Is It Time to Rethink Psychiatry Residency Training? Part I: Overview

During the last few years, several articles have been published, both in our journal and others, which indicate that psychiatry is at a critical juncture [1–5]. Psychiatric workforce shortages, the maldistribution of psychiatric care, and lack of availability of specialists such as child and adolescent psychiatrists are all accepted facts at this point in time. There have also been several advances in the field pertaining to new treatments and systems of care. These issues raise the question of whether psychiatrists train an appropriate psychiatric workforce or whether residency training needs to adapt substantially to address these changes and, if so, in what way.

In a series of editorials within this journal, we plan to take a critical look at the future of psychiatric residency training. In this introductory editorial, we examine the basis for why major changes to training may be needed. Here we focus on training in the USA, as opposed to other nations, although we realize that we have a lot to learn from how other nations conduct their training to meet the needs of the populations that they serve.

Are We Meeting Our Patient Population Needs?

According to a survey at the end of 2020 [1], the number of adults in the USA reporting symptoms of depression, anxiety, substance use, and suicidal thoughts has increased substantially. Additionally, the surgeon general [5] noted that the USA is in the midst of a mental health crisis for youth. Rates of depression, anxiety, loneliness, and suicidal thoughts and behavior have skyrocketed [5].

A 2017 national survey on substance use and mental health [6] found that among adults with any mental illness, only 42.6% received treatment in the year preceding the survey. This finding means that in the USA, out of 46.6 million adults needing treatment, only 19.8 million were able to receive services. This survey was prior to the COVID-19 pandemic, which has subsequently brought renewed attention to the need for mental health care. These findings highlight that many patients have difficulty finding access to psychiatric care. Patients belonging to certain racial, sexual, and gender minority groups; patients who were experiencing homelessness or incarcerated; and immigrant populations faced even more difficulty procuring treatment [1, 7]. Barriers to treatment for minority populations during the pandemic include lack of community-based interventions and resources, deficits in the number of psychiatrists who identify as underrepresented in medicine, and the role of bias and stigma [1, 7].

The USA is currently experiencing a psychiatric workforce shortage, which is expected to continue and potentially worsen [4]. Even though the number of residency positions offered in psychiatry has increased [8], there is still tremendous competition for places in residency programs, and it is also unclear whether this deficit in the workforce shortage will resolve by 2050 [4]. The mental health workforce shortage is even worse for subspeciality care. Serious concerns have been raised about the shortage of psychiatrists specializing in addiction, geriatrics, and child and adolescent psychiatry [1, 6] and about access to psychiatry in rural settings [9].

What Can Residency Training Do About Meeting These Needs?

Expansion of the psychiatric workforce and access to psychiatric care are both very complex issues. One possible solution is to continue to expand residency training slots, although this expansion will not completely solve deficits in access to services due to the large deficits in the number of psychiatrists needed. Although an important response, our focus here primarily concerns the curriculum for training residents and whether changes to how prospective psychiatrists are trained might better address unmet community mental health needs.

Another potential response is to expand the reach of individual psychiatrists, such as by being trained in how to supervise and work with advanced practice providers [10]. Solutions to expand the reach of psychiatrists and partially addressing maldistribution include collaborative care models, telepsychiatry, and providing consultations and education to primary care specialists providing mental health care [7].

In addition, psychiatrists might look to equip each general psychiatrist to provide some degree of subspecialty skills. That is to suggest that psychiatrists will need to think about the ability of the workforce to work with a wide range of diagnoses and age groups. Several authors [3, 11–13] have recommended changes in subspeciality education and exposures. Currently, an increasing number of medical students are interested in training to be psychiatrists, but this interest has not translated into more interest in fellowships. All subspecialities every year experience unfilled fellowship slots. Much discussion has occurred on how to get psychiatry residents interested in subspeciality fellowships. However, some authors [12, 13] have suggested that alternate approaches need to be considered also. This topic is complex, as sometimes psychiatry program directors and fellowship program directors can be at odds and a critical look at pros and cons of different approaches is needed.

