Sixty million Americans need mental health treatment. Seventy thousand psychiatrists and APPs exist to serve them. Even if every clinician worked at maximum capacity—four patients per hour, every hour, every day—we'd still fall short. The math doesn't work. This article explores “force multipliers” and the levers you can use to do more in your practice.
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How One Navy Corpsman Taught Me to Multiply Psychiatric Impact

In 2004, I deployed to Iraq the first time, I was assigned to a Marine Corps regiment, pretty much all alone, in the middle of the Al Anbar province. The job was to be a consultant to the Colonel, responsible for the mental health welfare of the unit, while also being the clinical psychiatrist for the unit, actively seeing clinic in our little Regimental Aid Station and also travelling around to visit with our various battalions, spread out all the way from the Syrian border to the Jordanian border, comprising maybe around fifteen thousand or so under my umbrella.
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People might think that’s quite a bit for one guy. (Especially one guy who graduated from residency training about thirty seconds ago …) But there’s no way around it. There are no more than one hundred active duty psychiatry billets in the Navy, every single one of us has too much to do, putting another psychiatrist in that regiment with me is just not an option; we’re just going to have to find a way to do more with less!

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But physics always wins, you don’t do more with less. You can only do less with less. You are one person, with one brain, two hands and two feet, and a certain number of minutes to spend until you run out of time, that resource is finished.

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But I did have one secret weapon the Navy very thoughtfully sent my way.

A Navy Corpsman, with psychiatric training. Now a Navy Corpsman is a legendary thing as it is, born of a seafaring culture—the kind where you can find yourself on a ship in the middle of the ocean with exactly zero chance of getting help any time soon—making these sailors uniquely capable and independent as it is, and this particular legend had all that, plus two scoops of psychiatry knowledge, giving him the ability to do close to ninety five percent of what I could do, coming to me for a little supervision, so that the two of us had an impact very close to double what I could make alone, with him being far less “expensive” in terms of years of training than a second psychiatrist would have been.

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This is how I learned about force multipliers.

In the combat theater, this term comes up all the time. It’s pretty common to find yourself up against the wall for resources and, rather than simply trying to “do more with less” you have to start thinking about how to multiply the impact of the resources you have.

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How to find force multipliers in psychiatry (find me a big enough lever and I can move mountains)

This can mean finding efficiencies (is everybody in the unit really working? If I have one hundred personnel, but only about seventy five of them are really working, not only am I better off sending the remaining twenty five away for non-performance, the seventy five I have left now have substantially more resources,) rethinking how my resources are used (do I need one billion dollar ship, or one hundred ten million dollar ships?) or even inventing novel tools/ways to bring resources to bear that can change the equation, ideally to 2x or 3x or more the impact that can be made with the immutable resources at hand.

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Twenty one years later, I’m looking at a different battlefield, in many ways far more overwhelming. For my entire career the word most associated with psychiatry is “shortage.”

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More than fifteen years ago, I read there were probably about half as many of us as there could be, and an absurd proportion of the number was over fifty five, so our already low numbers are expected to fall off a cliff.

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Even though more medical school graduates have been choosing psychiatry somewhat recently, the number of training spots in the country are limited, even if every training spot is filled, every year, it may not be enough to make up for expected attrition.

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Furthermore, the numbers of people in the country desiring of mental health treatment have increased dramatically, with most recent estimates suggesting around sixty million having some degree of distressing mental health symptoms.

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The most common way the resource of mental health clinician (meant to include both psychiatrists and advanced practice professionals,) is utilized is in the clinic setting, seeing patients in fifteen minute increments, writing prescriptions.

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The most optimistic estimate of the total number of practicing clinicians in the country is about seventy thousand total psychiatrists and APPs, meaning if every single one of 70,000 clinicians, seeing patients 15 minutes at a time, it might work out to something like this:

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• Each clinician sees 4 encounters/hour
• 32 encounters/day
• 160 encounters/week
• 8000 encounters/year (you have been given a very generous two weeks off.)
• 8000 x 70000 is a bit over half a billion encounters, enabling each of 60000000 patients to be seen about eight times in a year.

In the words of B.A. Barracus:  “That’s a terrible plan, Hannibal!!”

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Why 70,000 clinicians can't serve 60 million patients (and what to do about it)

First of all, just thinking that thought causes a little burnout. Four patients an hour, all day, every day, forever, is a truly Sisyphean task, and, second of all, just “seeing” every single patient is not the same thing as accomplishing anything. If I were to arrogate some of the goal setting to myself, I’d say helping people get well is what is desired here, and while seeing patients (access to care) is one step in the right direction, far more needs to be done, more resources are needed.Simply making more clinicians is not one of the options.

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It may be plausible that, in the long term, training could be made more efficient, the number of training spots could be increased, but significantly increasing the number of practicing clinicians in the country is about a ten year plan and the sixty million need attention today.

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So if we can't solve this by training more psychiatrists, what's the alternative? The same strategy that worked in AI Anbar: force multiplication. approached a few different ways, which we’ll explore now.

