“What about combined psychiatry-family medicine-neurology-internal medicine programs? Should I try to do a triple board program in psychiatry-child psychiatry and pediatrics?”
Every April, I field such questions from a slew of rising fourth year students who have become, to their surprise (and sometimes dismay), passionately interested in psychiatry. Psychiatry is a shortage specialty and psychiatric issues rank high among the challenges facing medical care systems here and around the world. For example, major depression has steadily advanced up the ladder of the World Health Organization’s ranking of conditions accounting for years lost to disability (YLD) and disability adjusted life years—to the point that major depressive disorder now accounts for the highest number of YLDs and is fourth leading contributor to DALYs worldwide. Together, alcohol, illicit drug and tobacco use are responsible for 9.1% of the total burden of disease around the globe. These numbers translate into millions of years of productive life loss, and billions of dollars of money inefficiently spent on medical consequences of preventable diseases. Don’t get me started on obesity.
While stress related illnesses, changing habits or adapting to chronic illness aren’t solely psychiatric concerns, within medicine , psychiatrists are uniquely qualified to address them with patients, and to enhancing the capacity of generalists and members of the allied health professions to diagnose and, sometimes, treat psychiatric, psychosocial, and behavioral problems.
Nevertheless, until now I have discouraged students from signing up for combined training programs. Even doctors who are eager and well prepared to deal with complex medical/psychiatric/behavioral problems cannot overcome the barriers of mental health “carve outs” and discriminatory reimbursement. Those who want to integrate psychiatry with another specialty may find themselves unable to bill for psychiatric services. If someone wants to integrate another specialty with psychiatry, problems of building and supporting the necessary teams are as daunting as problems of reimbursement and access. Graduates of combined programs struggle to find positions that allow them to practice both specialties once they leave training. Many default to practicing only one or the other, wasting precious skills acquired at considerable cost.
My advice is changing. Certain organized systems of care, in particular the Veteran’s Administration, have pioneered programs that make optimal use of psychiatric expertise at the interface of psychiatry and medicine/pediatrics/neurology. Provision 2704 of the Affordable Care Act has done much to encourage the creation of medical homes and accountable care organizations, places where the cost savings and increased professional satisfaction of providing integrated care quickly become apparent. At a recent meeting of the American Psychiatric Association, multiple presentations on integrated care attracted standing room only crowds. Many demonstration projects are sustained by grants; despite their obvious benefits, exciting new models for integrated care will not survive unless the system of payment for services evolves to make them viable.
Like my students, psychiatrists of every level of experience don’t want to give up being physicians in order to practice our unique specialty. We are eager to use our basic medical training throughout our professional lives, and to offer the fruits of what we have learned as specialists to our students and colleagues. For the first time in decades, I can now tell students this dream is becoming reality.
Come next spring, when a student sidles into my office and says, with some embarrassment, “Dr. Frank, I think I want to be a psychiatrist … um … er … what do you think about a combined program?” my answer is going to be “Go for it, kid!”
Julia Frank is a psychiatrist who blogs at Progress Notes.
