In this editorial, the author argues that expanding psychiatry residency slots alone won't fix the access crisis. The binding problems are where psychiatrists practice, how they're paid, and how care is delivered. Models like collaborative care and telepsychiatry stretch the existing workforce further than more training ever could.
Key takeaways
- This is a clearly labeled opinion piece; the views are the author's own.
- Federal shortage-area data shows the psychiatry shortage is concentrated, largely rural, not evenly spread.
- The author argues distribution, pay, and care models bind harder than raw headcount, so more residency slots alone won't fix access.
- The other side: efficiency has a floor, the workforce is aging, and demand is rising, so expansion may be necessary too.
The appeal of just training more
This is an opinion, and it's mine. When people hear that the country doesn't have enough psychiatrists, the intuitive fix is obvious: train more of them. Fund more residency positions, graduate more psychiatrists, and the shortage shrinks. It's a clean story, it's politically appealing, and it isn't crazy. The federal government does fund residency slots, and expanding them is a real lever. My claim isn't that training more psychiatrists is useless. It's that training alone can't solve this, and treating it as the answer distracts from the changes that would help faster.
The workforce numbers set the stage. Groups like the Association of American Medical Colleges have projected ongoing physician shortages, and federal data from the Health Resources and Services Administration shows large numbers of designated mental health professional shortage areas, most of them rural. That last detail is the tell. The shortage isn't evenly spread. It's concentrated. And a concentrated problem doesn't yield to a solution that just adds bodies to the top of the pipeline.
The problem is distribution, not just headcount
Here's what more slots won't fix. Newly minted psychiatrists don't distribute themselves evenly across the map. They cluster in cities and around academic centers, for the same reasons any professional does: jobs, spouses' careers, schools, and the pull of where they trained. A rural county that's been a shortage area for twenty years doesn't become well-served because the national count of psychiatrists ticked up. It stays a shortage area, because nothing in "train more" changes where those graduates choose to live and work.
Pay compounds this. Insurance-based practice, which I've argued elsewhere is punishing enough that many psychiatrists leave it, is especially thin in the places that most need coverage. If a new graduate can earn more, with less administrative grief, in a cash-pay urban practice, no amount of expanding the pipeline pulls them toward an underserved rural clinic. You can pour more water in the top of the funnel, but if the funnel is tilted, most of it still runs to the same places.
What actually stretches the workforce
The more promising path is to make each psychiatrist reach more patients. The collaborative care model is the clearest example. In collaborative care, primary care handles the bulk of routine mental health treatment, a care manager tracks patients using measurement, and a psychiatrist consults on a whole caseload rather than seeing every patient one at a time. One psychiatrist can support the care of many more patients this way, and the model has one of the stronger evidence bases in the field. The American Psychiatric Association actively promotes it for exactly this reason.
Telepsychiatry is the other force multiplier. A psychiatrist in a city can now see patients in a rural county without either of them moving, which attacks the distribution problem directly rather than pretending more graduates will relocate. Neither model requires a single new residency slot. Both make the workforce we already have go further, and both do it now rather than in the decade-plus it takes to train a psychiatrist from scratch. That's why I think the training-first framing is a mistake. It's not wrong so much as slow and incomplete.
The other side
The case for expansion is stronger than my framing lets on, and it's worth stating at full strength. Distribution and delivery models help, but they don't create clinical time out of nothing. Collaborative care still needs psychiatrists to run the consultations, and telepsychiatry still needs a real psychiatrist on the other end of the screen. If the total number of psychiatrists is too low, every efficiency you layer on top eventually runs into the same hard floor: there simply aren't enough of them. You can stretch a scarce resource only so far before the stretching itself becomes the bottleneck.
There's also a demographic argument. A large share of the current psychiatric workforce is near retirement age, and demand for mental health care has been rising, not falling. On this view, failing to expand training now guarantees a worse shortage later, and the long lead time to train a psychiatrist is precisely why you can't wait to start. Distribution fixes and care models are complements to expansion, not substitutes for it, and someone who takes the workforce projections seriously can reasonably conclude that we need both, urgently, and that downplaying training is a luxury the numbers don't support. I lean the other way, but that argument is a serious one, and it may well be right that without more training the rest won't be enough.
Common questions
Will building more psychiatry residency slots fix the shortage?
This opinion piece argues it won't fix it alone. The shortage is concentrated in rural and underserved areas, and new graduates tend to cluster in cities. Without changes to distribution, pay, and care delivery, more slots don't reach the places that most need coverage. The other side is presented fairly at the end.
What is the collaborative care model?
It's a model where primary care delivers routine mental health treatment, a care manager tracks patients with measurement, and a psychiatrist consults on a whole caseload rather than seeing each patient individually. It lets one psychiatrist support many more patients and has a strong evidence base.
Sources
- Health Resources and Services Administration. Health Professional Shortage Areas, including mental health designations. https://data.hrsa.gov/topics/health-workforce/shortage-areas
- Association of American Medical Colleges. Physician workforce projections and shortage reports. https://www.aamc.org/data-reports/workforce
- American Psychiatric Association. Learn about the collaborative care model. https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn