By Request, More Thoughts on the Psychiatrist Shortage

Vikram Kumar Rohra, a senior medical student who has own his blog site, Psihub, as for my comments on an article ( “Addressing the Escalating Psychiatrist Shortage” by Stacy Weiner, posted February 13, 2018, AAMC News) about the shrinking psychiatric work force. Part of the challenge is, as Vikram points out, is the graying out phenomenon. About 60% of us past the age of 55 (including me) are planning to retire soon.

I’m not sure what to do about that cohort effect, except to say that it’s probably past time for some older psychiatrists to retire at last (including me?). At the risk of sounding like I’m beating a dead horse, I can tell you one reason why I and other psychiatrists and physicians from other specialties are retiring and that’s the regulatory hassles, especially Maintenance of Certification (MOC).

Vikram may never have to deal with that scheme by certification boards for scamming money from hard-working doctors–if coming to American is not the plan. However, American physicians have been either putting up with this or protesting MOC for many years. Just type “MOC” in the search box to see what I’ve written on the subject.

I’ve chosen to drop any pretense of complying with MOC and continue to believe psychiatrists, internal medicine specialists, and surgeons can learn what they need to do on their own without expensive recertification examinations and other nonsense lacking any relevance to our practice. Take a look at the Clinical Problems in Consultation Psychiatry (CPCP) on this blog site if you want an idea of what lifelong learning can be. A quick link is on the left column of my blog home page.

You can also head over to Dr. George Dawson’s blog, Real Psychiatry, to get an idea about the ravages of managed care ruining the idealism of doctors, young and old.

That’s only part of the reality, though. After all, I don’t want to discourage Vikram. There are efforts to recruit psychiatrists and one of them is the exposure to medical students of what is admirable, enjoyable, and intellectually stimulating  about medicine and psychiatry. I gather the University of Nebraska Medical Center is doing a great job with that, according to the article under discussion.

They also create a strong culture of mentoring, which I think is critically important. I’ve not been a great or consistent mentor in my career although one medicine resident recently called me a mentor. I will always be grateful for his gratitude. And I’ll always wonder what I actually did to deserve it.

One statement caught my attention in the article: “…access to more varied client populations can decrease burnout and thereby increase workforce retention.” There are a couple of things going on there. I’ve been in private practice settings very briefly, and it can get a bit dull and frustrating waiting for no-shows in clinics. I’ve also had to cope with burnout, which led to my taking up mindfulness meditation.

This reminds me to plug Consultation-Liaison Psychiatry. It’s difficult to imagine a more varied work and patient access experience than C-L Psychiatry. You can view short videos of C-L Psychiatrists describing what they do and why they love it at the Academy of Consultation-Liaison Psychiatry website. Although it’s hard work, I’ve enjoyed it.

 

15 thoughts on “By Request, More Thoughts on the Psychiatrist Shortage

  1. Dear Dr. Amos,

    Thank you for your detailed response.

    I am really surprised and impressed by the steps taken by UIHC to assist smooth and swift transition to retirement life. I would really appreciate if you could keep us posted on those workshops and provide your valuable feedback.

    With regards to touching on the financial topics, I am of the opinion that they should be taught at resident level (Before they start earning really good salaries). On how now to invest in risky and complex investments. And introduce the idea of compound interest. Because 1 dollar saved today is worth much much more after 20 years. There are other basic concepts which can be taught. I would love to hear your opinion on this.

    The debate between Dr. Teirstein and Dr. Nora was fascinating. Is there any record of how Dr. Nora responded to the facts pointed by Dr. Teirstein in the debate?

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    1. Saving money for retirement is vital. I’m the wrong guy to ask about risky and complex investments. We did the safe things. I’m not recommending this by any means, but Physician on FIRE (Financial Independence Retire Early) gets mentioned a fair amount on the web, https://www.physicianonfire.com/

      Your question about where Dr. Nora’s part of the debate is right on target. Why do we not have her responses? It’s possible she might not have consented to have them publicized.

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      1. I have been following Physicians on FIRE blog since 3 years. It’s a golden blog. Every physician should read it and strive to achieve Financial Independence asap.

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      2. The conversation about MOC is fascinating and it gives a reflection of how the healthcare system works in the USA. Maybe I am over-analyzing a bit here.

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      3. If MOC were truly a voluntary process, it would not be tied to third party payer reimbursement or hospital privileging, see http://rebel.md/my-moc-failure/

        I and one of the residents created an American Board of Psychiatry and Neurology (ABPN) MOC Clinical Module on delirium, https://www.abpn.com/maintain-certification/moc-activity-requirements/improvement-in-medical-practice-pip/clinical-chart-review-module/clinical-chart-review-module-examples/, a topic near and dear to my heart because so many physicians fail to diagnose delirium or misdiagnose the syndrome as a primary psychiatric illness. I’m not opposed to the principle of lifelong learning.

        What bothers me about MOC is that certification boards restrict what educational “products” we can use to demonstrate our efforts to systematically improve our clinical knowledge and skills–and they charge us a lot of money for them.

        In my opinion, the boards get mixed up and make maintaining certification the goal instead of maintaining an honestly curious attitude about the most effective and efficient way to implement continuing reflective self-improvement regarding our ability to provide excellent patient care and training for the next generation of doctors.

        Liked by 1 person

      4. Thank you Doc for your response.

        I read both the articles mentioned above. The first one about MOC failure was downright scary.

