January 2007 | Back to Table of Contents
Feature
Freudian Slippage
By Cathy Madison
The diagnosis was blunt and painful. “The shortages of psychiatrists and of inpatient psychiatric bed capacity in Minnesota represent a crisis in the care of Minnesotans with mental illnesses,” a Minnesota Psychiatric Society (MPS) task force report intoned in 2002. That’s why a teenage girl who hinted at suicide to a friend was held for three days, then transported to a distant facility, when all she needed was a thorough assessment by a specialist. It’s why troubled patients in Winona and Mankato wait up to six months for an outpatient appointment. And it’s why friends and families of loved ones who need help are forced to ask the simple question: Where are all the psychiatrists?
Minnesota has 710 licensed psychiatrists, only 512 of whom provide direct patient care, according to the MPS. That number is up slightly from 490 in 2002 but still is 33 percent fewer per capita than the national average. Yet demand for mental health services continues to rise rapidly; the MPS noted a 16 percent increase in inpatient psychiatric and chemical dependency visits and a 39 percent increase in emergency visits between 1997 and 2001. Today, 70 of 87 Minnesota counties meet federal criteria for mental health professional shortages.
By 2010, the state will need an estimated 907 psychiatrists, assuming the national average remains at 16.5 for every 100,000 people. When, according to the U.S. Surgeon General, more than one in five Americans are affected by mental illness, a specialist shortage is indeed a crisis. Worldwide, psychiatric or addictive disorders account for five of the 10 leading causes of disability and more than 15 percent of the overall burden of disease—more than cancer.
In Minnesota, more than a million residents potentially need mental health services. Yet the current psychiatrist population is aging—their average age is 54—and will soon face retirement decisions. Only 93 residents are in training, and if past experience is a guide, many of those will choose to practice in warmer or richer climes. It’s no wonder many are asking: Is psychiatry an endangered specialty in this state?
Minnesota Psychiatric Society past president Eric Larson, M.D., says no. “It’s not a dying specialty at all,” he claims. In fact, it could be a specialty that is just coming of age. “Lewis Thomas once called medicine the youngest science. Well, psychiatry is the youngest science in medicine, one we’re just now learning how to study. You can stick a probe into the heart, but you can’t stick a probe as easily into the brain.”
To be sure, neuroscience is medicine’s frontier, accounting for most of the past decade’s scientific breakthroughs, from genetic mapping to brain-imaging technology. The intellectual challenge of such progress might entice some medical students to enter the field. But as Wayne Fenton, M.D., Regina James, M.D., and Thomas Insel, M.D., from the National Institute of Mental Health in Bethesda, Maryland, wrote in an article on the state of the specialty published in Academic Psychiatry in 2004: “To a substantial degree, the stunning advances we have seen in basic neuroscience have yet to be translated into innovations in clinical care.”
Research aside, the field of psychiatry seems plagued by anachronism on many counts, from thorny economics to public perception to the chasm that separates supply and demand. Past practices and ways of thinking simply haven’t caught up with present realities. Despite a growing need that should drive demand and numbers up, for example, psychiatrists don’t earn enough money or respect to keep their ranks filled, especially in Minnesota.
Why here, in particular? Some speculate that the early advent of managed care in the state coupled with the propensity of health plans to dissociate mental from physical health caused a quiet but profound exodus of psychiatrists years ago. Now psychiatrists everywhere face the same challenges, and Minnesota is still coming up short. Training programs are not full. Rural areas fail to attract specialists of any kind. And with demand for psychiatrists high everywhere, long cold winters don’t help keep them here.
Multiple Disincentives
For many medical students, the biggest disincentive for selecting psychiatry is economic. “The decline of psychiatry in general in the U.S. is related to payment,” says Roger Kathol, M.D., MPS president. “The support for services nationally is marginal at best, and the hassle of getting paid is more than in other medical specialties. Even if students are interested in going into it, there’s not a great deal of incentive to pursue it.”
