Post by Former NIMH Director Thomas Insel: Psychiatry: Where are we going?
At the recent annual meeting of the American Psychiatric Association (APA), a talk by Dr. Laura Roberts caught my attention. In her presentation on “living up to our commitments,” Dr. Roberts, the new chair of Psychiatry at Stanford, described a dire situation for psychiatry in 2011. While some of the most disabling and deadly medical problems, neuropsychiatric illnesses, have become the leading source of medical disability in this country1, the discipline of psychiatry is often still struggling with issues of stigma, scandal, and self-doubt.
Consider these numbers. While 37.6% of practicing physicians are age 55 or older, in psychiatry nearly 55% are in this age range, ranking as the second oldest group of physicians, surpassed only by preventive medicine. Part of this aging cohort effect is the low rate of medical school graduates choosing psychiatry. Only 4% of US medical school seniors (n = 698) applied for one of the 1097 post-graduate year one training positions in psychiatry2. As Dr. Roberts noted, it is troubling that the area of medicine addressing the leading source of medical disability is also facing a shortage of new talent. Indeed, over the past decade the number of psychiatry training programs has fallen (from 186 to 181) and the number of graduates has dropped from 1,142 in 2000 to 985 in 2008. In spite of the national shortage of psychiatrists, especially child psychiatrists, 16 residency training programs did not fill with either U.S. or foreign medical graduates in 20113.
Beyond these numbers, the profession is struggling with its identity, a theme echoed in other plenary talks at the APA meeting. Traditionally, psychiatry has been the medical discipline that cultivates a rich relationship with patients, countering suffering with empathy and understanding. But a recent article in the New York Times reported that only 11% of psychiatrists perform psychotherapy and described a psychiatrist who ran his office “like a bus station,” seeing so many patients for 5 -10 minute medication checks that he had to train himself not to listen to his patient’s problems4.
Is there a fix to these declining numbers? I think so. In fact, the change may be coming more quickly than most psychiatrists realize. Just as a new generation of chairs have taken over at many of the major academic departments (such as at Stanford, Pittsburgh, Yale, and Duke), a new generation of students is choosing to train in psychiatry. Over the past three years, NIMH has been running an annual “Brain Camp” for select psychiatry residents to give them a crash course in the most recent findings from cognitive science, neuroscience, and genetics. The residents we see at Brain Camp bring new perspectives. Many have PhDs in neuroscience. For today’s students intrigued with the mysteries of the mind, neuroscience has increasingly become the royal road to the unconscious. While these residents remain committed to the treatment of seriously mentally ill patients, today they are pursuing new venues in which to provide treatment such as in homeless shelters and jails, on battlefields, as well as globally in developing countries. While learning about the benefits of psychopharmacology and psychotherapies, they are also being taught to think critically about pharmaceutical company marketing messages and how to communicate thoughtfully with their patients in a multimedia-filled world.
A recent video module created by NIMH demonstrates the potential that a perspective in clinical neuroscience brings to psychiatric practice. “Translating Neural Circuits into Novel Therapeutics” describes recent findings elucidating the neurological basis of cognitive dysfunction in schizophrenia and how these findings may soon lead to new and better ways of treating one disabling aspect of the disorder.
Each of the last three years, we have seen more MD-PhD students choosing psychiatry, suggesting that some of the best students interested in research are moving into this field. As just one example, at Yale, where a new curriculum stresses clinical neuroscience, 12% of the graduating medical school class chose to go into psychiatry this year (relative to the national average of 4%). The Yale success may reflect their focus on teaching medical students about psychiatry as a neuroscience discipline.
The scientific foundation of psychiatry has shifted from psychoanalysis and is moving to cognitive science and neuroscience. The new generation of academic leaders recognizes the need to integrate these new perspectives with traditional psychodynamic theories, creating new training programs. Some residents in this generation are bringing an extraordinary set of tools and talents to the profession. Imagine a new discipline, clinical neuroscience that brings the best science of brain and behavior to the compassionate care of those with serious mental illnesses. Who would not want to be part of this revolution? What better way to live up to our commitments?
- World Health Organization Global Burden of Disease, http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
- AMA Physician Masterfile, January 2008
- Faulkner, et al, Academic Psychiatry, 35:1, 2011
- New York Times, March 5, 2011, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy” http://www.nytimes.com/2011/03/06/health/policy/06doctors.html