Thoughts On The Psychiatric Shortage And Congratulations To Graduating Residents

As our Psychiatry Department prepares to graduate another crop of outstanding residents this week, I’ve noticed a fundamental disagreement about the psychiatrist shortage in America. I’m going to mention only one aspect of it because it’s very complicated. Some psychiatrists believe that one of the biggest single problems contributing to the shortage are those who have cash-only or direct payment practices. According to a recent article in the May 2017 print issue of Clinical Psychiatry News (vol. 45, no. 5; “Solutions for Psychiatry: New report calls for better training, delivery models” by Gregory Twachtman), about 40% of U.S. psychiatrists work on a cash-only basis.

Underlying that story is a report by the National Council Medical Director Institute, “The Psychiatric Shortage: Causes and Solutions,” published March 28, 2017 which outlines that body’s view of the shortage. It’s a complicated multifactorial challenge with many moving parts and it requires collaborative solutions from several stakeholders. The authors say many times that cash-only practices are part of the problem, not the solution, saying frankly “…there is no need for more psychiatrists who work solely in cash only practices; refuse to take clients covered by Medicaid; do not include people with severe and persistent mental illness in their caseload; do not work with other behavioral health, primary care, peer counselors and family members in integrated teams or; are unwilling to consider alternative payment mechanisms and population health approaches to the most complex patients in their caseload or in the population of the local community served by their organization.”

On the other hand, in the April 2017 issue of Clinical Psychiatry News (vol. 45, no. 4; “Author found a way to take back his practice,” by Rodrigo A. Munoz, MD), cash-only practice is praised by the former President of the American Psychiatric Association (APA), Dr. Munoz. He wrote a review of Dr. Lee Beecher’s book “Passion for Patients.” Dr. Beecher is a staunch defender of the cash-only practice, identifying it as a way for the rest of us to take back our practice from managed care. If you go to Dr. Beecher’s web site, you’ll also find a link to his article entitled “ACA repeal will prove good for psychiatric practice,” published in an on line version of Clinical Psychiatry News, which I didn’t have access to because I have not registered as a user of the electronic version. I have also not read his book.

I suspect that current leaders within the APA might disagree with Dr. Beecher, given the alternative proposed by the current U.S. Congress, the American Health Care Act (AHCA). In fact, a letter from Dr. Saul Levin, MD, MPA, CEO and medical director of APA, and Arthur C. Evans, Jr., CEO and executive vice president of the American Psychological Association urges senators on both sides of the aisle to reject the AHCA and develop a bill that would increase coverage for mental health and substance abuse disorder treatment. They also said,

“Our nation cannot afford to go back to the days when insurers selectively enrolled individuals to avoid financial responsibility for needed services. Nor can we afford to return to viewing mental health and substance use services as optional,” they wrote. “Rather, we must further reduce the uninsured rate, develop integrated systems of care, and continue to foster an environment in which health plans compete on how efficiently and effectively they can provide services.” This was in the on line article “APA, American Psychological Association urge Senate to reject AHCA,” Psychiatric Annals, June 12, 2017.

I don’t know how they feel about cash-only psychiatry clinics as a solution for the problem.

One of this year’s graduating residents is preparing to enter community psychiatry practice where she’ll be seeing patients every 20 minutes in what the National Council Medical Director Institute would probably call a “cramped” clinic schedule. I’m still very proud of her and hope the best, as I do for all of the residents. I’m pretty sure most of them will be entering the job market and not likely to set up cash-only clinics. One thing I know from working with them is that they have a true passion for their patients. And I was delighted to find the name of one of our past graduates in the Appendix 1 list on the Expert Panel involved in the production of the report on the psychiatric shortage referred to above–Dr. Erik Vanderlip.

That doesn’t necessarily mean I absolutely disagree with what Dr. Lee Beecher stands for. After all, I haven’t given him a fair hearing by reading his book. He believes that progress in psychiatric care delivery could be improved if our system were changed so that more patients and psychiatrists approached it with a “skin in the game” attitude. He may be right. If you give patients the money and doctors the responsibility of running a competitive, effective psychiatric practice, things might turn out OK.

Who’s going to give patients the money? If they’re jobless, suffer from severe mental illness and substance use disorders impairing their ability to work or even have a home–how would they come up with the cash? I’m probably oversimplifying this. I have no head for business. And one of my department chairs told me I would never be a scientist. He was right. I’m just a geezer C-L psychiatrist who loved teaching medical students and residents. And I’m headed for phased retirement starting next month.

Boy, am I proud of the next generation of psychiatrists.

2 thoughts on “Thoughts On The Psychiatric Shortage And Congratulations To Graduating Residents

  1. Good points Jim,

    I think that the ideal solution is clinics that are managed for the good of the physicians and patients rather than corporations and bureaucrats. A cash only practice is at the extreme end of that spectrum. I have posted on models for ortho and ophthalmology. Anesthesiology and radiology were probably the pioneers. There have to be a few practices out there that could serve as models.

    There has been an uncontested race to the bottom in terms of quality psychiatry and that has been fueled by the notion that we need middlemen to manage resources for the benefit of patients. It should be clear that middlemen manage resources for the benefit of themselves. When that happens psychiatric care is a 10′ “med check” every 3 – 4 months for a very complicated problem.

    That destroys the profession in addition to providing minimal care compared with our true capabilities.


    George Dawson, MD, DFAPA

    Liked by 1 person

    1. George, you make an excellent point about the spectrum aspect of mental health care delivery systems, of which direct-pay arrangements are but one example. And there is more than one way to run them.

      I took a little time to read the excerpts from the 14 chapters of Dr. Beecher’s book on his website. I don’t disagree with much of what he writes about the primacy of the doctor-patient relationship and the importance of taking the time to understand the meaning of that partnership.

      I’m also pretty sure he wouldn’t go for a single-payer system.


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