Psychosomatics 41:204-209, June 2000
© 2000 The Academy of Psychosomatic Medicine
Quo Vadis, Psychiatry?
Problems and Potential for the Future of Medical Student Education in Psychiatry
Alan Stoudemire, M.D.
"Quo vadis, psychiatry?" or translated, "Psychiatry, where are you going?" was received June 16, 1999; revised November 9, 1999; accepted November 25, 1999. Published posthumously. Dr. Stoudemire died February 2, 2000.
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ABSTRACT
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Psychiatric education occupies a relatively low status level in most academic departments of psychiatry. This problem may be in part because career teachers rarely generate sustained external grant support. Their salaries may be regarded as perpetual drains on the budgets of department chairs. The author explores a possible relationship between the decline in the emphasis on psychiatric education and the decline in the number of medical students entering psychiatric residency programs. Recommendations for improvement in the support of psychiatric education are made that focus on greater accountability of how tuition fees are distributed to support the salaries of faculty educators. The unique role that consultation-liaison (C-L) psychiatry occupies in psychiatric education, the effects of managed care on C-L psychiatry, and the special problems that C-L psychiatry currently faces with its strong emphasis on nonreimbursable educational activities are discussed. Revitalization of the importance of education in undergraduate medical education is vital for the future of psychiatry.
Key Words: Medical Student Education
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INTRODUCTION
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Academic chairs in psychiatry and most medical school deans place relatively less importance on the role of psychiatric education compared with the capacity of faculty to generate external research funding. The pressure on faculty to be self-sustaining in respect to their salaries has increased dramatically because of decreases in Medicare reimbursements to teaching hospitals brought about by the congressionally mandated balanced budget act of 1997. This congressional act made no allowance for the approximately 30% greater overhead that teaching hospitals incur as a result of their teaching and training costs.1 As a result, less and less money that was once derived from Medicare funds to support teaching has been available to medical education institutions. Greater pressure has fallen on faculty to make up for the loss of indirect federal support for medical education by requiring faculty members either to increase their clinical activities or to seek independent sources of funding, including grants. Both alternatives inevitably detract from the amount of time for teaching.
Setting aside these financial realities, there is long-standing evidence that teaching excellence alone is not considered by medical school administrators as a "premium" quality of faculty members. Teaching excellence alone is rarely the sole criterion for promotion and never the sole consideration for tenure, unless a faculty member has also been proficient in procuring external grant funding.2 This policy in determining faculty promotions and granting tenure is driven by the reality that medical schools are highly reluctant to make long-term, tenure-based financial salary commitments to faculty members who are unlikely to secure self-sustaining sources of external income over the long term.
Psychiatry departments, compared with other medical school departments, were the first to face severe budget cuts as a result of managed care–determined reductions in reimbursements. Psychiatry departments were also the first to incur the wave of dramatic reductions in inpatient care. Therefore, psychiatry departments were among the first to grapple with decreased funding for faculty salaries and for clinical training of residents and fellows.
Federally funded training grants have also dramatically decreased, and in some subspecialty areas in psychiatry, such as consultation-liaison (C-L) psychiatry, federal support for fellowship training no longer exists. The federal government at present provides no designated grant money specifically dedicated to support the general psychiatric education of medical students. Federal agencies, as well other public and private agencies, sporadically do offer short-term educational grants directed—toward medical students— that focus on specific disorders, such as the psychiatric problems associated with HIV-AIDS and alcohol and drug abuse. As a rule, however, career psychiatric educators rarely secure long-term external departmental funding unless it is in the form of privately endowed chairs.
Medical student education, the primary focus of this paper, is reliant on tuition fees in private medical schools and is heavily supplemented by government funds in state-supported schools. Tuition and government funds received by medical school deans are then distributed to department chairs. High degrees of variability exist among medical schools as to what degree money exclusively designated by both deans and chairs for the support of medical student education is protected for this purpose. Allocation of funds intended to support education is usually at the discretion of department chairs with little or no subsequent supervision by the medical school dean.
