The future of psychiatry: psychiatrists of the future

OBJECTIVE: The authors' goal was to examine the changing demographic trends in psychiatry manpower. These changes have important implications for the practice of the profession in the future. METHOD: Each year, the APA Office of Membership, in collaboration with the American Association of Directors of Psychiatric Residency Training, conducts a census of all residents in psychiatry. A survey instrument is sent to the director of residency training in each U.S. program accredited by the Accreditation Council for Graduate Medical Education. Using data from this survey and from the American Medical Association, the authors conducted a study of the changes in the number of psychiatric residents over the last decade, particularly the increases in the number and percentage of women in medicine and psychiatry. RESULTS: They found that the number of psychiatric residents has grown from 4,674 in academic year 1978-1979 to 5,829 in 1987-1988, an increase of 25%. The percentage of women has increased from 32% of all psychiatric residents in 1978-1979 to 41% in 1987-1988. The largest proportions of female physicians and psychiatrists were found in the age groups younger than 35. CONCLUSIONS: Previously documented gender differences that affect practice patterns and career opportunities may very well change as a function of the increasing representation of women in the profession of psychiatry, and these changes need to be taken into account in planning for future patient care and research needs.     

Epilogue: Conversations between a psychoanalyst and a psychiatry resident

The authors discuss the importance of psychoanalytic training from the perspectives of a psychiatry resident about to begin psychoanalytic training and a psychiatrist who is a training and supervising psychoanalyst. Drs. Hyun and Alfonso discuss psychoanalytic motivations and engage in a dialogue reflecting on the relevance of psychoanalytic training in current psychiatric practice and the profession’s need for more dynamically trained psychiatrists. In doing so this article provides further insight from their firsthand experiences as to why young psychiatrists today still choose to engage in psychoanalytic training and its positive impact on their clinical practices.     

Are we training too many psychiatrists?

In contrast to the past decade's concerns about an undersupply of psychiatric manpower, the authors point out that the profession may soon be facing the prospect of an oversupply of psychiatrists. Given the present rate of producing psychiatrists, shifts in demands for psychiatric services, changing payment and access patterns regarding specialty medical care, increasing numbers of nonpsychiatrist mental health professionals, and a probable surfeit of primary care physicians, underemployment of psychiatrists may become commonplace. Future psychiatrists will likely be used more as consultants, and the profession will need fewer, but better trained, graduates. The authors present alternative proposals to deal with service needs related to such reductions.     

Stress, burnout, coping and stress management in psychiatrists: findings from a systematic review

BACKGROUND: Research into stress among psychiatrists has attempted to identify stressors, which can lead to physical illness and psychological distress. AIMS: The aim of the study was systematically to review the current evidence for the effectiveness of stress management interventions for those working in the psychiatric profession. METHOD: A systematic review of the current literature was conducted into stress and stress management within the profession of psychiatry. RESULTS: Twenty-three international studies were included in the psychiatry section of the review. Psychiatrists report a range of stressors in their work, including stress associated with their work and personal stresses. One personal stress, which psychiatrists find very difficult to cope with is patient suicide. Coping strategies include support from colleagues and outside interests. No studies evaluated the use of stress-management interventions for psychiatrists. CONCLUSIONS: Psychiatry is a stressful profession. Psychiatrists identified several stressors in their professional and personal lives.     

A survey of private practice psychiatrist's training and activity in activity in Aquitaine, France, in 1993

This study was conducted to gather information regarding the current professional activities of French private practice psychiatrists. METHOD: A mail survey was carried out in an attempt to find more about the characteristics of the 380 private practice psychiatrists in Aquitaine (south west France) in 1993. Data are reported in terms of psychiatrist's characteristics (demographics, training and practice activities), patient characteristics and trends in treatment modalities. RESULTS: There was a good response rate (55%), and this enabled us to statistically analyze the data to determine profiles of activities. For the respondents in this survey, the median age is 45 years and 30.7% of respondents are women. The portion of responders reporting a qualification in Neuropsychiatry versus Psychiatry, is low (1/7). The patients seen in private practice are generally young females with anxiety and affective disorders. An important feature was the trend for psychotherapy training and practice. Psychoanalytically oriented and individual psychotherapy were predominant over other forms of psychotherapy. Half of the psychiatrists reported using pharmacotherapy in combination with psychotherapy. There are only little differences in the practice of young and female psychiatrists. CONCLUSION: The impact of psychodynamic theories on the training of French private practice psychiatrists is still very important. Interestingly, these same psychiatrists seem to use an eclectic approach to their practice of psychiatry; about half of the respondents report using pharmacological treatments in combination with psychoanalytically oriented psychotherapy.     

