Until recently, many observers were concerned by the relatively low enrollments in psychiatric residencies. "The pipeline reversed this year," Eisdorfer explained. "It stabilized last year, and this year it went up. Primary care matches went down. Family practice residencies in a lot of places were unfilled this year. A lot of medical students expressed dissatisfaction in working in managed care systems, which is one reason psychiatry numbers went up. There's a group of students that is on the cusp between primary care and psychiatry, and this year most of them moved to psychiatry--and some to internal medicine."
Once trained, however, many of these new clinicians will be forced to look for high-paying positions.
"That may be relatable to the amount of debt that people have when they come out of medical school that becomes due July 1 of the year when they finish their residency," Eisdorfer said. "You have a lot of new psychiatrists with a great deal of debt, and that can't wait. One said to me, 'I have a mortgage on a house I can't live in.' They owe $100,000 and more.
"The risk of a shortage is out there. Right now, medicine is still seen [as an] attractive profession. The word has not yet permeated that you'll come up $150,000 in debt, which will limit your options. It's a systems problem: Part of the system is that medical school is attractive, but it's also expensive. The ratio between investment and payoff is shifting dramatically."
Many observers see a turn to evidence-based medicine as a means of persuading third-party payers of the value of psychiatry. Ray cited the example of the common perception that psychotropic drugs are sufficient treatment for mental illnesses. "People are not looking at the clinical research on outcomes, which show that therapy and medication together are better than psychotropic drugs alone. In the future, we're going to have to show results based on science-based practice, evidence-based care and best practices. In this case, the evidence shows that the best outcomes come with a combination of wraparound services, individualized treatment and good therapy.
"Scientific research does suggest different approaches," he continued. "Cognitive-behavioral therapy and medication yield impressive results. But psychiatrists haven't talked about what a difference treatment makes, because it would gore too many sacred cows."
Field concurred, and pointed out that psychiatry has not done a good job of communicating its message to the public at large and to the third parties. "It is important that the profession communicate to the public that it's often necessary to combine medication with psychotherapy or counseling and that medication alone doesn't obviate the need for therapy or counseling. It may be to drug companies' advantage to acknowledge that medication without follow-up is often inappropriate and, at the least, likely to be much less effective. That's an important message that the profession has to get out: not one or the other. Studies show the combination is more effective than either alone."
"You need to go to the science," Ray added."The whole field is reluctant. It's part of psychiatry's own self-destructive pattern of denial. There are so many differing factions that it has found it difficult to pull together as a discipline. But you have to go to quantifiable and empirical evidence, because that is the only way that payers will respect you. If you want to move reimbursement beyond commodity pricing, you have to show that the service is worth the cost. How can we expect payers to pay what we say is fair exchange of service if we're also not willing to hew to quantified data that will support higher payment rates?"