A Survey of Psychiatric Practice: Implications for Psychiatric Training

A SURVEY OF PSYCHIATRIC PRACTICE: IMPLICATIONS FOR PSYCHIATRIC TRAINING BERNARD D. BEITMAN, MD PETER MAXIM, MD, PhD ABSTRACT: One hundred and seventy-two of 334 psychiatrists in the state of Washington returned completed questionnaires inquiring into their practice activities. The results suggested that psychiatrists continue to be involved in a broad spectrum of activities; combining pharmacotherapy with psychotherapy appears to be a dominant trend. Although liaison, inpatient work, and target populations occupy a small percentage of time, future psychiatrists are likely to be increasingly involved in these areas. National psychiatric training guidelines have been formulated by placing relative weights upon the basic psychiatric skills, normative activities of practitioners, and the perceived present and future needs of psychiatric patients. Basic psychiatric skills are defined by the limits of both basic science and clinical research. Perceived present and future needs are determined in part by funding, fashion, and research attention. The variable of normative practitioners activity has received little attention but is accessible. We therefore undertook to define the basic elements of psychiatric practice in the state of Washington in order to guide our decisions in determining essential ingredients for our training program. The National Ambulatory Care Survey of 1975 found that psychiatrists spent 86 percent of their office visits in psychotherapy and 25 percent in pharmachotherapy. 1 A survey of psychiatric practice in southern Connecticut indicated that the principal psychiatric therapies were individual psycotherapy (25 percent), drug therapy (25 Dr. Beitman is Acting Associate Director of Residency Training and Dr. Maxim is Director of the Residency Training Program at the Department of Psychiatry and Behavioral Sciences of the University of Washington. Address reprint requests to Bernard Beitman, Department of Psychiatry and Behavioral Sciences, University of Washington RP-10, Seattle, Washington 98195. ©1984 Human Sciences Press 149 150 THE JOURNAL OF PSYCHIATRIC EDUCATION percent), group therapy (20 percent), and family therapy (15 percent).2 Patients tended to be adults from middle to upper socioeconomic classes suffering from schizophrenia, affective disorders, and psychoneuroses and a few aged, alcoholic, drug dependent, or sociopathic patients. Marmor et al. surveyed 440 private psychiatrists, 3 and Yager et al. 4 surveyed the practice patterns of UCLA graduates. METHOD In 1980, a fifteen-item questionnaire was sent to 334 psychiatrists on the mailing list of the Washington State Psychiatric Association, which included 95 percent of the psychiatrists in the state. Thirteen were returned uncompleted (five address changes and eight retirements) reducing the population to 321, of whom 172 (54 percent) completed the questionnaire. Variables included: city size, theoretic orientation, (analytic, dynamic, cognitive, existential, biologic), psychotherapeutic tactics (e.g., insight, active probing, focused cognitions, transference interpretations), types of treatment (individual, family group, medications), frequency of patient visits, mean number of patient visits, and types of services offered (e.g., psychoanalysis, psychosomatic, community psychiatry, administration, forensic). RESULTS The sample distribution of psychiatrists answering the questionnaire closely follows the distribution of all psychiatrists in the state (p = 0.03 Wilcox on signed rank sum test). Forty-eight percent (82 of 172) described themselves as analytic, 27 percent (27 of 172) as dynamic, 14 percent (24 of 172) as biological, 8 percent (14 of 172) as cognitive, and 3 percent (5 of 172) as existential. Analytically oriented psychiatrists are about as common in towns under 50,000 (47 percent) as in towns of one hundred to five hundred thousand (49 percent) while the percentage of biologically oriented psychiatrists dropped from 26 percent in towns smaller than 50,000 to 10 percent in the largest cities, which also have more dynamically oriented practitioners. Psychiatrists of all orientations in all cities spend at least 50 percent of their time in individual psychotherapy. Dynamic and analytically oriented therapists BERNARD D. BEITMAN and PETER MAXIM 151 in cities of one hundred to five hundred thousand see the greatest proportion of patients in this manner (85 percent). Group therapy in small towns is not available except for medication groups run by biologically oriented psychiatrists. Family therapy also is rarely offered in cities under 20,000 people. Children receive minimal treatment in the smallest towns and the most in the largest city. Psychiatrists in the small communities report involvement in a wide range of treatment contexts: private practice, community mental health centers, forensic and neurological evaluations, treatment of psychosomatic and schizophrenic patients. Psychiatrists in the larger cities report a more narrow, apparently more focused practice. Thirty-five percent of all patients are seen once each week by therapists of all types. The larger the city, the greater the reported frequency of visits. Biologically oriented psychiatrists see 80 percent of all patients at two weeks or greater intervals, presumably for medication