 |
 |
|
|
In the face of strong national trends pointing to fewer U.S. medical school graduates entering psychiatry and cost pressures imposed by the growth of managed care, Sheppard Pratt Health System and the University of Maryland School of Medicine have merged their psychiatric residency programs, with its first class of students starting in July 1997.
The joint program, which was accredited this spring, will welcome 14 first-year residents in July. The goal is to build the program to 74 residents by July 1998, according to Sheppard Pratt's director of residency training, Don Ross, M.D. That goal represents a decrease from the total trained in the separate programs, which was 95 residents.
The new residency program will conduct training at Sheppard Pratt, the University of Maryland, and a number of participating hospitals and facilities in the Baltimore area, said Jim Thompson, M.D., associate director of residency training at the University of Maryland. About 27 percent of the total costs will be borne by Sheppard Pratt, Ross said.
Like its predecessors, the new program will emphasize "understanding the person within a psychodynamic framework," commented George Balis, M.D., director of residency training at the University of Maryland.
Although the merger will reduce training and administrative costs, the content of the curriculum will change relatively little, according to Anne Stoline, M.D., assistant director of residency training for Sheppard Pratt.
Although the scope of the merger is unprecedented for both institutions, they have a decade of close collaboration in their child psychiatry fellowship program, noted Steven Sharfstein, M.D., Sheppard Pratt's president and medical director.
The combination of Sheppard Pratt's strong clinical orientation and the University of Maryland's diverse 200-person faculty will provide residents with optimal training, said John Talbott, M.D., chair of the department of psychiatry at the University of Maryland. He noted that as a long-time colleague and friend of Sharfstein's, the two had first discussed the idea of merging the programs many years ago.
In a candid assessment of the forces leading to the merger, Ross said that he and others "reluctantly agree" with projections by the American Association of Directors of Psychiatric Residency Training that the residency system will need to produce 25 percent to 30 percent fewer psychiatrists over the next several decades. He noted that in 1988 there was a total of 844 medical school graduates entering first-year psychiatry residencies, while this past year it fell to a record low of 476.
"The new models of practice, especially the capitated and HMO worlds, utilize psychiatrists almost exclusively in a medical model," Ross observed. "Psychiatrists are expected to be expert in the roles of diagnostician, psychopharmacologist, crisis manager, team leader, and consultant. Conspicuous by its absence is the psychiatrist in the role of psychotherapist."
In the new world of managed care, psychotherapy is done mainly by lower-cost providers such as social workers and psychologists and in a brief, focused model, he noted.
"While we can argue against this model" and "assert the importance of psychotherapy training for psychiatrists, the fact remains that when the workplace dramatically cuts the funds available to reimburse psychotherapy by psychiatrists, that has an impact on the number of available jobs."
Further, said Ross, "the interest of American medical students in psychiatry is decreasing," as indicated by the "steady and significant decline" in American medical school graduates entering psychiatry from 1988 to the present.
When "workforce projections say we will soon have too many psychiatrists, and the students graduating our medical schools show they are less and less interested in psychiatry, we need to wake up and listen. Our conclusion from this was that the market for psychiatry residency training positions is, and will continue to be, a candidate's market. The good candidates are clearly in the driver's seat and have their choice of programs."
Some programs will fold, and "only the very best programs will thrive," said Ross. Combining the programs will strengthen the training curriculum of both Sheppard Pratt and the University of Maryland and allow them to compete with any training program now and in the future, said Ross. It will also permit them to focus less "on training large numbers of residents and intensely focus on giving the best training to the best residents."
The Clinton Administration is "under tremendous pressure to cut Medicare support for graduate medical education," said Ross. If that happens, even if it is only a 10 percent rather than the predicted 30 percent cut, it "could be very hard to financially support large training programs without multiple partners."
In addition, patient revenues are "no longer a sure source of funding," said Ross. Some managed care systems don't allow payment for resident services, and some don't even let residents treat patients.
Combining the programs permits both institutions to be more flexible, to pick the best clinical sites for training, and to save by combining administrative and other overhead expenses, he noted.
In the future the program will have to train residents in internal medicine and psychopharmacology, to create doctors who are "real experts in the medical management of mental disorders," said Sharfstein. "But we also continue to revere the tradition of psychotherapy and are very much involved with that," he added. He noted that renowned therapists Harry Stack Sullivan, M.D., Lawrence Kubie, M.D., and others taught at Sheppard over the years.
The merger will serve as a model for other mergers, Sharfstein predicted. "Many training programs around the country are considering this kind of process, are moving in a planning phase toward it. We've done it, and I think it's something that other parts of the psychiatric training system are going to look to for leadership."
(Psychiatric News, December 6, 1996)