April 16, 1999

The number of U.S. medical school graduates entering first-year psychiatry residencies this year from the National Resident Matching Program is 482, up from 428 in 1998. This represents a gain of 54 medical students, but the pattern of gains and losses appears to have held steady since 1994.

The match figures have "been below 500 since 1993," observed Sidney Weissman, M.D., past president of the American Association of Directors of Psychiatric Residency Training (AADPRT) and a long-time observer of residency trends. From 1993 to 1994 those numbers dropped by 38, followed by a rebound, a drop, and a rebound, he noted.

Moreover, the match numbers in psychiatry have hovered between 420 and 482 since 1994, said Weissman. "We're delighted with a 13 percent increase [from 1998 to 1999]. It affirms the profession's stability, but much work still needs to be done. What we really need now is an increase" to more than 500, a level not seen since 1992, he noted. "That would really be breaking new ground."

Since a substantial number of medical school graduates also enter residencies outside the match, the full story on how many medical students are entering psychiatry in July will not be known until the additional figures on those who enter outside the match come in later in the year, Weissman pointed out. In 1998, for example, 35 U.S. seniors entered outside the match.

In other areas of career planning for physicians there has been "an upsurge of interest in specialties, such as anesthesiology and radiology, and a tapering of interest in some of the primary care areas, such as family medicine," said Weissman. "My own interpretation of this is that although graduates in radiology and anesthesiology can now find jobs, albeit not the stable jobs of a decade ago, the reality is they can find meaningful employment. I believe that the decline in interest in family practice may relate to the depictions in the media that family practitioners are the gatekeepers in HMOs. Medical students do not spend four arduous years in medical school to become gatekeepers. One goes to medical school to become a health care provider."

Quality Core of Students

James Thompson, M.D., is an APA deputy medical director and the director of APA's Office of Education. "I think we continue to see that there is a core of medical students who continue to be interested in a career in psychiatry," said Thompson. Although the numbers of American graduates entering psychiatry are not as high as they were prior to 1993, the numbers since 1993 have been "remarkably consistent," he added.

Although the match focuses on U.S. medical school graduates, it is important to acknowledge the significant role played by international medical graduates, observed APA's Thompson. "The number of psychiatry residents has not gone down thanks to a large numger of very well-qualified IMGs," Thompson observed.

From talking to residency training directors, Thompson concludes that "with regard to both American graduates and international graduates, we are attracting a very talented and well-prepared group of residents. And that's very good to see."

The post-1992 numbers reveal "a sawtooth pattern," which suggests that the numbers of people interested in going into psychiatry as a career is now fluctuating within a narrow range, Thompson commented. While APA would like to see the numbers return to prior higher levels, it is still "gratifying to see that core in place."

The numbers show no significant change toward multiple specialization, that is, psychiatry combined with another medical specialty, according to Weissman. Examples of multiple specialization include psychiatry/internal medicine and psychiatry/family medicine.

"The overwhelming number of people want to go into general psychiatry," he observed. With the exception of certain geographical areas with "limited resources," the multiple specialties are "boutique [niches] that attract very few physicians."

The exceptions are areas such as Mississippi and West Virginia, where there has been some increase in multiple specialization. There, the "dual board offers particular opportunities and is highly relevant to the quality of health care in those areas," said Weissman. This is not true in big cities such as Chicago and Los Angeles, he added.

Complacency Not Warranted

Roger E. Meyer, M.D., is a senior consultant on clinical research for the American Association of Medical Colleges (AAMC) and author of Between Mind, Brain, and Managed Care: The Now and Future World of Academic Psychiatry (American Psychiatric Press Inc., 1998). He commented, "The field should not become complacent based on one year's data. I think renewed efforts need to be made" to encourage medical students to enter psychiatry.

If a medical school's psychiatry department is attracting fewer medical school graduates into psychiatry than comparable departments elsewhere, "they really have some work to do," Meyer added. "They need to focus more on their medical students than they have in the past."

Should the increase reflected by this year's match be sustained and continue to rise, "then we need to look at the cohort," Meyer suggested. Although 482 medical students entering psychiatry from the match this year is better than last year, it is not good enough, Meyer suggested.

The field "needs to do a better job of defining the economic opportunities in psychiatry-and they are there," he continued. "What happens is we end up so often regretting what we've lost that we don't really look at the opportunities that might be there."

In particular, the opportunity to work with primary care patients, physicians in other specialties, and with patients and physicians in the public sector provides a range of opportunities, he observed. The field also needs "to emphasize that patients continue to pay for self-care in psychiatry."

The issue as Meyer sees it is that psychiatrists have an opportunity to have "diversified professional lives. Would you rather be able to choose to practice in a variety of settings for which you will be paid in different ways or would you rather see patient after patient in seven- to 10-minute segments for whom you have primary care responsibility?" he asked.

Those who would encourage medical students to enter psychiatry must "really focus on what makes the field exciting, and it's not the DSM-IV," said Meyer. "We spend too much time teaching from the DSM-IV. We have to use it, but it's not the basis of what makes the field interesting. The patients we see as human beings make the field interesting. The prospect of where neuroscience is leading us is interesting and exciting in terms of the future, but it doesn't give medical students or residents a handle on how they are going to be working in the present."

Residents "are still pouring into primary care because the incentives are in that direction," said Meyer. But Meyer added that he sees that development as only marginally relevant. "We have to [stop worrying] about the other guys and [instead focus on] how our own field is perceived and how we perceive ourselves," he asserted.

A recent poll from the American Association of Directors of Psychiatric Residency Training reported that physicians graduating from psychiatric residencies had no difficulty obtaining employment for this coming July, according to Weissman. -R.B.K.