Another potential response is to restructure psychiatry’s curriculum and services around prevention and population mental health, in the interest of reducing the mental health care burden relative to the limited supply [14–16]. This response would involve all future psychiatrists having a robust understanding of not only various levels of prevention but also the impact of epidemiology and the potential impact of public health policies. Special topics of interest might include, for example, interpersonal violence, including firearm violence; factors that contribute to suicidal behaviors; and topics related to meeting the mental health needs associated with a warming planet. They might also include how to advocate and to interact effectively with media to promote public mental health education and to dispel myths including misinformation about the etiology of psychiatric disorders and their diagnoses and treatment. Currently lacking are incentives, including financial reimbursements, for psychiatrists to engage in various prevention activities.

How Does Psychiatry Training Adapt to Innovations Now and in the Future?

As we discuss the training of future psychiatrists and the scope and balance of the curriculum, it will be important to consider how training is adapting to innovations in the field. Exciting new medications and treatment modalities are emerging, and there are many advances in the understanding of psychiatry, including neuroscience and genetics, expansion of the psychiatrist’s armamentarium with medications such as esketamine/ketamine and psychedelics, interventional treatments, advances in use of informatics, and changes in the practice of psychotherapy. Some of these advances may not yet translate well to day-to-day clinical applications.

Some of these changes in the practice of psychiatry are driven by financial disincentives or changing health care systems. For example, even though training in psychotherapy is considered a core skill, there is a documented decline in the use of psychotherapy by practicing psychiatrists [17]. Some changes like telepsychiatry have become common due to the COVID-19 pandemic and could mitigate the workforce maldistribution.

There are several critical questions to be answered. What percentage of time should be dedicated to the curriculum on these varied topics? Is there a way to make the training requirements more responsive to critical population needs in real time? What aspects of training should be mandated, and what should be considered flexible or open to the preferences of residents and their program directors? Are there elements of the current curriculum that should be omitted? What is essential for all psychiatrists to know, and what can be learned independently as individual graduates choose their practice focus?

Are Major Changes to US Psychiatry Residency Training Required?

Even addition or removal of one or two required elements of residency training is a significant matter. However, at this time, major elements as mentioned above warrant revisiting. Many of these elements need a more comprehensive examination of the pros, cons, and challenges in their implementation and associated examination of meaningful outcomes. We plan to address the following topics in future editorials.

Training in Medicine and Neurology

What should be the required rotation lengths and types in medicine and neurology? Should there be changes in the related curriculum requirements? What should be the changes in the curriculum and clinical experiences requirements related to treating patients with psychiatric illnesses for some of the other specialties like medicine and emergency medicine?

Training All Psychiatry Residents to Be General Psychiatrists

Are graduates of psychiatry residency training qualified to be general psychiatrists who can treat all patient populations? If not, what will be required for them to be able to do so?

Expanding the Reach of Individual Psychiatrists

What kind of curricular and rotation experiences would be required to expand the reach of individual psychiatrists? How do psychiatrists train residents to lead teams effectively?

Psychotherapy Training

Why is psychotherapy training an essential core skill for all psychiatry residents regardless of their eventual practice? How do psychiatry programs train residents in these skills with decreasing number of faculty practicing psychotherapy? What should be the required psychotherapy competencies that fit the practice needs of future psychiatrists?

Interventional Psychiatry

What should be the curricular requirements related to interventional psychiatry? Are there clinical experiences that should be required?

Curriculum Revisions

As psychiatry training programs consider adding to the curricular requirements, what should be taken away from the current requirements? How do programs establish a continuous process of evaluating how their training requirements match what the society needs from psychiatrists? How would the field ensure all psychiatry programs are able to provide the curriculum or clinical experiences that are proposed?

Call for Reader Engagement

We call on our community of readers and leaders in psychiatry to join us in this journey and to help answer questions that have been raised in this editorial and will be raised in this series. We invite you to write to us and share your thoughts on additional topics related to residency training that need to be addressed.

Declarations

Disclosures

On behalf of all authors, the corresponding author states that there is no conflict of interest.