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Training of psychiatrists
Training of Psychiatrists By D. EWES CA3II.;RON ARE INTHE ~ I I D S T of a g r e a t e x p a n s i o n of p s y c h i a t r i c activity. T h e numl)(.r of p s y c h i a t r i s t s , as s h o w n b y the A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n nlembershi. I) has g r o w n from 3,600 to over 14,000 since t h e e n d of V~Zorld \Var II, a n d it is c o m m o n l y c o n s i d e r e d that at least 30 to 40 p e r c e n t of p s y c h i a t r i s t s a r e not m e m b e r s of the A m e r i c a n P s y c h i a t r i c Associa-:, tion. Yet, so serious is the lack of facilities in the field, t h a t the late P r e s i d e n t K e n n e d y took a p e r s o n a l l e a d in the d r i v e to m e e t t h e s e d e s p e r a t e needs. S u p p o r t e d b y Congress, s u p p l i e d b y a vast b u d g e t througla the N a t i o n a l I n s t i t u t e of M e n t a l H e a l t h , a n d a i d e d t h r o u g h o u t the l a n d t)y all t h e skills a n d e n e r g i e s of the m e n t a l h e a l t h o r g a n i z a t i o n , p s y c h i a t r y is p u s h i n g w i t h s p e e d a n d d e t e r m i n a t i o n t o w a r d its g r e a t goals ......the . care of t h e m e n t a l l y ill a n d t h e concll~est of m e n t a l illness. But d e s p i t e this h i g h l y o r g a n i z e d , h e a v i l y f i n a n c e d drive, the k e y person r t ' m a i n s the key w e a k n e s s . His n u m b e r s are low. I n d e e d it m a y b e said that they are g r o w i u g lower y e a r b y y e a r r e l a t i v e to the e x p a n d i n g task. A dep a r t m e n t of p s y c h i a t r y w h i c h ten years at,ore m i g h t h a v e f o u n d itself w i t h the resl)ensibilit,¢, for suo~)lvina~, . ~ t e a c h i n g in two or three .years on t h e u n d e r g r a d u a t e level, a n d for the a p p r e n t i c e s h i p i n s t r u c t i o n of a h a l f d o z e n i:sychiatrists in t r a i n i n g , t o g e t h e r w i t h the s u p p o r t of a m e a s u r e of research, now finds it mtist b e p r e p a r e d to o p e n u p a n d to staff the f o l l o w i n g : L3ix'isions of c h i l d a n d a d o l e s c e n t l~sychiatry A division of i n d u s t r i a l p s y c h i a t r y A division of c o m m t m i t y l~sychiatry• S u p p l y a p s y c h o s o m a t i c service to t h e rest of the m e d i c a l c e n t e r O r g a n i z e an e m e r g e n c y p s y c h i a t r i c service in the hospital Operate a day hospital Set u p a h o m e care o r g a n i z a t i o n E s t a b l i s h h a l f - w a y h o u s e facilities T h e p o t e n t i a l research p r o g r a m is no less e x t e n s i v e a n d the d i a g n o s t i c a n d t r e a t m e n t facilities h a v e g r o w n e n o r m o u s l y . All h a v e to b e staffed. B u t statfed b y w h a t k i n d of p s y c h i a t r i s t s ? T h e r e is the real hul~ of the question. For d e s p i t e m a n y c o n f e r e n c e s , t r a i n i n g c e n t e r s r e m a i n m u c h too s m a l l for ef]Ficiencx........ the a v e r a g e n u m b e r ot s t u d e n t s b e i n g t h i r t e e n . ~ T h e e x p e r i e n c e is most v a r i e d from c e n t e r to center, a n d u n f o r t u n a t e l y in too m a n y centers, t h e r e is no v a r i a t i o n at all. Var too m a n y c e n t e r s still t e a c h on the basis of one k i n d of o r g a n i z a t i o n o n l y one k i n d of hospital, or de19artment, or c l i n i c o n l y . . , k s m u s t b e e x p e c t e d , the results are u n e v e n , a n d , for thor most part, poor. T h e "'schools," it is true, a r e s l o w l y f a d i n g into the b:ickgrc~und, b u t t h e y are still t<~o m i l c h w i t h us. T h e r e is a g r o w i n g b o d y of well-irain¢'d, g e n e r a l psycl~iatrists, b u t nonelh¢'less, there a r e still p o w ~ r f u l g r o u p s c~n the extr<,rne right a n d left w h o h a v e so little in c o m m o n that on W E
227 CO.%Ii'III.;IlI.;~Sl'*'I'; ]'SY(;IIIATltYt V()I,, 13, SO. 4 (Atr(;Us'r). 1965
