Healthcare's silent shortage

The demand for psychiatrists hit a record high in the past year, according to physician search firm Merritt Hawkins, a division of AMN Healthcare.

Psychiatrists were the third most-requested type of physician to recruit, behind family medicine physicians and internists. Much of this demand stems from a larger need for behavioral health professionals, as the nation's 30,088 psychiatrists in practice must collectively care for the nearly 13.6 million adults living with a serious mental illness.

But it's not just that. What makes this shortage especially pronounced is that psychiatrists are not evenly distributed around the country. In Texas, for example, there are 185 counties with no psychiatrist, according to Merritt Hawkins. As of April 2014, there were 3,968 mental health professional shortage areas nationwide, meaning there were nearly 4,000 areas with less than one mental health professional to every 30,000 residents, according to the Kaiser Family Foundation. To eradicate those mental health HPSAs, the U.S. would need 2,707 more practitioners.

We spoke with Travis Singleton, senior vice president of Merritt Hawkins, to get the scoop on the demand for psychiatrists. Here Mr. Singleton goes into depth on the firm's recent physician recruitment study, why mental health is suffering a "silent shortage," and what hospitals and health systems can do about it.

Question: The demand for psychiatrists skyrocketed this year, and it was more in demand in the last 12 months than in the last 27 years of the report. What caused this sudden spike?

Travis Singleton: The demand for psychiatrists has been a steady, huge spike for last three to four years. It's not new — unfortunately it didn't sneak up on us — we just didn't address it before. It's very difficult to get young physicians to go into psychiatry. We are seeing that in all fields of mental health. Not only do we have maldistribution problems in rural areas, but psychiatrists are also in the wrong setting. They are typically looking for urban, outpatient settings, but the greatest need is in inpatient psychiatry.

In the report, demand was calculated in two different ways. Mental health specifically is one of the largest specialties out there, so demand based on the number of search assignments in this field will also be among the greatest. We also reported absolute demand, or the demand in relation to its own specialty size. Even with the recalculation, family medicine and psychiatry were most in demand. Though the specialty is big, the demand is still enormous. I don't see that going away in the next two to three years.

Q: Psychiatrists were second to family medicine physicians and internal medicine physicians in terms of search requests. Given the demand for those specialties, why do you feel it is important to highlight the demand for psychiatrists?

TS: With primary care, there has been a dulling of the headlines. The restructuring of our healthcare system in terms of reimbursement, team-based care and population health means we are at least talking about the need for primary care physicians. Our fear about mental health — this not the case.

[Mental health] can be one of the most misdiagnosed and under-diagnosed fields in medicine. If you twist your knee and need to get it fixed, our healthcare system funnels you where you need to go. Mental health isn't quite so clear. Patients who are misdiagnosed or not diagnosed at all and sent back out into the general population could spark other issues. It's still flying under the radar, and that's what scares us most.

Q: The study shows psychiatrists are also among the top specialties with the most practitioners over age 55. Why aren't young physicians choosing this specialty?

TS: We know some reasons and we can guess on others. Even though compensation is not the worst, it's not going to compare with other surgical and procedural based specialties. There is certainly something to be said as well about the employee morale of mental health and psychiatry workers. There is no endpoint in a lot of cases. It's like cancer used to be: It's very difficult to go into because you can't cure your patients and it weighs on the psyche. It can be tough on younger physicians, and when you couple that with pay that's not great and a high patient load, especially in inpatient settings, it becomes too much.

Q: It looks like compensation for psychiatry generally increased over the last couple years. Is that what you are seeing and is that due to the shortage?

TS: Over the last five years, compensation has hovered around $220,000 to $225,000. Psychiatry really has run into same problem as primary care. Demand will only push it so far. Psychiatry could be the most demanded specialty in the world, but if there is no money left in the system to pay psychiatrists, compensation can only increase so much.

Just like in family practice, we see a lot of hospitals gobbling up physicians so they are the employer, they write the check and they can maybe pay the psychiatrists more than those three- and four-man groups. Still, the way we pay doctors still hasn't changed. We are pretty aspirational in the way we talk about value-based care making more money. The reality is there is not a lot of room for the salary of a psychiatrist to up to that of a neurosurgeon's. Psychiatry doesn't make a lot of revenue, so you can't raise salaries until you change reimbursement models and stop favoring procedural medicine over diagnostic medicine.

Q: Is there anything else — besides the sheer lack of practitioners — that makes accessing mental health difficult?

TS: Everything else is a symptom of that shortage. It used to be he who dies with the most physicians wins and now it's really he who has the right physicians, engages in the right behavior in the right setting wins. Although we don't have enough practitioners, the ones we do have probably aren't practicing the type of mental health we really need.

Physicians now are quality-of-life-driven — it's not that money isn't important, but what their vacation schedule is, their control of the schedule and quality of work is more so. That's why you see an employment boom. They can say, "I come in at 9 a.m. and I know what patients I am going to see." When you get into mental health, the only setting that occurs in is urban outpatient settings, and while we need those, we are still struggling with inpatient mental health.

Q: Is there any way in the short-term, and in the long-term, healthcare organizations can help combat the shortage?

TS: Telepsychiatry and non-physician clinical providers are two ways.

Telehelath really came out of the mental health industry. That is going to be the way of the future whether we want to or not. That and psychiatrists, licensed social workers, nurse practitioners — all of those positions — are going to have to practice to the absolute limit of their skills, in a team-based effort managed by a doctor. Some groups are already there; some are not. Larger employers, mega-groups or mega-systems are going to have to be flexible with scheduling, use a compensation model that's flexible, and use locums, or part times, because mental health is notorious for flexible supply. It will behoove them to be as accommodating as they can be.

Q: The report also noted psychiatrists are among the most difficult to recruit. What about psychiatrist recruitment is particularly challenging?

TS: They are going to have to lure more residents in the profession. Some of that could just be awareness about the challenging career path, but some of that is perceived. They are going to have to start focusing that issue and use, for lack of a better term, a PR campaign.

The second part is policy. I'm not sure we can make it happen. We have seen a lot of changes — a lot we hope will be good — but we have not seen a significant policy or regulation to address supply. Until you see increased residency slots and fundamental changes, we are just putting Band-Aids on a gash.


More articles on integration and physician issues:

7 biggest challenges medical residents face
The new physician leader in maternity care
AMA to add 20 schools to its medical education transformation program

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