Andrew Jackson said, “If you would preserve your reputation, or that of the state over which you preside, you must take a straightforward determined course; regardless of the applause or censure of the populace, and of the forebodings of that dastardly and designing crew who, at a time like this, may be expected to clamor continually in your ears” (1). His words are sound advice to anyone who attempts to make recommendations about our country's psychiatric workforce.
Few issues have provoked as much debate in medicine over the last several years as the discussion about medical manpower (2–6). In general, there seems to be a consensus that the United States has too many physicians, too many specialists, too few generalists, major problems with geographic and sociocultural maldistribution of the physician workforce, and significant deficiencies in the training of physicians to practice in modern service delivery systems (7,8). Although most authorities and physician groups agree with this assessment, considerable difference of opinion exists about possible solutions to the dilemma.
Suggestions have included the proposed closure of 25 percent of American medical schools, dramatic cuts in the funding of graduate medical education, funding priorities that emphasize generalist over specialist training and the training of physicians to practice in underserved areas, and sharp limitations in the number of international medical graduates accepted into graduate training programs; others have included creation of graduate medical education consortia with the authority and resources to control physician numbers and training and a strategy of nonintervention that relies on the ultimate effect of free market competition to “rightsize”the physician workforce (9–15).
Psychiatry has not been immune from this manpower debate (16). A significant difference of opinion exists about the adequacy of the current psychiatric workforce for meeting service needs (17). While some reports forecast major shortages of psychiatrists well into the next century (7,18), others predict large surpluses (3,19). Some of the suggested solutions to the overall medical manpower dilemma could also have major consequences for psychiatry, especially those that propose to decrease funding of specialist training or curtail the training of international medical graduates (20).
What should be the approach taken by psychiatrists and organized psychiatry to respond to these issues? We believe a well-designed and concerted effort will be required to determine the ultimate fate of our specialty in a struggle that will be played out over the next few years. The outcome of this conflict will determine not only the number of American psychiatrists but also the nature of psychiatric practice and education in the 21st century. In this paper, we outline a 13-step multidimensional strategic approach to the psychiatric workforce issue and discuss the implications of this approach for psychiatric practitioners, educators, and researchers, as well as for the organizations that serve them.
If psychiatry is to maintain a meaningful role in our country's health care system, two basic requirements must be met. First, the mental health needs of patients must receive adequate prioritization, and second, the psychiatric workforce must be sufficient in number and qualifications to meet those needs. Neither of these basic requirements will be easy to achieve. We believe the 13-step approach we outline can be of significant help in that effort.
We do not mean to imply that these steps are all that will need to be done to ensure that psychiatry thrives. Most certainly, other crucial issues exist that are not apparent to us at this time or that will arise in the future. The 13 steps we outline below are merely those that currently seem most pertinent to us. Many of these issues overlap considerably, and we have somewhat arbitrarily divided them to facilitate discussion. They are not necessarily presented in a particular order of priority. We believe they are all crucial aspects of the psychiatric workforce debate.
Step 1: Recognize the importance of the assumptions that underlie workforce requirements. This is no time for us to focus our efforts on issues that may be important in their own right but that are incidental to the workforce dilemma. Instead, our goal should be to address the following questions: What are the treatable mental illnesses? What mental illness treatments are acceptable? Which patients need which treatments? Which treatments must be provided by psychiatrists, and which can be provided by other clinicians? What direct and indirect service roles should psychiatrists perform in different settings?
Although finding the answers to these questions will require a tremendous commitment of energy and resources, we believe that the answers will dictate the nature of psychiatric practice and education in the new health care era. Much of the collective effort of our profession should be directed toward answering these questions in a manner that ensures patients receive the psychiatric care they need. In the process, a viable role for psychiatrists can be articulated and defended.
Step 2: Select credible, professional leadership with vision and courage. As in any major enterprise, high-quality leadership is essential to the success of this strategic approach. First and foremost, psychiatric leaders of the next decade must recognize the importance of the workforce issue to the future of the profession and articulate a strategy to deal with it. They must confront difficult and potentially divisive problems and advocate for positions that may be unpopular with certain groups of psychiatrists.
For example, controversial issues pertaining to board certification and recertification, practice guidelines, scope of practice, accreditation standards, and international medical graduates may all have a significant impact on psychiatric manpower. Leaders must be able to address these complex issues, achieve a measure of consensus within the field, and incorporate the results of that effort into policies pertaining to the psychiatric workforce. This challenge is not for the fainthearted.
Step 3: Adopt a strategic plan to clarify workforce assumptions. The answers to the questions that underlie psychiatric workforce requirements will not be provided by a quick fix or by disorganized and haphazard efforts. These difficult issues mandate a well-structured strategic approach involving the best researchers and political advocates in the field, supported by adequate resources to complete their tasks. To be successful, this massive effort will take a decade or more and will need to be coordinated at the national level by psychiatric organizations such as the American Psychiatric Association. The profession must also be prepared to accept the numerous compromises that may be required to produce a constructive plan.
