Shortage of Child Psychiatrists

Several weeks ago I was incredibly saddened by the news from a colleague and dear friend of mine, also a Duke child psychiatrist, that one of our mentors had passed away in his mid-80’s. He meant so much to me, I wish to mention and memorialize his name in my own little way in this humble esoteric blog. He was Dr. Marc (Marcelino) Amaya (with ‘Amaya y Rosas’ being his full last name).

He was one of the original child psychiatrists in a group that came down to Durham NC from Northeastern training centers to help start the department and to staff it. The other faculty was as were in all major medical centers of the last 50 years, superb instructors and fantastic clinicians that often left us rookies with our veritable mouths open at their insights.

Dr. Amaya started a complete children’s psychiatric hospital I think in the early or mid-1960’s to house what Duke could not offer on its grounds because it was private and not state affiliated and for funding issues. The Children’s Psychiatric Institute (CPI) was a fabulous training center on the level of such other state hospital affiliated and also lesser known than the more celebrated upper crust programs, but every bit as good as any of the Ivy League (Boston, NYC, Philly, etc.) centers such as the late and venerated Dr. Ralph Rabinovich of the University of Michigan at Ann Arbor. CPI has a short term and long term outpatient clinic, a family therapy program that was expanded by this writer and one of the veteran incredibly skilled social workers at CPI, Anne K. Parrish ACSW, LCSW, into a training program for child mental health trainees from Duke and UNC-Chapel Hill medical and graduate schools. Dr. Amaya was a superb supervisor and I always learned untold concepts, techniques, and gems at his feet so to speak. I also accompanied him to the testify in the Golden Days of Psychiatry and Psychology in this country to testify annually before the NC General Assembly (state legislature) as we would advocate for our state funded programs, but also for the private inpatient and outpatient programs at Duke and UNC! So there we would be harassing clinically and statistically the legislators (who in those days seemed to listen better..no matter their party affiliation). It was quite ironic but demonstrated the dedication that Dr. Amaya had to the delivery of mental health services to ALL children of the state and to any agency, institution, training program that was trying to provide such. His program was not his first concern in the statewide scheme of things, it was just another important part of the overall system of resources he foresaw for the state decades before some of them came into existence. He was a short man with a lyrical Hispanic accent that I as a Southwesterner could listen all day long and always feel like, when I was with him, I was a little bit ‘back home’ in the Southwest.”

Continue reading “Shortage of Child Psychiatrists”

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South Dakota Illustrates the Shortage of Psychiatrists

A recent and typical article in the South Dakota newspaper, the Argus Leader, “Psychiatrist shortage worsens court bottleneck,,” sadly but truthfully illustrates one of the worst reasons for one sector or causative reason for one aspect of the mental health crisis of delivery of services in this country in all sectors, public and private, inpatient and outpatient whether clinic or private office based. There is a tremendous shortage of shortage of psychiatrists in this country. This issue has been building for over 30 years!

It started when the ability of hospitals and training centers for many kinds of residencies in subspecialties in all aspects of training of “residents,” who are doctors in training in specialties such as family medicine, pediatrics, OB=Gyn, general surgery, psychiatry, internal medicine, and even the subspecialties such as all kinds of cardiology (interventional, electrophysiologic), pediatric surgeries (orthopedic, neurosurgical) dermatology, endocrinology, all the subspecialties in radiology etc. This obviously stupid development came about when during the Reagan administration, Congress in its misplaced attempt to do something about Medicare and Medicaid fraud, thought that training centers should be allowed to transfer (divert was pejorative condemning word that was  back then to convey some kind of behind the the scenes skullduggery in money manipulation) those revenues to help fund training programs.

Now it must be understood that ALL training programs in medical residencies are expensive. Residents have to have salaries to live on, though they have always been just enough to make ends meet especially if you have a family…and residents are NOT paid wild, glorious fantastic salaries and live the good life, driving Benz’s, Beemers and Lexus’es. They drive used cars (I sure did for years, but the truth being I do anyway as my motto became with bunches of daughters in 2 different cohorts and one later adopted son, “Never Buy Retail.” Buyin Easter shoes for all the girls annually was something we saved for after the Christmas-Hanukkah holidays and even then we shopped at place called “Discount Shoes,” which was almost a 200 drive away from our home in Durham so we could afford the Easter “pony shoes,” as I jokingly called them for the feminine horde.

