There is an ongoing debate as to whether there are too many or too few practicing psychiatrists in the United States. Of more than 45,000 U.S. psychiatrists, only about 23,000 are actually practicing outpatient psychiatry. Yet, many jobs in the public sector remain unfilled, and managed care networks continue to lose psychiatrists to independent practice. What is the real problem concerning the number of psychiatrists in America?
Our readers declined the challenge posed by this question, but Dr. William Goldman addressed it in some depth in December ("Economic grand rounds: Is there a shortage of psychiatrists?" Psychiatr. Serv. 52:1587-89).
Dr. Goldman, clinical professor of psychiatry at the University of California at San Francisco, observes that, since the end of World War II, in every system of delivery used for organized mental health services, the psychiatrist's journey has reached basically the same conclusion: "Reflecting on the modern history of organized mental health services, we see a repetitive pattern of initial engagement and clinical leadership and service by psychiatrists, followed by disengagement and marginalization. ...In each structure [state hospitals, community mental health centers, staff-model HMOs, and open-network managed care organizations], psychiatrists eventually came to function almost entirely as medication managers."
Noting that the supply of psychiatrists is shrinking at a time when the demand for services is increasing markedly, and citing data showing that primary care physicians are making an ever-growing proportion of mental illness diagnoses, Dr. Goldman voices concern that there are too few psychiatrists available and willing to deliver the high-quality integrated care that is expected of the profession--care that psychiatrists are uniquely qualified to give. "If psychiatrists are not available, who will be?" he asks.
Redressing the supply-demand imbalance would require competitive reimbursement in managed behavior health organizations and a greater acceptance of managed care by psychiatrists, but even this would not be sufficient, be says. Yet Dr. Goldman sees little likelihood that current conditions will reverse; psychiatrists are likely to continue to practice primarily in urban areas; to vary extremely in their geographic distribution; and to remain the least affiliated medical specialists, continuing to opt instead for private, solo, and small-group outpatient office practice.
In a somewhat pessimistic conclusion, he writes: "Even in their role simply as medication managers in split treatment, most psychiatrists in private practice seem accessible only to affluent, full-free patients outside managed care. I see few short-term remedies and little to applaud."
Dr. Fink's Response
Psychiatry has been seriously damaged by the unacceptable restrictions of fee schedules and the rules and regulations imposed by the insurance industry and government. Many psychiatrists, as a result, have elected to see only patients who can pay their fees, leaving a great many Americans without access to acceptable and decent care.
To make matters worse, the stigma against psychiatry (and mental illness) has led to the shameful undervaluation and underpayment for our services, which we endured for more than 15 years. …