October 24, 2006

There's A Shortage of Psychiatrists Somewhere, We Just Have To Find It

I was emailed a link to a 2003 article in the Psychiatric Times, which describes a maddening report out of California is so blatantly politicized that Arnold himself is embarrassed.

The report says, insanely, that there are not, and will not be in the future, enough psychiatrists to meet the needs of California.   (Actual report PDF here.)

Well, not exactly true, is it?

When you say shortage, what do you mean-- 5000 psychiatrists for one state isn't enough?  Oh, you mean that for some inexplicable reason, 63% of the entire state of California's psychiatrists work in the Bay Area or LA?  Sounds like you have plenty of shrinks, they're just not distributed very evenly.  Why would that be?

48% of all psychiatrists in California are in a solo or 2 physician practice.  Hmm. 75% were male, 65% white.  Hmm.  Perhaps the problem is that your solo psychiatrists want to work in a nice area with good pay, and not in an inner city where-- ironically or tragically, your choice-- the need is greatest but the pay is least?

The nuts filing the report continue to lament that there aren't enough child and geriatric psychiatrists.  Enough for what?  Oh-- enough for Medicaid and Medicare.  What did you expect?  After suffering through a Child psych fellowship, why would go work for peanuts in a community mental health clinic, where you have a better chance of getting stabbed than getting rich?

Their complaints are misplaced and deluded.  They do not reflect reality.  Let me give you reality: the shortage exists in community (read: Medicaid) mental health, primarily because the pay sucks.  But even there, the problem is not as dire as they make it sound.  

First, even if there are numerically more psychiatrists seeing private patients, the community mental health psychiatrists see many, many more patients in a day.  I'm going to guess the ratio is five to one. (Oh, you're upset they see them in ten minute intervals? When you give them a case load of 3000, what did you expect them to do?  Psychoanalysis?)

Second, psychiatrists aren't the only ones providing "community mental health."  Advance practice nurses (APN) and nurse practitioners (NP) also prescribe medications; in some states physician assistants can prescibe; and very soon psychologists will be able to prescribe, as they already can in New Mexico (and I think Louisiana.).  (Care to retract your asinine prophecy, "the center predicts that there may actually be too many psychologists in the future.")

Third, primary care docs handle far more psychiatry than we can imagine. They just can't bill for it.  (And so how good a job are they incentivized to do?)

The shortage is for "psychiatrists" proper (i.e. MD/DOs), not "providers of psychiatric medications." 

The question then, uniquely, is whether we need psychiatrists proper at all to do community mental health.  Are community mental health psychiatrists, as a group, better at diagnosing and treating than anyone else, for example an NP?  Sadly, the answer is currently undeniably no. No one reads anymore, no one studies, and worse, the half-learned information that still lingers is so incomplete as to be misleading.  Post residency, we get our info exclusively from drug reps and throwaway journals.  Ergo, most residents are better psychiatrists than someone in practice ten years.

Woah-- be careful.  Think long and hard before you hurl "clinical experience is more important" at me.  Make sure you want to go down this road.

I am certain that I can take anyone with a college degree in any science, and in four months make them better than an above average psychiatrist.  This is an open challenge to the APA.  I'll repeat it: I'll take any person with a B.S. and in four months make them an academic psychiatrist.

But back to our "shortage" problem, or more accurately our distribution problem.  The solution to this is elementary, but bitter.   Either raise the standards necessary to be a practicing psychiatrist-- more audits and tests, greater documentation in notes, recertification exams with consequences to failing, and outcome/performance evaluations graded against other psychiatrists-- but also raise the pay, dramatically-- you can use the prescription drug savings when you implement my other plan-- so as not to lose the smart people to internal med or neurology; or lower the requirements so that more people can be prescribers, and lower the pay so that you can afford more of them.  Either of these two will satisfy the growing "need."  Which is better for the patient is up to California to figure out.

1 Comment