Thursday, August 25, 2016

A Better Analysis Of The Psychiatrist "Shortage"

A paper in Health Affairs on the "psychiatrist shortage" has been getting a lot of press lately (1).  People are acting like the authors' conclusions are definitive rather than highly speculative, but that is a standard approach in the press.  In the article they use American Medical Association (AMA) Physician Masterfiles from 2003 and 2013 to calculate the number of psychiatrists per 100,000 population for those two dates.  They compare it to similar data for neurologists and family physicians.  Between 2003 and 2013 there was a -0.2% change for psychiatrists as opposed to a +35.7% change for neurologists, a 9.5% change for primary care physicians and a 14.2% change for all physicians in this time period.  They also calculated medians for all groups and coefficients to look at workforce distribution.  As expected psychiatrists and neurologists showed some skew of distribution compared with adult primary care physicians.  That could also be seen in the density of psychiatrists by region:  24.47 per 100,000 in New England to 13.33 per 100,000 in the Pacific area.  They show the geographic distributions by highlighting quartiles of distributions on a quartile map of the United States.  The regions highlighted are 300 - Hospital Referral Regions rather than states.

There appears to be a significant typographical error on page 1275: "Our finding that there was almost a 10 percent decline in the population adjusted mean number of psychiatrists per HHR supports the belief that the supply of psychiatrists likely limits patient access to their services".  They are referring to median numbers here and in their abstract where they use the correct term.  The actual number of psychiatrists in 2003 was 37,968 and in 2013 it was 37,889.  The real numbers just don't seem that dramatic.

In the context of these statistics the authors offer a very inconsistent analysis frequently equating the number of psychiatrists with access to services or imposing severe limitations on treatment as illustrated by their statement: "Since the current supply of psychiatrists is not meeting the needs of people with mental illnesses and is not keeping pace with population growth, policy makers and the medical community must consider ways to address the shortage and improve access to mental health care".  This conclusion is quite a stretch considering data that the authors include in the paper.  They use the figure of 9.6 million adults with severe mental illnesses and only 40% of those people receiving care.  That means if the 37,889 psychiatrists they counted had only 250 people with severe mental illness on their caseload - 100% of these patients would be treated.  I propose that psychiatrists only see patients with the severest forms of mental illness and in today's world 250 patients is a very modest caseload.  In the heyday of psychoanalysis, some analysts did not treat many more patients over the course of their career.   At the maximum this suggests a geographical mismatch between patients and psychiatrists rather than a global shortage of psychiatrists.  Is increasing the supply the best approach to this problem?

In another section of their paper the authors point out that psychiatrists account for only 5% of the mental health workforce; 95% being psychologists, social workers, therapists , and counselors.  They acknowledge that they have no equivalent statistics for those disciplines or nurse practitioners or physician assistants.  Many systems of care these days see a prescriber as a prescriber and selectively hire non-physician prescribers over psychiatrists.  Even without the data it would seem fairly obvious that there has been a proliferation of non physician prescribers over the past decade and no shortage of antipsychotic, antidepressant, stimulant, or benzodiazepine prescriptions.  How can there be a shortage of prescribers in a sea of overprescriptions?

The authors notion that "policy makers and the medical community" are going to provide the solution here is also incorrect on several grounds.  First and foremost - if there is a problem - these are the same people who got us here in the first place.  The authors themselves reference a Graduate Medical Education National Advisory Committee study from 30 years ago predicted the shortage.  Any Medline search looking at "psychiatrist shortage" will also yield papers on this topic dating back to 1979.  In that time frame there have been very modest attempts to expand the workforce in psychiatry.  I made that statement based on expansion of residency slots.  The reality is that there are many International Medical Graduates who are well qualified for residency positions and may have even completed equivalent certifications in their country of origin.  The authors also seem to miss the point that these same "policy makers" have initiated policies to expand non-physician prescribing that has led to decreased staffing by psychiatrists in many settings.  They make the typical mistake that policy makers can't have it both ways and they seem quite intent on reducing rather than expanding the psychiatric workforce.  In the argument the only function a declaration of a psychiatrist shortage limiting mental health treatment is to scapegoat psychiatrists for a problem that may be imaginary but at the minimum is out of their control.  The appeal to policymakers also ignores the fact that policy makers in the US, generally advance pro-business policies that place both physicians and their patients at a distinct disadvantage compared to the business.  I will address some of those points below.