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Triage not marketing: How to match 60 million patients to the right mental health resources

It seems impossible that with a number like sixty million potential patients you’d ever hear of any clinician not working as much as possible, or at least as much as they want to, and yet I continue to hear stories of practices having to close for lack of work. Reminiscent of the old stories of people going hungry while perfectly good grain rots in siloes, the problem is distribution. Somehow the legions of people in need aren’t finding their way to the resource, thus making the first multiplier the act of getting everybody up to 1x!

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For this, I’d suggest forgetting the word “marketing” and start using the word “triage”: the age old military art of prioritizing and then moving people to the resource they need, in order of urgency.

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Using some dynamic, intelligent consulting to direct people to the resource they need more quickly—be that therapy, medication treatment, psychiatric interventions or even higher levels of care—has the potential to cut the time it usually takes for necessary treatment to start by months, while also keeping practices appropriately busy.

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Thoughtful telepsychiatry: covering 200-mile practice areas

Not every one of those sixty million live in an evenly distributed way. There are parts of the country where a full patient panel can be found in no more than about a twenty five mile radius, while other parts would require a good two hundred mile range to come up with that number. The tools to address these already exist.

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The thoughtful use of telehealth can allow a single clinician to cover that two hundred mile range, without having to lose the four or five hours a week in driving it would take to cover multiple practice locations over that distance, thus also having the potential to force multiply by at least getting closer to 1x.

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Beyond medication: how TMS and esketamine can double your impact

Up until 2008, the tools available to a clinician were somewhat limited, comprising therapy, medication prescribing, and then a vast desert of nothing until you get to electroconvulsive therapy.

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In this context, the vast majority of practice is limited by time, you can only perform therapy in time limited blocks. You can only write just so many prescriptions per hour, even at maximum efficiency (see above). The clinician has a ceiling and it’s not a high one—in fifteen minute increments, it’s about 8000 encounters a year.

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(The clinician is allowed to take two weeks off.)

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If patients are being seen quarterly for refills, the hypothetical practice can serve 2000 people and that’s it (assuming everyone is exceedingly orderly and predictable, and simply show up every three months), practice is full, there’s no way to fit anything else into the workflow, especially not any of the new tools since 2008!

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But consider:A “sacrifice” of eight encounters a week, or four hundred a year, allows for enough time to start about one hundred transcranial magnetic stimuilation (TMS) cases in that year, with around two thirds of them or more having a great outcome.

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The great outcome would likely persist for a year or more, possibly enabling the same treatment for one hundred more in the following year, and so on, thus multiplying the effectiveness of the practice by greater than one.

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An additional eight encounters a week could additionally facilitate the beginning of one hundred esketamine cases in a year, many or most of whom will be substantially improved, or even in remission, and possibly quite stable on maintenance treatment.

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In this hypothetical circumstance, the redirection of 800 encounters enables the care of at least 200 additional people per year, with a bigger positive effect, while leaving 7200 encounters to be allocated as usual, having the potential to 2x or greater the practice over time.

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Now consider even more new and emerging tools, new ways to do TMS that have the potential to complete a full course of treatment in a fraction of the time, the multiplier grows more. Add in new and emerging digital therapeutics, enabling the patient to independently engage in treatment, even multiple times a day without consuming additional clinic time or even having to travel, yet another multiplier.

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The virtual medical center: building collaborative networks so psychiatrists share patients (not lose them)

Not every clinician wants to perform every intervention, use every single tool in a single practice. It hasn’t been intuitive to refer from one mental health clinician to another, often for fear of losing patients. But in this high demand environment, that should be a practically nonexistent concern.

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Since the extinction of the doctor’s lounge, mental health clinicians even more than most have been working in a highly siloed environment, with little access to the collaborative resources typically available in a medical center setting, leading to multiple clinicians, practicing in proximity, appearing to be doing the same things, but with no interaction, otherwise referred to as parallel play—superficially appearing to play together but it’s really just coincidental.

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Imagine instead a collaborative environment that spanned across practices, an EHR through which information can flow both ways, and appropriate patients could flow from a medication management setting to a TMS setting to an esketamine setting and back, no differently than if those settings were all in the same building. No one is “losing” patients; instead, they are simply triaging people around, dynamically, in this case obtaining force multiplication in a decentralized fashion.

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It’s already possible for a Learning Health System (an EHR that collects outcome data natively and in real time) to assist in the identification of appropriate patients for appropriate interventions at the appropriate time, no more languishing for months or years on only partially effective medication trials, aggressive intervention for residual symptoms can be brought to bear immediately, and patients who get better faster will consume less clinic time over all, yielding yet another multiplier.

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The beauty of force multipliers is that they multiply. Much like opportunities for error, 2x can quickly turn to 4x and 3x to 9x, allowing your limited resources to scale up in efficacy far faster than you might think.

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By combining triage systems, strategic technology use, and collaborative networks, psychiatrists can scale their impact exponentially rather than linearly. Compared to a number like sixty million, it might even be similarly overwhelming, but this time in the good way.