 |
 |
|
|
Despite a 7.36 percent drop in the number of U.S. medical school graduates entering first-year psychiatry residencies this year, the trend over the last five years is stable, according to the 1998 National Resident Matching Program (NRMP) results.
In 1994, for example, 438 U.S. graduates entered first-year psychiatry residencies. That figure jumped to 476 the following year, then dropped back to 448 in 1996, then climbed to 462 last year. This year's figures show that 428 medical graduates are entering first-year psychiatry residencies, about the same number as in 1994. The 1998 figure includes 22 graduates entering combined psychiatry/internal medicine residencies.
The number of psychiatry residency slots offered declined from 926 last year to 917 this year. Historically, the number of psychiatric residency slots offered dropped from just under 1,000 in 1994 to 960 in 1995, but has been relatively stable in the last three years. There were 917 psychiatry residency slots offered in 1996, the same number as this year.
The number of graduates entering family practice residencies declined about 7 percent, while the number entering general internal medicine programs rose about 4 percent. Both primary care specialties show a positive trend over the last five years, however. The number of medical school graduates entering combined internal medicine/psychiatry residencies dropped from 24 last year to 22 in 1998, but have increased from five in 1994.
Sidney Weissman, M.D., past president of the American Association of Directors of Psychiatric Residency Training, does not see a crisis in the match figures, but is concerned over the long-term implications for the field.
"These numbers are very similar to earlier years," said Weissman. "Although there has been a lot of emphasis on psychiatry/internal medicine residencies," relatively few medical graduates are pursuing that option, he noted. "There is no significant upsurge of interest."
There are some specific programs, for example, at the two campuses of the West Virginia University Medical School, that are continuing to fill their combined psychiatry/internal medicine residency slots successfully. The two sites have a total of four combined-discipline residents.
"It is striking that the West Virginia University Medical School, which has a long history of involvement in primary care psychiatry training, continues to do well with its program, filling all four of its positions," Weissman remarked.
The West Virginia program represents almost a fifth of the national total, he pointed out. Those who once thought that combined residencies might be the salvation of psychiatry were wrong, said Weissman. "It is clear that there has been no major influx of psychiatry residents into combined primary care/psychiatry residencies."
In general, there is "a plateauing of interest in primary care around the country," said Weissman. "We will need another year to see where this trend goes."
The 1998 match shows a slight decline in the number of international medical graduates (IMG's) entering U.S. psychiatry residency programs. "Although there is a slight decline in IMG's, it must be understood that the largest number of IMG's entered psychiatry residency outside of the match," said Weissman. IMG's filled a total of 396 first-year psychiatry residency slots.
The figures for IMG's are misleading, because of a total of 5,500 IMG's, 3,000 were matched to U.S. positions but did not appear in the match, because foreign students are not required to participate in the U.S. resident match system. The Association of American Medical Colleges (AAMC) tracks the residents not counted in the match and releases a survey each year sometime following the release of the match figures.
James Thompson, M.D., is director of APA's Office of Education. Although there has been a slight decline from last year, it "is more accurate to say that it has plateaued over the last five years," said Thompson. "We're looking at the trend, and the trend is flat." The match is a good indicator of trends among American medical graduates, although "a handful" do not show up in the match, Thompson added. That number, however, is insignificant, he said.
The same issues are true today that have been true for a number of years, Thompson observed. Students are being encouraged to enter primary care rather than psychiatry. In addition, he said, there continues to be some stigma associated with entering psychiatry.
Students must be exposed to a wide range of clinical settings. "Psychiatry is very broad, and we have to show students the breadth of the field," said Thompson. "We need to do a better job of conveying new advances in the field, both in terms of treatment and understanding how the brain works."
There is still a misconception among both the general public and medical students that psychiatric illnesses are more vague, ill defined, and harder to treat than other medical illnesses, said Thompson.
In addition to countering such misconceptions, "we must work more with our medical colleagues in training settings and convey to students that psychiatry is really an integral part of medical care," added Thompson.
He gently chided some of his colleagues for seeing the worst in recent annual match figures. "I think we play a bit of a breast-beating game here when we get the match and find that the numbers haven't gone up. But what it shows is that there is a core group of students that are determined to go into psychiatry despite the counter-vailing pressures, and that's very encouraging."
Given the leveling off of the match for psychiatry, the discipline "must do some significant soul searching," Weissman commented. "We are reaching the end of the Decade of the Brain, and we have not succeeded throughout the 1990's to communicate the renewed vigor and excitement of our field."
Despite the contemporary societal focus on cost containment in medicine, "we must find ways to communicate to students the vitality of our field," Weissman said. "If we fail, psychiatry might become a minor medical discipline."
An excessive focus on psychopharmacology could undermine psychiatry, according to Weissman. If psychiatry focuses on medication management, "you won't need a lot of psychiatrists," he asserted. "You're out of a job. We'll revert back to where we were 100 years ago when psychiatrists were seen only in state hospitals."
Psychiatrists must convince both the public and medical school graduates that "when there is a need for both psychotherapy and psychopharmacological treatment, effective mental health care can be done only by psychiatrists. If we can't do both, then there is the potential for a significant surplus of psychiatrists."
Jay Scully, M.D., chair of APA's Council on Medical Education and Career Development, sees the decline in the match as cause for concern.
"Even if the overall number of physicians decreases, we still need to do a better job of recruiting U.S. medical graduates into psychiatry," said Scully. "We need to have between 4 percent and 5 percent of the U.S. graduates. Even if we decided we had too many psychiatrists and had to cut back, we still need around 800 per year."
Discussion in Congress and elsewhere about potential cuts in funding for residency programs may be contributing to the relatively stable match figures, Scully speculated.
"I'm not surprised there weren't big changes this year because everybody is waiting to see what the funding for residency positions [from federal and other sources] is going to be," he said.
A substantial part of that funding comes from Medicare, he continued, and there has been much discussion in Congress of cutting Medicare funding of residency programs as a means of reducing a perceived surplus of physicians.
"There seems to be a consensus among the policy people to cut the total number of residents in all specialties," said Scully. "I don't see how we can escape that."
Such cuts could have unanticipated results for psychiatry, conceivably resulting in an increase in those entering psychiatry as a result of limited opportunities in other specialties, he said. "But we can't assume that and should assume that if there is a cut in the overall number of residents, psychiatry is likely to get cut too. We would not be protected in any way and would have to make our case that we should be an exception, which we have not done."
Economic competition has led to a division within the ranks of psychiatry over whether there are too many psychiatrists, Scully observed. "These issues in psychiatry are extraordinarily localized" because some areas, particularly those heavily impacted by managed care, have a perceived surfeit of psychiatrists, whereas in other areas there is still a shortage, Scully noted.
The profession "could still deal with a major cut in the total numbers, because the match is but a single area," Scully contended. "We have another 30 percent outside the match." He noted that there were nearly 400 IMG's entering psychiatry residencies this year, and that usually "another couple of hundred" residents go into psychiatry in their second year of residency.