Psychiatric Workforce: There Aren't Enough Psychiatrists

By Harold I. Eist, M.D.
APA President

Surprisingly, few areas stir as much heated debate and tension as do discussions of the appropriate size of the psychiatric workforce.

I believe medical needs should determine APA's position on workforce size. If psychiatric needs are unmet, then we need more psychiatrists. Even if we require our current workforce to work half again as hard as other doctors, we still wouldn't have enough psychiatrists, and those we have would break down and burn out given the extreme difficulty of our specialty. We, after all, need to be sensitive to more than symptoms and signs; we have to be attuned to their experiential, familial, and social as well as biological roots.

If we cleave to the position that need should determine workforce size, careful evaluations of need will be our guide, not someone's bottom line or someone else's bias.

Currently the managed care industry says that the American people need (la the orientation of "What's good for General Bullmoose is good for the country") four psychiatrists per 100,000 population. The managed care industry determines its workforce needs according to the amount of services it is reluctantly willing to pay for, not on the medical needs of the people. This approach to workforce determination is medically unacceptable and in my view is unethical. It ignores the proposition that the health of the many is more important than the wealth of a few.

It has been argued by people I respect that at 16 per 100,000, we have more psychiatrists per capita than any other nation on earth. In the rest of the world, 1 in 100 or fewer of those who require psychiatric care get it. In our country, 1 in 5 or fewer of those requiring psychiatric care get it. The numbers suggest to me not that we have too many psychiatrists but that the world has too few. More of those needing services get them in America than in other countries, but we are still a long way from providing all the care that is needed. Even if we assume that a significant number of those needing care refuse it, the remaining unmet need is deplorable.

It has been argued that our ratio of 16 psychiatrists per 100,000 could meet the treatment needs of our people if it was not for a significant maldistribution of our workforce. There is maldistribution, but it does not argue for retaining current workforce size or for diminishing it.

True, most of our psychiatrists are aggregated in or around large urban areas or in or around academic centers. However, though there are large numbers of psychiatrists in every one of these centers, there remain significant unmet needs in inner cities and in the care of children, the elderly, and the seriously and persistently mentally ill; those suffering combined mental illness and mental retardation; and those suffering comorbid mental illness and disabilities such as blindness, deafness, post-stroke brain damage, diabetes, AIDS, and so on. Those suffering from substance abuse and alcoholism are seriously underserved, as are those in prisons--there are more individuals with mental illness in prisons than in hospitals--and those homeless mentally ill on our streets who are untreated.

In states with fewer than 16 psychiatrists per 100,000, the unmet needs are even more glaring. As a profession, we cannot ignore or be insensitive to the suffering of the untreated, their families, or their communities. We cannot ignore or be insensitive to the devastating, largely preventable human tragedies of the untreated and the profound societal cost of the lack of care. The Epidemiological Catchment Area studies and the recent Science study indicate serious unmet needs now and even more so in the future. The way to meet these needs is to increase the size of the psychiatric workforce, not engage in the maddening newspeak we hear every day: "We will treat more mentally ill patients for less money and provide them with higher quality care with a smaller, more effective workforce. Less and cheaper is better."

Finally, there is a common argument that since resources for care of the mentally ill have been substantially ratcheted down (from around 10 cents on the dollar to around 2 cents on the dollar), there are not enough funds available to pay for the number of psychiatrists we need. This argument is made by many respected colleagues both inside and outside of academia. Available resources may determine how many psychiatrists we train, but should never determine our position on how many society requires. Of course, inadequate funding is an argument for fighting for appropriate funding, not scaling down workforce estimates. For the purpose of discussion, say a widely representative commission of all the stakeholders was set up to determine how much care for the mentally ill that America was willing to finance. Say for purposes of discussion they concluded that America was willing to pay for only 50 percent of the current workforce. We as physicians could not ethically, morally, or, ultimately, legally accept this contraction. We would have to increase our efforts to inform, educate, and convince society of the errors of this decision. Small experiments of this type have occurred in a number of locales in America. What we have seen is that treatment is provided to patients falling in only a few diagnostic groups, while we witness all about us in schools, in the workplace, and in families the suffering of the needy untreated who do not fit into these categories and the ensuing social carnage. We must not ignore the distress of a single patient or family. In psychiatry, we cannot accept becoming part of any discriminatory triage system.

After deep and thoughtful discussion, APA's Board of Trustees has charged Dr. Dale Walker, speaker of the Assembly, and me to appoint a work group to bring, once and for all, a consensus statement on workforce to the Board for consideration and approval. I have appointed Dr. Allan Tasman, APA vice president and president of the American Association of Chairmen of Departments of Psychiatry, to lead this work group. The work group will deliver its conclusions to the Board in March. We can wait no longer. Social responsibility requires our answer.

(Psychiatric News, January 17, 1997)