Residents in training also generate very little revenue from their clinical work. In the old days (imagine old man reminiscing vocal sounds and harrumphs in the background), residents at least in surgery could be billed to insurers including Medicare and Medicaid as “assistant surgeons,” and generate some lower fees which helped. This disappeared under the new punitive regulations until residents in the surgeries and other specialties that had procedures they could charge full rates for. That circumstance would typically come legally at the end of their training when they were “chief residents,” could function autonomously and ran the lower level residents and interns’ services, scheduling, teaching, assigning patients, reviewing work-ups, approving studies, in other word, the junior attendings. In this way the essential supervision of all residents lower than the chief, was handled and parcelled out at different levels and handled as appropriate to the training of the resident, by the resident one year ahead of the next resident. It worked for deacdes since the aftermath of the “Flexner” report which occurred in 1910 or so. It catalogued the incredibly sad state of medical training then in the USA and proposed virtually the entire modern training system we have today. It was a masterful work of presience with Dr. Flexner foreseeing what would be needed to train doctors to high standards, generally how to involve modern developments not even dremaed of then and legislate firm, universal standards of training at all training centerss. For instance courses were standardized and required, and another telling example is that surgery residents started to have to keep verified surgical diaries listing all the procedures they had performed, assissted in, and observed throughout their residencies. Even now these have to be reviewed and presented at the time being considered for board certification.

In psychiatry things were different as they always were. With the exception of psychological testing, psychiatry had no expensive, bodily invasive medical or surgical procedures that could be charged for with nice high fees. Psychiatry residents in training even in wealthy settings such as Cambridge, San Francisco, Westword in LA, the tony areas of New York City bordering Central Park, Ann Arbor, Chicago, Georgetown in DC, mostly had patients who were poor, had little or no insurance, even Medicaid especially in the early days of Medicaid. And when insurers began to pay for psychiatric services, they were paid for at the discriminatory rate of half, 50%, of medical/surgical rates. And so the residents in psychiatry did not generate enough monies to pay their own expenses to their training programs, office, staff, salaries and especially the time of their superising psychiatrists. Although youger pscyhiatrists in training always had psych resident mentors above that offered peripheral supervision, formal superision was conducted by one’s supervising faculty psychiatrist. It was very expensive, given the nature of what the psych trainee did, which was an interview. The supervision onsisted of the faculty psychiatrist who followed the case as long as the trainee treated the adult, teen or child, heard all the “material,” and then taught, offering advice how to interpret, how to supportively interview, how to form all alliance, how to foster self insight, how to help the person effect and move to real points of change in their lives, how to see them through crises in their lives. And of course, all the ancillary social issues were handled and learned as well, what to do with substance abuse, dysfuntional families and marriages, deaths and losses and on and on.

The point is that training of psychiatry and psychological Ph.D. level mental health clinicians was and still is tremendouls costly. Some experts estimate that until recently with the coming monies from the former Congressman Patrick Kennedy’s and other’s reparative training fund bills for the mental health professions, that some 80% of training funds nationally disappeared.

So what happened; by the end of the 1980’s training programs closed, not many but a fair number. Most reduced staffs and residents, especially the latter by half or more. My own program reduced the number of residents by 2/3.

All the big cheese observers of the “psychiatry scene,” especially but also all the other mental health discipline began to complain, then warn, then project the coming crisis of shortage of mental health provider crisis with astounding statistics and then starting to scream from the national battlements (a la the battlements of the French Bastille in my fertile imagination). We were not replacing the measley 6,500 or so child psychiatrists we used to have TOTAL in this country by the 2000’s. Those that died or retired were lost to service and most of the time communities did not have replacements.