The first blow is the daunting cost of education. Four years of medical school, four years of residency, and possibly more years of fellowship (residents can subspecialize in child and adolescent, geriatric, addiction, psychosomatic medicine, or schizophrenia psychiatry) more than max the credit cards. In May 2006, the American Medical Association found that nearly one-third of U.S. medical residents shouldered debts of more than $150,000. Of those so burdened, nearly half said that such heavy debt influenced their specialty and geographic choices.
The next blow is the even more daunting challenge of repaying debt within a reasonable time frame. Compared with other specialties, psychiatry is at the bottom of the compensation scale. According to the Medical Student’s Resource Guide, psychiatrists earn an average of $142,610 a year, compared with cardiologists ($283,298) or even neurologists ($186,653).
Low salaries are the product of a reimbursement system that psychiatrists uniformly say is dysfunctional. Not only are reimbursement rates lower than for other specialties, but insurance plans also separate mental health services from other health services, requiring both doctors and patients to navigate different payment systems. Medicare pulled the first punch decades ago by limiting psychiatric outpatient payments to 50 percent of its fee schedule, compared with 80 percent for services performed by other practitioners. According to the MPS’s 2002 task force report, Minnesota psychiatrists are paid 10 percent to 40 percent less per unit of service than primary care physicians. So while demand for services was rising, the percentage of health insurance premiums that went to mental health reimbursement dropped 16 percent between 1998 and 2002.
Even if they’re willing to accept low pay, potential psychiatry residents must also wrestle with the longheld disdain for the profession, a stigma that still dubs them witch doctors, kooks, and shrinks. “There’s no question that science in psychiatry has progressed phenomenally in the past 50 years,” Kathol says, “but we’re living with some of the older thoughts about it—that it’s hocus pocus, that nothing works, that people are just weak-willed.” Those who hail from elsewhere, such as Harvard-trained Michelle Wiersgalla, M.D., who supervises Hennepin-Regions psychiatry residents at Hennepin County Medical Center, notes that the perception problem can be particularly acute in the Upper Midwest. Woody Allen isn’t one of us, after all; stoic Scandinavians aren’t accustomed to casually sharing their therapy experiences at lunch.
Tom Mackenzie, M.D., director of the University of Minnesota Psychiatry Residency Training Program, admits that students may find such negative attitudes, however old-fashioned, discouraging. “What does psychiatry amount to if those we are taking care of are really morally weak, if we’re just structuring an institutional excuse for them or giving them license not to suck it up?” he asks.
Finding a Match
Mackenzie characterizes the field as “amorphous and challenging,” which must appeal to some, at least; the number of applicants to residency programs is increasing. Yet the total number of Minnesota psychiatry residents in the state’s three programs has remained relatively stable for the past decade. Mayo Clinic College of Medicine has about 30 residents in a program that could accommodate 35. It can admit nine a year but filled only eight slots last year. Mackenzie’s program is approved for 33 but only offers six or seven new slots per year, depending on available stipends.
“We’re almost always not able to fill at match time,” Mackenzie says, although he points out that his program did fill in the past few years. The National Resident Matching Program also reports a slight uptick in medical school graduates applying for psychiatry residencies. In 2002, 957 positions were offered and 907 filled; in 2006, 1,037 were offered and 983 filled. Foreign medical graduates filled about a third (340) of those positions.
International graduates figure prominently in the Hennepin-Regions Psychiatry Training Program, which currently has 20 of its 24 slots filled. Director Benita Dieperink, M.D., is pleased that applications from both international and U.S. medical schools are up more than 40 percent from last year and that so many of her residents come from diverse backgrounds. “I think it’s a wonderful thing because they’re more in step with the face of our actual patient population,” she says.
Christina Frazel, M.D., a Hennepin-Regions third-year psychiatry resident, says her positive experience during a med school psych rotation, combined with the explosion of brain research, drew her to the field. “There are so many directions to go at this point—research and clinical applications—and the intellectual piece of it really interested me,” she says. Another aspect that influenced her decision was the connection factor, which she considers one of the field’s major perks. “I enjoy the opportunity to feel like I can really talk with my patients. It’s very rewarding to help somebody feel better about who they are as a person. With good mental health, patients take better care of their physical health, too.”
