Every day, people call my office looking for help: A loved one has not left their bed in a week. A father is experiencing panic symptoms while preparing his children for school. A young woman is using substances in a way that feels dangerous to her.
These are not the worried well. They are people in crisis. Their conditions are complex and acute, and require the expertise of a psychiatrist who can talk with them, assess possible medical causes for their problems, manage withdrawal, prescribe medications when needed, and connect with other providers.
Some of the people who call seeking help are already taking part in a good talk therapy program. And sometimes the calls come from their psychotherapists, highly skilled psychologists, and licensed clinical social workers, who call to be sure I understand how much their patient is struggling.
Before the pandemic, I could almost always help. I would be able to find time to meet someone for a consultation, or make a few calls to secure the right referral. But now, my every available hour — even those that jut into my ability to meet my obligations to my family — is full. My colleagues tell me the same. They are starting work earlier, working later, contending with long waitlists and their own limits. All the while, patients in crisis are going without psychiatric help.
In the most recent Household Pulse Survey, one-third of U.S. adults reported experiencing symptoms of depression or anxiety. This comes on top of the burden experienced by the 40 million Americans living with substance use disorders and the 14 million who live with a serious mental illnesses.
There are too many patients and too few psychiatrist hours. I have been writing this essay during my commute to work.
To be sure, there are shortages of physicians — or looming shortages — in primary care and many other specialties. But in psychiatry in particular, there has been an exponential increase in the number of people who need care. This number will only increase and has come to include many of my colleagues across the healthcare workforce.
There are about 33,000 practicing psychiatrists in the U.S. By my back-of-the-napkin math, if all of us were treating only people with depression or anxiety, each of us would have to see more than 3,000 patients a year. But we also treat people with many other conditions, and even if we could see more than 100 patients a day, many need several visits and intensely focused follow-up at the start.
Further fanning the flames of this crisis, the psychiatry workforce is older than the general population of physicians and is growing slowly. In many of the calls I get from people seeking care, there is mention of a retired or deceased psychiatrist.
Learning that there are far too few psychiatrists is bewildering to me given the intense competition for coveted spots in medical schools and residency programs. The number of residency positions in the U.S. is limited by the availability of Medicare funding to pay for the cost of training. The Build Back Better Act includes two measures that are meant to widen this bottleneck for all physicians via the Pathway to Practice Training Programs. One will provide 1,000 scholarships to medical students to encourage practice in low-resource areas. The other expands the number of residency training positions across all specialties, but only by 1,000 — a less than 1% expansion that is not scheduled to be complete until 2026.
In the meantime, health care awaits action on the Resident Physician Shortage Reduction Act of 2021, which would allow for 14,000 new residency training positions — 2,000 additional spots each year for seven years. If the current proportion of psychiatry training spots remains steady at less than 5%, this would yield fewer than 700 additional psychiatrists, with the first class of that size graduating in 10 years.
We need far more psychiatrists than that, and we need them sooner.
A helpful first and immediate step would be to increase the capacity to train all qualified students along the pathway from undergraduate and medical education through residency training. Nationwide, only about 40% of applicants gain entrance to medical school. The most selective schools have far lower acceptance rates and there is deep inequity in the admissions process for students who come from marginalized backgrounds.
In 2022, there were 50% more applicants for psychiatry residency training than there were training spots for them, with high numbers of qualified international medical graduates going unmatched and thus without a path to practice and board certification. As in the path to medical school, those in the competitive application to residency who belong to groups underrepresented in medicine face an inequitable process. It is both by failure of planning and an attachment to the exclusive ideal of who is allowed to be a doctor that we are in this position of unmet need and overwhelmed physicians.
Medical education and residency training are stunning processes that create physicians out of students, readying them for one of society’s most profound responsibilities. This comes at great cost to the institutions that educate young doctors and to the young people who are willing to submit to this grueling process.
Remarkably, and thankfully, they continue to join the profession. We should welcome them rather than turn them away for lack of seats.
Christin Drake is a psychiatrist, vice chair for diversity and equity at NYU Langone Health, and a clinical associate professor of psychiatry at NYU Grossman School of Medicine.
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