first s e a r c h , the o n l y c h a r a c t e r i s t i c w h i c h t h e y s h a r e is t h a t t h e i r a d h e r e n t s r a r e l y talk to t h e i r p a t i e n t s . T h e c l a s s i c a l a n a l y s t was, a n d still is, a m a n w h o p r e s i d e s r a t h e r t h a n p a r t i c i p a t e s , w h o n e v e r talks to t h e f a m i l y , has n o t h i n g to s a y to, or l e a r n from, t h e social w o r k e r a n d p s y c h o l o g i s t . On the f a r left s t a n d s the o r g a n i e i s t w i t h his f i n g e r on the e l e c t r i c s w i t c h . H e will talk to t h e p a t i e n t "'lie d o w n , " "'o'o up," "'take t h e s e t h r e e t i m e s a day.'" But as far as t a l k i n g to u n d e r s t a n d , that's not for h i m . H e is t r e a t i n g a disease, not a p a t i e n t , a n d e l e c t r o s h o c k is the v e r y t h i n g for it. O u r t r a i n i n g p r o g r a m s s h o w e v e r y w h e r e the s p e c t r a l p r e s e n c e o f the past. T r a d i t i o n d u l l s a l i k e both their c o n t e n t "_and t h e i r m e t h o d . K r a e p e l i n , Bleuler, a n d F r e u d w e r e m e n of g r e a t i n f l u e n c e ip, the-it day. P a s s i n g t i m e s h o u l d h a v e a l l o w e d us b y n o w to w i n n o w out w h a t w a s g o o d a n d w h a t w a s f a u l t y . But t o a n a m a z i n g e x t e n t t h e s e t h r e e m e n still ~.~rently m"fluenec" w h a t w e t e a c h a n d h o w w e t e a c h . T h e r e is p.otlfing t e m p o r a l ) I t in t h e rest of m e d i c i n e . Safe s u r g e r y s t a r t e d w i t h Lister, b u t nobod'; n o w w o u l d teach the a n t i s e p t i c p r e c e d u r e s L i s t e r d e v i s e d . O s i e r d e s c r i b e d the a n e m i a s as he k n e w t h e m , b u t w h o w o u l d t e a c h his classification of a n e m i a s t o d a y ? \Ve can u n d e r s t a n d t h a t our field is full of so m u c h u n c e r t a i n t y , so h a r d to g r a s p , so h a r d to w o r k in, t h a t i n s e c u r i t y is h i g h , a n d that it is p e r h a p s for this r e a s o n t h a t t e a c h i n g is so d o m i n a t e d b v d e f e r e n c e to authority'. B u t t h o s e w h o h a v e so t a u g h t , w h o ]rove 'been i n t e n t not u p o n a w a k e n i n g m e n ' s m i n d s , b u t u p o n i n d o c t r i n a tion, h a v e s e r v e d to b l o c k a n d s t u l t i f y t h e i n i t i a t i v e a n d e n t e r p r i s e of two g e n e r a t i o n s of y o l m g ps)'ehiatrists. L e t us t a k e a look at a n d ask six q u e s t i o n s a b o u t p r e s e n t d a y t r a i n i n g o f p s y c h i a t r i s t s a n d see w h e t h e r f r o m t h a t w e can d r a w s o m e c o n c l u s i o n s . T h e q u e s t i o n s a r e c o m p r e s s e d into t h o s e little w o r d s w h i c h m e n , s e e k i n g h a r d facts, h a v e u s e d f r o m e a r l i e s t times. 1. W h o ? \ V i m is to b e t a u g h t , a n d w h o is to do tim t e a c h i n g ? In r e g a r d to t h e first it can r e a s o n a b l y b e s a i d t h a t t h e r e is g e n e r a l a g r e e m e n t that m e n entering training must have passed through accredited m e d i c a l schools and i n t e r n s h i p s . \ V h e n w e c o m e to the q u e s t i o n of s e l e c t i o n of t h o s e w h o m i g h t b e e x p e c t e d to do p a r t i c u l a r l y w e l l in p s y d f i a t r v , w e e n c o u n t e r two m a j o r clitfieulties. T h e first is that w e h a v e no g e n e r a | a g r e e m e n t as to w h a t k i n d of f i e l d a m a n is to b e fitted for. A n d t h e s e c o n d d i f f i c u l t y is o n e w h i c h , in f a i r n e s s to o u r s e l v e s , w e m u s t s a y w e s h a r e w i t h m a n y others, a n d t h a t is t h e r e d o n o t exist at t h e p r e s e n t t i m e r e a l l y g o o d m e t h o d s of p e r s o n a l i t y t e s t i n g w h i c h w o u l d e n a b l e us to s a y this is an i m a g i n a t i v e , p e r c e p t i v e , s t a b l e p e