Latest / Becker's Healthcare Behavioral Health / John Walkup, MD, President of the American Academy of Child and Adolescent Psychiatry and Chair of the Pritzker Department of Psychiatry and Behavioral Health at Ann and Robert H. Lurie Children’s Hospital of Chicago

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John Walkup, MD, President of the American Academy of Child and Adolescent Psychiatry and Chair of the Pritzker Department of Psychiatry and Behavioral Health at Ann and Robert H. Lurie Children’s Hospital of Chicago · Becker's Healthcare Behavioral Health

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  - Hi, everyone. Welcome to the Becker's Behavioral Health
• 1:01
  - Podcast. I'm Ella Reuter, behavioral health reporter with
• 1:04
  - Becker's. Today, I'm joined by John Walkup, MD,
• 1:08
  - president of the American Academy of Child and
• 1:11
  - Adolescent Psychiatry.
• 1:13
  - Across the country, demand for behavioral health care
• 1:15
  - among children and adolescents continues to put pressure
• 1:19
  - on the health care system.
• 1:21
  - But hospitals and health systems face a fundamental
• 1:23
  - workforce challenge.
• 1:25
  - There simply aren't enough child and adolescent psychiatrists
• 1:28
  - to meet the need.
• 1:29
  - We're going to talk about what's driving the
• 1:32
  - psychiatrist shortage, how it's affecting hospitals and health
• 1:34
  - systems, and what health care leaders can do
• 1:37
  - to expand access to care. Doctor. Walkup, thank
• 1:39
  - you so much for being here today.
• 1:42
  - My pleasure. Good to good to be here.
• 1:45
  - Wonderful. Could you start us off by telling
• 1:47
  - the audience a little bit more about yourself
• 1:49
  - and your work with the American Academy of
• 1:52
  - Child and Adolescent Psychiatry?
• 1:55
  - Sure. Hi, I'm John Walkup, and I'm a
• 1:58
  - child and adolescent psychiatrist. And I'm currently the
• 2:00
  - president of the American Academy of Child and
• 2:02
  - Adolescent Psychiatry. I'm also the chair of the
• 2:05
  - Pritzker Department of Psychiatry and Behavioral Health at
• 2:08
  - Lurie Children's Hospital and a
• 2:11
  - professor at Northwestern
• 2:13
  - University Feinberg School of Medicine.
• 2:16
  - We're a big organization. We have about 11,000
• 2:19
  - members that includes
• 2:20
  - practicing child psychiatrists as well as medical students
• 2:24
  - and residents who are interested in the field.
• 2:27
  - That's not a lot of us, and so
• 2:29
  - this shortage is a particularly sensitive issue.
• 2:35
  - Wonderful. Thank you so much for that background.
• 2:37
  - And I'd love to start off here with
• 2:39
  - the scope of the problem.
• 2:41
  - How would you characterize
• 2:43
  - the current shortage of child and adolescent psychiatrists
• 2:46
  - in The US?
• 2:48
  - Well, the mental health crisis is not new.
• 2:51
  - It's been going on for a really, really
• 2:53
  - long time. We have
• 2:55
  - never really gotten to the point where we
• 2:57
  - can take on the scope and magnitude of
• 3:00
  - the behavioral health challenge.
• 3:03
  - The longitudinal data suggests
• 3:06
  - twenty percent of kids will have a mental
• 3:07
  - health problem before they graduate from high school.
• 3:10
  - So, you know, and we've never really been
• 3:12
  - able to kind of meet that that need.
• 3:15
  - And in many places, less than half of
• 3:17
  - kids get any kind of intervention whatsoever.
• 3:20
  - So,
• 3:21
  - it's it's it's been a problem. But during
• 3:24
  - COVID nineteen, it became a real problem,
• 3:38
  - the
• 3:40
  - stable families, all of that kind of went
• 3:42
  - by the wayside. So you began to see
• 3:44
  - kids who are otherwise
• 3:46
  - kind of impaired,
• 3:47
  - but kind of getting along in the world.
