For nearly four decades, the United States has struggled with the question of how many physicians it needs. The landmark Medicare legislation that funded health care for the elderly focused attention on physician supply. Numerous studies argued that an inadequate supply of physicians existed. The elderly, the studies concluded, even with Medicare, would not receive adequate care without an increase in the supply of physicians. With this background and the suggestion of a physician shortage, the federal government intervened to increase physician supply and supported an increase in the number and size of medical schools. From the early 1960s to 1975, the number of U.S. medical school graduates rose from 8,000 to 16,000 per year.
By the late 1970s, the pendulum began to swing in the opposite direction and concerns rose that the United States was heading for a surplus of physicians. New studies were commissioned including one by the Graduate Medical Education National Advisory Committee (GMENAC). This group reported an overall physician surplus, but cited massive shortages in some specialties. Their report argued that shortages of tens of thousands of child psychiatrists existed (30,000 to be exact) along with major shortages of general psychiatrists. Since the publication of this report, psychiatry has used these numbers as the basis for arguing that general psychiatry and child psychiatry are shortage medical disciplines and need special support.
In the late 1980s, a new government-funded group was charged with redoing the GMENAC studies. The new group, the Council on Graduate Medical Education (COGME) did not have funds to fully review workforce projections from the earlier GMENAC study, and initially simply restated the arguments for the shortage of psychiatrists. By the mid-1990s, COGME gradually shifted away from that position. Instead, in its most recent reports, including 1997, it only observes we have a surplus of specialist physicians. Psychiatry is included with other medical specialties in this alleged physician surplus.
In response to this physician surplus, COGME has proposed restricting first-year residency positions to 110% of U.S. medical school graduates. Currently, these positions are at 143% of U.S. medical school graduates or over 24,000. This action would dramatically reduce international medical graduates (IMGs) in U.S. residency programs.
In a 1996 monograph, the Institute of Medicine (Lohr and colleagues) reported a surplus of specialists but made no special reference to any shortage of psychiatrists. Indeed, current federal policy reflects the belief that the nation has a growing surplus of specialists and a shortage of primary care physicians (family practitioners, general internists and general pediatricians).
Most current physician workforce studies or proposals, in addition to COGME, argue that the country has a surplus of thousands of specialists and call for reducing the number of specialists in residency training. One aspect of the $115 billion reduction in Medicare spending over the next five years in the 1998 federal budget agreement is a reduction in funding for resident education. This decrease will lead to a reduction in resident positions. At this time, IMGs fill nearly one-third of all first-year resident positions. With IMGs filling nearly half of first-year psychiatric residencies, any reduction in IMG residents will likely significantly decrease the number of psychiatrists in training.
But are there really too many or too few psychiatrists? How are we to know? With the advent of managed care, government policy planners assume we are a surplus like most other specialties. Reference to a 20-year-old GMENAC study will not support a claim of shortage in today's world.
A number of parameters determine how many psychiatrists our nation needs. First is the incidence and prevalence of mental disorders. Excellent studies exist to provide this data. Second is the kind of clinical care individuals with mental disorders will need, and who will provide that care. Individuals with mental disorders require a thorough diagnostic assessment. Does this need to be provided by a psychiatrist? Obviously, some individuals will need medications as an aspect of their care. These medications must be prescribed by a physician. Does that physician need to be a psychiatrist? Some individuals with mental disorders will need, with or without the use of medication, to be involved in psychotherapy. Does the psychotherapy need to be provided by a psychiatrist?
Independent of the issue of cost, some psychiatrists today feel their role should be limited to making diagnostic assessments and providing medications. Psychotherapy, they feel, should be provided by other mental health providers. Others feel that the psychiatrists' unique skill is their ability to integrate biologic, psychologic and social elements of behavior in assessing and treating individuals. They feel psychotherapy is a core psychiatric skill even though it, like pharmacotherapy, can obviously be provided by nonpsychiatrists.
The level of care assumed by psychiatrists and supported by research findings will have a profound impact on the number of psychiatrists our country needs. If psychiatrists only perform assessments and prescribe drugs, very few are needed. Further, with the development of new drugs with fewer side effects and easier dosage schedules, nonpsychiatrists may be able to effectively prescribe many of them. On the other hand, by maintaining a broad role dealing with psychosocial as well as neuroscience aspects of behavior, significantly more psychiatrists will be needed.
A third parameter in determining the number of psychiatrists is the scope we assign to our therapeutic role in society. Historically, psychiatry has broadly addressed issues of mental health, not just treating patients who come to us, but seeking out and identifying the mentally ill needing treatment-ergo, the national institute which deals with mental disorders is called the National Institute of Mental Health (NIMH) not the National Institute of Mental Disorders (NIMD). Some psychiatrists and patient advocacy groups would prefer a narrower scope for psychiatry and a new name for the institute. Others argue, as previously noted, that we should narrow the range of psychiatric practice to treat only those disorders which they feel have clear biologic causes. This argument is made even though it is clear that environmental (including psychological) factors are essential in the development and ongoing functioning of the brain and that environmental factors also have roles in all mental disorders.
Finally, the fourth parameter is the price society is prepared to pay. It is striking that the surge in the production of physicians occurred during the Vietnam War when our country, under the aegis of President Johnson's Great Society, argued that, through taxes, it could support "guns and butter." Today, after 50 years of talking of a peace dividend, with the end of the Cold War, we find that the United States and most other Western democracies are struggling to maintain the current level of medical care of their citizens. Since the Reagan presidency, the United States has moved away from taxes that support health and social programs. Around the world many countries following similar imperatives wonder how to reduce medical service; or, more correctly, how to ration care. Indeed, managed care is, in economic terms, only a way of rationing and restricting care. In this economic climate, using the entire U.S. population, there are an average 14.1 psychiatrists per 100,000 citizens (Institute of Medicine 1996). Many managed care firms say we need only one-third that number.
In most economic discussions of managed care, issues of quality and its relationship to accessibility are not addressed. The key health care issue of this decade is cost reduction. Quality is frequently cited as a critical factor in corporate health care decision-making but despite some exceptions, cost determines most corporate health care decisions for employees. From an economic perspective, by reducing and restricting resources devoted to psychiatric service in the country as a whole we have created a surplus of psychiatrists even though some locales may have shortages. If we examine epidemiologic studies indicating the incidence and prevalence of psychiatric disorders, we can argue that we have a shortage of psychiatrists.
Unfortunately, economic decisions seem likely to determine medical policy for the remainder of this decade and well into the next. Organized psychiatry, individual psychiatrists and patient advocacy groups will have to battle to assure that adequate and appropriate resources are committed to mental health. Further, psychiatrists must unite with an agreed agenda and a broad-based definition of the discipline. Any narrow definition of our discipline restricting our scope of responsibility and our scope of practice to medication management and assessment will support the view that there is a major surplus of psychiatrists. This will lead eventually to psychiatry having a peripheral role in mental health care.
The stakes for the future of psychiatry are high. Our science and knowledge of the brain, psychology and social milieu, if presented clearly, can give us a vibrant future. To ensure that future, we must communicate the unique and essential qualities we provide in the treatment of the mentally ill. We must also be able to present data that supports the economic benefits of a broad-based psychiatry. The final answer to the question "are we a shortage or surplus" will not be available for some years. But we, by our actions today, will determine the outcome.