Psychiatrists' attitudes toward prescribing medication for patients treated by nonmedical psychotherapists

Although many psychiatrists prescribe medications for patients whose primary therapist is a nonmedical professional, few guidelines exist for this practice. Two-thirds of a sample of Connecticut psychiatrists surveyed by mail provided medication backup services, but only one-third considered the practice generally ethical. Seventy-five percent of respondents who provided this service reported that the arrangement was initiated by the nonmedical therapist. Many of the respondents were concerned about the prescribing psychiatrist's legal responsibility for the therapist's activities, but responses suggested that few psychiatrists use a consistent method to evaluate the therapist's qualifications. The authors propose areas that need further study before professional guidelines can be developed.     

Community psychiatry—A new profession,a developing subspecialty,or effective clinical psychiatry?

Developments in community psychiatry are creating great controversy within the profession. This paper examines community psychiatry, assesses its place in the history of our science and practice, explores possible additions and modifications in residency training, and suggests possible patterns of practice. Community psychiatry is based on more than 20 years of developments within the profession. As such, there is a solid but limited base for its operation. Extensive program and basic research are essential. More psychiatrists will spend more time in the future in community psychiatry activities. Some will become specialists in community psychiatry, a subspecialty within the field of psychiatry.This paper was initially presented at a Joint Meeting of the Ohio Medical Association and the Ohio Psychiatric Association in May, 1965.     

The tipping point from private practice to publicly funded settings for early- and mid-career psychiatrists

OBJECTIVE: Practice settings for American psychiatrists were examined for recent trends. METHODS: Surveys were conducted in 1996 (N=970) and 2002 (N=917) among members of the American Psychiatric Association. RESULTS: Between 1996 and 2002 the percentage of direct patient care hours in publicly funded settings increased from 40 to 50 percent for early-career psychiatrists and from 29 to 44 percent for mid-career psychiatrists. By 2002 the percentage of direct patient care hours was higher in publicly funded settings than in solo office practices for early-career psychiatrists (50 percent versus 17 percent) and mid-career psychiatrists (44 percent versus 29 percent). CONCLUSIONS: The popular image of the psychiatrist sitting in a private office does not conform with current survey data, which show that psychiatric practice is increasingly taking place in publicly funded settings. Because it extends to mid-career psychiatrists, the shift from private office practice to publicly funded settings is not just a manifestation of early-career psychiatrists' earning a salary while building up their private practices but is a more enduring change in the landscape of psychiatric practice. The authors discuss the implications of these findings with regard to professional identity and training of psychiatrists.     

Psychiatrist-patient sexual contact: results of a national survey. I: Prevalence

In a nationwide survey of U.S. psychiatrists, 7.1% (N = 1,057) of the male and 3.1% (N = 257) of the female respondents acknowledged sexual contact with their own patients. Eighty-eight percent of the sexual contacts occurred between male psychiatrists and female patients. All offenders who had been involved with more than one patient were male. Forty-one percent of the offending psychiatrists sought consultation because of their sexual involvement with patients. The authors compare these results with those of previous surveys of psychiatrists and psychologists and discuss the need for addressing this problem within the psychiatric profession.     

The Canadian Psychiatric Association practice profile survey: I. Methods and general sample characteristics.

OBJECTIVE: To describe the rationale, methodology, and general sample characteristics of the Canadian Psychiatric Association (CPA) practice profile survey, a national survey of psychiatrists and psychiatric practice. METHOD: Mail-in interviews were sent to all Canadian psychiatrists listed in their provincial registers and to all active CPA members (total = 3628). Respondents provided general information about their professional activities for one 24-hour day and detailed information for 1 randomly selected hour. Patient information--including sociodemographics, diagnostic profiles, functioning levels, risk of harm to self or others, and disposition--was elicited for 1 patient seen during the random hour as well as for the most seriously ill patient receiving clinical services that day. RESULTS: There was a 45.5% response rate. Questionnaires completed by nonpsychiatrists or with a large percentage of missing or incorrect data were eliminated (107 surveys), resulting in a final sample size of 1570. CPA members and those from Western Canada responded at a higher rate to the survey. The results suggest some cause for concern about future manpower shortages. Most psychiatrists practise eclectically, seeing patients across the life-span, and working in both community and institutional settings. The old and the young appear to be underserviced, compared with adults. CONCLUSIONS: This study represents an important step forward in evaluating the profile and activities of the profession.     

