Psychiatry is a very unique specialty, with a history of both curiosity and controversy. Perhaps more than any other medical specialty, the way psychiatry has been practiced has changed dramatically since patients were first hospitalized for mental conditions in the third century BCE. Gone are the days of outdated practices and diagnoses, such as drapetomania (a mental illness given to enslaved Africans who escaped captivity), phrenology (a pseudoscience that used sizes and shapes of one’s head to justify racism), the lobotomy (a traumatic psychosurgical practice used to treat a variety of mental ailments), and conversion therapy (used to change one’s sexual orientation – although this practice can still be found in certain communities).

With the rise of evidence-based medicine and increased social consciousness, Psychiatry and Medicine have evolved greatly – but much work remains. As we are becoming more aware of the forces that affect society and patient care (ie, structural racism, implicit bias), we are also seeing how these forces are engrained in the fabric of psychiatry itself, and how we – as emerging practitioners – are called to task to address them.

DEI Must Address the Digital Divide

Diversity, Equity, and Inclusion

We believe strongly that the future of psychiatry rests on increasing the amount of diversity, equity, and inclusion (DEI) in our practice and in the education of trainees, from residents to early career psychiatrists and clinical psychologists. Specifically, as it regards racial and ethnic makeup, disparities exist in psychiatric care as well as in the clinician workforce. (See Dr. Amanda J. Calhoun’s first-hand account on systemic racism in mental health care). And while it may seem those are two separate issues – they are very much interrelated.

Several studies have shown that racial and ethnic minority patients – marginalized individuals – benefit from having doctors that look like them. According to Brookings, racial and ethnic minorities are on track to become racial and ethnic majorities with 49.7% of the US population estimated to be “minority white” by the year 2045.1 As the population becomes more diverse, so do their individual health needs and the needs for clinicians that represent them.

Physician and Mental Health Care Professional Shortage

Unfortunately at this time, when it comes to trainees, underrepresented racial and ethnic minorities make up only 16.2% of residents, 8.7% of faculty, and 10.4% of practicing physicians.2 This gap is compounded by the fact that, according to the American Association for Medical Colleges (AAMC), by the year 2032, there will be a physician shortage of 122,000 doctors.3 This shortage will mainly affect underserved areas composed mostly of racial and ethnic minorities. The future of psychiatry is charged with addressing this impending crisis.

Digital Divide Extends to Healthcare Access, Telemedicine

“Digital Divide” – a term we began to hear in the mid-1990s – describes the inequities and inequalities that exist between communities of various demographic and/or socioeconomic levels that lead to disparities in technological access and digital connectivity. The recent and ongoing COVID-19 pandemic has forced the medical community to find ways to continue to provide patient care while remaining physically distanced (enter a new level of telemedicine in psychiatry). Increasingly, provider-patient relationships have been established and maintained through telemedicine encounters and virtual visits. Yet, as we progress through the coronavirus reopening phases, we are not yet noticing a swift shift back to in-person office visits. Instead, many clinicians are discussing ways to continue to develop and incorporate teletherapy into their practices as they move rapidly toward various digital and technological platforms.

Teletherapy has its benefits. For example, when considering patient populations who suffer from impaired mobility and unreliable (or lack of access to) transportation, virtual visits may increase attendance. However, what about the individual with impaired mobility who is without reliable transportation and also lacks the technological hardware needed to carry out their virtual visit? (Steven Starks, MD, further discusses gaps in mental health care access among under-resourced communities.)

It is precisely here that we can highlight how one may be affected by the digital divide and begin to identify some of the hidden drawbacks to a necessary adaptation that, to many, may be an imperfect solution. Research shows members of the Black, Indigenous, and People of Color (BIPOC) community have lower percentages of households who own a computer and/or internet subscriptions. Similar patterns are present within the non-English speaking community as well as in rural communities. Notably, many factors contributing to health disparities also serve to widen the digital gap. As this chasm grows, arguably, so too will the health disparities within these marginalized communities.

Trauma-Informed Care Should Include Race-Based Trauma

Another concept gaining broad recognition across the mental health and medical fields is trauma-informed care. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma-informed care encompasses realization of the widespread impact of trauma and potential paths for healing, recognition of the signs and symptoms of trauma in patients,  integration of knowledge about trauma into practice, and resisting re-traumatization.4 Trauma-informed care recognizes and addresses the unique traumas all people face based on identity and experience.

