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The teaching of psychiatry: A statue without a socle
BIOL PSYCHIATRY 1988;24:863-864
863
EDITORIAL
The Teaching of Psychiatry: A Statue Without a Socle There are a number of American folktales about the little moron, one of which tells of the time he and his friends decided to build a house quickly by starting with the second floor. When he was told that that was the wrong way to do it, that he had to start with the basement, he exclaimed, “Gosh, you’re right!” and hollered to his friends, “Tear ‘er down, boys. Gotta start all over!” It seems that the teaching of psychiatry nowadays also often starts with the second floor, with no adequate underpinning in the relevant basic sciences: a building without a foundation, a monument without a base, a statue without a socle. A typical medical school training program consists of three modules: basic sciences, clinical sciences, and clinical practice, all taught sometimes sequentially, sometimes overlapping. The first module is of crucial importance and acquaints the student with the fundamental processes and functions of the body, provides the tools to understand malfunction in disease, and instills habits of systematic observation. In most medical schools this basic science module is oriented toward the two major disciplines of medicine and surgery, with relative neglect of the sciences basic to the behavioral disciplines (represented in medical schools mainly by psychiatry). A student might well assume that the sciences basic to psychiatry either do not exist or are the same as those supporting the medical and surgical disciplines. However, both assumptions would be false. One possibility to envisage is a basic science curriculum for psychiatry that could include three separate but interrelated parts. The first would be concerned with the relationship between brain and behavior and would fit nicely into the current basic science courses. Here the principles of nerve conduction and neurotransmission should be taught, with examples of their role in the psychological functioning of animals and man in health and in disease, and their responsiveness to pharmacological and psychological measures. The second part would be concerned with the psychological sciences. In that module one would discuss such psychological functions as information processing, memory, cognition, and regulatory mechanisms of mood and aggression-to mention a few. The interaction among these would be discussed, together with the methods available to measure these or to influence their efficiency. Human psychological development would be outlined, as would its responsiveness to influence for change. Next, abnormal psychological functioning would be analysed in relation to both behavior and physical disease, together with some typical means for restoration of homeostasis. This kind of analysis of the psychic apparatus would be the equivalent of the physical anatomy and physiology traditionally taught in our schools, and would be fully justified by the importance of the public health and economic impact of mental disorder. The third and final part would deal with the environmental or ecologic aspects of human behavior. This could blend into other aspects of medical sociology and would include such topics as epidemiology, population genetics, nutrition, prevention, etc.
864
5IOL PSYCHIATRY l988:24:863-8~
Editorial
All this, to be sure, would impose additional burdens on our already overcrowded curriculum within the sacrosanct limits of available time. But if these considerations are reasonable, some overall recasting of the entire curriculum would be in order. One does not derogate the importance of the medical and surgical disciplines if one deplores the glaring underrepresentation of the behavioral sciences and of psychiatry as a clinical discipline in the current training program for physicians-all of whom will encounter almost daily problems of mental health and psychosomatic interaction in their medical activity. The absence of a basic curriculum for the behavioral sciences in the training of physicians feaves the student completely unprepared for his in~~uction to psychiatry as a clinical science and as a practical discipline. This omission, moreover, suggests that psychiatry has no scientific base, perpetuates the stereotype that it is not scientific, a merely verbal exercise without supporting data, a statue without a socle. It discourages the entry of students into our field and does serious injustice to the impressive achievements of our discipline and of related fields in the past decades. It is about time for the academic departments of psychiatry, together with the American Psychiatric Association, to begin serious discussions on this matter, and to formulate concrete proposals for the agencies entrusted with medical education. If not us psychiatrists, who else? ~ermun
154. van Pruag
863
EDITORIAL
The Teaching of Psychiatry: A Statue Without a Socle There are a number of American folktales about the little moron, one of which tells of the time he and his friends decided to build a house quickly by starting with the second floor. When he was told that that was the wrong way to do it, that he had to start with the basement, he exclaimed, “Gosh, you’re right!” and hollered to his friends, “Tear ‘er down, boys. Gotta start all over!” It seems that the teaching of psychiatry nowadays also often starts with the second floor, with no adequate underpinning in the relevant basic sciences: a building without a foundation, a monument without a base, a statue without a socle. A typical medical school training program consists of three modules: basic sciences, clinical sciences, and clinical practice, all taught sometimes sequentially, sometimes overlapping. The first module is of crucial importance and acquaints the student with the fundamental processes and functions of the body, provides the tools to understand malfunction in disease, and instills habits of systematic observation. In most medical schools this basic science module is oriented toward the two major disciplines of medicine and surgery, with relative neglect of the sciences basic to the behavioral disciplines (represented in medical schools mainly by psychiatry). A student might well assume that the sciences basic to psychiatry either do not exist or are the same as those supporting the medical and surgical disciplines. However, both assumptions would be false. One possibility to envisage is a basic science curriculum for psychiatry that could include three separate but interrelated parts. The first would be concerned with the relationship between brain and behavior and would fit nicely into the current basic science courses. Here the principles of nerve conduction and neurotransmission should be taught, with examples of their role in the psychological functioning of animals and man in health and in disease, and their responsiveness to pharmacological and psychological measures. The second part would be concerned with the psychological sciences. In that module one would discuss such psychological functions as information processing, memory, cognition, and regulatory mechanisms of mood and aggression-to mention a few. The interaction among these would be discussed, together with the methods available to measure these or to influence their efficiency. Human psychological development would be outlined, as would its responsiveness to influence for change. Next, abnormal psychological functioning would be analysed in relation to both behavior and physical disease, together with some typical means for restoration of homeostasis. This kind of analysis of the psychic apparatus would be the equivalent of the physical anatomy and physiology traditionally taught in our schools, and would be fully justified by the importance of the public health and economic impact of mental disorder. The third and final part would deal with the environmental or ecologic aspects of human behavior. This could blend into other aspects of medical sociology and would include such topics as epidemiology, population genetics, nutrition, prevention, etc.
864
5IOL PSYCHIATRY l988:24:863-8~
Editorial
All this, to be sure, would impose additional burdens on our already overcrowded curriculum within the sacrosanct limits of available time. But if these considerations are reasonable, some overall recasting of the entire curriculum would be in order. One does not derogate the importance of the medical and surgical disciplines if one deplores the glaring underrepresentation of the behavioral sciences and of psychiatry as a clinical discipline in the current training program for physicians-all of whom will encounter almost daily problems of mental health and psychosomatic interaction in their medical activity. The absence of a basic curriculum for the behavioral sciences in the training of physicians feaves the student completely unprepared for his in~~uction to psychiatry as a clinical science and as a practical discipline. This omission, moreover, suggests that psychiatry has no scientific base, perpetuates the stereotype that it is not scientific, a merely verbal exercise without supporting data, a statue without a socle. It discourages the entry of students into our field and does serious injustice to the impressive achievements of our discipline and of related fields in the past decades. It is about time for the academic departments of psychiatry, together with the American Psychiatric Association, to begin serious discussions on this matter, and to formulate concrete proposals for the agencies entrusted with medical education. If not us psychiatrists, who else? ~ermun
154. van Pruag