r s o n , w i t h g o o d g r o w t h p o t e n t i a l s . D e a n s h a v e b e e n t r y i n g to find this sort of t h i n g s i n c e s e l e c t i o n b e c a m e o n e of t h e facts of life in m e d i c a l schools, anti t h e y h a v e not s u c c e e d e d p a r t i c u l a r l y well. N o r d i d the a r m e d forces. ~Vc'. t a n select out the gross things, t h e p s y c h o n e u r o t i c , the p s y c h o t i c . \Ve c e r t a i n l y can't g u a r a n t e e that our s e l e c t e e will n e v e r h a v e a p s y c h o s i s or a n e u r o s i s in his l i f e t i m e . T h e s e c o n d p r o l ) l e m w h i c h resides in tile qllestion "\VIle'.a'' is '~vllf) shall d o tim t e a c h i n g . T i m a n s w e r v e r y s i m p l y is those w h o are g o o d t e a c h e r s . A n d g o o d teaclu;rs a r e nc)t o n l y tlmse wh¢) can stir ancl i n s p i r e t h e s t u d e n t s , b u t
"I'RAIN1N(; 0 1 " I > S Y ( . ' I I I , - t T I I I S ' I ' S
2290
also those who can give a truly balanced account of what the student must know. A n d h e r e one llltlSt l)anish all extremists. You c a nnot have s o m e o n e take r e s p o n s i b i l i t y for a t e a c h i n g p r o g r a m w h o is p r e e o n l m i t t e d . If he has a l r e a d y show n that his l x let is that the u l t i m a t e solution of all p s y c h i a t r i c ills is b i o c h e m i c a l , let him 1)3, all m a t t e r of m e a n s teach the b i o c h e m i s t r y of 1)sychiatry", an i n t e r e s t i n g a n d v a h l a b l e field. But let h i m not take the h e l m of the w h o l e program. If lie is a psychoanalyst, let him fetich psychoanalysis. L o n g e x p e r i e n c e has fully shown that those m e n who ,,,,,ere t r a i n e d in psychoanalysis early in their careers, a n d who h a v e then r e t u r n e d to work in the p s y c h i a t r i c field, new>¢.1 fully .. recover from their initial indoctrination. T h e r e fore, t h e p r o g r a m should be d i r e c t e d by a b r o a d l y tr a ine d person not tills y m p a t h e t i c either to o r g a n i c or p s y c h o a n a l y t i c viewpoints, b u t f u l l y pers u a d e d t h at tim a n s w e r to p s y c h i a t r i c prol)tems is to be f ound in psyc hia tr y . This is s o m e t h i n g w h i c h requires tile firmest possible e mpha sis. O u r m e d i c a l c¢ll(:ae, ue. w ho constitute the m e m b e r s h i p of the selection c o m m i t t e e s for n e w c h a i r m e n ot7 p s y c h i a t r y , t)ewildered u n d o u l ) t e d l y b y our own confusion, h a v e in the htst d e c a d e or two passe(:l through fashions in w h i c h only those w h o w e r e p r e d o m i n a n t h , neurologists, biochemists, or endocrinologists, ,,,,,ere seriously c o n s i d e r e d for these pivotal posts, or equall.v as foolish, only those w h o w e r e ps.x,ehoanalysts. All such types of selection are q u i t e disasterous to a large modern university ps)'ehiatrie program. 2. W h a t ? "~Vhat s h o u l d be t a u g h t ? Prot)ably, the best x,'ay to a p p r o a c h this is to ask ourselves, w h a t are the e n d u r i n g facts of p s y c h i a t r y a n d w h a t are. the n e w d e m a n d s . Tile e n d u r i n g facts are that the t r a i n e d psve hia tr is t 111ust h a v e a clear and c o m p l e t e grasp of the different p a t t e r n s of d e v i a n t behavior. Hence phenomenology in the sense of syniptonmtolog.x" iniist be well alid thoroughl)- [aright. T h e trained psx,chialrisl lllllSl ])e able to diagnose w i t h a(,cilracy and o~er a SOtlild prognosis. This is Fllndamental to all medicine. F r o m l i m e i m n l e m o r i a l lllell lid'v-e tried to hel l) each othe r 1)v. persuadin,~. discussing, taking counsel together, exl)laining, and comforting. D o w n the ages this h a s a p p e a r e d as one form or a n o t h e r of p s y c h o l h e r a p y . I t is b a s i c an d is p e r h a p s tile most w i d e l y u s e d form of t r e a t m e n t in p s y c h i a t r y . It must be g i v e n a p l a c e of major a n d c o n t i