I first have to make my disclosure statement: I am a child psychiatrist, in addition to being and adult, and geriatric psychiatrist. I trained and was board certified in all three subspecialties but I am a child psychiatrist and that will necessarily makes its way into this post and I wish the reader to know that up front.
The Arab news agency Al-Jazeera had a very recent article that caught my week several days ago. It was entitled: “Shortage of child psychiatrists plagues the US.” It appeared June 25, 2015. It was very fair and well done and I appreciated the factual, accurate and in depth reporting that went into it. But as an American and a child psychiatrist, it stung a little. One of our 30 year old problems that we have unconscionably neglected and is a big part of our present self inflicted, national “mental health crisis” is catching the attention of the foreign press more and more. This hurts. And part of why it hurts is that the venerable, sort of business-y conservative, Wall Street Journal has been reporting on the shortage of child psychiatrist now for well over a decade. If the reader will Google ‘child psychiatrist shortage Wall Street Journal’ you will get a few pages of listings of well done articles published in the past by the Wall Street Journal in past years.
In my earlier years in practice after finishing training I made informal talks to residents in psychiatry who were closing in on their last year of training or in their last year. I had remained in the medical center-university-medical school city where I had trained for further training beyond residency stuff and to teach trainees which was and still is very important to me and which I enjoy immensely. Part of what I did in those days was particularly with the prospectively graduating child psychiatry fellows (as child psych ‘residents’ are called), to exhort, not just suggest or encourage, that they not emulate me, not do as I did and stay to practice in the city of our training but to get out into areas of shortages of psychiatric practitioners. I beat this propaganda drum with all the residents and fellows. It was clear by the 1960’s that there was an enormously maldistribution of medical specialists in this country. The ideal of being the country doctor for the town and having NO competition or having a few colleagues but having so much business that you were guaranteed a busy and full practice from the very first week you opened your office’s door, had lost its luster. Physicians were going more and more into super subspecialties and having to congregate, locate themselves in the larger population centers in order to have a large enough population that would have enough folks with their not so common maladies that they treated, so they could support the overhead of a practice.
Other factors have long plagued adult and child psychiatry, but have perhaps not been as openly acknowledged as I feel they should be in psychiatry in general. Psychiatrists do not tend to come from farms, football teams, the jock cliques in high schools and colleges. They are more cerebral. They are less mechanically inclined and not into procedures as much, in comparison with say an orthopedic surgeon whose practice other than clinic follow up, is mostly doing mechanically oriented surgeries. Screwing in screws, implanting and attaching rods, inserting and affixing hip joint prostheses, new knee joints, parts of shoulder joints, etc.
Psychiatrists used to be taunted and belittled as not being real doctors and the old joke was the a psychiatry trainee was a “Jewish intern afraid of blood and likes to talk a lot.” Being a Jew I will assume responsibility for putting that slur out there…But psychiatry has “medicalized” itself dramatically in the last 50 years, simply because brain science, like psychiatry was long frozen as a descriptive exercize, studying morphology and structure and anatomy of the brain and not much else for a while. Then instrumentation, brain stains, imaging techniques began to emerge 100 years ago with the latter mentioned technologies exploding onto the medical research scene over 40 years ago and furnishing psychiatry, neurosurgery, psychology, ENT specialists, neurology, and others who were handicapped in varying degrees by the model of working on the brain by methods of hit or miss, inference, or the old black box model of “we don’t know what is going on in there’ but if we ring the bell, the dog salivates.”
So in psychiatry there were even in the early days, the neuroscience oriented types, who early on emphasized “somatic treatments,” such as ECT, insulin coma shock therapy, etc; then there were the verbal geek intellectual types interested in the more social sciences before medical school, then in the talking therapies in training, especially in the heyday of the 1940’s-1980’s of psychoanalysis the most intensive form of psychotherapy, four times a week, heavy emphasis on highly abstract intellectual interpersonal issues such as “transference,” as vehicles of change, which did work and still do, but truly are “labor intensive,” if there ever was a labor intensive human endeavor. And psychoanalysis takes a long time for “working through” of issues, is inefficient and not practical for addressing the needs of a nation in mental health care delivery. But it was never intended to be so, but that is another story for another topic.