Helen Wood, M.D., a University of Minnesota third-year resident, concurs. Whereas other specialties have gotten perhaps too specialized—are there really cardiologists who deal only with left ventricles?—psychiatry deals with the whole person.
“There’s something about a patient feeling validated by just being listened to. I don’t see that in other specialties,” she says. “It’s great helping with diabetes or hypertension, but this is different from looking at a number on a sphygmomanometer. It’s one thing to get blood sugar down and another to hear a patient say, ‘I feel happy again and I never thought I would.’”
Systemic Changes
Honoring this holistic view of patient health—and understanding that addressing mental health issues will ultimately cut costs by reducing emergencies and improving compliance—may be the key to reinvigorating interest in psychiatry as a medical specialty. But the significant and essential systemic changes in reimbursement and care delivery models may be long in coming. “I shouldn’t be skeptical because there are things being done. But to be polite, it’s very early in the process,” says Kathol. “One of the major problems is that psychiatric illness is separated from the rest of medical illness. That creates an artificial barrier, as if mental health isn’t a part of health. That barrier makes it more difficult to support [psychiatry] because it’s out on its own, while the rest of medical practice is part of a big conglomerate.”
L. Read Sulik, M.D., medical director of child and adolescent psychiatry at St. Cloud Hospital Behavioral Health Services, says that separation of mental from physical health is a fantasy, “an experiment that has failed miserably. The need to integrate mental health care is one of our highest priorities. Finally, the leaders of significant medical societies are beginning to recognize the importance of collaborating and integrating our services in the care of patients.”
That primary care doctors often treat psychiatric symptoms is without question; they prescribe some 70 to 80 percent of medications such as antidepressants, Kathol says. But because they have neither the time nor the skill to carefully monitor patient progress, success rates are marginal at best. That’s where specialists come in. “A number of studies show that when primary care doctors work with psychiatrists, with backup and support, good outcomes can and do occur,” he says. Apparently, the approach is working in St. Cloud as well as at Mayo’s family practice clinic in Kasson and at the Duluth Clinic.
Few worry that psychologists, social workers, and primary care physicians will replace psychiatrists in providing comprehensive mental health care. Indeed, the demand for services is so great that there is plenty of work to go around, and the skill set each professional provides is an important piece of the whole. “We should also be educating primary care physicians in this field. They’re treating these patients already, and we could help them get better at it. That would improve care and spread our expertise around more widely,” says Larson.
Meanwhile, psychiatrists would do well to stay on their primary care toes. Although psychiatry is not a primary care specialty, it often functions that way. “We’re often the only doctor patients see with any regularity. Mentally ill patients are far less likely to access regular health screening or have contact with primary care physicians,” Dieperink points out. Not only should psychiatrists be tuned into a patient’s physical health needs, but they also should acknowledge their special role as advocates for the health needs of the population, she adds.
So how to bridge the growing gap between the need for services and the supply of psychiatrists? Many of these professionals do what they can to mentor mental health students and residents, educate the public, and advocate for reform. But most agree that what will help most is money: more scholarships, loan repayment or forgiveness programs, Medicare reimbursement changes, and health plan overhauls. Gov. Tim Pawlenty’s 2006 Mental Health Initiative attempted to address Minnesota’s psychiatrist shortage by pledging more than $10 million, including a 23.7 percent increase in reimbursement rates for psychiatrists and other mental health professionals, beginning in 2007. But it is too early to tell how much impact these changes will have on individuals, or whether they will be enough to encourage newcomers to enter the field.
Surprisingly, perhaps, today’s professionals remain cautiously optimistic. Mackenzie hopes that the university’s push to become one of the world’s top-three universities will enhance neuroscience research, thereby attracting top faculty and students. Kathol hopes that the reimbursement disincentive will gradually disappear and that psychiatry will become just another medical specialty akin to surgery, pathology, or ob/gyn.
