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The number of 1998 U.S. medical graduates entering general psychiatry residencies declined 9 percent from 1997, and for the first time since records have been kept the number of women entering psychiatry residencies exceeded the number of men.
The data come from a report by the Association of American Medical Colleges, which also compiles data on the annual resident match (Psychiatric News, April 3).
Although a higher proportion of women than men have entered psychiatry since 1980, it is striking that women, for the first time, slightly outnumbered men in psychiatry residencies, remarked Sidney Weissman, M.D., a past president of the American Association of Directors of Psychiatric Residency Training. Within psychiatry, women are twice as likely to enter child psychiatry as are men, he noted.
Although it is impossible to predict the future, a continuation of current trends suggests there could be a significant increase in the number of women and a decline in the number of men entering psychiatry, said Weissman.
At present, there are slightly more men than women psychiatry residents, not because of the number of U.S. medical graduates in the field, but because international medical graduate (IMG) psychiatry residents are more likely to be men.
"If you reduce the number of IMGs-which include more men than women-you will decrease the total number of men going into psychiatry and eventually wind up with psychiatry overall having more women than men," Weissman explained. Women have long complained of being passed over for leadership positions, and those complaints are bound to grow if the field comes to include more women than men, observed Weissman. "There will be a challenge to psychiatry to open up more critical leadership positions in APA and academic psychiatry to women."
James Thompson, M.D., is director of APA's Office of Education. "We wish the numbers [of residents entering psychiatry] had been higher than they were, but in the last three or four years the numbers have gone up and down within a relatively narrow range," he commented. Psychiatry recruitment "has always followed societal attitudes toward mental health in general and psychiatry specifically," and this trend has continued.
The recent emphasis on primary care has affected recruitment in all specialties, said Thompson. "What worries me in terms of recent history" is that a number of medical schools have decreased the time accorded psychiatric education. This has affected not only the clinical clerkships, where students make decisions about what specialty to pursue; it has also affected the first- and second-year curricula, where psychiatry traditionally played a large role in teaching residents interpersonal and diagnostic skills related to being a physician, he added. "We really need to pay attention to this and make sure we're not losing the ball game for lack of being at bat."
Surveys show that many medical students "come into medical school thinking about psychiatry as a viable option for them," said Thompson. But as they advance through medical school, many are "drawn to other specialties and actively discouraged from pursuing psychiatry. We need to find some ways to reverse this."
Why have the numbers of U.S. graduates entering psychiatry continued to erode?
"We do not give U.S. medical students a well-rounded picture of what the discipline of psychiatry is in 1998," said Weissman. Further, medical students are "clearly aware of the impact of managed care on psychiatrists."
It is not easy to attract a large pool of graduates into a field perceived as increasingly defined by medication management, he added. "The only way the field is likely to attract a significant pool of students is if it can maintain its grounding in both biological and psychological treatment of patients."
Those who believe it is possible to sustain the field through combined primary care/psychiatry programs are mistaken, according to Weissman. "If you look at the internal medicine and family medicine psychiatry programs, there is no significant change from 1997. You can also say there is no evidence that psychiatry can sustain itself on the basis of psychiatrists being trained as both primary care physicians and psychiatrists." Few aspiring physicians see themselves as doing both, he added.
James Scully, M.D., chairs the APA Council on Medical Education and Career Development.
"I agree strongly with Weissman that in order to retain its viability in recruiting students, psychiatry must reaffirm the role of the psychiatrist within a biopsychosocial model beyond the limits that some in managed care would impose," said Scully.
Medication management is only one aspect of psychiatry. "The importance of the psychiatrist's role in maintaining the doctor-patient relationship, including understanding the meaning of illness and exploring that with patients, is an area we must not abandon," he said.
Future recruitment will be aided by APA's and allied organizations' fight to ensure "the full role of the psychiatrist in the treatment of mental illness," Scully added. To the extent that fight succeeds, the field will succeed in attracting new residents, he contended. "We must not give up hope and become defeatists. Patients and society need us in this full role. We can't let economic concerns override everything."
It is critical to "find ways to maintain the interest in psychiatry throughout medical school," said Thompson. APA is collaborating with several other psychiatric education organizations in a workforce consortium aimed at strengthening relations with medical student organizations and medical students, he noted. The American Association of Directors of Psychiatric Residency Training (AADPRT) is taking the lead in this effort, which includes, in addition to APA, the Association for Academic Psychiatry, the Association for Directors of Medical Student Education in Psychiatry, and the American Association of Community Psychiatrists, Thompson said.
Relevant Web sites include the Association of American Medical Colleges at www.aamc.org.-R.B.K.