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Workforce size, scope of practice, accessibility of treatment, and the role of minority and international medical graduates (IMG's) in the U.S. health care system are the primary issues confronting the profession of psychiatry, according to a panel of speakers at APA's annual meeting last month in Toronto. The session was moderated by Allan Tasman, M.D., APA president-elect and chair of the APA Work Group on Workforce Issues.
Many of the questions facing the field of psychiatry are related to workforce and needs-based issues, said James Scully, M.D., professor and chair of the department of psychiatry at the University of South Carolina and the former director of the APA Office of Education. It is difficult to tell how many psychiatrists are needed, he said, but studies should be done to determine how many patients need psychiatric services, which patients need which treatments, and the type and amount of psychiatric treatments that are acceptable for patients.
"There is tremendous concern about the size of the physician workforce and psychiatry workforce," said Tasman. "Decisions about need will be made in the political arena-there are a variety of government regulations, proposals, and issues that need to be addressed."
In light of these political pressures, psychiatrists need to define what psychiatry is and what it does, said Scully. They need to determine the skills and knowledge base that every psychiatrist ought to deal with. Psychiatrists also have to redefine and work out their roles in primary care and with other mental health professionals in terms of supervising and working on teams. To do so, said Scully, psychiatrists need to participate in discussion and develop strategies.
Psychiatrists must also address the need to define diagnostic classification of mental illness, the prevalence of mental illness, and acceptable treatments, said Scully. Spending on research in psychiatry is second only to that in internal medicine, he said, and psychiatric knowledge continues to grow. In addition to having access to information on new medications and psychotherapies, psychiatrists have a better idea about the effects of stigma on those seeking treatment, the use of acceptable treatments, and the ability to access care.
"The access to care issue can't be overestimated," said Mary Kay Smith, M.D., an assistant professor of psychiatry at the Medical College of Ohio and chair of the APA Committee of Early Career Psychiatrists. The presence of managed care, location of populations, hours of operation, and transportation costs all affect access to care, she said.
"A lot about the way managed care has interacted with the public health system fosters impeded access by denying treatment or the proper level of care," said Smith.
Questions psychiatrists need to address include the following, she said: What are the responsibilities of the public mental health system and managed care? What can be done to improve service to minorities, homeless people, and the elderly? Are the individuals who need psychiatric care getting it?
Part of the answer to access to care problems, said other panel members, is to provide opportunities for minorities and international medical graduates (IMG's) to study and train in psychiatry. Gloria Pitts, D.O., a professor of psychiatry at Wayne State University and chair of the APA Committee of Black Psychiatrists, said that African-American psychiatrists are on the "verge of extinction" and that the deterioration of affirmative action is taking a telling toll. For example, she said, in her department at Wayne State, which is the second largest program in medicine after internal medicine, there is only one African-American clinician. "That is unconscionable in a city that's 90 percent African American," she said.
In some inner-city areas, said Pitts, there is minimal to no access to mental health care, and in some areas there is inappropriate care. She called for more research on African-American populations and efforts to ensure that the clinical needs of patients are correctly addressed, she said. Physicians need to have cultural competency to serve their populations, and more African Americans are needed to serve African Americans.
IMG's are also needed to serve many underserved areas, said Nyapati R. Rao, M.D., a professor of psychiatry at Brookdale University Hospital in Brooklyn. While some psychiatrists see IMG's as a threat because they may take jobs from U.S.-born citizens, he said, others believe IMG's fill a gap by practicing in underserved areas. Research has shown that IMG's work where the infant mortality rate is high and provide needed services, said Rao.
Rao noted that a new certifying exam for IMG's was to be instituted on July 1 and said that the exam could have a devastating effect on the presence of IMG's in the United States (Psychiatric News, March 6). The Clinical Skills Assessment Exam will only be administered in Philadelphia, making access to it difficult for many IMG's. Yet IMG's will need to pass this test; otherwise, they will not be able to enter residency training in the U.S.