This situation, in which career teachers are heavily dependent on the largesse of department funds for their salaries, results in some chairs viewing psychiatric education as a "cost center" on their budget ledgers. It is common for faculty members who serve as the principal teachers and administrators of medical student teaching programs in psychiatry to be assigned other primary departmental responsibilities, either clinical or administrative (unrelated to teaching), which provide the majority of their salary rather than their salary being drawn from tuition funds intended to protect their time for educational endeavors. If teaching faculty can be assigned nonteaching-related positions that provide most of their salary, the department chair may then divert funds intended for education to other purposes, such as paying for the general overhead expenses of the department or to support research activities. For the medical student educator, saddled with other responsibilities that serve to pay their salary, these other administrative or clinical obligations to which they are assigned compete for the time and energy they might otherwise devote to teaching activities. Educationally oriented faculty may find themselves retaining the title and responsibility for directing an educational program yet be laden with a variety of administrative and clinical duties on which their salary is predominantly based.
The lack of protected time for teaching within most departments of psychiatry is indirectly shown by the fact that the majority of directors and associate/assistant directors of medical student education in psychiatry are relatively junior faculty members who rarely remain in their host departments beyond the time for the first promotional evaluation. This is especially true if the predominant amount of their professional time has been devoted to educational activities. Although one national survey that examined the professional status and job satisfaction of psychiatric clerkship directors was relatively optimistic about the professional standing of this particular academic group,3 it should be noted that the position of being a clerkship director is usually a heavily clinically oriented position and requires a fraction of the time required to be a director of a comprehensive preclinical behavioral science and introductory psychiatry curriculum. This generally positive cross-sectional survey of clinical clerkship directors by Sierles and Magrane3 also indicated a relatively high percentage of these clerkship directors having achieved promotion to the associate and professor level. The finding of promotional achievement among these faculty members is most likely the result of a "survival effect." This is to say that such cross-sectional surveys may capture faculty at points in their careers after they have found positions with institutions where they have found strong departmental support for teaching endeavors.
Cross-sectional surveys do not account for faculty members who have migrated from one medical school to another in an effort to find a secure teaching position, nor do they account for the numbers of faculty who have left academia altogether out of professional frustration. For example, one longitudinal study examined over a 15-year period the attrition rates of medical school faculty from two large research-oriented midwestern medical schools who had received awards for excellence in teaching.4 At each institution, the findings revealed that one-half of the awardees eventually had left their academic positions altogether and that at one of the medical schools, half of the faculty member recipients had left their institutions within 3 years of winning their award. However, whether these attrition rates are representative of national trends is unknown because of lack of comparable studies.
There have been no comprehensive studies that have measured the rate of turnover in faculty who have primary psychiatric teaching positions, the number of career teaching faculty who have been promoted on the basis of excellence in teaching, the number of individuals who have left faculty positions because they failed to meet criteria for promotion, the average amount of salary support teaching faculty receive for their time devoted to education, or to what extent the time purportedly designated for teaching is adequately protected from other responsibilities the faculty member may be obligated to meet. Given the lack of any comprehensive available data to answer these questions and the unlikely prospects of ever obtaining such data, the assumptions made in this paper regarding the difficulties that psychiatric educators encounter in their career development within predominantly research-oriented institutions remain primarily based on anecdotal and impressionistic information collected informally from teaching faculty from across the United States. Systematically collected empirical data would obviously be ideal to support both the assumptions and conclusions that have been made here. Nevertheless, certain observations, subject to face validity, lend credence to the positions that have been and will be taken in this discussion.
For example, one striking observation that may reflect problems with the professional advancement of career educators in psychiatry is reflected by the very small number of senior faculty members at the full professorial level whose professional activities have been principally devoted to psychiatric education. The same observation could be made regarding the small number of department chairs whose academic success has been garnered by virtue of their contributions to psychiatric education.
An additional source of evidence indicating the devaluation of psychiatric education can be gathered by examining the professional demographics of members of the several small academic organizations that are primarily devoted to undergraduate medical student psychiatric education and other larger multifaceted psychiatric groups that have sectional components specifically dedicated to medical student education. An example of the former group would be the Association of Directors of Medical Student Education in Psychiatry and of the latter, the Association of Academic Psychiatry. These small organizations predominantly consist of nontenured junior faculty members. As might be predicted, it is common knowledge within these professional organizations that directors of psychiatric education and their assistants will tend to eventually drift out of academic departments altogether because of adverse salary and promotional considerations. Alternately, junior faculty seeking more job security and income stability may gradually shift into other areas that are considered to be more important to their department's functioning, such as becoming predominantly high-volume, income-generating clinicians, joining commercial pharmaceutical research teams, or assuming other primarily administrative positions that have a stable and more predictable salary.