Step 4: Re-examine the structure and function of established programs. We must be willing to take a hard and objective look at all aspects of what we do. Established educational, research, and clinical service programs must be analyzed for effectiveness and efficiency. Psychiatry will only be made better by challenging current practices and developing relevant new programs. In the process, new opportunities for psychiatrists will likely result.
Step 5: Prepare trainees for work in the 21st century. The new era of medical care will require psychiatrists with special skills and the ability to adapt themselves to an ever-changing service delivery system. These requirements may have critical implications for the structure, function, and location of psychiatric training programs. The ability of training programs to incorporate the changes required to modernize their curricula and their readiness to pursue educational opportunities in nontraditional settings will determine whether or not their graduates possess the types of skills that will make them valuable in the new era. Of course, all of these training efforts can be reinforced by accreditation and certification standards that are also in step with modern requirements, and careful attention must be paid to any upcoming revisions in these processes.
Step 6: Preserve psychiatry's humanistic tradition. In the headlong rush to embrace its new biological foundation, modernize training programs, and redesign service delivery systems, psychiatry must exert the maximal effort possible to preserve its humanistic tradition. Continued emphasis on the prime importance of the doctor-patient relationship and the active involvement of psychiatrists in the psychotherapeutic aspects of patient care have significant implications for workforce requirements. If psychiatry allows itself to be compartmentalized into a very narrow, purely medical management style of practice, very few psychiatrists will be required in the new era.
Step 7: Enlist the support of nonacademic psychiatrists. Perhaps the biggest challenge to the profession will be convincing typical psychiatrists that the workforce issue is not merely a philosophical and academic discussion, but that it is so crucial to their own future welfare that they must set aside the time and energy to take an active part in this debate. Getting the attention of busy practitioners will be no easy task. It will require that psychiatric leaders develop clear and precise plans for practitioner education and involvement at both the national and the local levels.
Step 8: Reinforce involvement in the fiscal and political aspects of medicine. It is important to appreciate that the clarification of many of the issues that underlie psychiatric workforce requirements will depend on the involvement and expertise of psychiatrists in the fiscal and political arenas. These debates are not purely philosophical, nor will they be resolved only with scientific data in the halls of academia. Many issues will have to be addressed in the real world of state legislatures and the United States Congress. Psychiatrists must be prepared to help answer the questions posed by politicians so that the profession is not perceived as just another demanding and entitled group. This type of political involvement must be part of any credible strategy that hopes to influence psychiatric workforce requirements.
Step 9: Focus attention on important policy issues. An endless search for the exact formula that will reveal the true number of required psychiatrists will not engender the type of support needed to ensure the continued development of the profession. A more helpful strategy underscores important policy issues with significant workforce implications. For example, ensuring adequate access to psychiatric care for underserved populations, mandating standards of care that specify minimum amounts of psychiatric time for patient encounters, and requiring psychiatric involvement in the administration of clinical services are all policies that could have a major impact on the required number of psychiatrists. They may also require significant changes in the structure and function of existing service and education programs. These and related issues ought to be the foci of our attention.
Step 10: Secure the support of patients, families, and advocates. Psychiatry's strongest allies in any discussion about workforce requirements could well be patients, families, and advocates. Most of these individuals appreciate the value of adequate access to high-quality psychiatrists for themselves or their loved ones. Many are willing to speak up on psychiatry's behalf at times and in forums where our own efforts come across as self-serving. The challenge will be to establish an effective dialogue with these groups and to develop specific strategies for how they might be most helpful in the workforce debate.
Step 11: Endorse a multidisciplinary, biopsychosocial approach to the evaluation and treatment of mental illness. Effective and efficient clinical practice mandates the participation of mental health professionals of different disciplines in the evaluation and treatment of mental illness. Outcome data are needed on the effectiveness of psychiatrists and other mental health disciplines in providing specific treatments to different types of patients. The profession must be prepared to accept the results.
The specific scope of practice of the different disciplines is an issue that will have to be confronted and resolved if real headway is to be made in the workforce debate. The constructive resolution of this issue could bring the various disciplines together into a potent strategic alliance to advocate for adequate manpower levels for all mental health professionals.
Step 12: Minimize divisive conflicts within and between national organizations. The workforce debate has many facets, and considerable divergence of opinion will continue to exist about the appropriate strategies to pursue. It will be important for vigorous negotiations to occur both within and between national psychiatric organizations. At some point, however, a consensus must be reached on the crucial workforce issues so that a unified front can serve as the foundation for advocacy efforts on behalf of psychiatric workforce requirements. Political infighting at the national level, especially if it spills into the public arena, may well doom any strategic effort.
Step 13: Develop strategic alliances with other medical disciplines. A more complete integration of psychiatry into the mainstream of medical education and service delivery systems could have major implications for workforce requirements. However, integration will occur only if psychiatry is able to earn the respect of other medical disciplines by demonstrating its relevance to meeting the challenges they face in the new health care era. Such a demonstration will require the development of innovative, multidisciplinary training models and a focus of psychiatric services on the needs of primary care patients. The willingness of psychiatry to become a collaborative partner, standing side by side in the trenches with other medical colleagues, could greatly broaden its base of political support and open many new professional opportunities.