• 3:49
  - All of a sudden, those kids began to
• 3:51
  - show up for care simply because the basic
• 3:53
  - support network around them was gone. And,
• 3:56
  - and the good thing about that was that
• 3:59
  - the dialogue about behavioral health increased quite dramatically
• 4:03
  - during that period of time. And children's hospitals
• 4:05
  - where I work,
• 4:08
  - we we really felt the brunt of that
• 4:09
  - with kids coming into our emergency departments looking
• 4:12
  - for
• 4:13
  - outpatient care, inpatient care, partial care.
• 4:16
  - So we really saw a huge influx of
• 4:19
  - kids during COVID nineteen due to the loss
• 4:21
  - of structure and support in their daily daily
• 4:24
  - lives.
• 4:27
  - And I was curious too, how is limited
• 4:29
  - access to child and adolescent psychiatrists affecting areas
• 4:33
  - like you mentioned in the,
• 4:35
  - emergency department, inpatient behavioral health programs, and pediatric
• 4:39
  - care in general?
• 4:41
  - Yeah. It you know,
• 4:43
  - once once things stabilize post COVID,
• 4:46
  - in some settings, you're beginning to see things
• 4:48
  - kind of going back to normal a little
• 4:50
  - bit in terms of the volume.
• 4:52
  - But the acuity is so much higher now
• 4:55
  - than it was before.
• 4:56
  - And so we're seeing more kids in need
• 4:59
  - of
• 5:00
  - extended care, if you will, not just inpatient
• 5:04
  - care, but residential care at a very high
• 5:07
  - and sophisticated level.
• 5:09
  - And those resources just aren't there. Our continuum
• 5:13
  - is quite patchy.
• 5:15
  - So it's not just a shortage of child
• 5:16
  - psychiatrist, but it's a shortage of really the
• 5:19
  - kind of essential services,
• 5:21
  - within the behavioral health continuum.
• 5:24
  - Mhmm. And as we know, hospitals and health
• 5:27
  - systems can't simply recruit their way out of
• 5:30
  - this national shortage.
• 5:32
  - What can health care leaders do right now
• 5:34
  - to expand access
• 5:36
  - to adolescent and child psychiatric care with the
• 5:39
  - workforce that they have right now?
• 5:42
  - Yeah. I think there's a couple of things.
• 5:44
  - You know, one of the ways that we've
• 5:46
  - approached this problem in Chicago
• 5:48
  - is really to develop collaborative and integrated care.
• 5:52
  - You you take a full time general pediatrician
• 5:55
  - and they see about eleven hundred unique kids
• 5:57
  - a year. And if twenty percent of those
• 5:59
  - kids will have a mental health problem, they're
• 6:01
  - talking about seeing two hundred kids or so
• 6:04
  - with behavioral health issues. And clearly during COVID
• 6:07
  - nineteen, they were seeing many more than that.
• 6:10
  - So we're doing a pretty good job now
• 6:12
  - of training,
• 6:14
  - residents in pediatrics
• 6:16
  - on the behavioral health side.
• 6:18
  - But we're still working very hard to train
• 6:21
  - those existing pediatricians
• 6:22
  - to take on that mental health challenge.
• 6:25
  - And there's lots of things that can be
• 6:27
  - done to kind of support
• 6:28
  - pediatricians
• 6:30
  - in beginning to do that
• 6:32
  - early,
• 6:33
  - essential behavioral health screening and early treatment.
• 6:36
  - So, those collaborative care programs,
• 6:39
  - are really important.
• 6:41
  - So
• 6:42
  - at statewide level,
• 6:44
  - really advocating for those kind of resource, child
• 6:47
  - psychiatry resource lines. There are a couple of
• 6:49
  - programs around the country that are very effective.
