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Child and Adolescent Psychiatry Work Force; A Critical Shortage and National Challenge

Child and Adolescent Psychiatry Work Force; A Critical Shortage and National Challenge. AACAP Steering Committee for Workforce Issues.

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Child and Adolescent Psychiatry Work Force; A Critical Shortage and National Challenge

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  1. Child and Adolescent Psychiatry Work Force; A Critical Shortage and National Challenge AACAP Steering Committee for Workforce Issues

  2. “There is a dearth of child psychiatrists… Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals... This places a burden on pediatricians, family physicians, and other gatekeepers to identify children for referral and treatment decisions.” (Mental Health: A Report of the Surgeon General, 1999)

  3. Prevalence and Magnitude of Child and Adolescent Psychiatric Problems • About 20 percent of U.S. children and adolescents (15 million), ages 9 to 17, have diagnosable psychiatric disorders (MECA, 1996, the Surgeon General, 1999) • The Center for Mental Health Services (1998) estimated that 9 to 13 percent of U.S. children and adolescents, ages 9 to 17, meet the definition of “serious emotional disturbance” and 5 to 9 percent of U.S. children and adolescents, “extreme functional impairment.” • Only about 20 percent of emotionally disturbed children and adolescents receive some kind of mental health services (the Surgeon General, 1999), and only a small fraction of them receive evaluation and treatment by child and adolescent psychiatrists. • The demand for the services of child and adolescent psychiatry is projected to increase by 100 percent between 1995 and 2020, and for general psychiatry, by 19 percent (U.S. Bureau of Health Professions, DHHS, 2000). • The population of children and adolescents under age 18 is projected to grow by more than 40 percent in the next 50 years from the current 70 million to more than 100 million by 2050 (U.S. Bureau of the Census,2000).

  4. Prevalence and Magnitude of Child and Adolescent Psychiatric Problems • About 20 percent of U.S. children and adolescents (15 million), ages 9 to 17, have diagnosable psychiatric disorders (MECA, 1996, the Surgeon General, 1999)

  5. Prevalence and Magnitude of Child and Adolescent Psychiatric Problems (continued) • The Center for Mental Health Services (1998) estimated that 9 to 13 percent of U.S. children and adolescents, ages 9 to 17, meet the definition of “serious emotional disturbance” and 5 to 9 percent of U.S. children and adolescents, “extreme functional impairment.”

  6. Prevalence and Magnitude of Child and Adolescent Psychiatric Problems (continued) • Only about 20 percent of emotionally disturbed children and adolescents receive some kind of mental health services (the Surgeon General, 1999), and only a small fraction of them receive evaluation and treatment by child and adolescent psychiatrists.

  7. Prevalence and Magnitude of Child and Adolescent Psychiatric Problems (continued) • The demand for the services of child and adolescent psychiatry is projected to increase by 100 percent between 1995 and 2020, and for general psychiatry, by 19 percent (U.S. Bureau of Health Professions, DHHS, 2000).

  8. Prevalence and Magnitude of Child and Adolescent Psychiatric Problems (continued) • The population of children and adolescents under age 18 is projected to grow by more than 40 percent in the next 50 years from the current 70 million to more than 100 million by 2050 (U.S. Bureau of the Census, 2000).

  9. Supply of Child and Adolescent Psychiatrists • There are currently about 7,000 and adolescent psychiatrists practicing in the U.S. (AMA, 2006). • In 1980, GMENAC recommended that the number of child and adolescent psychiatrists be increased to 8,000 - 10,000 by 1990 in order to meet the projected needs for treatment of child mental disorders. • In 1990, COGME reported that the nation would need more than 30,000 child and adolescent psychiatrists by 2000, based on increasing rates of child mental illnesses and managed care staffing models. • There is a severe maldistribution of child psychiatric services in the U.S., with children in rural areas and areas of low SES having significantly reduced access. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts with an average of 8.7 (Thomas and Holzer, 2006). • While the U.S. Bureau of Health Professions (2000) projects that the number of child and adolescent psychiatrists will increase by about 30 percent to 8,312 by 2020 if the funding and recruitment remain stable at the current level, this is far less than the estimated 12,624 needed to meet demand.

  10. Supply of Child and Adolescent Psychiatrists • There are currently about 7,000 child and adolescent psychiatrists practicing in the U.S. (AMA, 2006).

  11. Supply of Child and Adolescent Psychiatrists (continued) • In 1980, GMENAC recommended that the number of child and adolescent psychiatrists be increased to 8,000 - 10,000 by 1990 in order to meet the projected needs for treatment of child mental disorders.

  12. Supply of Child and Adolescent Psychiatrists (continued) • In 1990, COGME reported that the nation would need more than 30,000 child and adolescent psychiatrists by 2000, based on increasing rates of child mental illnesses and managed care staffing models.