So if many psychiatrists were these verbal, thinking, well read, interpersonal types, they tend not to go the boondocks and practice. They understandably are also interested in the arts, the reading world, the social world, societal issues, and are for want of a better way to put it, social city creatures. They tend to stick in urban areas. Some years ago I had to recruit another child psychiatrist for a number of reasons, loss of my partner to serious illness and sudden medical retirement, and the loss of the three mental health center child psychiatrists to the unwise implementation and treatment of those child psychiatrists, pure and simple. I practiced seven days a week for nearly two years, seeing the public mental health center child patients and Saturdays and Sundays. I did this in a MSA (metropolitan statistical area) of 80,000 plus. It doesn’t sound all that big if you are reading this in New York City, or Houston, or L.A., or Atlanta or Boston or Detroit or Chicago, but if you are “it,” the practice demands were simply enormous. All this time I actively recruited a child psychiatrist partner. I had several candidates come to our medium small city of some 30,000 or so. It had average amenities with some of them spectacular, the Smoky Mountains, the state playhouse for Broadway productions all the time, a small symphony, a highly national rated community college, ethnic and cultural festivals galore of all types and snooty value, lots of small very very good private colleges near, one state university branch, one of the most active arts and music centers in the country (estimated actually to be sixth in importance in the country by real economic parameters (like Bob Dylan likes to record there…) etc.
But the candidates and their families would come and start asking telling negative questions like, how far is the international airport, why can’t you get the New York Times here, why is there no full symphony, how far is it to the nearest megamall (and they meant with stores like Macy’s, Saks, Nordstrom, maybe a Neiman Marcus, an Apple computer store, and more than one regional bookstore. When I heard those questions I knew that candidate would not even call me back. And almost all of them were like that. Big city urban creatures accustomed ALL their lives to those kinds of perks and unable to see the smaller equivalents often of nearly as good quality in the smaller urban environment I practiced in. Needless to say I was not able to recruit a fellow child psychiatrist, even after I would show them my waiting list of dozens and dozens of patients and families that would truly fill that candidate’s practice as soon as my office mananger could call and schedule the appointments for at least three to four months out! No dice.
The other factor other than this sociological cohort issues among psychiatrists and child psychiatrists, is that there are so few of us child psychiatrists left. It is estimated that there are still less than 6,500 child psychiatrists in this country. A substantial proportion of child practitioners now suddenly are practicing by televideo and some very recent sampling data shows that child psychiatrists are doing this more than ANY other sub specialty in medicine!
At my training program like EVERY other child psychiatry training program in the country, the number of trainees has been decimated and reduced by an average of 2/3 (!) since the Reagan years when the “you can’t use Medicaid reimbursement funds for graduate medical training purposes” was passed. This affected all types of training programs even surgical ones. But in surgery you could still make the salary of the average surgery resident because their doing surgery minted money! Child psychiatry fees in the public patient arena which is what most child psychiatry trainees worked in anywhere, did not generate enough revenue to pay for themselves, when treating those without insurance, and those with Medicaid which had fee structures that paid a minority fraction of what resident reimbursement in other training programs generated. This is and was called lack of parity in reimbursement, meaning that those in training in psychiatry/child psychiatry, got 50% or less routinely under ALL insuror’s fee structures compared to any of the other medical/surgical specialties. So EVERY trainee in psychiatry/child psychiatry was a “loss leader,” in retail commerce terms except seeing a child psychiatry fellow in training for a child’s medication management or developmental play psychotherapy, did not lead a nice big fat gravy profit check for a heart catherization or coronary artery graft bypass surgery or a joint replacement. The loss in any psychiatry training program’s supporting the training years of a psychiatric resident or child psychiatry fellow (three years for a future adult psychiatrist, FIVE for a future child psychiatrist) only led to more loss. And the training costs are in their own way enormous. While psychiatry training does not require million dollar imaging machines, surgical microscopic aiding robotic hands and gobs of other expensive equipment, there are other unseen and largely unknown to the public and the bean counters, very expensive training costs. For instance an hour of individual supervision utilizing the expensive hour of a tenured senior faculty psychiatrist…., for every hour of the trainee’s hour with the ‘training clinic patient,’ supervision for group therapy, supervision for child therapy, for child assessments, team meetings about every adult or child psychiatric evaluation that supervises and gives educational feedback to the trainee by a psychiatrist, social worker and a psychologist! Then if you do family therapy, you have a faculty family therapist supervising by either being your co-therapist IN the session with the family or spending the same amount of ttime behind the one way mirror taking in the entire family session as it unfolds so the family therapy supervisor can afford the trainee another expensive hour of supervision going over what went on in the session, how to handle it, what the communication dynamics were, what kinds of interventions to try next time and on and on. Consultation child psychiatry requires a senior training psychiatrist often at your side when you go into a school and classroom and observe one of your patients to try to confirm or disconfirm a diagnosis or issue or determine whether the educational placement is appropriate, Can’t do that by phone…Learning to consult in the pediatrics services in hospitals requires an accompanying faculty as does going into a youth training school to render child psychiatric evaluations, consultations with staff and treatment of the disturbed juvenile, especially if the consult question is whether or not the consigned kid is so ill as to need psychiatric admission. Try to get paid for that.
