A model that would address the shortage
Overall, 7,826 PGY-1 applicants were unmatched in 2019, according to data from the 2019 Main Residency Match.19 Psychiatry residency programs could give these unmatched graduates 6 months of training (arbitrary duration) in psychiatry, which is not at all difficult with the program modules that are available.20 We could use them as physician associates as a major contributor to our workforce to complete administrative and other clinical tasks.
Administrative tasks are not necessarily negative, as all psychiatrists have done administrative tasks as medical students, residents, and fellows. However, at this point, administrative tasks are not an effective use of a psychiatrist’s time. Those physician associates could be paired with two to three psychiatrists to do administrative tasks (for making daytime and overnight phone calls; handling prescriptions, prior authorizations, and medication orders, especially over-the-counter and comfort medications in the inpatient units; doing chart reviews; ordering and checking laboratory tests; collecting collateral information from previous clinicians and records; printing medication education pamphlets; faxing; corresponding with insurance companies/utilization review; performing documentation; billing; and taking care of other clinical and administrative paperwork).
In addition, physician associates could collect information using rating scales such as the 9-item Patient Health Questionnaire for measurement-based care21 and Geriatric Depression Scale, both of which are currently not used in psychiatric practice because of time constraints and lack of manpower. Keep in mind that these individuals are medical doctors and could do a good job with these kinds of tasks. Most of them already have clinical experience in the United States and know the health care system. These MDs could conduct an initial interview (what medical students, residents, and fellows do) and present to the attending psychiatrist. Psychiatrists could then focus on the follow-up interview; diagnoses and treatment; major medical decision making, including shared decision making (patients feel that they are not part of the treatment plan); and seeing more patients, which is a more effective use of their time. This training would give these physician associates a chance to work as doctors and make a living. These MDs have completed medical school training after passing Medical College Admission Test – equivalent exams in their countries. They have passed all steps of the U.S. Medical Licensing Examination and have received Educational Commission for Foreign Medical Graduates certification. Some have even completed residency programs in their home countries.
Some U.S. states already have implemented these kinds of programs. In Arkansas, Kansas, and Missouri,22,23 legislators have passed laws allowing unmatched graduates who have not completed a residency program to work in medically underserved areas with a collaborating physician. These physicians must directly supervise the new doctors for at least a month before they can see patients on their own. Another proposal that has been suggested to address the psychiatrist shortage is employing physician assistants to provide care.24-26
The model proposed here is comparable to postdoctoral fellow-principal investigator and resident-attending collaborative work. At hospitals, a certified nurse assistant helps patients with health care needs under the supervision of a nurse. Similarly, a physician associate could help a psychiatrist under his or her supervision. In the Sheppard Pratt Health System in Baltimore, where I worked previously, for example, nurses dictate and prepare discharge summaries for the attending physician with whom they work. These are the kinds of tasks that physician associates could do as well.
The wait time to get a new evaluation with a psychiatrist is enormous. The policy is that a new patient admitted to an inpatient unit must be seen within 24 hours. With this model, the physician associates could see patients within a few hours, take care of their most immediate needs, take a history and conduct a physical, and write an admission note for the attending psychiatrist to sign. Currently, the outpatient practice is so busy that psychiatrists do not have the time to read the discharge summaries of patients referred to them after a recent hospitalization, which often leads to poor aftercare. The physician associates could read the discharge summaries and provide pertinent information to the attending psychiatrists.
In the inpatient units and emergency departments, nurses and social workers see patients before the attending physician, present patient information to the attending psychiatrist, and document their findings. It is redundant for the physician to write the same narrative again. Rather, the physician could add an addendum to the nurse’s or social worker’s notes and sign off. This would save a lot of time.
Numerous well-designed studies support the adoption of collaborative care models as one means of providing quality psychiatric care to larger populations.27,28 The American Psychiatric Association (APA) is currently training 3,500 psychiatrists in collaborative care through the Centers for Medicare and Medicaid Services’ Transforming Clinical Practice Initiative.29,30 Despite this training and the services provided by the nurse practitioners and physician assistants, the shortage of psychiatrists has not been adequately addressed. Hence, we need to think outside the box to find other potential pragmatic solutions.
Simply increasing the hours of work or the number of nurse practitioners or physician assistants already in practice is not going to solve the problem completely. The model proposed here and previously31 is likely to improve the quality of care that we now provide. This model should not be seen as exploiting these unmatched medical graduates and setting up a two-tiered health care system. The salary for these physicians would be a small percentage (5%-10%; these are arbitrary percentages) from the reimbursement of the attending psychiatrist. This model would not affect the salary of the attending psychiatrists; with this model, they would be able to see 25%-50% more patients (again, arbitrary percentages) with the help and support from these physician associates.