Lower pay, limited respect for specialty blamed for scarcity
March 16, 2014 12:00 AM
Jennifer Bowman will graduate from Robert Morris University’s psychiatric nurse practitioner program in May. With a high demand for psychiatrists, she has been recruited by three psychiatric practices and has received two offers.
Chandan Khandai, a fourth-year medical student at the University of Pittsburgh, is waiting to see if he will land one of the 1,300 or so psychiatric residencies opening up nationwide in the fall.
By Joe Smydo / Pittsburgh Post-Gazette
Chandan Khandai, a fourth-year student at University of Pittsburgh School of Medicine, will be on pins and needles until he finds out Monday whether he has landed one of the 1,300 or so psychiatric residencies opening up nationwide this fall.
Mr. Khandai's interest in psychiatry is fueled by developments in brain science and, he said, concern for a patient population often made to feel "like the kids who get picked last in the class to play kickball."
The profession needs him. Amid a growing demand for mental health services, the nation is wrestling with a chronic shortage of psychiatrists, who get less pay and respect than doctors in other specialties.
"We're short in a sort of really bad way," said Gary Swanson, president of the Pittsburgh Psychiatric Society and director of psychiatric residency at Allegheny General Hospital, noting patients in some areas wait two months or more to see a psychiatrist.
In Westmoreland County, Ray Grabowski, director of behavioral health for Excela Health, has spent 15 months seeking a psychiatrist for the health system. He has used two recruiting firms and sent his job notice to 16,000 doctors nationwide. He has offered the job to eight candidates; none accepted.
Mental illness is a leading cause of disability in America, yet medical students' interest in psychiatry is so low that nearly 14 percent of the 1,360 psychiatric residencies up for grabs last year went to non-U.S. citizens who graduated from foreign medical schools -- a higher percentage of foreign participation than in many specialties' residency programs.
A similar scenario could play out this year. Medical school seniors around the country will find out Monday whether they've been matched with residencies in their preferred fields. On Friday, they'll find out the names of the schools that want them.
The nation has about 46,000 psychiatrists, according to 2010 data from the Association of American Medical Colleges. An estimated 2,600 more are needed to eliminate 3,900 federally designated "mental health professional shortage areas," including parts of Allegheny, Washington and Westmoreland counties.
That's just the tip of the iceberg. More than 7,000 psychiatrists specialize in treating children and adolescents, but the field could use thousands more, said Gregory Fritz, president-elect of the American Academy of Child and Adolescent Psychiatry and professor at Alpert Medical School at Brown University in Providence, R.I.
Also in demand are "culturally literate" psychiatrists for minorities and those willing to work with prisoners, substance abusers and parolees with severe personality disorders or histories of sexual deviance, said Michael Welner in an email. He's a nationally known forensic psychiatrist who examined Pittsburgh mass murderers Richard Baumhammers and Ronald Taylor.
Pennsylvania has 1,788 psychiatrists, more than many other states, according to the medical college association. But 42.6 percent are 60 or older, underscoring the need for recruitment. Rural parts of the state -- as in the case with parts of Westmoreland County -- can struggle to find psychiatrists.
PG graphic: Compensation (Click image for larger version)
To cope with the lack of psychiatrists, other health care professionals are being pressed into service.
Robert Morris University last year received a three-year, $923,000 federal grant to graduate more psychiatric nurse practitioners, who are trained to provide therapy and prescribe medications. By 2016, the school hopes to boost enrollment to 76, more than triple the current number, partly by using videoconferencing to reach students in other parts of the country, said Kirstyn Kameg, nursing professor and program coordinator.
Jennifer Bowman, a Mt. Lebanon resident and longtime nurse who will graduate from the Robert Morris program in May, said she has been recruited by three psychiatric practices and has two offers.
In legislation aimed at improving access to care, U.S. Rep. Tim Murphy, R-Upper St. Clair, who is a psychologist, proposed grants to expand the use of telepsychiatry -- providing care via technology -- and giving liability protection to mental health professionals who volunteer their services.
The Medical College of Georgia at Georgia Regents University has used telepsychiatry to evaluate adults and children -- and found that distance is not a barrier to assessing patients, Peter Buckley, the dean, said.
Barbara Van Dahlen, a Washington, D.C., psychologist who built a network of mental health professionals willing to donate an hour weekly to treat military personnel and their families, predicted that volunteerism would work with other patient groups, too.
Since 2005, her nonprofit, Give an Hour, has leveraged more than 112,000 hours from nearly 7,000 psychiatrists, psychologists, nurses and other professionals nationwide. And they're helping without the kind of liability protection Mr. Murphy proposed.
"Once people understand what it is we're doing and why we're doing it, we have not had any trouble getting people on board," Ms. Van Dahlen said.
