CHICAGO — Medical student Mila Grossman had just begun her first clinical rotation when she started to get an idea of what kind of doctor she wanted to be.
Working at a women’s mental health clinic, she met a new mom who appeared put-together but inwardly suffered from painful postpartum depression.
Grossman decided to pursue psychiatry, and is among a growing share of medical students doing the same.
“That opened my eyes to the severity and stigma that really exist,” said Grossman, 29, who is set to graduate this year from the University of Chicago’s Pritzker School of Medicine and enter a psychiatry residency. “I pretty quickly became intrigued by the patients and fascinated by the transformative effects of therapy and psychopharmacology.”
Psychiatry’s growing popularity as a career choice comes as the nation grapples with a stubborn shortage of psychiatrists that some fear will continue to deepen.
The shortage is most acute in rural areas and poor urban neighborhoods that often aren’t the first choice for in-demand doctors with plentiful options, but is also being felt across big cities as the need for mental health professionals outpaces supply.
“We feel it is an emergency,” said Marvin Lindsey, CEO of the Community Behavioral Healthcare Association of Illinois, which represents mental health agencies that serve mostly low-income residents. “We feel it’s getting worse.”
The reasons for the shortfall are varied. Greater awareness, diminished stigma and a worsening opioid crisis are driving more people to seek mental and behavioral health care. Meanwhile, nearly 60 percent of psychiatrists are over age 55, fueling a retirement wave that experts say exceeds the pipeline of new doctors who fill limited psychiatric residency slots.
Low insurance reimbursement rates for psychiatrists might also be keeping some people from pursuing the specialty, or, if they do, from joining insurance networks, which keeps services out of reach of many people who can’t afford to pay out of pocket.
The shortage of psychiatrists, who are distinct from psychologists and other general mental health service providers because they can prescribe medication, is not evenly spread. Community health clinics and some low-income hospitals struggle to hire psychiatrists, which limits their ability to provide services and forces more mental health cases into emergency rooms not staffed to deal with them.
At St. Bernard Hospital in Chicago’s Englewood neighborhood, CEO Charles Holland said it has been extremely difficult to recruit psychiatrists as it expands its mental health services.
The hospital, which serves a primarily low-income population on Medicaid, has found that many young psychiatrists with medical school debt choose to work at more affluent hospitals that can afford better pay, or at academic centers where they can spend part of their time on research, said Chief Operations Officer Roland Abellera.
The hospital is instead moving toward using more nurse practitioners to prescribe medication and plans to offer telepsychiatry, he said.
Doctors say insufficient psychiatric services in the community have driven more mental health issues into emergency rooms, where psychiatric patients increased 42 percent between 2014 and 2017.
In October the hospital launched a telecrisis pilot program that connects those patients, via tablet, to a crisis worker staffing the overnight shift at another facility, to get the transfer paperwork started. It used the system more than 70 times during the last three months of 2017, Bordo said.
Central DuPage Hospital, which recently expanded its substance abuse unit in response to rising opioid-related visits, started a pilot telepsychiatry program last April to cover weekend shifts, said Allison Johnsen, manager of business and program development at the hospital.
Pipeline of doctors
Meanwhile, the supply of new psychiatrists is growing.
The number of U.S. medical students matching into psychiatry residencies rose to 982 this year, representing 5.5 percent of all matches, up from 681 students, or 4.2 percent of all matches, five years ago.
Dr. Daniel Yohanna, interim chair of the University of Chicago’s Department of Psychiatry, attributes the growing interest in part to more scientific evidence of psychiatry’s effectiveness.
“It reduces the stigma around psychiatry, both for students and our colleagues in other areas,” Yohanna said.
At University of Chicago’s medical school, 10 students in the 2018 graduating class are pursuing psychiatry, a record for the school, which typically sees five or six, said Dr. Michael Marcangelo, the school’s director of medical student education in psychiatry.
The most important reason for the rise, Marcangelo said, is that “psychiatry is the last field of medicine that really pays a lot of attention to people as people.”
“The rest of medicine is becoming very technical,” he said. “A lot of people who go into medicine want to work closely with patients.”
Addressing the shortage
While interest in psychiatry grows, demand is growing faster. For two consecutive years, psychiatry has been the second-most requested search assignment at staffing firm Merritt Hawkins, after family medicine, and is the most difficult specialty to fill, Singleton said. A decade ago, psychiatry was ninth on the list.
Where and what psychiatrists end up practicing after their four-year residency ends matters most in addressing the shortage, said Dr. Sidney Weissman, clinical professor of psychiatry and behavioral sciences at Northwestern University’s Feinberg School of Medicine. Many decide it is in their financial interest to go directly into private practice rather than continue collecting a resident stipend for a fifth year as they train in a subspecialty where the need is most dire, such as geriatric or child and adolescent psychiatry, Weissman said. He advocates letting psychiatrists train in a subspecialty in their fourth year of residency to make it more economically viable.
“Psychiatry has to look at itself to rethink how we do business,” Weissman said. “It needs to relook at how we train people, how long is the training and what we expect them to do.”
The crunch is forcing some providers to rethink how they provide services.
Turning Point, an outpatient mental health center in Skokie, had received a private foundation grant to hire a part-time advanced practice psychiatric nurse — a position that can prescribe medication — but abandoned the search after repeated recruitment efforts failed.