Race-Based Trauma

However, identity-based trauma comes into play here as well, especially given the growing anti-black and anti-Asian racism and violence in the US. Statistics aggregated by Mental Health America, a mental health nonprofit, showed that after the COVID-19 outbreak in the US, there were nearly 1,500 reported incidents of anti-Asian racism in just 1 month, including physical and verbal attacks.5 Additionally, in 2018, 38% of Latinx people were called a racial slur, verbally attacked for speaking Spanish, or were told to “go back to their countries.” (See also, Dr. Nia Heard-Garris’ report on vicarious racism.)

Psychiatrists must be able to recognize and screen patients from diverse ethnic and racial backgrounds that are vulnerable to racism and race-based trauma, especially given the intersecting and compounding aspects of multiple identities. Although not currently recognized by the DSM-5 as a Criterion A event, racism and race-based trauma can lead to symptoms that overlap with Acute Stress Reactions and Post-Traumatic Stress Disorder (PTSD).

Screening for Race-Based Trauma

There are currently a few tools that can screen for race-based trauma including:

Screening is crucial, and just as important is a diverse workforce that can implement the principles of trauma-informed care.

Psychiatry’s Structural Vulnerabilities Need Strengthening

Medical education often fails to address the lack of awareness of structural vulnerabilities that exist within the medical community – including mental health care professionals. This omission is pervasive and detrimental not only to the patient population we serve but also to under-represented minority physicians who train and practice within our medical system.

Lack of awareness and acknowledgment of structural (and systemic) vulnerabilities that exist within marginalized communities lead to less competent care and make it impossible to practice medicine holistically. It is, therefore, imperative that we identify both structural and social determinants of health.

Health Disparities

The responsible practitioner recognizes that intervention must occur at specific levels in order to truly address the health disparities deeply embedded within our society. Psychiatrists and other mental health professionals must also clearly acknowledge that this lack of awareness perpetuates racist practices, widens gaps in DEI and healthcare access, and ultimately worsens social determinants of health.

Diversity in the Medical Workforce

According to Wilbur et al, 2020, only 23% of African Americans, 26% Hispanics, and 39% Asian Americans have a physician that shares their race and ethnicity compared to 82% of White Americans. Research shows that similarities in race between the patient and physician lead to improved patient satisfaction as well as better health outcomes.

Further, it is known that members of underrepresented minority groups are far more likely to find fulfillment working within underserved communities and marginalized populations. As diversity encompasses much more than race and ethnicity, it is important to create a truly diverse workforce in psychiatry. Because diversity is directly proportional to health outcomes, as diversity within the psychiatric community increases, so too will mental health outcomes. By taking active measures to diversify the medical community, we can begin to adequately address the needs of our increasingly diverse society responsibly and competently.

The Future of Psychiatry: Residents’ Vision

Residency is a time of specialized training and personal development where residents should be in constant consideration of the impact they would like to have on the communities they choose to serve. Our vision for the field of psychiatry is as follows.

A Diverse Workforce Grounded in Cultural Responsiveness

The future of psychiatry will consist of a workforce that believes in and encourages equal access to healthcare. Practitioners will not only be knowledgeable about disease processes but also about social determinants of health. The mental health care workforce will be dedicated to thinking critically about how to best serve their patients within the political and socioeconomic structures of our society. Workshops and seminars offering training in cultural competency and structural vulnerability will be a requirement for all healthcare practitioners regardless of specialty. At the same time, the prudent psychiatrist will recognize the importance of identifying the structures set in place that prevent their patients from accessing resources necessary to improve health outcomes individually and collectively.

It is time to take things a step further. Diversity and equity should become mandatory and unwavering components of psychiatry residency training. Is it past time to include measurable outcomes and parameters to ensure that the needs of our diverse patients and trainees are met.

Overturn Structural Vulnerabilities with Adequate Training

Change (or create) an Accreditation Council for Graduate Medical Education (ACGME) milestone that explicitly focuses on the need for competency in identifying and addressing structural vulnerabilities. MK2 (knowledge of diagnostic testing and procedures) is the only milestone that takes diversity into account however, the context is unclear as “diversity” can encompass anything.

An ACGME milestone that includes DEI specifically as training goals for the development of culturally competent psychiatrists who are at the very least aware of how sociopolitical forces impact the delivery of healthcare services and access to resources should be considered. This milestone would require residents to improve their awareness and engagement in identifying vulnerabilities and detrimental structures that impede not only the quality of patient care but also that impede personal growth and advancements among under-represented minority clinicians within the medical community.

This article was reviewed and supported by Danielle Hairston, MD, Psychiatric Residency Program Director, Howard University, and Guest Editor of this series on racism in psychiatry, including a look at disability justice, media exposure, being a Black LGBTQ+ youth, and more.  

 

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Last Updated: Aug 16, 2021