Dieperink is realistic. “There are challenges. There really is a mental health crisis in this country for both adults and children. On the flip side, it’s an interesting and exciting era. We’re recognizing the mind-body connection, tuning into patients’ emotional needs, and acknowledging the impact of emotional problems on physical health,” she says. “I think the spirit of the field is actually very strong.” MM
Cathy Madison is freelance writer in Minneapolis.
The Kids Aren't All Right
Children have an even more difficult time than adults getting psychiatric care.
If psychiatrists are rare in Minnesota, child and adolescent psychiatrists are even rarer. The average number of child psychiatrists per 100,000 people in the United States is 6.73, compared with only 4.6 in Minnesota, the Minnesota Psychiatric Society (MPS) said in a 2002 task force report. It wasn’t many years ago that Abbott Northwestern Hospital’s child and adolescent unit in Minneapolis was turning away two to 10 patients a week during the winter—not because they lacked beds but because they lacked doctors. The busy psychiatrists employed there were taking call every third weeknight and one weekend per month, and recruitment efforts were failing.
As with psychiatry in general, demand for child and adolescent services is soaring. A 2002 survey conducted by the Minnesota Hospital and Healthcare Partnership reported that between 1997 and 2001, demand for emergency mental health treatment for children younger than 14 increased 49 percent. For adolescents ages 15 to 20, demand for treatment went up a whopping 68 percent. Everywhere, it seems, anxiety and depression are rampant.
“Our world is a completely different place for children and families today. It just is. And we’re not doing what we need to do,” says L. Read Sulik, M.D., medical director of child and adolescent psychiatry at St. Cloud Hospital Behavioral Health Services. An advocate for change, he has helped the CentraCare Health Foundation raise more than $4 million to develop child and adolescent behavioral health services, including Clara’s House, a freestanding facility for kids dealing with mental health and chemical dependency issues.
Sulik knows well the challenges that face anyone considering this subspecialty. Not only must they continue their education beyond eight years of medical school and residency, but once in practice, they also must deal with myriad patient scenarios and circumstances.
“Just follow me in my outpatient practice on one particular day,” he says. “First I’ll see a 20-year-old college student by herself. Next I’ll go into a room with eight people—patient, foster care provider, social worker, school principal, and so on. Next it will be a group home counselor with a patient, or a patient brought in by a personal care attendant. Then a single mom with four kids.”
No other specialty requires interfacing with so many different care providers, he adds, yet that is necessary to develop a comprehensive treatment plan. His vision for the specialty includes psychiatrists acting more as consultants, especially to primary care providers who need their help early in the treatment process. That way, patients who need a higher level of care can get it on a timely basis.
“That doesn’t mean that everyone went into this field with the idea of treating the sickest people,” he says. “But we are specialists, and that is the role we have to have. Kids who need to see us now must be able to see us now.”
Sulik notes a growing recognition that child and adolescent psychiatry practice is different from other types of medicine and should be compensated appropriately. But, he adds, the current system does not support giving the best care in a sustainable way. “Sometimes it requires a lot of time, thought, effort, and energy. The system doesn’t necessarily reimburse us for that,” he says.
The focus on use of a new generation of psychotropic medications in the past few years is a case in point. Prescribing them and monitoring their use is only a first step; ongoing specialized care to assess their safety is also required. No psychiatrist can sit in a room without also providing behavioral and cognitive therapy, he says. He cites antidepressant trials that required every patient, whether on medication or placebo, to spend 30 to 60 minutes each week with a doctor; the results showed placebo rates as high as 60 percent, which means that the healing power of support and talk therapy should not be discounted.
Sulik and others suggest that treating children and adolescents carefully and well might help reduce the need for adult mental health services down the road. As the world becomes yet more stressful, all of us must learn how to cope. As Sulik sees it, “There’s a huge need to be thinking about how we can prevent depression and anxiety disorders in kids.”—C.M.
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