follow-up. Fifty percent of all patients were seen less than twenty times by all therapists. In towns smaller than 50,000, 65 percent of patients were seen fewer than twenty times while analytically oriented therapists in the larger cities reported seeing more than onethird of their patients for greater than 100 visits. Approximately half of all patients seen by psychiatrists in the state of Washington are not on medication. In the smaller towns, 60 percent are taking medications, and in the larger cities 40 percent are receiving them. Concerning the combination of pharmacotherapy and psychotherapy, 38 percent of all patients are being treated concurrently with medications and psychotherapy. Respondents were asked to indicate the percent of time they used different tactics with patients in a typical week. The majority indicated that this task was quite difficult, since they did not think about their tactics in terms of proportions. Instead they indicated the tactics they did use without regard to relative use. The percentages of psychiatrists reporting the use of four tactics was: insight, face-toface, 54 percent; active probing 54 percent; recommendations 46 percent; focused cognitions 35 percent; and interpretation of transference 35 percent. Other tactics reported in decreasing frequency included relaxation training, modeling, behavioral rehearsal, assertion training, desensitization, and hypnosis. In regard to responses concerning areas of interest, very little activity was reported in psychosomatics, partial hospitalization, geriatrics, handicapped, mental retardation, drug addiction, alcoholism, and inpatient work. 152 THE JOURNAL OF PSYCHIATRIC EDUCATION DISCUSSION A good psychiatric education requires the residents to be exposed to a wide variety of experiences in order to provide them with several foundations from which viable professional careers may be built. This survey indicates that psychiatrists in Washington state are involved in a wide variety of patient care roles. Such diversity is likely to continue, especially in smaller towns and cities. Among the future practice patterns illustrated by this survey is the combining of pharmacotherapy and psychotherapy. Approximately 40 percent of the patients seen in psychotherapy by psychiatrists were also receiving psychoactive medications. The evidence is growing to suggest that combined therapy may be more effective than either alone. 5 Psychiatric educators will need to contribute to efforts to develop clinical and theoretical models for enhancing the teaching of this aspect of current and future psychiatric practice. The survey indicated that psychiatrists spend relatively little time in consultation-liaison. While it is possible that this trend will continue, a shift in funding priorities could radically alter the current pattern. The reason to anticipate this shift is that primary care medicine acts as the de facto mental health delivery system of the United States. 6 Therefore, consultation and liaison training are required in order to provide future psychiatrists with the potential to develop these necessary roles in general medicine. Relatively little psychiatric time is spent in serving federally targeted populations. However, the number of recent graduates trained to deliver such services is quite small compared to the pool of psychiatrists surveyed. The data clearly indicate the paucity of child psychiatric activity in small towns. Few psychiatrists reported service on inpatient units, a finding that questions the requirement of one full year of inpatient service. The many conflicting positions around this issue include the service requirements of the institution, the intense exposure to a wide variety of acute psychiatric patients, the details of team participation and management, the potential sense of accomplishment resulting from the mastery of such experience, the too-heavy emphasis in administration versus patient care, and the role of inpatient experience in developing an identity as a psychiatrist. Perhaps the bottom line of this debate is the likelihood that acute inpatient care will grow and that psychiatrists need to be trained to lead such units. The debate about the value of acute inpatient experience suggests a need to pay BERNARD D. BEITMAN and PETER MAXIM 153 more attention to the manner in which these units are run especially in regard to the role of the resident. REFERENCES 1. Cypress, B.K.: Office visits to psychiatrists. National Ambulatory 2. 3. 4. 5. 6. Medical Care Survey, United States, 1975-76, U.S. Department of Health, Education and Welfare: No. 38, August 1978, from National Center for Health Statistics, Washington, D.C. Redlich, F., Kellert, S.R.: Trends in American mental health. American Journal of Psychiatry 135:22-28, 1978. Marmor, J., Scheidemandel, P., Kanno, C.: Psychiatrists and Their Patients. Washington, D.C., Joint Information Service, 1975. Yager, J., Pasnau, R.O., Lipschultz, S.: Professional characteristics of psychiatric residents trained at the UCLA Neuropsychiatric Institute, 1956-197 5. Journal of Psychiatric Education 3:72-85, 1979. Karasu, T.B.: Psychotherapy and pharmacotherapy: Toward an integrative model. American Journal of Psychiatry 139:1102-13,1982. Regier, D.A., Goldberg, LD., Taube, C.A.: The de facto U.S. mental health services system. Archives of General Psychiatry 35:685-93.