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Psychiatric education in the 1980s: The role of consultation psychiatry
RICHARD C. W. HALL, M.D. ROBERT E. HOLT, M.D. THOMAS P. BERESFORD, M.D.
Psychiatric education in the 1980s: The role of consultation psychiatry The education of psychiatrists in recent years has been based upon the concept of eclecticism. Because of the broad academic base of the profession, it has been necessary for psychiatric residents to learn about psychoanalytic concepts, social and biologic psychiatry, interpersonal relations, existentialism, behavioral therapy, interviewing, crisis management, ,nosology, differential diagnosis, somatic and pharmacologic therapies, and a variety of psychotherapeutic treatment modalities. However, different training centers specialize in different approaches to psychiatric problems and may selectively emphasize particular areas of knowledge. In addition, first- and second-year residents often specialize in their own area of interest, feeling that their practice will be determined by
this interest or treatment skill and that it is therefore not essential that they devote as much attention to the broader aspects of the field. We believe that a training program must provide both a model and a place to integrate all of the facets of knowledge that we expect the welltrained physician to master. Training programs must also keep abreast of the advances 'in other areas of medicine if they are to produce physicians capable of practicing by the standards that will be demanded of psychiatry in the I980s. General hospital as training site We predict that the remainder of this decade will see a significant extension in the use of the general hospital as a training site. Psychia-
Dr. Hall is chief of staJ! and Dr. Beresford is chief of the psychiatry service at the Veterans Administration Medical Center, Memphis; Dr. Hall is also professor of psychiatry and medicine and Dr. Beresford is associate professor ofpsychiatry at the University ofTennessee Centerfor the Health Sciences. Dr. Holt is clinical director of the division ofgeneral hospital psychiatry, Milwaukee County Medical Complex, and assistant professor ofpsychiatry at the Medical College of Wisconsin. Reprint requests to Dr. Hall allhe VAMC, 1030 JeJ!erson Ave, Memphis, TN 38104 AUGUST 1983 • VOL 24 • NO 8
trists doubtless need to be well schooled in the intrapersonal and interpersonal aspects of our profession. They must also, however, keep abreast. of the rapid progression of diagnostic and treatment advances in other specialties if they are to practice successfully in a general hospital environment. It is estimated that by 1990, 90% of the psychiatry beds in this country will be located in general hospitals.· If the general hospital is to become a primary place of practice for a significant proportion of physicians engaged in our profession, then it should also become a training site for our residents. It is a worthy training site since it provides an ideal arena for the integration of psychiatry with the rest of medicine. And yet, a list of the requirements for an ideal psychiatric residency published in the early 1970s 2 did not mention consultation~liai· son training. A survey in 19763 indicated that only 10% of residency training time was spent in consultation work. Consultation training, when offered, is usually provided late in the 745
Psychiatric education
course of the residency. One reason for this is the practical requirement that the resident must know something about psychiatry before serving as a consultant to his or her colleagues. Another reason is that consultation work requires rapid decision-making in the practical setting of a medical or surgical ward. The latter part of psychiatric training provides a more opportune time for the resident to successfully integrate the knowledge necessary to make these complicated differential judgments. However, isolation of the psychiatric resident for a period of two or three years before serving in this capacity often tends to enhance his or her sense of isolation and alienation from colleagues in other medical disciplines. In short, it makes the resident feel less comfortable interacting in a medical arena. Perhaps training programs should consider a phased consultation experience integrated with other aspects of the first two postgraduate years. No psychiatrist practices exactly as taught. The studies and theories presented on university inpatient wards and outpatient clinics are offered only as models to the resident and must be modified according to the trainee's personality and the ultimate nature of his practice setting. The general hospital provides a setting in which the resident can encounter the multiple variables and performance demands that stimulate the acquisition of knowledge and the development of professional role attributes. A recent study4 suggested that psychiatric educators felt that the acquisition of differential diagnostic abilities was a critical factor in residency training, as was the resident's ability to make appropriate treatment and dispositional decisions. The 746
teaching, strengthening, integrating, and reformulating of these skills in a patient-based setting, utilizing work-up data in association with other physicians, is inherent to the consultation model. s Working on medical 'turf' Many residents fear that practicing psychiatry on another's "turf' puts them at a disadvantage and is not conducive to learning. However, the requesting physician and his patient are usually in considerable need of psychiatric expertise. If the