Some additional points not considered by the authors:    

  1.  Inefficiencies in the psychiatric workforce are large - Those inefficiencies are two fold.  First, the practice of psychiatry is notoriously inefficient.  I have done comparisons with both ophthalmology and orthopedic surgery on this blog where comparatively fewer specialists cover an impressive array of serious illnesses.  They do this largely through a much better triage system focused triaging the most serious illnesses.  By comparison, the conditions treated by psychiatrists all receive rationed care and in some cases - the care is completely displaced to a non-medical facility.  In most others there is inadequate infrastructure to address the problem.  The facilities themselves are managed by non-medical administrators who in may cases have caused disruptions in care and severe quality problems.  Care is further fragmented by the fact that managed care companies and governments do not provide realistic reimbursement for the care delivered and incentivize hospitals to provide minimal care.

Second,  managed care and government bureaucrats in their infinite wisdom have made psychiatry even less efficient.  I interject the term "medication management" here as an example and will elaborate below.

2.  The prevailing model of care is antiquated and a throwback to the 1980s - The preferred business and government model of care is the so-called medication management visit also more pejoratively known as the med-check.  It is based on a thoroughly poorly thought out idea that people with severe mental illnesses can be treated with medications for the symptoms of those illnesses.  That model does not work at even the most basic idea that there are social etiologies of symptoms that need to be addressed by social and psychotherapeutic interventions.  There are no medications that treat unemployment, separation and divorce, or the sudden loss of a loved one and yet the entire billing and coding structure for psychiatric visits was based on this model.  Even worse - the productivity scale for employed psychiatrists is still based on this model with a rough correlation between how many people are seen in one day and compensation.

3.   Academic and intellectual approaches to psychiatry are at an all-time low -  An intellectual approach to the field is critical whether considering phenomenology, the conscious state of the individual or all of the medical factors associated with treating the psychiatric disorder.  The environment is also frequently neglected because it is managed by non psychiatrists - at least until there is an incident or violence, aggression, self-injury, or suicide that requires analysis.  The intellectual approach to the field requires study of both the individual and the environment that they are in.  An intellectual approach to psychiatry also requires centers of excellence where people with those problems can go to receive expert care.  Centers of excellence are much less common in psychiatry than other fields.  Over the past 20 years academics and educators in the field have been subjected to the same productivity demands as clinicians.  Academic work of all kinds is devalued in order to increase the number of  patients visits focused on medications.  All incentives in place from the policy makers point toward a continued non-intellectual approach to the field.

4.  Practically all employer based positions are burn-out jobs - Reasonable people will work them for a time and then quit and ask themselves how they got involved in that situation in the first place.  The authors seem to think that better compensation or collaborative care models would increase the participation of psychiatrists in these flawed systems of care where they are "supervised" by unqualified business people.  To me the best insurance against burnout and practicing a higher standard of care is to not accept any payment arrangement that involves your work or professionalism being compromised.

5.  Public health and infrastructure needs are always neglected when it comes to psychiatry and mental health -  The most pressing issue is the dismantling of hospital structures and hospitals with therapeutic environments.  We cannot expect this to be rebuilt with the current paradigm of containment and maximizing profit by discharging people without adequate treatment.  Another way to look at the situation is that we cannot expect intellectually stimulating, state-of-the-art treatment environments when the only admission criteria is business and government defined dangerousness.  We also need therapeutic environments for the psychiatrically disabled rather than psychiatric slums and homelessness.

 The public health measures do not stop there.  America's huge appetite for addictive drugs drives a lot of psychiatric morbidity.  This offers one of the best areas for reducing the incidence of psychiatric problems and the need to see a psychiatrist.  Nobody at the policy level seems to be very interested in this problem.  Perhaps it is a resignation to the political success of the cannabis movement and more recent ideas about psychedelics being therapeutic drugs.  Reducing drug addiction and exposure would not only reduce the incidence of accidental overdoses but it would also reduce the incidence and severity of psychiatric disorders by an additional 30%.  Addictive drugs is just one aspect of prevention that is ignored by policy makers.  I would list violence and homicide prevention as a close second.

I still operate from the basic assumption that physicians are bright, well intentioned people.  That means they operate best when they have a manageable schedule, are not overworked and sleep deprived, and are allowed time for intellectual pursuits in their field.  You don't go into medicine to put in 8 hours, punch a clock and go home.  Ideally there is intellectual stimulation at work every day.  The intellectual stimulation certainly needs to be there if the psychiatrist has any involvement in teaching psychiatric residents.  It can't be there if physicians are managed like production workers especially when the product they are producing is an inferior one.

And practically every psychiatrist knows that the business-managed work product that they produce is markedly inferior to what they were trained to do and what they are capable of.  That is what fuels the private practice movement - NOT financial remuneration.

How can anyone expect to recruit and retain psychiatrists when their practice environment is actively being destroyed?  Why would anyone be interested in the field?

George Dawson, MD, DFAPA

1: Bishop TF, Seirup JK, Pincus HA, Ross JS. Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care. Health Aff (Millwood). 2016 Jul 1;35(7):1271-7. doi: 10.1377/hlthaff.2015.1643. PubMed PMID: 27385244.

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