        The second one about the Delirium module was a really great read. You mentioned that delirium is sometimes misdiagnosed as primary psychiatric illness. What psychiatric conditions is delirium usually misdiagnosed as? Also, is there a way to find out if a patient was wrongly diagnosed as some other condition but in reality he had delirium? Sounds really tricky.

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      5. I have seen delirium misdiagnosed as mania, schizophrenia, depression, and I was even consulted once on a case in which the primary team consulting me thought the patient was faking delirium–a novel situation. Hypoactive delirium is often misdiagnosed as depression, which I’ve seen a number of times. I think experience in the bedside clinical diagnosis is the best way to detect delirium, using the Confusion Assessment Method (CAM) which was a simple screening tool designed by Dr. Sharon Inouye, an internist and geriatrician–not a psychiatrist. A colleague here at UIHC. Dr. Gen Shinozaki, has been working with a surgeon, Dr. John Cromwell, on a simplified EEG procedure to assist detection in a more objective way, see the bottom of the page at link, https://shinozaki.lab.uiowa.edu/research

        Maintaining a high degree of suspicion for delirium in the general hospital is critically important. The occurrence rate is about 20% there and ranges up to 80% and higher in the ICU. See the American Delirium Society website for more, https://americandeliriumsociety.org/ads-2018

        I’ve often used the Clock Drawing Task (part of the Mini-Cog) along with the CAM to detect delirium. See the video made by a couple of residents under my Basic Links, entitled Lightning Fast Mini-Cog. It’s not foolproof but I’ve persuaded a lot of doctors, both resident and faculty, using very abnormal clock drawings, that delirium is the main problem.

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      6. Thank you doc.
        Faking delirium? That’s novel indeed.

        Just read through Dr. Shinozaki’s research page and he is working on pretty cool stuff! Not only him, I guess University of Iowa faculty is doing a wonderful job overall.

        Maybe once portable EEG is out in the market, we can compare Mini Cog + CAM and portable EEG and see who wins hehe 🙂

        Liked by 1 person

  2. Jim,

    In my discussion with a younger colleague today about training issues – I recalled very bright residents from the UK who were already trained, certified, and practicing there who had to come to the USA and go through another residency in order to practice here.

    I see no reason why a psychiatrist fully trained and certified in the UK should do another residency in the USA. That would in effect double a certain number of positions because it would open up additional residency positions in addition to increasing the practicing psychiatrists.

    George

    Liked by 1 person

      1. No idea – I was shocked the first time I encountered this about 12 years ago when I found myself working with a resident from the UK who was already a trained psychiatrist. My speculation would be the old bias that our body of knowledge is somehow superior to yours. There is an interesting spin in there for MOC. I recall one of Dr. Teirstein’s eye opening observations was seeing one of his cardiology colleagues study a subject that he would never need in his specialized field just for MOC purposes.

        A trained medical specialist should be able to adapt in whatever country they move to if there is general agreement on the body of knowledge.

        Liked by 2 people

  3. Dear Dr. Amos,

    Thank you very much for this post. It was really beneficial. And I guess you can retire at last 🙂

    We touched upon a number of topics on this post and I would really appreciate if you could help me answer some of the following questions:

    1) Yes majority of the Psychiatrists will retire in next couple of years. And that trend is inevitable. One of things we can do before they retire is to arrange maximum interactions between them and young psychitrists in order to shape and nurture next generation of leaders.

    Do you think it’s possible to engage retired psychiatrists to participate in mentoring activities? Or make them accessible to young psychiatrists for their expert opinions/guidance?

    2) What is the most common reason given by Pro-MOC on why we should continue with the status quo of keeping MOC?

    Thank you again for the post. I will read more on C L Psychiatry specialty and CPCP. Looking forward to discuss these topics with you soon. Good night:)

    Liked by 1 person

    1. Great questions. Your first one I can probably answer best after mid-September 2018. I’ll be participating in a University of Iowa Hospitals and Clinics (UIHC) Career Transitions workshop entitled “Career Transitions–Preparing for Life Without a Day Job.” I plan to attend the entire program and have a small role discussing phased retirement opportunities along with another faculty member who’ll do the same. There will be several sections including Financial Topics, Wellness Considerations, and pertinent to your question about how to engage retired or retiring psychiatrists in mentoring–Medical Educator Opportunities. Maybe that will be connected to mentoring. There is also something I’m not familiar–The Maven Project, http://www.mavenproject.org/ It’s a Medical Alumni Volunteer Expert Network. I’m not sure that I would get involved with that, but it certainly sounds something like consulting and I can well imagine that some of my colleagues might be interested in exploring this option. UIHC is ahead of the game on supporting educational roles for health professionals.

      Your second question is a little harder for me to answer, mainly because I’m so opposed to MOC that confirmation bias probably tends to interfere with my objectivity. I think most Pro-MOC doctors believe that many physicians, especially as we age, tend to lose clinical knowledge and skills. I have no argument with that. However, they would also contend that MOC is an effective way to counter that problem–for which many don’t believe there’s any convincing evidence. I think there are many ways for experienced, motivated physicians to successfully navigate the Practice-Based Learning and Improvement core competency. I happen to believe that our department’s CPCP is a more effective way to model the principle of lifelong learning. Another way for you to learn the pros and cons would be to view the video, https://nbpas.org/, of a debate about MOC between Dr. Paul Teirstein, MD, one of the founders of the National Board of Physicians and Surgeons (NBPAS, which does not require MOC or recertification exams), an alternative to the American Board of Medical Specialties (ABMS), and Dr. Lois Nora, MD, who was President and CEO of ABMS until recently.

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