If the general hospital is to become a prinuuy place of practice for a significant proportion ofphysicians engaged in our profession, then it should also become a training site for our residents. consultation is handled appropriately, it provides for excellent dialogue and the application of a myriad of psychiatric skills. The need for correct, reasoned, testable input provides compelling motivation for the resident to update and use his or her knowledge and to improve professional competence and skill, since most consultations require an understanding of the patient's medical and surgical problem as well as the role of pharmacologic, familial, and social forces as they affect the patient's condition. A resident must also consider the patient's current social setting (both in the hospital and outside) and develop a physicianpatient relationship. Consultation work permits long-term therapy as well as short-term evaluation and
disposition. Training can be selectively tailored to meet the needs of individual residents. When these activities are carefully supervised and focused at the bedside by an interested. mentor, the acquired facts take on new significance. An initial impression can be developed into a careful differential diagnosis, which is then augmented by data acquisition, reformulation of the diagnostic hypothesis, and the development of a testable treatment plan. The logical thought processes developed by this sequence become the foundation for development of future clinical decisions and practice styles. In short, they represent the elements of the Olserian tradition upon which our dicipline should be based. In addition to its importance as a training site for future practice, the general hospital is crucial as a site for continuing medical education. No one can ever "know" all of medicine, but psychiatrists must acquire the ability to learn continuously about the patient's disease, condition, or treatment without undue fear or anxiety. Acquisition of such knowledge is intrinsic in consultation work on a medical or surgical unit. This acquisition of new knowledge over a career is even more crucial for psychiatry than for other disciplines because of the rapid progress our field is making, the diverse thinking it encompasses, and our less stringent internship requirements. In short, consultation psychiatry permits psychiatric residents to combine previously acquired skills as general physicians with newly gained capability as psychiatrists and to update both. In addition, successful performance on a consultation service teaches the resident that he has something important t~ offer to PSYCHOSOMATICS
others and enhances his sense of collegiality with the rest of the medical community. The friendships and affiliations established on the "front lines" of medical practice provide colleagues the psychiatrist can call on for assistance, and they, in turn, can rely on him. Successful training in such a setting also builds confidence in expressing one's opinions based on data, and facilitates the understanding of new technology that the resident can increasingly incorporate into his own practice. At a time when psychiatry has received considerable criticism for its retreat from medicine and from the seriously ill patient, the consultation service can become an important vehicle for reestablishing these ties. In addition, the psychiatrist's special competence in interviewing and psychotherapy can provide a new dimension with which to approach many difficult problems. It is not uncommon for the psychiatric consultant to elicit a medical history that is different from or more definitive than that obtained by the referring physician. The end product can be a timely and constructive intervention for the patient that no other professional can provide. Bedside teaching We concur with Donald Langsley6 that there is a common tendency today in psychiatric education for the teacher to gain distance from the patient and from daily clinical activity. This is unfortunate, since it diminishes the supervisor's ability to provide a clinical role model. The consultation service provides a perfect training ground where mentor and student can interact, watch each other work, and incorporate elements of each other's AUGUST 1983 • VOL 24 • NO 8
Table 1-Areas of Specific Learning in a General Hospital Consultation Service Evaluation and management of: Alcoholism Withdrawal states Overdose Drug addicllon Pain patients DeliriOUS, confused, demented patients Conversion reactions Somatopsychic disorders Hysterical patients Depression Pseudodepresslon Pseudodementla HomiCidal patients SUICidal patlen s Dlsrup Ive patients Borderline pa len s unchausen's syndrome Bnquet's syndrome Hospitalized children Patients who self-mutilate Dependent pallents
practice. The central activity in consultation training is the "staffing." With the trainee observing. the attending psychiatrist sees the patient shortly after the trainee has evaluated him. This "hands on" activity provides the trainee with an immediate model with which to compare his performance. As in days of old, it also permits the supervisor to directly interact with and critique each resident individually. Bedside teaching. in which teacher and student stand together with a patient, can never be replaced by seminars, books, afterthe-fact supervision, notes, or video tapes. Such training emphasizes for the resident his role as a physician, rather than as a therapist or an
Ii
Dying patients Dialysis patients ACCident Victims Victims of violence Rape Victims Post-traumatic stress reactions Burn victims Paralyzed patients Patients With se ual disorder Patients with relapsing illness
Practical knowledge of: Psychotherapy Hypnosis edicallaw Emergency medicine life support Medical pharmacology Psychiatric side effects of medical drugs PsychiatriC research techniques Psychopharmacology
i
.'