Child psychiatry practice patterns in Ontario.

OBJECTIVES: To examine the demographics, training, distribution, venues of practice, remuneration patterns, and professional affiliations of child psychiatrists in Ontario. METHOD: In July 1997, questionnaires were sent to 229 Ontario psychiatrists. A second mailing was sent to nonresponders in the fall of 1997. The overall response rate was 66.8%. RESULTS: Compared with other research regarding the ratio of child psychiatrists to children with mental health problems, Ontario fares relatively well (1:6148). Generally, Ontario child psychiatrists report having received formalized training in the speciality. Child psychiatrists are disproportionately concentrated in Toronto and in midsize cities with medical schools compared with rural regions. Out-reach services to smaller communities are provided by 30% of child psychiatrists, but it is not clear whether the services are sufficient and equitably available. Approximately 50% of current psychiatrists will be aged 65 years or older in 15 years, and it is unclear whether sufficient numbers will replace them. The profession appears to be reaching an equitable gender representation. Most child psychiatrists belong to the professional organizations that support the profession; however, they are least likely to belong to the Ontario Psychiatric Association (OPA). CONCLUSIONS: An optimal ratio of child psychiatrists per population served still needs to be determined, with special consideration given to the needs of rural communities. The small ratio of child psychiatrists to the population of children with mental health needs highlights the importance of collaborating with other medical and mental health professionals. Recruiting and retaining child psychiatrists will need to be monitored. Child psychiatrists in Ontario need a unified voice to address these issues.     

Termination of psychotherapy: a training perspective

Given the constraints of the prevailing mental health system in the United States, it has become very challenging for psychiatrists to offer psychotherapy services to patients in need of this modality of treatment. In spite of this situation, the profession has made a consistent effort not only to retain this type of psychiatric care but also to train psychiatric residents in this psychiatric intervention technique and its appropriate indications. In this article, the authors highlight a very important aspect of psychotherapy treatment-the termination phase. They review relevant literature on this subject, discuss some of the most common problems faced by psychiatrists, especially psychiatric residents, when addressing the termination phase of psychotherapy, and then present two cases to illustrate these issues.     

Psychiatry in public service: challenge of the eighties.

Contrary to popular opinion, there are now more psychiatrists in public service than ever before. Psychiatrists' contributions in this area have been masked by a decreasing growth in the total number of psychiatrists, the simultaneous expansion of other mental health disciplines, and the proliferation of mental health treatment facilities. The authors examine the reasons for the decline in the over-all growth of the profession and describe some new federal initiatives to encourage more American medical graduates to specialize in psychiatry and to work in traditionally underserved areas in the public sector.     

Burnout and psychiatrists: what do we know and where to from here?

Medicine in most parts of the world is becoming a stressful profession. Psychiatrists represent a high-risk group among doctors for experiencing burnout, alcohol and drug use, posing suicide risk and other forms of work-related stress. There are reports that entrants in the profession of psychiatrists are decreasing globally. Conceptual issues related to burnout are explored and factors contributing to burnout in psychiatrists are reviewed. Methodologically sound studies are needed to help us understand positive aspects of psychiatry as a profession and the environment psychiatrists work in. Effective treatment programmes for burnout are also needed not only to reduce suffering but also to retain psychiatrists in the profession.     

Private psychiatry in Switzerland

INTRODUCTION: Two-thirds of Swiss psychiatrists are engaged, either exclusively or partially, in private practice, a proportion that is higher than in other countries. METHOD: A questionnaire survey of 1000 psychiatrists was carried out. RESULTS: Psychiatrists in private practice display a greater degree of clinical activity, mainly with individuals, than do psychiatrists employed by public institutions; and they work principally within two practice profiles, psychoanalytical and generalist, and much less in the biological profile. They show a preference for the psychological model, mostly in a psychoanalytical orientation. Psychiatrists who have a mixed privatepublic practice &#45 more than half of them &#45 are even more psychoanalytically oriented than psychiatrists working exclusively in private practice. They act as an interface between the public and private sectors, playing a pivotal role as guardians of psychoanalysis, proclaiming its principles to psychiatric residents. CONCLUSION: With the transformations taking place in the health care system, new care concepts are being developed, there is a wider variety of theoretical orientations, and the profession is therefore undergoing substantial changes. ( Int J Psych Clin Pract 2000; 4: 227 - 232)     

A program of research training in psychiatry: ten-year evaluation and follow-up.

