Editorial

238 Academic Psychiatry, 27:4, Winter 2003

Psychiatric Workforce: Past Legacies, CurrentDilemmas, and Future Prospects

Nyapati R. Rao, M.D., M.S.

GUEST EDITORDr. Rao is Director of Residency Training and visiting As-

sociate Professor of Clinical Psychiatry in the Department of Psy-chiatry at the State University of New York (SUNY) DownstateMedical Center. Dr. Rao chaired the Council on Medical Edu-cation and Lifelong Learning for the American Psychiatric As-sociation from 2001–2004. Address Correspondence to Dr. Rao,SUNY-Downstate Medical Center, 450 Clarkson Avenue, Box1203, Brooklyn, NY 11203, nrraomd@pol.net (E-mail).

Copyright � 2003 Academic Psychiatry.

In a provocative editorial in The American Journal ofPsychiatry titled “Why Be Concerned About Re-

cruitment?,” James Scully, M.D. (1) stated, “Whateverthe right number (of psychiatrists) turns out to be,we’ll still need to recruit new psychiatrists. To fail todo so is to abandon our profession and our patients.”(1). These words of admonition by a leader in theprofession have provided the rationale for this specialissue of Academic Psychiatry devoted to psychiatricworkforce as well as the retreat conducted by theCouncil on Medical Education and Career Develop-ment of the American Psychiatric Association (APA)that took place February 9–11 of 2001 in Washington.

The backdrop of the retreat was provided by sev-eral developments pertaining to physician workforcethat occurred in the preceding decade. The late 1980sand 1990s were marked by publication of a flurry ofreports by think tanks and governmental agencies ex-pressing deep concerns that the United States washeading toward a major physician surplus and thatthis physician excess—especially that of specialists—was fuelling an escalation of health care costs. Unlessthis excess was curtailed, so went the argument, es-calating health care costs would have adverse con-sequences for the economy as a whole.

These concerns regarding health care costs anddelivery led to the failed attempt by the Clinton ad-ministration to reform health care with one boldstroke. In addition, the same concerns resulted in theevolution of managed care, which called for training

of more generalists to act as gatekeepers to containhealth care costs and reduce the number of specialistsbeing trained. With major shifts in graduate medicaleducation (GME) financing by Medicare, medicinebegan to downsize its GME workforce.

Closer to home, psychiatry was seen by managedcare as having far too many practitioners than wasneeded to deliver cost-effective mental health ser-vices. Consequently, the scope of psychiatric practiceshifted in favor of psychopharmacological manage-ment and less psychotherapy. Mental health profes-sionals of other disciplines began to fill the void inproviding psychotherapy. As these paradigmaticchanges were occurring in the field, fewer U.S. medi-cal graduates (USMGs) were choosing psychiatry asa career. As fewer USMGs entered psychiatry, inter-national medical graduates (IMGs) rushed in to cor-rect the shortfall.

As the 1990s came to an end, reports began toappear that other Western nations, such as Canadaand the United Kingdom, that carefully planned theirphysician workforces, were confronting major phy-sician shortages as well as physician maldistribution.Here in the United States, the Education Council forForeign Medical Graduates (ECFMG) introduced anadditional qualifying exam called the Clinical SkillAssessment Examination (CSA) for IMGs that wasadministered only in the United States, which hin-dered access to ECFMG certification for many oth-erwise qualified IMGs for pecuniary reasons. In ad-dition, several immigration-related changes occurredthat further restricted IMG entrance into U.S. medi-cine. Ironically, this time, concerns were raised that areduced number of IMGs would have severe impacton residency training programs that depended onthem as their trainees. Finally, secondary to managedcare’s emphasis on quality of care, the field becamejustifiably concerned about the competency of itspractitioners and the ensuing debate over core com-

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Academic Psychiatry, 27:4, Winter 2003 239

petencies, which added further complexity to theworkforce examination.

Thus, workforce studies in psychiatry, which inearlier times used to be narrowly focused on resi-dency recruitment issues, began to include more com-plex ones such as the scope of practice, access to care,the economics of health care delivery, practitioner’scompetence, etc. Against this backdrop, the Councilon Medical Education and Career Development helda meeting where experts in the field of workforcestudies shared their perspectives on various aspectsof the psychiatric workforce. There were presenta-tions about the supply and maldistribution of psy-chiatrists, factors affecting USMGs’ interest in psy-chiatry, the gap-filling role of IMGs, the scope ofpsychiatric practice, and the workforce needs of sub-specialties. A representative of the ECFMG and animmigration lawyer shared their views on changesaffecting IMGs. In addition, there was a presentationregarding Canada’s experiences with its workforcereforms. After 2 days of deliberations, a strategic ac-tion plan that was supported by Daniel Borenstein,M.D., then president of the APA, and Richard Har-ding, M.D., then president-elect, was developed. TheAPA’s board of trustees also took on this action plan.A decision was made to share with the field some ofthe important findings from the retreat, and hencethis special issue of Academic Psychiatry.