My own experience with this was telling. In 2006 i lost my psyhiatry partner to a terminal diagnosis of cancer in a close member of his family. He was in his mid 70’s and decided to retire, moved with his wife to be near their family. This was an unexpected and rapid necessary exit from our practice but it left me in the veritable “lurch.” Our practice was an almost half child oriented practice. At the time mental health reform in NC was a true disaster mostly because it was in the middle of its development, little was finished or formed or ready in the new outpatient service delivery structures across the state. Long term employee professional of the local county or combined several county mental health centers were told they had to re0\-apply for their positions, including the Ph.D.’s and MD’s. So what happened in our town was typical; all three lady child psychiatrists left within two months and there were no practitioners other than me for the entire country. I worked for two years trying to recruit another child psychiatrist to come to my practice. I thought the prospect of the magnitude of the immediate need would surely attract someone. I recall telling several visiting candidates, ‘Don’t worry, you’ll be full in one or two weeks. guaranteed.” They all had better offers elsewhere in the medical centers or big cities. I worked two years on Saturdays and Sundays seeing and caring for the public mental health center county kids, and finally truly “burned out,” something I thought would never, ever happen to me! I finally had to face reality and closed my practice of many years and took a salaried job, but a wonderful one working as the first psychiatrist on the Cherokee Qualla Boundary Indian Reservation, my wife’s ancestral home. It was wonderful for both of us and my wife was able to return to her childhood home and be with all her relatives especially her elders. I worked my contract and helped to find a Native American replacement psychiatrist finishing psychiatric training (there was only one in the entire country) and persuaded him to come and after nearly five years’ development work there, my work was done and I then faced my now olde rage ‘category-status’ and decided to return to my original first rotation at my training residency and become a state hospital psychiatrist and “give something back.” However, slightly selfishly this state hospital offered a full range of psychiatric residency teaching opportunities that made me “teaching self” water with great anticipation since it took residents in psych rotations from several medical schools. But it so doing I in effect contributed to the growing shortage myself of psychiatrists in the country.

So what does all this have to do with South Dakota? South Dakota has a smaller population and only one state hospital. It has had even FAR worse problems staffing their one hospital with psychiatrists and has had to close beds the last one or two years because of lack of coverage or clinicians to treat them.

But as in the rest of the country the huge new influx of “legal patients,” has swamped the hospital, doing as this near tsunami of “incompetent to proceed” to trial patients has done is almost ALL the other state hospital hospitals [including my own], taken beds always for ordinary psychiatric patients in crisis.

The result as this article typically reports patients have been stranded for days to weeks in ill equipped small community hospital ERs, waiting for an acute admission bed to ‘open up.’ This practice is so widespread in the country that it has acquired a convenient name, “psychiatric boarding,” or just plain “boarding.” In some states, advocacy organizations have sued states and their hospitals for such practices. It is a widespread problem with presently no real solutions. Most state legislatures are not willing to fund and construct the many dozens or hundreds of beds that would accommodate these legal patients so they are treated and accepted first by the admissions units of the state psychiatric hospitals who have NO choice but to do so because these patients are court ordered.

I will take the liberty and quote three paragraphs from the above referenced article to illustrate the problem as it currently bottlenecks both the inpatient psychiatric hospital’s mission and obligation to treat its patients and the legal system that must observe and uphold the constitutional right for a defendant to be able to understand and participate in a capable manner in their court proceedings and to fully cooperate with their counsel.

From the Argus Leader, “A shortage of psychiatrists in South Dakota is hampering efforts to address a bottleneck for court-ordered mental health evaluations in the state.

An Argus Leader Media investigation found mentally ill defendants were jailed for half a year or more as they waited for exams to determine whether they are competent to stand trial.

The state’s mental health hospital says it is not responsible and does not have the resources to conduct all of the exams, and that’s forced counties to seek out private psychiatrists to help manage a surge in criminal cases involving defendants with mental illnesses.

The problem is that few private practitioners in the state are qualified…”

Finally, to close out this long winded treatise on the shortage of psychiatrists, I will further take the liberty to quote the Argus Leader’s data in this article which gives startlingly information on how understaffed the entire state is with (or if you prefer from a pessimistic standpoint) without psychiatrists, the following passages will delineate the dimensions of the shortage that exists NOW:

“A Kaiser Family Foundation analysis this year found South Dakota has enough mental health professionals to meet only about 15 percent of the need for services in the state. There were an estimated 30 psychiatrists statewide in 2014, according to the U.S. Bureau of Labor Statistics.

The South Dakota Department of Labor and Regulations puts its estimate at just 20 psychiatrists statewide.

Based on BLS and Census data, South Dakota has fewer than one psychiatrist for every 30,000 people, one of the lowest ratios in the region.”

At the end of the article, the author listed the relative ratio’s of psychiatrists per 100,000 persons in 2014 that last year for which such data was fully available. These statistics are woeful as one accepted statistic commonly accepted for urban areas is ONE psychiatrist per only 3,000 people to 30,000 persons at most. The Midwest illustrates its serious shortage more than almost any area of the country. But all areas have them, except by and large cities in which there are one of more medical schools and concentrations and availability of specialty training programs.

Psychiatrists per 100,000 people, 2014

Nebraska   3.2

South Dakota  3.5

Iowa  4.8

Minnesota  6.6

Wyoming  6.8

Montana  11.7

North Dakota  Data not available

Sources: Bureau of Labor Statistics, U.S. Census Bureau