• 6:52
  - So your government advocacy,
• 6:55
  - groups within hospitals can work with state governments
• 6:59
  - to kind of talk about setting up those
• 7:01
  - those help lines, if you will, for
• 7:03
  - primary care docs to make sure that they
• 7:06
  - get trained to do good behavioral health, but
• 7:08
  - also that they have ready access to child
• 7:11
  - psychiatry.
• 7:12
  - That way the limited number of child psychiatrists
• 7:15
  - can really be leveraged,
• 7:17
  - if you will, with a larger workforce
• 7:19
  - of primary care providers.
• 7:23
  - Where do you see the most potential in
• 7:25
  - these models? Like you mentioned, collaborative care, and
• 7:29
  - what should health system leaders understand about maybe
• 7:31
  - their limitations or challenges?
• 7:36
  - I think collaborative care is our future. There's
• 7:38
  - upwards of 60,000
• 7:40
  - pediatricians.
• 7:41
  - There's 11,000 child psychiatrists. If we put that
• 7:44
  - workforce together
• 7:45
  - and really had an effective continuum of care
• 7:48
  - across pediatrics and child psychiatry,
• 7:51
  - we we would have a workforce that really
• 7:53
  - can address,
• 7:55
  - address the mental health challenges.
• 7:57
  - The thing great thing about pediatricians is that
• 7:59
  - they see kids really early in life,
• 8:02
  - and we know what the fundamental risk factors
• 8:05
  - are for kids in terms of developing behavioral
• 8:08
  - health problems.
• 8:09
  - And we know when those things begin.
• 8:12
  - So having the pediatric workforce that sees kids
• 8:15
  - really at the first well baby visit, if
• 8:18
  - not before,
• 8:19
  - having them really ready understanding the importance of
• 8:22
  - family history,
• 8:24
  - parenting capacity,
• 8:25
  - all of those kinds of things, and beginning
• 8:27
  - to work with families where there are some
• 8:29
  - mental health risks to begin to prepare them
• 8:32
  - to raise that child and to be on
• 8:34
  - the lookout
• 8:35
  - for the emergence of behavioral health concerns. That
• 8:38
  - that for me is the best way to
• 8:39
  - go.
• 8:40
  - Pediatricians
• 8:41
  - have that longitudinal
• 8:43
  - look. People have called it
• 8:45
  - the pediatric advantage.
• 8:47
  - They really do have that long term look
• 8:50
  - on kids and families and have a deeper
• 8:52
  - understanding.
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  - By the time a kid gets to see
• 8:55
  - me, they may have been ill for three
• 8:57
  - or four years, seen other providers.
• 8:59
  - I have to go back and do a
• 9:01
  - whole longitudinal
• 9:03
  - reboot
• 9:03
  - of everything that's happened in that kid's life.
• 9:06
  - But pediatricians
• 9:07
  - are accumulating that data on a longitudinal basis
• 9:11
  - over time. Their knowledge of and interaction with
• 9:14
  - families over time is so important in this
• 9:17
  - behavioral health sphere
• 9:19
  - that that really maximizing what we do with
• 9:22
  - pediatricians and the collaboration between pediatricians and child
• 9:25
  - psychiatrists
• 9:27
  - really, really important for the future of behavioral
• 9:29
  - health care.
• 9:34
  - And I'm curious too. Do any specific moments
• 9:36
  - come to mind for you where you've really
• 9:38
  - seen collaborative care,
• 9:41
  - improve outcomes in behavioral health and pediatric behavioral
• 9:44
  - health?
• 9:46
  - Oh, yeah. We just we just see it
• 9:48
  - all the time,
• 9:50
  - because we have really good treatments. I know
• 9:53
  - I know there's a lot of skepticism in
• 9:55
  - the in the media environment.
• 9:57
  - But, you know, over the past thirty years,
• 10:00
  - we've really built the evidence base for the
• 10:02
  - treatment of the majority of psychiatric problems that
• 10:05
  - kids can experience across their their childhood and
• 10:08
  - adolescence.
