Competency and the Psychiatric Workforce

To the Editor: The status of the U.S. medical workforce continues to be the focus of considerable attention. Right or wrong, the consensus seems to be that there are significant problems in the number, characteristics, and distribution of U.S. physicians (1,2). Although several different strategies have been proposed for determining the appropriate number of required physicians in each specialty, I believe the most relevant approach is one based on patient needs (3).

The needs-based approach not only is patient centered, but it also clarifies issues related to scope of practice and access to care. Questions such as what type of service a psychiatrist should provide and what type and how much psychiatric treatment a patient needs must be answered to adequately determine psychiatric workforce requirements.

Discussions of the psychiatric workforce have been directed toward such complex and controversial issues as determining the current and future numbers of psychiatrists required and the effect of government policies limiting the number of international medical graduates allowed into the country. Other discussions have focused on changes in government policies related to service delivery systems (for example, managed care) and the discipline and training required to qualify clinicians to perform specific clinical services, such as medication management or psychotherapy.

I believe that many psychiatric workforce issues could be clarified by interjecting competency into the debate. After all, the only legitimate "scope of practice" is competent service, and the only legitimate "access to care" is access to competent care. This means, of course, that attention must be directed toward the complex process of determining which core competencies—biological, psychotherapeutic, sociocultural, and so forth—a psychiatrist should possess in specific areas. It also means that the only legitimate core competencies are those that can actually be evaluated.

Focusing on the core competencies required of psychiatrists could have significant implications for the size, structure, and function of residency training and continuing medical education programs, board certification and maintenance of certification processes, and even the clinical privileges and reimbursement of practicing psychiatrists. It might also affect the relative roles and relationships of psychiatrists and the other medical and mental health disciplines.

Considerable effort and the resources of many different psychiatric organizations would be required to establish core competencies and to develop effective and efficient methodologies to evaluate them. Difficult and painful as it might be, there is no alternative in workforce calculations to demonstrating the basic competency of the psychiatrists being counted. To do less is to perpetrate a hoax on the public.