The core of general psychiatry is being diluted by the proliferation of subspecialties and by managed care, and thus APA should restrain from advocating the recognition of new subspecialties. APA lifted its two-year moratorium on considering approval of further subspecializations in psychiatry in 1994.

So said Kenneth Altshuler, M.D., immediate past president and former director of the American Board of Psychiatry and Neurology (ABPN), at APA's Institute on Psychiatric Services.

"We are in a time of diminished interest in psychiatry, decreased remuneration for our services and support for our training programs, and a nibbling away of the content of our field," said Altshuler.

Since 1991 the number of American medical graduates (AMG's) applying for psychiatry residency programs has declined by 30 percent, according to Altshuler's figures from the National Residency Matching Program (NRMP).

Meanwhile, the number of international medical graduates (IMG's) applying for psychiatry positions through the NRMP has increased, surpassing the number of AMG applicants last year, said Altshuler.

"The AMG's know what is going on in this country and have a choice of where they go. The IMG's need to get established and are taking jobs where they exist," said Altshuler.

Managed care has resulted in lower income for psychiatrists and fragmentation of the core of general psychiatry by "giving psychotherapy to social workers in HMO staff models of care and uncomplicated medication visits to general practitioners," said Altshuler.

"Take away psychotherapy, medication visits, geriatrics, addictions, forensics, and consultation-liaison psychiatry, and what remains will be too narrow or uninteresting a specialty to practice."

The ABPN created a new certification category of "added qualifications" to recognize psychiatrists with a special expertise in a psychiatric subspecialty; geriatrics, addictions, and forensics were granted this status in 1991, 1993, and 1994, respectively.

Altshuler questioned the wisdom of ABPN's "added qualifications" one-year training requirement if the goal is to attract clinicians to academia to advance knowledge in the field. In contrast, ABPN's "special qualifications" training requirements for child and adolescent psychiatry, for example, involve two years of research, teaching, and clinical training.

Altshuler cited a problem that has developed in the subspecialty of addictions, which is nearing its five-year deadline to meet ABPN's requirements of 25 accredited programs and 20 graduating candidates a year.

"Addictions has only nine accredited programs and 14 graduating candidates this year, and it appears this trend will continue," he noted. A lack of funding for residency positions is a major factor, and forensics training programs will face similar problems, he predicted.

Furthermore, Medicare reform proposals have called for diminished federal funding for subspecialty training with the exception of geriatrics.

Support for Addictions

Sheldon Miller, M.D., an ABPN director and chair of the Residency Review Committee for Psychiatry, agreed that there are already enough subspecialties but disagreed with Altshuler's explanation of why addictions is struggling as a subspecialty. Miller is also a consultant to APA's Committee on Training and Education in Addiction Psychiatry.

"Funding is not the only issue. Department chairs and program directors we have talked to only recently became aware of the subspecialty."

He attributed this lack of awareness about psychiatrists working in addictions to their being considered "outsiders" in their departments. In contrast, geriatric psychiatrists "were well aware of and involved in their training programs when geriatric subspecialization came up," said Miller.

"So the reason we need and continue to need addictions as a subspecialty is because our field is not immune from the same stigma that has tracked addictions problems in patients and those who have worked in the field for a long time," Miller stated.

"I don't think [the subspecialty of] addictions is a threat to the core of psychiatry because the goal is to develop a cadre of teachers and experts to help general psychiatrists take care of very difficult patients."

About 1,000 psychiatrists have been certified as addictions subspecialists, noted Miller. "Given that 14 percent of the general population has problems with addictions, these specialists will be very busy taking care of everyone."

He commented on the status of forensic psychiatry training programs. The criteria and standards for accreditation are complete, and the first group of psychiatrists has been trained to conduct site visits. He also disagreed with Altshuler that forensic residency programs will have the same difficulty obtaining funding as other specialties. Law practices can afford to hire residents and "do not have to worry about managed care."

(Psychiatric News, January 17, 1997)