•
Table 2Professional Skills Acquired from Consultation Training Collegial behaVior DeCISion making Data analySIS as applied 0 diagnOSIs and management Communlcalion skills Time management Medical JUdgmen Consultallon skills Understanding how patients and staff cope With Illness AppreclallOn of medical ethiCS
747
Psychiatric education
agent of social change. It is as a physician that the resident must be comfortable in order to fully discharge his medical duties following completion of his training. It is not only knowledge we teach, but also an approach to judgment. Desirable qualities of professional conduct and behavior, such as compassion, logical judgment, and empathy, must be modeled-they cannot be mandated or learned from a book. Competence and compassionate interaction with patients are the consequences of the Oslerian tradition.
Topical and professional knowledge Finally, in considering a consultation service in the general hospital as a training site, one must look at what can and cannot be taught in such a setting. The resident can acquire much specific topical knowledge (Table I), but more importantly he can develop professional skills and knowledge (Table 2) that are much broader and more important in shaping the nature of the physician's interaction with subsequent generations of patients. 7
We do not believe that the general hospital can teach all that must be taught to the psychiatric resident, but that it will become an increasingly important and sophisticated training site in the decades to come. 8 As medicine changes, so too will the role of psychiatric physicians. Jfwe are to adequately prepare such physicians, we must place them in an environment at the forefront of technologic change, where they can develop the skills necessary to succeed and reintegrate themselves into the mainstream of American medicine. 0
REFERENCES
consultation education-1976. Arch Gen Psychiatry 33; 1271·1273. 1976. 4. Bowden CL. Humphrey FJ. Thompson MGG; Priorities in psychiatric residency training. Am J Psychiatry 137;1243-1246.1980. 5. Cohen-Cole SA. Haggerly J. Flatt 0: Objectives for residents in consultation psychiatry: Recommendations of a task force. Psychosomatics 23:699-703. 1982.
6. Langsley 00: Presidential address: TOday's teachers and tomorrow's PSYChiatrists. Am J Psychiatry 138;1013-1016.1981. 7. Hackett TP. Cassem NH; Massachusetts General Hospital Handbook of General Hospital Psychiatry. 51. Louis. CV Mosby. 1978. 8. Hales RE. Fink PJ; A modest proposal for consultation/liaison psychiatry in the 19805. Am J Psychiatry 139;1015-1021.1982.
1. Brook Lodge Conference On Consultation-Liaisen Psychiatry. Kalamazoo. Mich. February 1982. 2. Langee H. Glick 10. Hottman B. et al: The requirements of a psychiatric residency program circa 1972. Am J Psychiatry 130:11511152. 1973. 3. SChuberl D5P. McKegney FP: Psychiatric
Letter to Editor Invited Brief letter commenting n publi hed article r ther ubject of intere t treader f P yell 0malic are in ited. mmeot on publi hed arti I will be f, rwarded to the author f, r rept at the discretion of the edit r . Correp ndence ma . be edited nd publi hed. Write t : Wilfred Dorfman, M.D., Edit r in hief. Ps cho omalics, 55 H 11 Hill Lane, B x 4010, Greenwich, T 06 30.
