Psychiatrists have the most diverse population of any medical specialty and it is the farthest to the left. More psychiatrists are liberals and psychiatry is the only specialty group that is predominately predominately composed of Democrats. The broad range of interests of psychiatrists are evident at any American Psychiatric Association [APA] meeting and various annual subspecialty meetings. Courses are available on a broad range of medical, neuroscientific, and psychosocial topics. Psychiatrists work in a number of specialty areas and it is very likely that certain practices are highly specialized and focus only on the diagnosis and treatment of specific conditions. That is not the structure of a monolith. The total number of psychiatrists varies on the source. The American Medical Association [AMA] census in 2010 put the number at 42,885. The Census put the number at 40,600 in 2009 and of those 26,200 were office based. According to the Bureau of Labor Statistics there are only about 25,000 psychiatrists who are employees of organizations. The remainder are in private practice. The American Psychiatric Association sent me the following data on the membership for the past 15 years.
[redrawn to include full ordinate scale]As a measure of monolithic behavior, in one of the most critical APA election in recent years regarding maintenance of certification [MOC] only 6,943 members voted. Action requires a vote of at least 40% of the membership. Interestingly the MOC vote occurred in 2011, the year of the lowest number of members. The total vote was not close to the 40% number, but it exceeded the vote for the President Elect and Secretary by about 1,300 votes each. Presidents are typically elected by less than 20% of the members. These facts illustrate that the majority of psychiatrists in this country at any one time are being directly influenced by employers and in the overwhelming number of cases those employers are managed care organizations whose policies are generally inimical to quality psychiatric care. It is also apparent from the vote and the election patterns within the APA, that there is not a lot of political activism or interest for that matter. Hardly the behavior of a monolith…
Supplementary 2: Psychiatry is dwarfed by the number of other mental health providers including 88,000 Family Practice specialists, 162,400 Internists, 100,000 psychologists and 120,000 Social Workers. I don’t know the number of Psychiatric Nurse Practitioners or Physician Assistants whose primary role is to prescribe psychotropic drugs, but I will happy to add it if somebody has that information. Although I am sure that some of the physicians in these primary care groups don’t prescribe some psychotropics, I am sure that 80% of all psychotropic medications in the US and most western countries are not prescribed by psychiatrists…
I’ve been on both sides of this argument so I get it. Obviously not all psychiatrists think alike, hence this blog and a few others. But it does appear that most psychiatrists and not by a small margin belong to the APA. Therefore the argument that the APA represents psychiatry is not without some merit. If there is someone or some group that better represents psychiatry, I’m not sure who it is. If the APA is not representing their interests and voices, then I think it’s fair to say the the membership does a lousy job of voting for leadership and needs to pay attention a lot better than it does. If the membership is not cool with mangled care, you wouldn’t know if from how they vote, because only one President ever opposed it. APA leadership is going all in on collabo-care which is a disaster for the average practitioner (and malpractice to boot) but I haven’t heard any calls for outright rebellion.
So either “psychiatry thinks” X or “psychiatry is not minding the store”. Either way, it doesn’t look good. Especially when said profession is supposed to be comprised of experts on the issue of human behavior. And why I don’t belong to the organization.
I tend to see the APA “speaking for psychiatry”, but what they say represents the thoughts of a few, not the body psychiatric. It’s the stuff of oligarchy, I think. Your example is a good one. The models of “collaborative care” presented are, in my humble opinion, close to routinized malpractice. It’s unlikely that any psychiatrists worth consulting will go along with it. I sure wouldn’t. Yet to read things like PsychiatricNews, it’s the wave of the future.
My thesis is that the power grab of 1980 that produced the DSM-III and the neoKraepelinian age that followed may have resolved the conflicts of that hour, but produced an analog of the old Russian Central Committee that has been in charge ever since to our collective detriment…
I think the “about 25,000 psychiatrists who are employees of organizations” needs to be more carefully analyzed before concluding “the majority of psychiatrists in this country at any one time are being directly influenced by employers and in the overwhelming number of cases those employers are managed care organizations whose policies are generally inimical to quality psychiatric care.”
