A Call to Restructure Psychiatry General and Subspecialty Training

Published Monday, February 25, 2013
by Paul D.S. Kirwin, MD, AAGP President

Over the past few months an AAGP working group convened to formulate ways to restructure general psychiatry residency and fellowship programs in order to incentivize training in geriatric psychiatry. For several years the AAGP has proposed similar positions to the American Council of Graduate Medical Education (ACGME). We now seek support of other psychiatry subspecialties and psychiatry professional organizations to advocate our position before the ACGME and the American Board of Psychiatry and Neurology (ABPN).

An alarming shortage of psychiatrists with special expertise in geriatrics, addictions, forensics and psychosomatics creates barriers to care for subpopulations with mental illness and poses a significant public health concern. To address these disparities in access to care, we propose streamlining graduate medical education to increase efficiency and enhance cost effectiveness. A reduction of general training in psychiatry by one year for residents interested in subspecialties would allow trainees to complete their general training in three years, and then utilize their fourth year to gain expertise in geriatrics, addictions, forensics, or psychosomatics. Eligible trainees would then qualify for psychiatry subspecialty certification and general psychiatry certification at the end of four years. This reduction in time spent in general psychiatry residency is congruent with the opportunity available to trainees sub-specializing in child and adolescent psychiatry.

In July 2012, the Institute of Medicine released a report outlining the mental health and substance use workforce needs for the growing population of older adults in the United States. The IOM report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?, documents the prevalence of mental health and substance use issues among older adults, the interaction between these issues and physical health, and the changes needed in legislation, training, and reimbursement to provide quality care for the nation’s older population.

The report asserts that the rate of specialized providers entering the workforce is dwarfed by the pace at which the population is growing. It is projected that the number of adults age 65 and older in the U.S. will grow to more than 72 million by 2030, and current estimates indicate 14-20 percent of the elderly population deal with mental health or substance use conditions, such as depressive disorders and dementia-related behavioral and psychiatric symptoms (IOM).

The need to incentivize trainees to gain expertise in geriatric mental health issues is immediate. Culling data from various sources the IOM report conveys an alarming national trend. In academic year (2012-2013), there are 77 geriatric psychiatry fellows nationwide in 55 programs (ACGME, 2013). Less than half of the available geriatric psychiatry fellowships have been filled since 2006 (GWPSC, 2012). Since 1991, when the credential was introduced, 3,067 psychiatrists have been certified in geriatric psychiatry (ABPN, 2011a). As of 2011, 1,543 geriatric certificates were still active, with the 2012 MOC exam results pending (ABPN, 2011b).

The IOM report further asserts that the attrition in board certification for addiction psychiatrists parallels those of geriatric psychiatrists. The ABPN has awarded 2,102 certificates in addiction psychiatry since 1993 (ABPN, 2011a). Only 872 certificates have been maintained as of 2011(ABPN, 2011b).

The mental health needs of our nation will only grow in the future. Subspecialty expertise within psychiatry is critical to help address growing unmet demands for clinical, research and education efforts for the health of our nation.

Advantages to reducing the total time of graduate medical education (GME) in psychiatry include:

  • The fourth year of general psychiatry training is not essential to train competent psychiatrists. It is usually an elective year used to focus on areas of clinical interest, research and education of junior trainees. Subspecialty training in the fourth year would focus those interests, enhance productivity, and promote efficiency in training. 
  • Reducing the total years of residency/subspecialty training from five to four years will reduce federal spending on graduate medical education, consummate with inevitable efforts to trim and make more efficient the Medicare budget (Emmanuel, p. 1144). Savings to society realized by shortening training are a responsible use of public funds and may incentivize trainees to choose underserved areas in medicine (Zweifler, p. 886). It would also encourage careers in academic medicine where lead times are crucial and funding increasingly limited—these careers are critical to training the next generation of psychiatrists.
  • Reducing one year of residency training will generate substantial benefit for trainees financially and psychologically, enabling them to enter the workforce one year earlier. Physicians graduating from U.S. medical schools in 2011 owed an average of $161,290 for their education, with 59 percent owing at least $150,000. Almost forty percent of these graduates said that salary expectations were a moderate or strong influence in determining their specialty (AMA). Some have proposed that the most effective way to decrease the significant financial burden of medical education is not to reduce the cost of medical education, but rather reduce the time of graduate medical training (Dorsey, p. 248). Reducing the delay in paying down this debt combined with garnering an extra year of a practicing physician salary is a potent incentive at a time in life when many trainees are beginning families and seeking to buy a home. Several senior educators from diverse disciplines have called for reductions in years of training including: family practice, surgery, pediatrics and internal medicine (Dorsey, p. 249; Zweifler, p. 885).

In conclusion, significant shortages of subspecialty trained psychiatrists expertly equipped to meet major public health needs warrant strategies to incentivize training in these critical areas. Restructuring graduate medical education in psychiatry to allow fellowship training to occur in the fourth year of residency, thereby allowing trainees to sit for the general and subspecialty boards at the end of four years of psychiatry training, will encourage trainees to receive subspecialty training, promote efficiency in federal expenditure for GME, enhance decisions to pursue research/academic careers, and trim unnecessary delays in entering a productive and fulfilling profession serving those afflicted with mental illness.


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