748
PSYCHOSOMATICS
Psychiatric education in the 1980s: The role of consultation psychiatry The education of psychiatrists in recent years has been based upon the concept of eclecticism. Because of the broad academic base of the profession, it has been necessary for psychiatric residents to learn about psychoanalytic concepts, social and biologic psychiatry, interpersonal relations, existentialism, behavioral therapy, interviewing, crisis management, ,nosology, differential diagnosis, somatic and pharmacologic therapies, and a variety of psychotherapeutic treatment modalities. However, different training centers specialize in different approaches to psychiatric problems and may selectively emphasize particular areas of knowledge. In addition, first- and second-year residents often specialize in their own area of interest, feeling that their practice will be determined by
this interest or treatment skill and that it is therefore not essential that they devote as much attention to the broader aspects of the field. We believe that a training program must provide both a model and a place to integrate all of the facets of knowledge that we expect the welltrained physician to master. Training programs must also keep abreast of the advances 'in other areas of medicine if they are to produce physicians capable of practicing by the standards that will be demanded of psychiatry in the I980s. General hospital as training site We predict that the remainder of this decade will see a significant extension in the use of the general hospital as a training site. Psychia-
Dr. Hall is chief of staJ! and Dr. Beresford is chief of the psychiatry service at the Veterans Administration Medical Center, Memphis; Dr. Hall is also professor of psychiatry and medicine and Dr. Beresford is associate professor ofpsychiatry at the University ofTennessee Centerfor the Health Sciences. Dr. Holt is clinical director of the division ofgeneral hospital psychiatry, Milwaukee County Medical Complex, and assistant professor ofpsychiatry at the Medical College of Wisconsin. Reprint requests to Dr. Hall allhe VAMC, 1030 JeJ!erson Ave, Memphis, TN 38104 AUGUST 1983 • VOL 24 • NO 8
trists doubtless need to be well schooled in the intrapersonal and interpersonal aspects of our profession. They must also, however, keep abreast. of the rapid progression of diagnostic and treatment advances in other specialties if they are to practice successfully in a general hospital environment. It is estimated that by 1990, 90% of the psychiatry beds in this country will be located in general hospitals.· If the general hospital is to become a primary place of practice for a significant proportion of physicians engaged in our profession, then it should also become a training site for our residents. It is a worthy training site since it provides an ideal arena for the integration of psychiatry with the rest of medicine. And yet, a list of the requirements for an ideal psychiatric residency published in the early 1970s 2 did not mention consultation~liai· son training. A survey in 19763 indicated that only 10% of residency training time was spent in consultation work. Consultation training, when offered, is usually provided late in the 745
Psychiatric education
course of the residency. One reason for this is the practical requirement that the resident must know something about psychiatry before serving as a consultant to his or her colleagues. Another reason is that consultation work requires rapid decision-making in the practical setting of a medical or surgical ward. The latter part of psychiatric training provides a more opportune time for the resident to successfully integrate the knowledge necessary to make these complicated differential judgments. However, isolation of the psychiatric resident for a period of two or three years before serving in this capacity often tends to enhance his or her sense of isolation and alienation from colleagues in other medical disciplines. In short, it makes the resident feel less comfortable interacting in a medical arena. Perhaps training programs should consider a phased consultation experience integrated with other aspects of the first two postgraduate years. No psychiatrist practices exactly as taught. The studies and theories presented on university inpatient wards and outpatient clinics are offered only as models to the resident and must be modified according to the trainee's personality and the ultimate nature of his practice setting. The general hospital provides a setting in which the resident can encounter the multiple variables and performance demands that stimulate the acquisition of knowledge and the development of professional role attributes. A recent study4 suggested that psychiatric educators felt that the acquisition of differential diagnostic abilities was a critical factor in residency training, as was the resident's ability to make appropriate treatment and dispositional decisions. The 746
teaching, strengthening, integrating, and reformulating of these skills in a patient-based setting, utilizing work-up data in association with other physicians, is inherent to the consultation model. s Working on medical 'turf' Many residents fear that practicing psychiatry on another's "turf' puts them at a disadvantage and is not conducive to learning. However, the requesting physician and his patient are usually in considerable need of psychiatric expertise. If the
