It is 7:00 pm on a Thursday, which marks the end of another challenging and complex day in the child psychiatry fellows’ clinic. Although the clinical day has officially ended, there is a palpable sense of dread and an unspoken consensus among us fellows that the real work has just begun. We start to review the daunting number of tasks on our clinical to-do list: documenting, billing, attending systems meetings, completing prior authorizations, and contacting collaterals such as therapists, caretakers, Department of Children and Families, and schools, just to name a few examples. Overwhelmed and exhausted, we find ourselves frozen, like deer in headlights, staring blankly at our desktop screens. The expectation to complete these tasks outside of designated clinical hours feels unrealistic, particularly within the context of a fast-paced training environment.

Perhaps more troubling than our to-do list is the feeling that our most well-intentioned efforts may never address the unspeakable trauma and severe mental illness that many of our patients endure. On the other hand, the thought of not giving our all for children and their families triggers feelings of guilt. We perceive this burnout experienced by many child psychiatry trainees as akin to a candle burning at both ends. We feel torn between continuing to work through exhaustion to do everything possible for children and their families, often at the expense of sacrificing emotional reserve for our own families. This dilemma between over-extension and self-preservation gives way to a collective sense of futility.

The expectation of trainees to fill in the gaps of a porous mental health system has been discussed with our supervisors, who at times have invited us to view our role in the mental health system as a conductor of the orchestra. The musicians are the other key stakeholders in a child’s life, including caretakers, therapists, community partners, and schools. While being a “conductor” may be seen as a privilege, this expectation to do more and more with less and less is a recipe for burnout and runs the risk of sparking an already incendiary system into billowing flames. We are concerned that if child psychiatry trainees are experiencing burnout at the earliest phases of their career, then we could be exacerbating the nationwide scarcity of child psychiatrists.

The shortage of child psychiatrists is staggering. In 2019, the American Academy of Child and Adolescent Psychiatry (AACAP) estimated that the USA needed 47 child psychiatrists per 100,000 youth, while the actual number was only around 9.75 child psychiatrists per 100,000 youth [1, 2]. These estimates do not account for the increase in children with serious mental illness over the past 4 years, with both the American Academy of Pediatrics and AACAP declaring a national mental health emergency among youth in 2021 [3]. According to the National Resident Matching Program, 31.5% of child and adolescent psychiatry training programs went unfilled in 2023 [4]. While these statistics are alarming and highlight the need for greater recruitment, our field is also grappling with a simultaneous problem of workplace retention.

Through recent conversations with colleagues, we have witnessed a “great exodus” of the brightest young child psychiatrists gravitating toward private practice as a means to mitigate the emotional wear and financial toll that comes from a decade’s worth of training. Child psychiatrists are also more likely to practice in higher-income US counties, with 92% of them practicing in the top-two income quartiles of US counties between 2007 and 2016 [1]. Thus, while the need for child psychiatrists is widespread, assistance is concentrated within privileged socioeconomic pockets of the country. It seems that a call for global action in our field is met with a weary workforce that feels less empowered to support those with the most severe and persistent mental illness.

We recognize the challenges inherent in child psychiatry training, including its novelty and our lack of experience, and we remain optimistic that increased training will foster growth and confidence. Nevertheless, we propose the following changes to sustain the well-being of early career child psychiatrists and to prevent attrition in the field.

We must advocate for protected time, outside of direct patient care, to complete the essential tasks on our aforementioned to-do lists. Child psychiatry is a unique discipline in which the biopsychosocial nature of work requires a team-based collaboration across numerous systems and disciplines. Protected time to engage in this multidisciplinary collaboration is therefore essential for providing optimal care for each child and family. In parallel, institutions must acknowledge the considerable time and effort these tasks require and optimize credit structures and remuneration models for completion of this work to prevent burnout and attrition from the field.

Systematically, we need to standardize a model of child psychiatry training that exposes all trainees to integrative settings to ultimately expand the scope and impact of child psychiatrists. We need to advocate for more experience in pediatric practices, schools, and outpatient consultation to address the shortage of providers and share the burden of care. We are optimistic that greater integration of child psychiatrists within these settings could offer a more sustainable model to alleviate collective burnout among clinicians. Lastly, we acknowledge the necessity of refining our capacity to identify compassion fatigue within ourselves and our colleagues. This process should involve facilitating cross-generational dialog between child psychiatrists, focused on upholding emotional resilience and self-preservation while delivering thoughtful and timely care.

While we will not claim that we have the perfect solution, we hope that this conversation continues to inspire discussion for the central question of how we sustain the well-being of child psychiatrists, for the future of child psychiatry, starting in the earliest phases of training. Ultimately, a paradigm shift is needed to envision a mental health system with a complete “orchestra” where the “conductor” feels adequately supported, has the time and space to perform their craft, and can retain a dose of optimism in the face of growing clinical acuity. We envision a mental health system in which the conductor can orchestrate music amidst the “chaos.”