Evidence of the relative inattention to medical student education is also shown by the relative lack of attention given to this area by both the clinical and academic members of the American Psychiatric Association (APA). Although teaching awards such as the Vestermark Award and the Nancy Roeske Award are given annually to APA members in recognition of excellence in medical student education, the number of continuing medical education courses, discussion groups, and workshops that are directed at topics relevant to medical student education are minimal at the annual meetings of the APA. Papers sessions presenting research relevant to medical student education at the APA annual meetings are also extremely rare.
Stable salary funding for medical student educators is becoming more difficult to secure. When medical school educators in psychiatry manage to secure sufficient funding to devote time developing quality teaching programs, there is no guarantee that their efforts at teaching excellence will be rewarded by either promotion or job security. The available evidence suggests the contrary, that the attrition rates from career teaching pathways are high.
In an effort to better recognize quality teaching, especially of clinical teaching, a number of medical schools have adopted clinician-teacher career tracts as pathways to promotion, but these pathways essentially never grant tenure status. In part because of the heavy financial pressures on teaching institutions noted earlier, the "gold standard" for promotion and tenure is heavily dependent, directly or indirectly, on the income-generating capacity of the faculty member. Individuals with the greatest chance of internal departmental support for promotion are faculty members with a proven track record of procuring external grant funding (e.g., from the National Institutes of Health or pharmaceutical companies) or who have secured and maintain government contracts to provide mental health services (e.g., state and county facilities that pay resident and faculty salaries in smaller medical schools specifically designed to address the needs of rural regions of the country and emphasize primary care). These career educators are more likely to find secure faculty positions that give them freedom to teach. Most primary care–oriented medical schools are vitally concerned with providing clinicians for rural areas where psychiatrists are still relatively rare.
It has now been documented for years that the majority of mental health treatment is delivered, with various degrees of quality and expertise, through the general medical sector and not through the formal mental health system by psychiatrists.5 Although clinical epidemiologic data confirm that primary care physicians, even in urban areas, are the "front line" for providing psychiatric care to the general population, primary care–oriented medical schools are typically more vigorous in their support of psychiatric education for their future physicians.
Substantial evidence also indicates that primary care–oriented approaches to teaching that emphasize the interpersonal, psychosocial, and family systems aspects of medical care improves recruitment rates of students into psychiatry.6 Higher recruitment rates into psychiatry are consistently reported by schools emphasizing primary care medicine compared with more research-focused urban medical schools.6 Self-selection by students also very likely plays an important role in this phenomenon because students choosing primary care–oriented medical schools are more likely to have a predetermined interest in the interpersonal aspects of medicine and therefore would be more likely to be attracted to psychiatry as a career.
Given the rather bleak potential for junior faculty members who desire a professional career with a primary focus on psychiatric education, it is inevitable that the quality of teaching in psychiatry at the undergraduate medical school level will suffer. The discouraging outlook for those individuals who wish to be primary educators may be one reason why recruitment into psychiatry has fallen significantly over the past 15 years. Recruitment rates into psychiatric residencies averaged between 6.4% and 10% between 1949 and 1969. Although a transient upswing in recruitment was experienced between 1985–1988, in 1970, a fluctuating but generally progressive decline in recruitment began that now averages around 3% of each graduating medical school class in the United States.6
One of the most consistent findings in research in medical student education is that there is a positive correlation between increased rates of recruitment into psychiatric residencies in departments of psychiatry whose undergraduate medical school teaching programs in psychiatry are rated as "good to excellent" by students and where psychiatric departments commit major department resources to teaching students.6 Most of the schools with high recruitment rates into psychiatry are found in primary care–oriented schools (particularly in the southeastern United States, for unexplained geographic reasons).