If the general hospital is to become a prinuuy place of practice for a significant proportion ofphysicians engaged in our profession, then it should also become a training site for our residents. consultation is handled appropriately, it provides for excellent dialogue and the application of a myriad of psychiatric skills. The need for correct, reasoned, testable input provides compelling motivation for the resident to update and use his or her knowledge and to improve professional competence and skill, since most consultations require an understanding of the patient's medical and surgical problem as well as the role of pharmacologic, familial, and social forces as they affect the patient's condition. A resident must also consider the patient's current social setting (both in the hospital and outside) and develop a physicianpatient relationship. Consultation work permits long-term therapy as well as short-term evaluation and
disposition. Training can be selectively tailored to meet the needs of individual residents. When these activities are carefully supervised and focused at the bedside by an interested. mentor, the acquired facts take on new significance. An initial impression can be developed into a careful differential diagnosis, which is then augmented by data acquisition, reformulation of the diagnostic hypothesis, and the development of a testable treatment plan. The logical thought processes developed by this sequence become the foundation for development of future clinical decisions and practice styles. In short, they represent the elements of the Olserian tradition upon which our dicipline should be based. In addition to its importance as a training site for future practice, the general hospital is crucial as a site for continuing medical education. No one can ever "know" all of medicine, but psychiatrists must acquire the ability to learn continuously about the patient's disease, condition, or treatment without undue fear or anxiety. Acquisition of such knowledge is intrinsic in consultation work on a medical or surgical unit. This acquisition of new knowledge over a career is even more crucial for psychiatry than for other disciplines because of the rapid progress our field is making, the diverse thinking it encompasses, and our less stringent internship requirements. In short, consultation psychiatry permits psychiatric residents to combine previously acquired skills as general physicians with newly gained capability as psychiatrists and to update both. In addition, successful performance on a consultation service teaches the resident that he has something important t~ offer to PSYCHOSOMATICS
others and enhances his sense of collegiality with the rest of the medical community. The friendships and affiliations established on the "front lines" of medical practice provide colleagues the psychiatrist can call on for assistance, and they, in turn, can rely on him. Successful training in such a setting also builds confidence in expressing one's opinions based on data, and facilitates the understanding of new technology that the resident can increasingly incorporate into his own practice. At a time when psychiatry has received considerable criticism for its retreat from medicine and from the seriously ill patient, the consultation service can become an important vehicle for reestablishing these ties. In addition, the psychiatrist's special competence in interviewing and psychotherapy can provide a new dimension with which to approach many difficult problems. It is not uncommon for the psychiatric consultant to elicit a medical history that is different from or more definitive than that obtained by the referring physician. The end product can be a timely and constructive intervention for the patient that no other professional can provide. Bedside teaching We concur with Donald Langsley6 that there is a common tendency today in psychiatric education for the teacher to gain distance from the patient and from daily clinical activity. This is unfortunate, since it diminishes the supervisor's ability to provide a clinical role model. The consultation service provides a perfect training ground where mentor and student can interact, watch each other work, and incorporate elements of each other's AUGUST 1983 • VOL 24 • NO 8
Table 1-Areas of Specific Learning in a General Hospital Consultation Service Evaluation and management of: Alcoholism Withdrawal states Overdose Drug addicllon Pain patients DeliriOUS, confused, demented patients Conversion reactions Somatopsychic disorders Hysterical patients Depression Pseudodepresslon Pseudodementla HomiCidal patients SUICidal patlen s Dlsrup Ive patients Borderline pa len s unchausen's syndrome Bnquet's syndrome Hospitalized children Patients who self-mutilate Dependent pallents
practice. The central activity in consultation training is the "staffing." With the trainee observing. the attending psychiatrist sees the patient shortly after the trainee has evaluated him. This "hands on" activity provides the trainee with an immediate model with which to compare his performance. As in days of old, it also permits the supervisor to directly interact with and critique each resident individually. Bedside teaching. in which teacher and student stand together with a patient, can never be replaced by seminars, books, afterthe-fact supervision, notes, or video tapes. Such training emphasizes for the resident his role as a physician, rather than as a therapist or an
Ii
Dying patients Dialysis patients ACCident Victims Victims of violence Rape Victims Post-traumatic stress reactions Burn victims Paralyzed patients Patients With se ual disorder Patients with relapsing illness
Practical knowledge of: Psychotherapy Hypnosis edicallaw Emergency medicine life support Medical pharmacology Psychiatric side effects of medical drugs PsychiatriC research techniques Psychopharmacology
i
.'