Nineteen psychiatrists who participated in the research training program at Boston University School of Medicine from July 1962 to June 1972 were surveyed by questionnaire to determine how participation in the training program may have affected their subsequent professional careers. Results indicate that-probably via a happy combination of self-selection, screening, and the actual experience of research training-these 19 psychiatrists constitute an impressive group who are active in research, publish extensively, and assume substantial teaching responsibilities at medical schools. The authors suggest tha a postresidency program in research training can be extremely important to the development of careers in psychiatric research and to a more scientifically grounded profession.     

Australian psychiatrists today: proud of their profession but stressed and apprehensive about the future

OBJECTIVE: To examine the levels of satisfaction and stress of Australian psychiatrists. METHOD: A survey was mailed in December 2002 to all Fellows of the Royal Australian and New Zealand College of Psychiatrists residing in Australia; 1039 out of 2059 (50%) returned the questionnaire. RESULTS: The large majority of respondents (79%) were proud of being a psychiatrist. Most (88%) reported being satisfied with their work. Reasons for dissatisfaction varied between public and private psychiatrists. Private psychiatrists nominated litigation/indemnity issues as the most frequent (69%) while the most common for public psychiatrists was lack of beds (47%). The main reason for satisfaction was helping patients get better (72%). Sixty-two percent found their work in the previous 12 months to be stressful. Dissatisfied psychiatrists were 11 times as likely to report being stressed as those satisfied. In the previous 12 months, 34% reported having had a threat of legal action, 39% had to answer a formal complaint, 67% had been verbally or physically abused by patients or relatives and 29% had patients who had suicided. Overall, psychiatrists were more pessimistic about the future than optimistic and 15% said they would not do psychiatry again. There were few differences according to state of origin or type of practice. However, females differed from males in several areas. CONCLUSION: Helping patients was reported as the main source of satisfaction for Australian psychiatrists while not being able to provide the best care for patients was described as one of the main reasons for dissatisfaction. Although most Australian psychiatrists are satisfied and proud of their profession, they are stressed and often experience verbal or physical abuse and threats of legal action and complaints. They are apprehensive about the future. The increasing number of females in the profession, their higher levels of stress and dissatisfaction, and other differences from males must be taken into account as the profession reshapes its future. There is a need for regular surveys of this kind.     

Christian Psychiatry: the impact of evangelical belief on clinical practice

OBJECTIVE: The authors surveyed psychiatrists in the Christian Psychiatry movement to assess the role of religious belief in their practices. METHOD: The psychiatrists were members of the Christian Medical and Dental Society; questionnaires were sent to 260, and usable responses were received from 193. The subjects were asked about demographic and practice variables, "born again" religious experiences, group cohesion, and beliefs about using the Bible and prayer in treatment. RESULTS: The respondents were somewhat more religious than Americans overall, who are themselves more religious than most psychiatrists. Nearly all reported having been "born again," after which they generally experienced a decrease in emotional distress. There was a significant difference in the respondents' affiliative feelings toward psychiatrists in the Christian Psychiatry movement and other psychiatrists. For acute schizophrenic or manic episodes, the respondents considered psychotropic medication the most effective treatment, but they rated the Bible and prayer more highly for suicidal intent, grief reaction, sociopathy, and alcoholism. Whether or not a patient was "committed to Christian beliefs" made a significant difference in whether the respondents would recommend prayer to the patient as treatment. About one-half said they would discourage strongly religious patients from an abortion, homosexual acts, or premarital sex, and about one-third said they would discourage other patients from these activities. CONCLUSIONS: Many studies have suggested a need for more sensitivity to religious issues by psychiatrists, and this study provides systematic findings on one approach. It remains important to evaluate ways in which a religious perspective can be related to clinical practice and what benefits and problems may derive from such a relationship.