• 10:08
  - And our treatments work. It's really getting those
• 10:12
  - kids evaluated
• 10:13
  - and getting them to treatment. That's the big
• 10:15
  - issue. And once that happens,
• 10:19
  - you know, the pediatricians
• 10:20
  - who have embraced,
• 10:22
  - this kind of collaborative care model, I think
• 10:24
  - they find that they have a ton of
• 10:26
  - success.
• 10:27
  - We even have some pediatric practices here in
• 10:30
  - Chicago,
• 10:31
  - that during COVID, which was interesting,
• 10:35
  - a lot of kids didn't present to their
• 10:37
  - pediatrician at all during COVID,
• 10:39
  - but they presented with behavioral health concerns. And
• 10:41
  - many of the practices here in Chicago were
• 10:44
  - able to pivot,
• 10:45
  - do that behavioral health work during COVID nineteen
• 10:48
  - and keep their practices open. So there is
• 10:51
  - a value and and an opportunity there within
• 10:54
  - pediatric primary care to really address this behavioral
• 10:57
  - health challenge.
• 10:59
  - Mhmm.
• 11:02
  - And I'm curious to the gap between screening
• 11:04
  - and treatment. Is there anything that you would
• 11:06
  - like to mention there and
• 11:08
  - making that happen?
• 11:09
  - And are there challenges there? How are you
• 11:12
  - seeing success in connecting patients after they're screened
• 11:16
  - to get treatment
• 11:18
  - effectively?
• 11:20
  - Yeah. You know, the screening thing is is,
• 11:23
  - is kind of complicated because the screening advice
• 11:25
  - comes out in bits and pieces. So, you
• 11:28
  - know, ADHD
• 11:29
  - screening came out early, and then
• 11:32
  - teen depression screening came out after that and,
• 11:35
  - you know, we're doing some autism spectrum disorder
• 11:38
  - screening and so the the screening advice is
• 11:41
  - piecemeal. We still don't really have a robust
• 11:45
  - model for screening for the anxiety disorders, which
• 11:47
  - are probably the most prevalent.
• 11:49
  - And we really don't have great screening methods
• 11:52
  - for kind of behavioral challenges that kids may
• 11:54
  - have.
• 11:55
  - So so we've built this thing kind of
• 11:58
  - piecemeal
• 11:59
  - as opposed to kind of thinking about
• 12:02
  - who are the kids, what are the risk
• 12:04
  - factors,
• 12:04
  - how do we build a kind of a
• 12:06
  - screening mechanism that's personalized to the kids and
• 12:09
  - families'
• 12:10
  - specific risk factors. That that we have not
• 12:13
  - done,
• 12:14
  - And that really would make it a lot
• 12:16
  - easier because then, since we know what the
• 12:18
  - risk factors are and we know when these
• 12:21
  - conditions
• 12:22
  - begin to develop, then we can personalize the
• 12:25
  - screening
• 12:26
  - based on family history
• 12:28
  - as well as family other family risk factors
• 12:30
  - and begin to do an appropriate level of
• 12:33
  - screening across the whole behavioral spectrum. But that's
• 12:36
  - not how we've been organized.
• 12:38
  - And so we have these gaps here and
• 12:40
  - there where where things just don't get picked
• 12:43
  - up simply because we we do it in
• 12:45
  - a piecemeal way as opposed to a kind
• 12:48
  - of comprehensive way.
• 12:51
  - And really looking ahead here,
• 12:53
  - what workforce or policy changes
• 12:56
  - do you see making the biggest difference in
• 12:59
  - addressing the child and adolescent psychiatrist shortage?
• 13:03
  - Well,
• 13:04
  - you know, one of the things that that,
• 13:07
  - training takes a long time in child psychiatry.
• 13:10
  - It could be somewhere between five and six
• 13:12
  - years total time.