•
Table 2Professional Skills Acquired from Consultation Training Collegial behaVior DeCISion making Data analySIS as applied 0 diagnOSIs and management Communlcalion skills Time management Medical JUdgmen Consultallon skills Understanding how patients and staff cope With Illness AppreclallOn of medical ethiCS
747
Psychiatric education
agent of social change. It is as a physician that the resident must be comfortable in order to fully discharge his medical duties following completion of his training. It is not only knowledge we teach, but also an approach to judgment. Desirable qualities of professional conduct and behavior, such as compassion, logical judgment, and empathy, must be modeled-they cannot be mandated or learned from a book. Competence and compassionate interaction with patients are the consequences of the Oslerian tradition.
Topical and professional knowledge Finally, in considering a consultation service in the general hospital as a training site, one must look at what can and cannot be taught in such a setting. The resident can acquire much specific topical knowledge (Table I), but more importantly he can develop professional skills and knowledge (Table 2) that are much broader and more important in shaping the nature of the physician's interaction with subsequent generations of patients. 7
We do not believe that the general hospital can teach all that must be taught to the psychiatric resident, but that it will become an increasingly important and sophisticated training site in the decades to come. 8 As medicine changes, so too will the role of psychiatric physicians. Jfwe are to adequately prepare such physicians, we must place them in an environment at the forefront of technologic change, where they can develop the skills necessary to succeed and reintegrate themselves into the mainstream of American medicine. 0
REFERENCES
consultation education-1976. Arch Gen Psychiatry 33; 1271·1273. 1976. 4. Bowden CL. Humphrey FJ. Thompson MGG; Priorities in psychiatric residency training. Am J Psychiatry 137;1243-1246.1980. 5. Cohen-Cole SA. Haggerly J. Flatt 0: Objectives for residents in consultation psychiatry: Recommendations of a task force. Psychosomatics 23:699-703. 1982.
6. Langsley 00: Presidential address: TOday's teachers and tomorrow's PSYChiatrists. Am J Psychiatry 138;1013-1016.1981. 7. Hackett TP. Cassem NH; Massachusetts General Hospital Handbook of General Hospital Psychiatry. 51. Louis. CV Mosby. 1978. 8. Hales RE. Fink PJ; A modest proposal for consultation/liaison psychiatry in the 19805. Am J Psychiatry 139;1015-1021.1982.
1. Brook Lodge Conference On Consultation-Liaisen Psychiatry. Kalamazoo. Mich. February 1982. 2. Langee H. Glick 10. Hottman B. et al: The requirements of a psychiatric residency program circa 1972. Am J Psychiatry 130:11511152. 1973. 3. SChuberl D5P. McKegney FP: Psychiatric
Letter to Editor Invited Brief letter commenting n publi hed article r ther ubject of intere t treader f P yell 0malic are in ited. mmeot on publi hed arti I will be f, rwarded to the author f, r rept at the discretion of the edit r . Correp ndence ma . be edited nd publi hed. Write t : Wilfred Dorfman, M.D., Edit r in hief. Ps cho omalics, 55 H 11 Hill Lane, B x 4010, Greenwich, T 06 30.
748
PSYCHOSOMATICS