If the primary thesis of this paper is correct, that is, that there has been a gradual devaluation in the importance of undergraduate psychiatric education and less support for career teachers in psychiatry over the past 10 to 15 years, this erosion in support for teaching may form part of the explanation of why the percentage of medical students entering psychiatric residencies has dropped so dramatically. Sierles, who has performed much of the seminal research in this area, cites multiple factors contributing to this decline in recruitment: 1) disillusionment caused by the "failure" of the community mental health movement to bring about significant sustained improvement in the prevention of mental illness or major improvements in the overall care of the chronically mentally ill; 2) the fact that psychiatry gradually became more medically "conventional," thereby losing some of the profession's "mystique" provided by the psychoanalytic culture, which had formerly attracted at least a percentage of medical students to the profession; 3) competition from primary care specialties, such as family practice and general internal medicine that emphasize comprehensive care of patients, including their psychosocial needs, similar to psychiatry but where students do not face the prospect of having their hard-won medical identities and skills atrophy; 4) reports of managed care–determined declining income-generating potential of psychiatrists (a factor especially important to graduates of private medical schools whose students are likely to have high educational debt); 5) the gradual shift to a biological focus in psychiatry and away from the psychological dimensions of patient care; and 6) a variety of other highly speculative factors involving changing demographics of medical student populations, such as increased numbers of women who purportedly are more likely to choose pediatrics and obstetrics-gynecology.6
Although none of these factors has or will likely be proven to be the sole cause of the dramatic decline in recruitment into psychiatry, a recent study found that medical students currently entering medical school are already biased against psychiatry as a career.7 In this study, the majority of students on entering medical school viewed both psychiatry and psychiatrists with low regard. This same study found that these negative attitudes toward psychiatry were shared by the majority of more advanced medical students, their attending physicians, and even the families of the students. Hence, there are strong preconceived negative biases against psychiatry—from the start of medical training—that seem to persist.
The existing evidence suggests that the primary strategy that might change these negative attitudes toward psychiatry would be a strong commitment of department resources to ensuring excellent teaching of behavioral science and preclinical psychiatry together with positive clinical clerkship experiences in psychiatry. Most important is providing attending physician role models for students, role models worthy of admiration and respect. Research outside of psychiatry has shown that attending role models most admired by medical students (and therefore more likely to influence their choice of specialty) are those attending who devote at least a quarter of their time to direct patient care, emphasize the doctor-patient relationship in medical practice, and teach within the context of a psychosocial model of patient care.8 It would seem that psychiatric teacher-clinicians would be ideally suited to meet these criteria as role models, at least the type of teacher-clinicians who have been traditionally associated with the profession. As previously noted, the survival in academia of teacher-clinicians who meet the qualifications of ideal teacher-clinicians is in serious jeopardy.8,9
It's likely that a number of other factors are involved in the low recruitment rates into psychiatry. Although not limited to psychiatry, students are well are aware of the negative influence of managed care on the morale of the psychiatric profession and the adverse effects managed care has had on the practical aspects of patient care.10 Nevertheless, the two primary factors that are likely to counteract negative attitudes toward psychiatry and improve recruitment into psychiatric practice are high-quality teaching and exposure to positive clinician role models.2,6,8
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PROSPECTS FOR REVITALIZING THE ROLE OF PSYCHIATRIC EDUCATION
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As we enter the 21st century, the following recommendations are made as initiatives to improve the quality of medical student psychiatric education, which forms a critically important part of the recruitment process into the profession and an essential element of psychiatry's humanitarian mission. At the undergraduate level of medical education, it is incumbent on deans and department chairs to scrutinize their budgets to assess whether their psychiatric educators are directly receiving support from tuition fees to protect their time for teaching as a fair percentage of their salary. Career educators should also be assisted in developing strategic plans for their academic development commensurate with the faculty member's professional goals and ambitions. If a promotional pathway along a teacher-clinician track has not been developed at the faculty member's current institution, then alternative career plans might be suggested or the individual be advised regarding positions at medical schools where the opportunities for advancement along career teacher-clinician promotion tracks are more favorable. Choosing to devote one's career to teaching should not be an act of professional suicide.
Medical schools that do not have a promotional track for teacher-clinicians should develop one, and the need for such an option is increasingly being recognized by the majority of U.S. medical schools.2,8,9 Many medical schools have developed separate guidelines for advancement of non-research-oriented faculty with criteria for promotion defined by assessment of the candidates' excellence in clinical care, teaching, or more commonly, both factors.