Training a mental health practitioner, and especially a psychiatrist is unbelievably expensive. Almost all psychiatric residency programs are ratholes that the parent medical schools pour money down endlessly with not enough funding support as previously was afforded starting after World War II when it was realized, uh, we need psychiatrists.
So what has been the consequence. Even wealthy child psychiatry training programs, those affiliated with the richly endowed super-universities, or those with huge research faculty cohorts who suck in money from drug company and federal research grants like Electrolux vaccuum cleaners, all have had to drastically reduce the number of psychiatric trainees since the 1970’s. National leaders in child psychiatry have sadly and wryly joked that we are not training enough child psychiatrists to replace our specialties’ retirement and death rate, and this is apparently true. So what is one consequence, and this is almost unbelievable and a sad comment on what the profession has informally, individually done to compensate. Many child psychiatrists NEVER retire until they die or become too infirm. I have former supervisors that are in their 80’s and still teaching, supervising and seeing patients! And I am 67.
My cruel joke in response to this state of affairs goes something like this, “Next time you see your kid’s child psychiatrist, wake him up from his semi-demented slumber and thank him for still being there.”
When Patrick Kennedy was still a congressional representative from his home district before he relapsed very publicly with an intoxicated driving infraction, had to go back into residential treatment and then did no run for Congress again, he had introduced the most ambitious and comprehensive bills in at least 30 or more years to address the mental health care provider shortages in this country that have been worsening as the nation’s population has increased, research showing now that at least 10% of all adults have psychiatric, emotional, psychological, substance abuse or other mental health issues that NEED but are not receiving treatment and the numbers of mental health providers of most levels and professions have been steadily declining. His bill has languished in Congress now for ?four years without action until the recent crises of school shootings, mass shootings, more and more mental health related tragedies on the streets, in correctional facilities, the attempted murderous stabbing of Virginia State Senator Craige Deeds whose known schizophrenic young adult son Gus, who shortly after the incident himself suicided. All these and many other more openly reported neglected mental health related tragedies have finally galvanized our ossified special interest dominated politicians into realizing they had better do something. For further background information on this development please use this link: Need for Child Psychiatrists Gets Congressional Attention.” It has a link to the text of the Child Health Care Crisis Relief Act of 2007″ which is worth reading. Sadly this bill has been in Congress since before 2005 when it was introduced by the former Rep. Patrick Kennedy (D-RI) himself an openly known bipolar person with an also well known recurrent substance abuse problem. He left Congress after that term when he had a very public relapse episode in DC with an impaired driving incident and decided to return to his treatment center and restitution of his recovery efforts. Unfortunately without his subsequent leadership after his leaving Congress and deciding to work in the public advocacy sector, his bill has suffered and languished. Fortunately though it has been picked up and re-invigorated by the Congressional Mental Health Caucus on a bipartisan basis by Rep. Grace Napolitano and Rep. Tim Murphy. It appears now that the bill will garner renewed support and have a chance of passage and starting to repair and replenish our training pipelines and programs in all the mental health disciplines. It is noteworthy that even though this bill singles out for emphasis the most serious shortage, that of child psychiatrists, it also offers new supports to training programs of other disciplines as well. This is welcomed by all and there are no turf battles here, we child psychiatrists need the supportive collaborative work of more of the other mental health professionals to be addressed in House Bill 1106 as former Rep. Kennedy’s bill is titled. The link to the complete current text of this bill is here: House Bill 1106: Child Health Care Crisis Relief Act of 2005.
The Mental Health Reform Blog 