The organizations and their policies regarding psychiatric care may vary widely. For example, are some of those organizations universities?
Also, could not a lack of “political activism or interest” among the 81.6%-86.2% of psychiatrists who belong to the APA indicate passivity rather than diiversity?
Good post. And I enjoyed Dr. Dawson’s piece. And I agree with you guys that to say or treat Psychiatry as a monolith is nonsense. But you know what? I think “Academic Psychiatry” may well be a monolith.
Tom,
That’s an excellent point. I’m not sure that was true in bygone days, or at least it wasn’t apparent to me. But Academic Psychiatry has seemed monolithic in this era. I find myself often using the phrase “Academic and Organized Psychiatry” in an anthropomorphic way as a unitary object. If it weren’t such an awkward phrase, I’d probably say “Academic and Organized Psychiatry and Tom Insel’s NIMH.”
HA! In addition to “Academic Psychiatry” being a monolith, I think it is also an oxymoron.
I agree that academic/institutional psychiatry is a hegemonic influence and I think logrolling has a lot to do with that. You will notice that with a few exceptions (Allen Frances being the most notable) most academicians kind of agree on most major issues.
I will never understand why the rank and file continue to financially support them. In terms of what they do for private practice, it’s irrational. Maybe it’s just inertia, maybe it just appeals to the inner PGY-2 fawning over the academics in charge. I think we all sort of understand Skinner and the importance of not rewarding behavior that is destructive to the profession, but you wouldn’t know it by who gets elected and how many people still pay dues.
A psychiatrist friend who is a dissenter and about 60 recently told me thinking in psychiatry is like a fruitcake that’s been passed around for years, has gotten stale and moldy, and needs to be thrown out and replaced with a new fruitcake.
He also described academic psychiatry (UCSF in particular) as a bastion of orthodoxy (meaning the old fruitcake).
“dissenter” about?
He’s like you when it comes to psychiatry, Mickey.
I just can’t believe that even 60% of psychiatrists belong to the APA, it just doesn’t make sense. But, I would believe that over 80% of psychiatrists over 70 years old belong. Hence the fraternity model that is medicine.
Dear Mickey:
Once again there are comments to your blog which take the position that the members of the APA [and, therefore, presumably, the AACAP] should quit these guilds. Or, at least feel guilty for how these organizations say they speak for general and child and adolescent psychiatry.
Unfortunately these guilds have for a considerable number of years been heavily influenced by the “pharmaceutical, health insurance and academic industrial complex,” which comes with massive amounts of money and lobbying power.
Clinicians, though they constitute the majority of members, are not allied with such power. And they are in a variety of other ways disempowered. Their chance of gaining power is militated against in many way, including the constitutions of these heavy, top-down led institutions.
But the truth of the matter is that there still exists within each organization members who long for change and are willing, as best they can, to fight for it. And sometimes we even do make for at least for small increments of change. While those of us who wish for reform could quit and join those who complain in your comment sections about the faults of the organizations, I believe it is much better to think as did the organizers of the labor unions in this country 80 years ago—“agitate, educate, organize!” Could it be that those who fail to fight for what is right should be the ones to feel guilty?
A Child Psychiatrist,
A strong point, well made – something each of has to make our own peace with. No-one fighting the good fight needs to feel guilty. Thanks for the comment…
I admire your spirit CP, but as long as they are collecting dues and doctors aren’t voting with their feet, nothing is going to change. The other APA went through a schism many years ago for the same basic reasons, and it’s long overdue with this APA.
Which is the other APA? I’m thinking the psychologists, but I ask, because there are many. My undergraduate degree is in Classics, so the first thing I think of is the American Philological Association, but I also have a number of friends who are Philosophy professors, and they have an APA too.
I was referring to the APS, which broke with the American Psychological Association a while back.
https://en.wikipedia.org/wiki/Association_for_Psychological_Science
The rap on the old organization was that it was a guild and leaned to heavy on clinical vs scientific psychology. I suppose the rap on our APA would be that it is an ineffective guild not clinically oriented enough. And that the academic side is too agenda-ridden.