  13. Supply of Child and Adolescent Psychiatrists (continued) • There is a severe maldistribution of child psychiatric services in the U.S., with children in rural areas and areas of low SES having significantly reduced access. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts with an average of 8.7 (Thomas & Holzer, 2006).

  14. Supply of Child and Adolescent Psychiatrists (continued) • While the U.S. Bureau of Health Professions (2000) projects that the number of child and adolescent psychiatrists will increase by about 30 percent to 8,312 by 2020 if the funding and recruitment remain stable at the current level, this is far less than the estimated 12,624 needed to meet demand.

  15. Recruitment Problems • There has been a steady decline in the recruitment of PGYI USMG’s into general psychiatry through the NRMP, from 664 in 1990 to 481 in 2000, although increasing to 524, 564, 597, 641, 653, 643 in 2001-2006. However, the total number of psychiatric residents has remained relatively stable, about 6000. • The number of child and adolescent psychiatry residents has not increased in the past decade of the 20th century; 712 in 1990, and 718 in 2000. The number of child and adolescent psychiatry training programs has decreased by 5 to 114 in the same period. However, the numbers have been increasing slightly; 723, 742, 766 in 2004-6 and 3 new programs opening (ACGME, 2006) • The proportion of IMG’s in child and adolescent psychiatry residency programs has substantially increased from about 20 percent in 1990 to 34.8 percent (AMA, 2006). The recommendation made in the 14th COGME report (1999) to enforce exchange visa status of IMG’s to return to their home country after training and post 9-11 events will likely further reduce the future workforce. • Close to 13 percent of child and adolescent psychiatry residency positions were unfunded or unfilled in 2006; 766 residents filled 882 approved positions (ACGME, 2006). • It is estimated that about 20 percent of U.S. medical schools do not sponsor child and adolescent psychiatry residency programs and more than 30 percent of U.S. medical students have minimum or no clinical clerkship arrangement in child and adolescent psychiatry–a critical void in the recruitment and education of future physicians.

  16. Recruitment Problems • There has been a steady decline in the recruitment of PGYI USMG’s into general psychiatry through the NRMP, from 664 in 1990 to 481 in 2000, although increasing to 524, 564, 597, 641, 653, 643 from 2001 to 2006. However, the total number of psychiatric residents has remained relatively stable, about 6000.

  17. Recruitment Problems (continued) • The number of child and adolescent psychiatry residents has not increased in the last decade of the 20th century; 712 in 1990, and 718 in 2000. The number of child and adolescent psychiatry training programs has decreased by 5 to 114 in the same period. However, the numbers have been increasing slightly; 723, 742, 766 in 2004-6 and 3 new programs opening (ACGME, 2006).

  18. ACGME Resident Census And *GME Track (AMA/AAMC, APA) Zip: Kim_ACGME Census 1999-06

  19. CHILD PSYCHIATRY MATCH TABLE 1 NRMP Child and Adolescent Psychiatry Program Statistics Note: NRMP=National Resident Matching Program

  20. CHILD PSYCHIATRY MATCH TABLE 2 NRMP Child and Adolescent Psychiatry Applicant Statistics Note: NRMP=National Resident Matching Program Total Enrollment= A+W, Unmatched= A-M, *Total Combined or Separate numbers in some years

  21. Recruitment Problems (continued) • The proportion of IMG’s in child and adolescent psychiatry residency programs has substantially increased from about 20 percent in 1990 to 34.8 percent (AMA, 2006). The recommendation made in the 14th COGME report (1999) to enforce exchange visa status of IMG’s to return to their home country after training and post 9-11 events will likely further reduce the future workforce.

  22. Recruitment Problems (continued) • Close to 13 percent of child and adolescent psychiatry residency positions were unfunded or unfilled; 766 residents filled 882 approved positions (ACGME, 2006).

  23. Recruitment Problems (continued) • It is estimated that about 20 percent of U.S. medical schools do not sponsor child and adolescent psychiatry residency programs and more than 30 percent of U.S. medical students have minimum or no clinical clerkship arrangement in child and adolescent psychiatry–a critical void in the recruitment and education of future physicians.

  24. Recruitment Problems (continued) • Increasing educational debt, pressure and incentives to pursue a primary care career in the 1990’s, a long training period, further sub-specialization of medicine including psychiatry and reimbursement problems in the managed care era are some of the factors that discourage medical students in choosing a career in child and adolescent psychiatry.

