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The number of American medical graduates entering psychiatry residency programs increased slightly this year, but the trend among students in recent years to favor family practice and pediatrics continues.
A total of 462 graduates matched into psychiatry residency programs through the National Residency Matching Program (NRMP), up by 3.13 percent from last year's figure of 448, according to the NRMP.
Meanwhile, medical graduates continued to gravitate toward primary care. More than 2,300 students matched into family practice, an increase of 56 percent since 1988, and just under 2,000 graduates will enter pediatrics through the match.
The number of U.S. medical school seniors entering psychiatry would appear to have stabilized somewhat after a precipitous decline beginning in 1990.
This year's figure is roughly equivalent to the numbers in the previous four years; an average of 460 seniors have opted for psychiatry in each of the years since 1993.
Yet, the 1997 figure represents a nearly 40 percent decrease since 1988 when 745 U.S. seniors--a figured unequaled since then--matched into psychiatry.
Moreover, psychiatry continues to rely heavily on international medical graduates to fill residency slots. A total of 326 graduates trained in medical schools outside the United States matched into U.S. residency programs in psychiatry this year; that figure probably underrepresents the number of IMG's entering psychiatry, since many more enter the profession outside of the match program.
Reliance on IMG's to fill the ranks of psychiatry could prove perilous; last month the American Medical Association, the Association of American Medical Colleges, and four other organizations issued a "consensus statement" calling for a reduction in the number of residency positions, with special emphasis on reducing slots for international medical graduates.
At the same time, the federal government announced a demonstration project in New York State that will pay teaching hospitals to downsize their residency programs, a move that is likely to mean fewer psychiatrists will be graduating from those programs (Psychiatric News, March 21).
The number of psychiatrists needed in the future is a subject of debate within APA. Some such as APA President Harold Eist, M.D., maintain that there is a shortage of psychiatrists, while others contend the profession is headed toward a surplus.
Last month, APA's Board of Trustees approved a statement on workforce issues following the consensus statement issued by the AMA (see below).
APA President-elect Herbert Sacks, M.D., told Psychiatric News that he believes the slight increase in this year's match, and the stabilization of numbers over the last four years, "leaves some room for encouragement." He suggested, however, that the over- reliance on international medical graduates could leave the profession vulnerable if restrictions are placed on IMG's entering U.S. residency programs.
"Every established medical organization--the AMA, the Institute of Medicine, the AAMC, and many specialty organizations--have recommended imposing restrictions on IMG's as a way of reducing the number of physicians in residency programs," Sacks said.
He noted that the White House is appointing a bipartisan commission to address issues surrounding graduate medical education associated with Medicare reform. Sacks added that he believes "future IMG's who come to the United States will be powerfully induced to return home after training."
IMG's in psychiatry "provide compassionate service to state hospitals, community clinics, the corrections system, and underserved, rural, and inner-city populations," Sacks said.
Regarding the place of IMG's in American medicine--and immigrants in American society generally--Sacks said, "This nation of immigrants is facing a major moral and ethical problem."
Yet he posed the question: "Do we have an obligation to serve the needs of over 1,300 medical schools around the world? I think not."
APA Vice President Allan Tasman, M.D., chair of the department of psychiatry and behavioral sciences at the University of Louisville, told Psychiatric News that he believes there is "no nationwide evidence that there is a surplus" of psychiatrists.
"In certain geographic areas and in certain managed care systems, it is tight," Tasman said. In other areas of the country and among many subgroups of the population, however, there is a shortage of psychiatrists, he said.
Tasman added that it is not necessarily true that American medical students are "voting with their feet" by entering specialties other than psychiatry.
"The fact is that certain schools do very, very well in attracting students to psychiatry," Tasman said. "I think it is possible to increase the number of American graduates entering the profession."
Tasman said that the department of psychiatry at the University of Louisville has garnered 10 percent of the graduating medical class of approximately 120 students for several years in a row.
"We pay a lot of attention to teaching, especially in the third year of medical schooling, when students are on their clinical clerkships," Tasman said. "It's nothing magic, just nuts and bolts. We get students to see what the profession is about. . . . We are not the only school like that."
James Shore, M.D., chair of APA's Council on Medical Education and Career Development, called the stabilization in numbers of American graduates entering psychiatry "encouraging."
"Our field is stable," he said. "I think it is too early to make any clear, long-term predictions."
Shore also cited as important the small growth in double- and triple-board programs. These include programs in internal medicine-psychiatry and pediatrics-psychiatry-child psychiatry.
Twenty-four students entered the double-board program of internal medicine-psychiatry, and 17 graduates entered the triple board program of pediatrics-psychiatry-child psychiatry.
Regarding last month's consensus statement on reducing U.S. residency slots, Shore suggested that the recommendations put forward by the groups were not new.
"I think it is premature to speculate on the demise of IMG's and their very valuable contributions to psychiatry," he told Psychiatric News. "Certainly, if this rationing system [recommended by the AMA and the other groups] were implemented, it would have serious consequences for psychiatry. But my crystal ball does not go beyond that."
Sidney Weissman, M.D., who is a past director of the American Association of Directors of Psychiatric Residency Training and maintains a keen interest in workforce issues, has stressed that the profession must seek to define itself clearly as the one specialty that can integrate the biological, psychological, and social aspects of treating mental illness.
In this way, he said, the profession can make itself attractive to American graduates--an urgent necessity in light of the possibility that psychiatry may no longer be able to rely on the influx of IMG's to fill residency slots.
Weissman underscored the point in a memorandum last month to members of an informal "workforce interest group" that includes training directors and others concerned about workforce issues.
"Psychiatry's continued reliance on IMG's to maintain its workforce has significant risks to the profession if Congress passes legislation either reducing graduate medical education funding or restricting the training of IMG's to reduce the physician workforce," he noted. "Pending the terms of such legislation, we could lose one-half of all our trainees. . . .
"While current economic considerations may detract from the appeal of psychiatric careers for U.S. graduates, they do not for IMG's," Weissman continued. "As we address the integration of IMG's into our profession, we must distinguish that, whether we agree or disagree with proposed initiatives to restrict IMG's remaining in the U.S. after training, any physician currently in training. . .is entitled to the same quality of training and profession opportunities."
He concluded: "[W]e must ask what continues to bog down our recruitment of U.S. graduates to their current level in spite of the major advances in our understanding of mental disorders and our advances in pharmacologic and psychologic therapies. For example, how does the perceived economic uncertainty of our profession impact on U.S. graduates? Will society fund psychiatrists treating an array of mental disorders utilizing pharmacotherapy, psychotherapy, or a combination? Or will society only fund psychiatrists treating patients with medications? The future size of our profession and future recruitment hinge on how society addresses these questions and on how we communicate to the present generation of medical students the excitement of our discipline."
APA's Board of Trustees last month approved the following statement regarding the future workforce in psychiatry:
"Previous federal government reports have identified psychiatry, and especially child psychiatry, as shortage medical specialties. Given that there has been no substantial change in the size of the psychiatric workforce since those studies, and given the projected prevalence of psychiatric illness in the coming decades, there is no justification for a shift in policies that might serve to destabilize the size of the psychiatric workforce. Further, there is substantial evidence of unmet clinical and research needs in specific populations and areas, e.g., children; the elderly; members of certain racial, ethnic, and cultural communities; those in rural areas; those living in poverty; those in forensic settings; those with developmental disabilities and psychiatric illness; and the chronic mentally ill, which indicates a need for greater access to psychiatrists."
(Psychiatric News, April 18, 1997)