• 13:14
  - And,
• 13:15
  - I think we're beginning to see
• 13:18
  - the kind of historical method of training physicians
• 13:21
  - with kind of fundamental base training and then
• 13:24
  - subspecialty training,
• 13:26
  - really being in that five to six year
• 13:28
  - duration period
• 13:30
  - and
• 13:31
  - often including a kind of a period of
• 13:33
  - kind of research work,
• 13:35
  - where they they are part of an academic
• 13:38
  - institution and doing kind of early research work
• 13:41
  - to kinda build their more academic careers in
• 13:43
  - order to become a subspecialist.
• 13:46
  - And I think there's enough pressure in medicine
• 13:48
  - now,
• 13:51
  - to really increase the workforce more globally because
• 13:54
  - it's we're short of doctors, period.
• 13:57
  - To increase that shortage more globally is to
• 13:59
  - think about, are there ways to increase the
• 14:02
  - size of the workforce,
• 14:04
  - the training workforce,
• 14:06
  - by shortening training,
• 14:09
  - if you will. So we we put forward
• 14:11
  - a proposal a couple of years ago where
• 14:14
  - we would,
• 14:15
  - get boarded,
• 14:17
  - board certified in adult and child psychiatry
• 14:20
  - in a four year time period.
• 14:23
  - And, traditionally, we do it in five.
• 14:25
  - So we could do four residents for five
• 14:28
  - years, or we could do five residents for
• 14:31
  - four years. That's a 20% increase in our
• 14:33
  - workforce
• 14:35
  - over a period of time. And so there
• 14:37
  - are ideas like that, and we're beginning to
• 14:39
  - hear rumblings within,
• 14:41
  - pediatrics where they're shortening some of the subspecialty
• 14:44
  - programming
• 14:45
  - from three years to two years.
• 14:48
  - And even in internal medicine, they're beginning to
• 14:50
  - talk about how to address this workforce shortage
• 14:53
  - by shortening training.
• 14:57
  - And I guess, are there any concerns about
• 15:00
  - shortening
• 15:01
  - training
• 15:02
  - in terms of making sure that they still
• 15:04
  - have all the skills and the quality
• 15:06
  - and all of that still intact?
• 15:09
  - That's all happening simultaneously,
• 15:12
  - because the the move is away from time
• 15:15
  - based training, meaning, you know, you have to
• 15:17
  - spend four years one way or another
• 15:20
  - or five years one way or another to
• 15:22
  - competency based medical education,
• 15:24
  - which means that you're benchmarking people's competencies and
• 15:28
  - skill development over time.
• 15:30
  - The the one thing that's happening in psychiatry
• 15:32
  - more generally and child psychiatry more generally is
• 15:35
  - the competence of people coming into the field
• 15:38
  - at this point is super high.
• 15:42
  - Psychiatry has become a new destination specialty for
• 15:45
  - many of the young people today, early career
• 15:48
  - people today.
• 15:49
  - There's something about this generation that is really
• 15:52
  - interested in this human part of medicine,
• 15:56
  - psychiatry, and particularly in children and adolescents. And
• 15:59
  - so we've benefited over the past four or
• 16:02
  - five years from,
• 16:03
  - a very high quality group of people
• 16:06
  - coming from medical school into psychiatry and child
• 16:09
  - psychiatry. It's been it's been a real
• 16:12
  - eye opener to see how good the people
• 16:14
  - are coming into our field at the current
• 16:16
  - time.
• 16:17
  - And and they're they're gonna be the leaders
• 16:19
  - of tomorrow. Right? They'll be leading these collaborative
• 16:21
  - care efforts working with pediatrics and and other
• 16:24
  - pediatric
• 16:25
  - providers.
• 16:27
  - Well, wonderful. And if you could give hospital
• 16:30
  - and health system leaders one priority to focus
• 16:32
  - on right now, what would that be?
• 16:37
  - This is this is kind of a complicated
• 16:39
  - situation because many hospital systems
• 16:43
  - are painfully aware at what it costs to
• 16:46
  - provide behavioral health care
• 16:48
  - and,
• 16:49
  - are always thinking about what's the burden from
• 16:52
  - a financial point of view. Because we we
• 16:55
  - do
• 16:56
  - place a burden on health systems
• 16:58
  - because reimbursement isn't very good, and,
• 17:02
  - and the challenges the challenges are real.
