 percent to 8,312 by 2020 if the funding and recruitment remain stable at the current level, this is far less than the estimated 12,624 needed to meet demand.

10

Supply of Child and Adolescent Psychiatrists

• There are currently about 7,000 child and adolescent psychiatrists practicing in the U.S. (AMA, 2006).

11

Supply of Child and Adolescent Psychiatrists (continued)

• In 1980, GMENAC recommended that the number of child and adolescent psychiatrists be increased to 8,000 - 10,000 by 1990 in order to meet the projected needs for treatment of child mental disorders.

12

Supply of Child and Adolescent Psychiatrists (continued)

• In 1990, COGME reported that the nation would need more than 30,000 child and adolescent psychiatrists by 2000, based on increasing rates of child mental illnesses and managed care staffing models.

13

Supply of Child and Adolescent Psychiatrists (continued)

• There is a severe maldistribution of child psychiatric services in the U.S., with children in rural areas and areas of low SES having significantly reduced access. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts with an average of 8.7 (Thomas & Holzer, 2006).

14

Supply of Child and Adolescent Psychiatrists (continued)

• While the U.S. Bureau of Health Professions (2000) projects that the number of child and adolescent psychiatrists will increase by about 30 percent to 8,312 by 2020 if the funding and recruitment remain stable at the current level, this is far less than the estimated 12,624 needed to meet demand.

15

Recruitment Problems• There has been a steady decline in the recruitment of PGYI USMG’s into general psychiatry

through the NRMP, from 664 in 1990 to 481 in 2000, although increasing to 524, 564, 597, 641, 653, 643 in 2001-2006. However, the total number of psychiatric residents has remained relatively stable, about 6000.

• The number of child and adolescent psychiatry residents has not increased in the past decade of the 20th century; 712 in 1990, and 718 in 2000. The number of child and adolescent psychiatry training programs has decreased by 5 to 114 in the same period. However, the numbers have been increasing slightly; 723, 742, 766 in 2004-6 and 3 new programs opening (ACGME, 2006)

• The proportion of IMG’s in child and adolescent psychiatry residency programs has substantially increased from about 20 percent in 1990 to 34.8 percent (AMA, 2006). The recommendation made in the 14th COGME report (1999) to enforce exchange visa status of IMG’s to return to their home country after training and post 9-11 events will likely further reduce the future workforce.

• Close to 13 percent of child and adolescent psychiatry residency positions were unfunded or unfilled in 2006; 766 residents filled 882 approved positions (ACGME, 2006).

• It is estimated that about 20 percent of U.S. medical schools do not sponsor child and adolescent psychiatry residency programs and more than 30 percent of U.S. medical students have minimum or no clinical clerkship arrangement in child and adolescent psychiatry–a critical void in the recruitment and education of future physicians.

16

Recruitment Problems• There has been a steady decline in the

recruitment of PGYI USMG’s into general psychiatry through the NRMP, from 664 in 1990 to 481 in 2000, although increasing to 524, 564, 597, 641, 653, 643 from 2001 to 2006. However, the total number of psychiatric residents has remained relatively stable, about 6000.

17

Recruitment Problems (continued)

• The number of child and adolescent psychiatry residents has not increased in the last decade of the 20th century; 712 in 1990, and 718 in 2000. The number of child and adolescent psychiatry training programs has decreased by 5 to 114 in the same period. However, the numbers have been increasing slightly; 723, 742, 766 in 2004-6 and 3 new programs opening (ACGME, 2006).