This special issue has had a prolonged gestationalperiod, spanning more than 2 years. All the present-ers at the APA’s retreat were encouraged to submittheir presentations to this issue. The papers were re-viewed internally in the Council before being sub-mitted to the editor, Laura Roberts, M.D., for the jour-nal’s peer review process. Many of these papers aredata-based, and others provide thoughtful commen-taries on the current status of the psychiatric work-force in the United States and offer prognosticationson their future course. This special issue cannot fullycapture the excitement and the depth of discussionsthat were in evidence at the retreat. We are fortunateto have expert commentary on the issues raised inthis publication. In his insightful commentary enti-tled “Where Is Psychiatry Going and Who Is GoingThere?,” Richard Cooper, M.D. confronts psychiatry’spredicament with workforce identity, along withother issues, as a sharp-eyed analyst would zero inon the narcissistic and identity conflicts of his anal-ysand. In his compelling commentary entitled “Bull-

ish on Psychiatry,” Craig Van Dyke, M.D. presents acareful analysis of historical and current factors influ-encing medical student choice of specialty residencytraining in psychiatry.

In his paper entitled “Implications of a Needs-Based Approach to Estimating Psychiatric WorkforceRequirements,” Larry Faulkner, M.D., elucidates aneeds-based approach to understanding how manypsychiatrists the nation requires. His takes a complex,methodical, and cogent approach to a befuddlingarea of physician workforce projection. In “SelectedCharacteristics and Data of Psychiatrists in theUnited States, 2001–2002,” James Scully, M.D. andJoshua Wilk, Ph.D., provide basic data about the phy-sician workforce in the United States and the relativeplace of psychiatrists in the total workforce. They alsopresent data on characteristics of psychiatrists’ workactivities in routine psychiatric practice.

In a reflective paper entitled “Recruitment of U.S.Medical Graduates Into Psychiatry: Reasons for Op-timism, Sources of Concern,” Frederick S. Sierles,M.D., Joel Yager, M.D., and Sidney H. Weissman,M.D. make a case for recruiting USMGs into psychi-atry and share their optimism about future recruit-ment as well as their concerns about problems thatcould hinder it. While not part of the original set ofpapers presented at the APA’s retreat, the second pa-per by Frederick S. Sierles, M.D. et al. entitled “Fac-tors Affecting Medical Student Career Choice of Psy-chiatry From 1999 to 2001” fits appropriately into thisissue. In their study, students from a wide variety ofmedical schools were asked a series of questions inorder to assess the extent to which regional and localextrinsic and intrinsic factors determine the choice ofpsychiatry as a specialty. Sierles et al. found that,while extrinsic factors did not influence the choice ofpsychiatry as a career, the proportions of IMGs in oneparticular psychiatric residency did impact specialtyresidency choice.

In my paper, entitled “Recent Trends in Psychi-atry Residency Workforce With Special Reference toInternational Medical Graduates,” I point out thatthere was substantial reduction in the number of res-idents in psychiatry in the 1990s and that IMGs madesignificant inroads into medical school and nonmed-ical school-based residency programs located in allregions of the United States. Finally, in a paper enti-tled “Child and Adolescent Psychiatry Workforce: ACritical Shortage and a National Challenge,” Wun

EDITORIAL

240 Academic Psychiatry, 27:4, Winter 2003

Jung Kim, M.D., M.P.H. and the American Academyof Child and Adolescent Psychiatry (AACAP) TaskForce on Workforce Needs present a sobering assess-ment of the current acute shortage of child psychia-trists and its impact on our nation’s ability to care forthe mental health needs of our children.

In presenting this special issue of Academic Psy-chiatry, devoted to workforce issues, I thank manywho have contributed to this effort by writing articlesand many more by reviewing them. Personally, shep-herding the process has been both an exhilaratingand, at times, a demanding experience for me. I amespecially grateful to Laura Roberts and her capableteam for their support, encouragement, and commit-ment to producing a quality product.

In conclusion, any serious student of psychiatric

workforce studies is impressed by the appearance ofrecurring themes, resulting in a sense of deja vu. Onemajor preoccupation of the field in the past three de-cades has understandably been on how to increaseUSMGs’ interest in psychiatry. Psychiatry exultedwhen their numbers in the field increased and be-came despondent when their numbers declined.However, the world has dramatically changed withthe phenomenon of globalization and its emphasis onfree movement of goods and labor across nationalboundaries. Our nation’s demographics havechanged as well, in favor of a more racial heteroge-neity. I hope we will adapt and move on to more en-lightened workforce policies that will keep psychia-try vibrant. Not doing so will be tantamount toabandoning our profession and our patients.

Reference

1. Scully JH: Why be concerned about recruitment? Am J Psy-chiatry 1995; 152:1413–1414