Our multistep strategic approach has a number of important implications for psychiatric clinicians, educators, and researchers, as well as for the organizations that serve them.
Psychiatric clinicians must make time in their busy schedules to educate themselves about workforce issues and the importance of the assumptions that underlie specific requirements. Once educated, they must be willing to become active advocates at the local and national levels within the American Psychiatric Association, American Medical Association, and other psychiatric and medical organizations, accept the fact that resolving the workforce dilemma will require a commitment of time and resources of both themselves and the organizations to which they belong, and do all they can to ensure that psychiatric leaders who appreciate the importance of workforce issues to the future of the profession are identified.
Psychiatrists must also be willing to re-examine the structure, function, and location of their clinical practices, demonstrate the flexibility to adapt to the requirements of modern service delivery systems, and embrace new multidisciplinary interactions with other medical and mental health professionals. Opportunities will surely become available in the new era of medicine, and psychiatrists must position themselves to take advantage of them.
Like clinicians, psychiatric educators must be willing to carefully re-examine all they do. Training programs must ensure that they provide the appropriate mix of clinical experiences, faculty supervision, didactic instruction, and seminars so that their graduates possess the requisite knowledge, skills, and attitudes to thrive as clinicians in modern service delivery systems. New training alliances will need to be forged with educational programs of other medical and mental health disciplines so that trainees are prepared for a multidisciplinary style of practice. Educators must also take steps to prepare at least some of their trainees to assume administrative and leadership roles and to become the educators and researchers of tomorrow. In the process of doing so, however, educators must continue to require these trainees to receive excellent clinical training.
While all of these curricular modifications are essential, psychiatric educators must be vigilant to ensure that training programs are developed on a firm foundation that preserves the best of psychiatry's humanistic tradition. Specific safeguards must be incorporated into training programs so that they focus the attention of trainees on the doctor-patient relationship and the psychotherapeutic aspects of clinical care. To lose these unique components of psychiatric training would truly damage the heart and soul of our specialty and threaten a major rationale for its existence.
The activities of psychiatric researchers will be crucial to the outcome of the workforce debate. Careful studies must be designed to answer key questions that form the assumptions underlying psychiatric workforce requirements. Data pertaining to such issues as practice guidelines for various psychiatric disorders, the scope of psychiatric practice, the effects of multidisciplinary practice, the impact of psychiatric involvement in nonpatient care services in mental health systems, patient access to psychiatric care, and the psychiatric requirements of patients with other medical problems all have relevance to psychiatric workforce requirements. The results of research pertaining to these issues will not only help determine the number of required psychiatrists but will also be extremely important as psychiatry attempts to develop an effective political strategy concerning manpower.
Organized psychiatry must assume an active role in the workforce debate if it is to be resolved to the benefit of our profession. Members must be educated about the implications of workforce issues and how they can become effective advocates for ensuring that adequate psychiatric manpower is available to meet patients' needs. Specific strategic plans must be developed to support required modifications in psychiatric education, manpower research, and political advocacy concerning workforce policy issues. Strategic alliances will need to be forged with other mental health and medical specialty organizations, as well as with advocacy groups. Disparate groups within psychiatry must be brought together to negotiate and achieve consensus on workforce issues. None of these activities will be possible unless vigorous, progressive psychiatrists are found to assume leadership roles within organized psychiatry.
The psychiatric workforce dilemma is a complex and difficult problem that has no easy solution. A well-structured, concerted approach will be required to resolve it in a way that meets patients' needs and secures a meaningful role for psychiatry in the 21st century. This difficult process, involving psychiatric clinicians, educators, and researchers as well as organized psychiatry, may also serve to integrate the efforts of psychiatrists and instill in them a sense that they are determining their own destiny, rather than being relegated to roles mandated by those outside the profession.
In many ways, this approach could become a grand “voyage of discovery” for psychiatrists and psychiatry. To be successful, it will most certainly need to be guided by a spirit reminiscent of Thomas Jefferson's description of Meriwether Lewis:“Of courage undaunted, possessing a firmness and perseverance of purpose which nothing but impossibilities could divert from its direction, careful as a father of those committed to his charge, yet steady in the maintenance of order and discipline…against losing time in the description of objects already possessed, honest, disinterested, liberal, of sound understanding and a fidelity to truth” (21).
Dr. Faulkner is vice-president for medical affairs and dean of the School of Medicine at the University of South Carolina, Columbia, South Carolina 29208 (e-mail, faulkner@ med.sc.edu), where Dr. Scully is chair of the department of neuropsychiatry and behavioral science.Dr. Scully is also director of the William S. Hall Psychiatric Institute of the South Carolina Department of Mental Health. Dr. Shore is chair of the department of psychiatry at the University of Colorado Health Sciences Center and superintendent of the Colorado Psychiatric Hospital in Denver.