18

ACGME Resident CensusAnd *GME Track (AMA/AAMC, APA)

APPROVED

POSITIONS

FILLEDPOSITIO

NS

APPROVED

POSITIONS

FILLED POSITIO

NS

APPROVED

POSITIONS

FILLED POSITIO

NS *GME Track, APA

Census

ACADEMIC YEAR

Years 1 & 2 Year 1 Year 1 Year 2 Year 2

1999 – 2000

874 718 669

2002 – 2003

834 673 434 338 400 335 664

2003 – 2004

852 709 443 354 409 355 692

2004 – 2005

881 723 455 366 426 357 720

2005 – 2006

879 742 454 368 425 374 706

2006 – 2007

882 766Zip: Kim_ACGME Census 1999-06

19

CHILD PSYCHIATRY MATCH

TABLE 1NRMP Child and Adolescent Psychiatry Program Statistics

Appt. Year

Participating Programs

w/ Rank Order

List

Program withdrawls / No ROL

Positions Offered

Positions Filled Programs Filled

n % n %

1996

88 5 270 170 63 36 41

1997

89 7 272 193 71 43 48

1998

82 7 244 177 73 38 46

1999

80 15 234 179 76 45 56

2000

76 7 229 167 73 40 53

2001

75 11 230 167 73 35 47

2002

77 0 242 177 73 41 53

2003

78 7 243 173 71 39 50

2004

81 4 259 223 86 59 73

2005

83 3 275 236 86 61 73

20062007

8491

02

293308

246263

8485

5061

6067

Note: NRMP=National Resident Matching Program

20

CHILD PSYCHIATRY MATCHTABLE 2

NRMP Child and Adolescent Psychiatry Applicant Statistics

Appt.

Year

Active Applicant (A)

Applicants MatchedApplicant*

Withdrawls / No Rank Order List

(W)n %(M)

1996 189 170 90 20

1997 215 193 90 33

1998 202 177 88 43

1999 208 179 86 50

2000 206 167 81 43

2001 181 167 92 24/23

2002 191 177 93 56

2003 208 173 83 40/21

2004 256 223 87 27

2005 291 236 81 39

20062007

269297

246263

9189

20/199/17

Note: NRMP=National Resident Matching Program

Total Enrollment= A+W, Unmatched= A-M, *Total Combined or Separate numbers in some years

21

Recruitment Problems (continued)

• The proportion of IMG’s in child and adolescent psychiatry residency programs has substantially increased from about 20 percent in 1990 to 34.8 percent (AMA, 2006). The recommendation made in the 14th COGME report (1999) to enforce exchange visa status of IMG’s to return to their home country after training and post 9-11 events will likely further reduce the future workforce.

22

Recruitment Problems (continued)

• Close to 13 percent of child and adolescent psychiatry residency positions were unfunded or unfilled; 766 residents filled 882 approved positions (ACGME, 2006).

23

Recruitment Problems (continued)

• It is estimated that about 20 percent of U.S. medical schools do not sponsor child and adolescent psychiatry residency programs and more than 30 percent of U.S. medical students have minimum or no clinical clerkship arrangement in child and adolescent psychiatry–a critical void in the recruitment and education of future physicians.

24

Recruitment Problems (continued)

• Increasing educational debt, pressure and incentives to pursue a primary care career in the 1990’s, a long training period, further sub-specialization of medicine including psychiatry and reimbursement problems in the managed care era are some of the factors that discourage medical students in choosing a career in child and adolescent psychiatry.

25

Funding Problems• Governmental agencies and the medical community have promoted a

decrease in the overall physician workforce, an increase of primary care workforce, a reduction of specialty workforce, and a decrease in the number of IMG’s entering graduate medical education–a so called 50-50-10 model; 50 percent generalists, 50 percent specialists, 10 percent IMG’s (COGME, 1992, 1994, 1995; Pew Health Professions Commission, 1995; the 1997 consensus statement by AAMC, AACOM, AMA, AOA, AAHC, NMA).

• The Balanced Budget Act (BBA) of 1997 reduced direct GME funding by 50 percent for subspecialty training beyond the primary specialty board eligibility. This is an added cut to child and adolescent psychiatry that had not received indirect GME funding in the past.

• The 1997 BBA provided incentives to teaching hospitals for reduction of GME positions. It also resulted in the severe reduction of Medicare reimbursement to teaching hospitals. Although the BBA of 2000 will provide some temporary relief to teaching hospitals, the GME programs, especially child and adolescent psychiatry residency programs will suffer from funding cuts.