A few states passed or are considering legislation allowing psychologists -- mental health therapists who have doctorates, not medical degrees -- to prescribe psychiatric medications after receiving additional training. Other states have considered and rejected the idea, which sometimes is opposed by psychiatrists. The Pennsylvania Psychological Association says it doubts the measure could win legislative approval here.
If they agree to work in underserved areas, foreign doctors may apply to remain in America after completing residencies here. Currently, omore than 100 doctors -- 18 of them psychiatrists -- practice in Pennsylvania under the program. Mr. Grabowski, the Excela director of behavioral health, said he'd like to see the easing of guidelines that exclude some hospitals and restrict numbers of participating doctors.
Pay is blamed for holding down the number of psychiatrists and affecting the availability and quality of care.
According to one survey by the American Medical Group Association and SullivanCotter consultants, the 2012 median compensation for psychiatrists was $224,878 -- third lowest among 30 specialties. Paul Summergrad, president-elect of the American Psychiatric Association and chairman of psychiatry at Tufts University School of Medicine in Boston, cited inadequate Medicaid reimbursements and some private insurers' reluctance to cover psychiatric care, despite a 2008 federal law requiring parity for mental and physical health coverage.
Because of low reimbursements, psychiatrists have all but ceded psychotherapy -- talk therapy -- to other mental health therapists, said Dr. Welner, who consulted on Mr. Murphy's bill and chairs The Forensic Panel, a New York-based consulting practice.
"The reality is that psychiatry is far better than a pill-pushing discipline. However, the current and evolving health care system in the United States promotes shorter visits of less frequency and primarily for medication management," he said.
Young psychiatrists with a mountain of debt -- some first-year medical students face upward of $60,000 in tuition and costs for 2013-14 -- have little incentive to get the extra training needed to specialize in the treatment of children. "I don't get paid any more for working with children than I do with adults," Dr. Swanson of the Pittsburgh Psychiatric Society said.
A doctor who agrees to work in a high-need field and underserved area may apply for tens of thousands of dollars in federal tuition relief, but few psychiatrists have taken advantage of the competitive programs. Over the past two years, psychiatrists accounted for 2 percent of applicants to a U.S. Health Resources and Services Administration loan-repayment program and less than 1 percent of applicants to the agency's scholarship program.
The agency could not explain the low numbers of applicants but noted that the number of psychiatrists participating last year -- 221 -- was up from 98 in 2009. It said psychiatric nurse practitioners and other professionals also may apply to the programs, and that, thanks to record budget allocations in recent years, their numbers also are up.
Dr. Welner said doctors should have financial incentives to work with children and the toughest cases. Yet money is not the only problem.
Alexis Chidi, midway through a Pitt program leading to a medical degree and doctorate, said some future doctors are dissuaded by the complexity of mental illnesses -- "it's difficult even to wrap your head around what's going on with the patient" -- and the potentially slow rate of patient improvement. "I think it's not for the weak in spirit," she said.
Medical students also can be turned off by psychiatry's image and by the stigma of mental illness. Tejas Patel, a third-year student at Drexel University in Philadelphia who's in a six-week psychiatric rotation with Allegheny Health Network, said he has heard psychiatry described as "driving a minivan" instead of a Lexus.
Psychiatrists say they're the butt of professional jokes and public ignorance, and Dr. Summergrad of the American Psychiatric Association said family members sometimes are disappointed with a loved one's choice of psychiatry instead of another specialty. "Is that a real doctor?" Dr. Swanson said the psychiatrist sometimes is asked.
Thomas Insel, director of the National Institute of Mental Health, hopes that better integrating brain science into psychiatry will lure more medical students into the profession. It helped to rope in Mr. Khandai, who interrupted his medical schooling to get a master's degree in neuroscience from Pitt.
Dr. Fritz said infusing psychiatry into undergraduate programs could get future doctors thinking about the field before medical school, and some medical schools have created streamlined programs combining psychiatry and other specialties.
At Pitt medical school, 6 percent of graduates go into psychiatry, 2 percent above the national average. Pitt has "several programs that involve undergraduates in mental health research and provide exposure to the clinical challenges of psychiatry," Ken Nash, associate professor of psychiatry, said in an email.
Still, recruiting psychiatrists -- even among medical students interested in the brain -- likely will remain a challenge. Ryan Williamson, a medical and doctoral student at Pitt who already has a degree in electrical engineering, said he is interested in the parts of the brain that control vision and motor function, not cognition.
Mr. Khandai said he is aware of psychiatry's drawbacks and considered other specialties. "Again and again, psychiatry is what I came back to," he said.
Joe Smydo: firstname.lastname@example.org or 412-263-1548.
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