  25. Funding Problems • Governmental agencies and the medical community have promoted a decrease in the overall physician workforce, an increase of primary care workforce, a reduction of specialty workforce, and a decrease in the number of IMG’s entering graduate medical education–a so called 50-50-10 model; 50 percent generalists, 50 percent specialists, 10 percent IMG’s (COGME, 1992, 1994, 1995; Pew Health Professions Commission, 1995; the 1997 consensus statement by AAMC, AACOM, AMA, AOA, AAHC, NMA). • The Balanced Budget Act (BBA) of 1997 reduced direct GME funding by 50 percent for subspecialty training beyond the primary specialty board eligibility. This is an added cut to child and adolescent psychiatry that had not received indirect GME funding in the past. • The 1997 BBA provided incentives to teaching hospitals for reduction of GME positions. It also resulted in the severe reduction of Medicare reimbursement to teaching hospitals. Although the BBA of 2000 will provide some temporary relief to teaching hospitals, the GME programs, especially child and adolescent psychiatry residency programs will suffer from funding cuts.

  26. Funding Problems • Governmental agencies and the medical community have promoted a decrease in the overall physician workforce, an increase of primary care workforce, a reduction of specialty workforce, and a decrease in the number of IMG’s entering graduate medical education–a so called 50-50-10 model; 50 percent generalists, 50 percent specialists, 10 percent IMG’s (COGME, 1992, 1994, 1995; Pew Health Professions Commission, 1995; the 1997 consensus statement by AAMC, AACOM, AMA, AOA, AAHC, NMA).

  27. Funding Problems (continued) • The Balanced Budget Act (BBA) of 1997 reduced direct GME funding by 50 percent for subspecialty training beyond the primary specialty board eligibility. This is an additional cut to child and adolescent psychiatry that had not received indirect GME funding in the past.

  28. Funding Problems (continued) • The 1997 BBA provided incentives to teaching hospitals for reduction of GME positions. It also resulted in the severe reduction of Medicare reimbursement to teaching hospitals. The reductions in health care services and health professions training grants in 2001 have affected, and the state and federal budgetary problems will further affect negatively teaching hospitals, the GME programs, especially child and adolescent psychiatry residency programs.

  29. SUMMARY: The need and voice of child and adolescent psychiatry have been buried under the sweeping forces of the federal mandates and national medical organizations’ consensus on the oversupply of specialists. They have failed to recognize the continuing critical shortage of child and adolescent psychiatrists. The serious undersupply of practitioners has resulted in children receiving inadequate care from mental health professionals who lack the necessary training. However, there have been increasing recognition of shortage of physicians in general but also child and adolescent psychiatrists, resulting in increasing numbers of new residents and programs.

  30. A CALL TO ACTION: CHILDREN NEED OUR HELP STRATEGIC PLAN American Academy of Child and Adolescent Psychiatry 10 year initiative

  31. Recruitment/Workforce • Biopsychosocial • developmental • multimodal • Systems intervention • Multilevel collaboration

  32. EXPANDING THE PORTALS OF ENTRY FOR CAP TRAINING • Traditional Program (5 or 6 Years); 3 to 4 yrs GP + 2 yrs CAP • Triple Board Program (5 Years); 2 yrs Peds+3 yrs GP & CAP • Integrated Training (5 Years); traditional + CAP exposure • Integrated Training, Innovative (5-6 Years); + research • Pediatrician track (6 Years); 3 yrs Peds + 3 yrs GP & CAP

  33. Legislative efforts; • Stark bill to support GME funding for shortage specialties, e.g. CAP, nephrology, etc. failed by 2000 • The Child Healthcare Crisis Relief Act, H.R. 1106; bipartisan by Kennedy (D-RI) and Ros-Lehtinen (R-FL) • Senate Companion Bill (S.537); bipartisan by Sen. Bingaman (D-NM) and Collins (R-ME),

  34. The Child Healthcare Crisis Relief Act • Recognition of national shortage of child mental health professionals • Incentives to help recruit and retain child mental health professional by loan repayments, scholarships and grants • Increase of CAP by extending Medicare GME years and cap for GME funding • Total appropriation; $45 mill annually for 4 years

  35. Advocacy • Public image; media • Governmental; federal (DHHS:FDA, NIH, SAMHSA, etc)), congress, state, local • Mental health community; consumer groups, CMHC, hospitals • Medical community; professional organizations (AMA, ACGME, AAMC, AAP, etc), medical schools

  36. Medical Education & Mentoring • Education of medical students: curriculum • Exposure to clinical child psychiatry by medical students • Availability of mentor in ROCAP • Information on professional satisfaction, job market and life style

  37. Survey of graduating residents • Center for Health Work Force Studies at SUNY, Albany (http://chws.albany.edu) • all graduating residents and fellows in NY (4400-4500) and CA(2600-2700) in 27-28 specialties each year in 1998-2002 • 40 to 65 % response rates • Child and adolescent psychiatry ranked #1 in many categories of career opportunity, although the rankings from NY survey in 2003-2005 were lower.

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