26

Funding Problems• Governmental agencies and the medical community

have promoted a decrease in the overall physician workforce, an increase of primary care workforce, a reduction of specialty workforce, and a decrease in the number of IMG’s entering graduate medical education–a so called 50-50-10 model; 50 percent generalists, 50 percent specialists, 10 percent IMG’s (COGME, 1992, 1994, 1995; Pew Health Professions Commission, 1995; the 1997 consensus statement by AAMC, AACOM, AMA, AOA, AAHC, NMA).

27

Funding Problems (continued)• The Balanced Budget Act (BBA) of 1997

reduced direct GME funding by 50 percent for subspecialty training beyond the primary specialty board eligibility. This is an additional cut to child and adolescent psychiatry that had not received indirect GME funding in the past.

28

Funding Problems (continued)• The 1997 BBA provided incentives to teaching

hospitals for reduction of GME positions. It also resulted in the severe reduction of Medicare reimbursement to teaching hospitals. The reductions in health care services and health professions training grants in 2001 have affected, and the state and federal budgetary problems will further affect negatively teaching hospitals, the GME programs, especially child and adolescent psychiatry residency programs.

29

SUMMARY:The need and voice of child and adolescent psychiatry have been buried under the sweeping forces of the federal mandates and national medical organizations’ consensus on the oversupply of specialists. They have failed to recognize the continuing critical shortage of child and adolescent psychiatrists. The serious undersupply of practitioners has resulted in children receiving inadequate care from mental health professionals who lack the necessary training. However, there have been increasing recognition of shortage of physicians in general but also child and adolescent psychiatrists, resulting in increasing numbers of new residents and programs.

A CALL TO ACTION: CHILDREN NEED OUR HELP

STRATEGIC PLAN

American Academy of

Child and Adolescent Psychiatry

10 year initiative

31

Recruitment/Workforce

• Biopsychosocial

• developmental

• multimodal

• Systems intervention

• Multilevel collaboration

32

EXPANDING THE PORTALS OF ENTRY FOR CAP TRAINING

• Traditional Program (5 or 6 Years); 3 to 4 yrs GP + 2 yrs CAP

• Triple Board Program (5 Years); 2 yrs Peds+3 yrs GP & CAP

• Integrated Training (5 Years); traditional + CAP exposure

• Integrated Training, Innovative (5-6 Years); + research

• Pediatrician track (6 Years); 3 yrs Peds + 3 yrs GP & CAP

33

Legislative efforts;

• Stark bill to support GME funding for shortage specialties, e.g. CAP, nephrology, etc. failed by 2000

• The Child Healthcare Crisis Relief Act, H.R. 1106; bipartisan by Kennedy (D-RI) and Ros-Lehtinen (R-FL)

• Senate Companion Bill (S.537); bipartisan by Sen. Bingaman (D-NM) and Collins (R-ME),

34

The Child Healthcare Crisis Relief Act

• Recognition of national shortage of child mental health professionals

• Incentives to help recruit and retain child mental health professional by loan repayments, scholarships and grants

• Increase of CAP by extending Medicare GME years and cap for GME funding

• Total appropriation; $45 mill annually for 4 years

35

Advocacy

• Public image; media• Governmental; federal (DHHS:FDA, NIH,

SAMHSA, etc)), congress, state, local• Mental health community; consumer

groups, CMHC, hospitals• Medical community; professional

organizations (AMA, ACGME, AAMC, AAP, etc), medical schools

36

Medical Education & Mentoring

• Education of medical students: curriculum

• Exposure to clinical child psychiatry by medical students

• Availability of mentor in ROCAP

• Information on professional satisfaction, job market and life style

37

Survey of graduating residents

• Center for Health Work Force Studies at SUNY, Albany (http://chws.albany.edu)

• all graduating residents and fellows in NY (4400-4500) and CA(2600-2700) in 27-28 specialties each year in 1998-2002

• 40 to 65 % response rates• Child and adolescent psychiatry ranked #1 in

many categories of career opportunity, although the rankings from NY survey in 2003-2005 were lower.

38

39

40

41

42

43

44

45

46