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SPECIAL CONSIDERATIONS FOR C-L PSYCHIATRY
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In the context of psychiatric education, C-L psychiatry deserves special consideration in this discussion. First, C-L psychiatry has always struggled financially from the reimbursement standpoint, and the advent of managed care has threatened the very existence of this subspecialty with arbitrary and shortsighted restrictions on reimbursements for psychiatric consultations and follow-up care.11 Psychiatric C-L services have always been heavily dependent on the fiscal underwriting of their sponsoring institutions. This underwriting has gradually declined because of Medicare and managed care–driven cost cutting.
A wealth of evidence now exists that demonstrates a high prevalence of psychiatric comorbidity in general medical patients, that psychiatric comorbidity adversely affects patient outcomes in almost every disease entity in which it has been systematically examined, and that concurrent medical-psychiatric illness increases medical hospital lengths of stay.12 The most striking demonstration of the cost-efficiency and cost-benefits of C-L services has been demonstrated in delirium.13 In a seminal study by Inouye et al.,13 screening preventative measures for patients identified to be at high risk for delirium decreased hospital morbidity and decreased the length of their hospital stay.
C-L psychiatry is the only subspecialty of psychiatry that overtly defines itself as having an educational identity and mission through liaison teaching. This nonreimbursable component of the C-L psychiatrist's time commitment is taken into account with decreasing frequency in determining C-L psychiatrists' salary structure, further jeopardizing this subspecialty's fiscal viability.
The threat to C-L psychiatry has significant implications for the psychiatric profession as a whole, as this subspecialty is usually the principal window onto which students, residents, and other faculty members look upon the clinical practice of and clinical utility of psychiatric practice. If C-L psychiatry is to maintain a positive and viable presence in teaching hospitals, and if C-L psychiatrists are to continue to provide on-site role models for medical students, institutional underwriting for their professional time must be maintained.
Careful examination must be given to whether departments of psychiatry and hospital budgets are fairly and accurately reimbursing the liaison educational activities of C-L psychiatrists. In psychiatry, as well as other medical specialties, to attract and retain career teachers, quality individuals will need to be valued as reflected in their salary support, which should be commensurate with the amount and ratings of their teaching efforts. These individuals must also be provided with well-defined and realistic criteria for academic career advancement. The comments of the American philosopher Elbert Hubbard, from 1911, are relevant for medical education today.
I will never be quite willing to admit that this country is enlightened, until we cease the inane and parsimonious policy of trying to drive all the really strong men and women out of the teaching profession by putting them on the payroll at one-half the rate, or less, that which the same brains and energy can command elsewhere ... It is not the necessity of the economy that dictates our actions in this matter of education—we simply are not enlightened. But this thing can not always last—I look for the time when we shall set apart the best and the noblest men and women of earth for teachers, and their compensation shall be so adequate that they will be free to give themselves for the benefit of the race, without apprehension of a yawning almshouse. A liberal policy will be for our own good, just as a matter of expediency; it will be enlightened self interest.14
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SUMMARY
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This paper has outlined only some of the problems associated with developing, supporting, and maintaining quality teaching at the undergraduate medical student level. Unfortunately, it is unlikely that any of the recommendations made here will be implemented unless there is a fundamental shift in the value placed on teaching by department chairs and sufficient resources are devoted to enhancing the quality of teaching and appropriately rewarding and promoting faculty members. The positive outcomes of a renewed emphasis on ensuring quality psychiatric education for medical students will be physicians who are better trained to care for the emotional and psychosocial needs of their patients, increase in the number of medical students who choose psychiatry as their career, and improved patient outcomes.
Components of this paper were originally read as the Vestermark Award Lecture at the annual meeting of the American Psychiatric Association, May 19, 1999, Washington, D.C. It has been edited and revised for purposes of publication.
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REFERENCES
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Wright SM, Kern DE, Kolodner K, et al: Attributes of excellent attending physician role models. N Engl J Med 1998; 339:1986–1993
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Stoudemire A (ed): Psychological Factors Affecting Medical Conditions. Washington, DC, American Psychiatric Press, 1995
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ABSTRACT
INTRODUCTION