• 17:07
  - That said,
• 17:08
  - I know in our workplace, and it's been
• 17:10
  - documented in other workplaces,
• 17:12
  - that
• 17:13
  - when
• 17:16
  - medical doctors
• 17:18
  - are
• 17:18
  - specialized in anything other than psychiatry,
• 17:22
  - when they are working at the top of
• 17:24
  - their license, what they bump into oftentimes are
• 17:27
  - behavioral health concerns that that really impact patient
• 17:31
  - outcomes and the ability for physicians
• 17:34
  - to function at their highest level.
• 17:36
  - And I think
• 17:38
  - that that moral injury, if you will, of
• 17:41
  - having a skill, seeing a patient, know what
• 17:44
  - the patient needs, but then bumping into a
• 17:46
  - behavioral health concern
• 17:48
  - that that you can't really manage
• 17:51
  - is is the kind of moral injury, I
• 17:53
  - think, that leads to burnout.
• 17:55
  - So one thing I'm telling our hospital leadership
• 17:57
  - is, listen, we are,
• 17:59
  - an important anti burnout resource
• 18:02
  - for the rest of the physician group within
• 18:05
  - your hospital settings as well as nursing and
• 18:08
  - social work and and other providers within that
• 18:10
  - medical setting.
• 18:12
  - We provide that kind of work for those
• 18:15
  - patients who have behavioral health concerns that allows
• 18:18
  - other practitioners to function at their highest level.
• 18:25
  - Wonderful. Are are there any other conversations that
• 18:27
  - you're having or anything else you'd like to
• 18:29
  - mention,
• 18:31
  - in general over the course of this conversation
• 18:33
  - that you feel like was left out?
• 18:38
  - I think I think,
• 18:42
  - it's it's hard to know exactly what to
• 18:44
  - say because there's there's a lot of,
• 18:48
  - kind of chatter at the at the policy
• 18:50
  - level within our kind of national government about
• 18:53
  - behavioral health care and about the safety of
• 18:56
  - medications, their efficacy,
• 18:59
  - about whether kids should be on medicines or
• 19:01
  - not. There's a whole kind of set of
• 19:03
  - issues there that are important for,
• 19:06
  - hospital leaders and and the public really to
• 19:09
  - come to terms and understand what that what
• 19:11
  - that debate is all about, what that discussion
• 19:13
  - is all about.
• 19:15
  - There is an evidence base in child and
• 19:17
  - adolescent psychiatry.
• 19:19
  - Our treatments get people better.
• 19:22
  - We do have a workforce challenge.
• 19:25
  - We do have,
• 19:27
  - an overt demand that is is potentially overwhelming.
• 19:31
  - But we have treatments that work, and families
• 19:34
  - should feel comfortable
• 19:36
  - kind of seeing a child and adolescent psychiatrist
• 19:38
  - or or work in a system with child
• 19:41
  - and adolescent psychiatry
• 19:42
  - to be comfortable that with the fact that
• 19:44
  - we have treatments that work and that their
• 19:46
  - kids can get better.
• 19:50
  - Wonderful. Well, doctor Wachup, this has been a
• 19:52
  - really important conversation
• 19:54
  - about the child and adolescent psychiatrist shortage and
• 19:57
  - what hospitals and health systems can do to
• 19:59
  - improve access despite
• 20:01
  - all of these constraints. So, thank you so
• 20:03
  - much for joining us today.
• 20:05
  - Thank you, Ella.
• 20:06
  - And thanks to our listeners for tuning in
• 20:08
  - to Becker's Behavioral Health Podcast. From our conversations
• 20:11
  - with behavioral health leaders across the country, you
• 20:14
  - can find us wherever you get your podcasts.