Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.
“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.
Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.
A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.
While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”
Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.
“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”
That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.
“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”
Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.
According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.
“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”
MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”
Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.
“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH
Jane Jerrard is a frequent contributor to The Hospitalist.