Subspecialty Shortages: Is Psychiatry in Need of a Cultural Defibrillation?

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COMMENTARY

The United States is in the midst of a mental health crises and the aftermath of the COVID-19 pandemic on mental health continues to reverberate.¹ Unfortunately, only about half of those struggling with mental illness receive treatment² and this is exacerbated by the deficit in the number of psychiatrists needed to meet public demand.³ Even worse however, are the shortages seen among psychiatry subspecialists with only 27.7% of counties having at least 1 child and adolescent psychiatrist, 10.5% having a geriatric psychiatrist, and 7.6% with an addiction psychiatrist.³

Despite growing interest among medical students to pursue psychiatry residency training, this interest has not resulted in an increase in fellowship matches for subspecialty training.⁴ Reasons for this are multifactorial, with residents reporting the extended duration of training and financial concerns as primary deterrents.⁵ As a result, a significant portion of fellowship positions go unfilled every year.⁶ While continued efforts towards increasing the number of residents pursuing fellowship training remains imperative, even if recruitment were not an issue and all training positions were filled each year, there would still exist a shortage of subspecialists to meet public demand given the enormous deficit.⁶

With large-scale supply deficits in available subspecialist psychiatrists and the continued challenges in enticing residents to pursue subspecialty training, action needs to be taken on multiple fronts to tackle the shortfall in supply. Many solutions have been proposed to ameliorate this issue, including creating financial incentives to pursue fellowship training,⁷ the allowing of fast tracking into all fellowships,⁶ and creating child and adolescent psychiatry residencies with the option to fast track into adult training programs.⁸

Calls have also been made for more robust subspecialty training during general residency. It is thought this hopefully may translate into an increase in the likelihood of nonfellowship trained graduates functioning as “generalists,” in the truest sense of the word, referring out only the most complex of cases to subspecialty psychiatrists, thereby relieving some pressure on demand.⁹ However, strengthening subspecialty training alone amongst generalists may be a fruitless endeavor without first addressing existing cultural barriers. As such, residencies often train psychiatrists to routinely refer out all subspecialty patients, regardless of complexity, rather than providing care—a self-perpetuating issue that graduating residents may continue into practice.⁹

Though common cultural practices amongst generalists may shoulder some blame in the supply/demand imbalance, there may also exist a need for a broader cultural defibrillation within psychiatry, one extending beyond generalists. In my observation, psychiatry is unique amongst medical specialties in which its subspecialists will routinely see a substantial number of general patients in their caseload. As an example, it would be unusual to see subspecialists in other areas of medicine, such as a cardiologist, practicing general internal medicine. While entirely within the subspecialists right to practice as they see fit, this cultural practice represents an inefficient use of an already scarce resource and demands discussion on whether this practice should be discouraged or requires external intervention.

Though this has been my consistent observation having worked in multiple hospital systems, both rural and urban, and having worked at multiple hospital locations within each system, it is unclear how widespread this practice is. Unfortunately, to the best of my knowledge, no contemporary study or recent data exists comprehensively exploring to what extent this cultural practice exists among all psychiatric subspecialties. However, there are older studies looking at the psychiatric workforce from several subspecialties suggesting this practice is not only widespread but sizable.^10-12 For example, in one of the workforce studies which looked at geriatric psychiatrists, only 42% of their patients were over the age of 65,¹⁰ while 36% of the addiction psychiatrists reported to be in general practice rather than the addiction setting.¹¹ Similarly, such findings are also reflected in incidental accounts as reported by individual subspecialists describing their practice, with one child and adolescent psychiatrist reporting that two-thirds of their patients are adults¹³ and another reporting about half of their patients are adults.¹⁴ Therefore, this demands further study to determine the prevalence of such practice patterns and whether cultural changes are needed to address the unmet public demand. Moreover, psychiatric subspecialists should be encouraged to focus on providing care more exclusively to their respective subspecialty populations given the severity of shortages. ​Independent of the extent by which this cultural phenomenon exists, large or small, this would represent an unaddressed new front in which our profession can adapt to meeting the dynamic health needs of the country.

Dr Stoneis a PGY-4 psychiatry resident in the TJUH Department of Psychiatry & Human Behavior.

References

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2. Statistics. National Institute of Mental Health. Accessed April 5, 2024. https://www.nimh.nih.gov/health/statistics

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14. Fox G. Child and adolescent psychiatry as a career. 2017. Accessed April 5, 2024. https://www.aacap.org/AACAP/Medical_Students_and_Residents/Residents_and_Fellows/Child_and_Adolescent_Psychiatry_as_a_Career.aspx#three