n u i n g i m p o r t a n c e thro~lghout the entire teachi n g c u r r i c u l u m . T h o u g h its p o t e n c y as a t h e r a p e u t i c p r o c e d u r e still r e m a i n s love, it has g r e a t p r o m i s e a n d ab ove all things, it is Hie w a y in w h i c h the y o u n g m a n gets to k n o w the facts of h u m a l l nature. T h e s e are t h e e n d u r i n g r e q u i r e m e n l s for the w e l l - t r a i n e d psychiatrist, b u t ours is a d a y of revolution in t h e r a p y a nd facility. T h e one to one t h e r a p e u t i c r e l a t i o n s h i p is b e i n g i m n l e n s e l y e x p a n d e d by g r o u p work, by. w o r k i n g w i t h families, 1)y w o r k i n g in teams, and liv the utilization of a tremendous range Of eolnnltlllitv facilities w h i c h have b e e n 1)rought into b e i n g in the last two or three decades, t t e n c e , the psychiatrist in t r a i n i n g m u s t l e a r n to work not only w i t h c o m m u n i t y resources, b u t also in the c o m m u n i t y ; lie must learn to h n d a c o m m o n l a n g u a g e w ith the psychologist, the social worker, social psychiatrist, the visiting nliirse organizations, the eoinnlnnity mental healtl, faeililies, lhe jllv('ni]e eOlll'l personnel, lind lluit ,Tro;ll ;ll'ra~ of pt,liph~. ;ill
~30
D. Ir~.VEN CA,'NIEItON
of whona h a v e come into b e i n g to deal with the vast eomplexities of m e n t a l illness. A firm g r o u n d i n g in the n a t u r e of the h u m a n or ga nism is essential. Behavioral functions, w h i l e possessed of a high d e g r e e of a u t o n o m y , carmet exist without, and are a s s u r e d l y m u c h affected b,,, tim supl)ort systems, . physiological, b i o c h e m i c a l , a n d endocrinologieal. T h e organism is h i g h l y integrated. It functions in a u n i t a r y m a n n e r , yet c a n n o t act c o m p l e t e l y with respect to all its functions save ira r e l a t i o n s h i p to others, e.g., sexual functions. And moreover, the ]roman b e i n g is, of necessity, in constant interaction with its immediate environment. Partial a n d ad hoe concepts of h u n m n nature, such as the "id, ego," "superego" st n l c tures, o p e r a t i n g in terms of a v a r i e t y of drives, or the reflex-mounted m o n s t e r d e r i v e d from our k n o w l e d g e of c onditioning, are of the most limite d v a l u e for the purposes of m o d e r n p s y c h i a t r y . T h e w o r k i n g m o d e l of w h i c h the y o u n g m a n ml,st possess h i m s e l f is one w h i c h will free him to take into consideration a n y kind of force w h i c h bears upon the patient ...........genetic, chilclhood trauma, the i m m e d i a t e reality situation, conflict, insecurity, endoerinological, a n d b i o c h e m i c a l dysfunctions, the pressures of the family, a n d work. F i r m possession of such a m o d e l will also free h i m to m a k e use of each and e ve r y k i n d of t h e r a p y w h i c h x~dll serve to a m e l i o r a t e a n d t e r m i n a t e m e n t a l illness. A n d so he must b e c o m e expert, not only, in p s y c h o t h e r a p y , g r o u p work, and c o m m u n i t y skills, but also in the u n d e r s t a n d i n g a n d use of the so-called somatic theral)ies. It is n e c e s s a r y for us to b e a r in m i n d that b y far, the most potent tools we ha ve at the p r e s e n t t i m e are the somatic therapies , w h e n used for the a p p r o p r i a t e cases. N o t h i n g t h a t we n o w have a p p r o a c h e s the old t h e r m a l t r e a t m e n t of general paresis ira terms of p e r c e n t a g e recoveries, and the recovery rate of severe r e t a r d e d depressions treated b y electroshock is far h i g h e r than the recovery rate of severe p s y c h o n e u r o t i c illness in patien ts trealed b y psyclaotherapy. A1)ove all, they m u s t be t a u g h t w i s d o m ira the a p p r o p r i a t e use of these therapies. It is q u i t e w r o n g to treat the d e e p l y r e t a r d e d de pr e ssion 1)y p s y c h o t h e r a p y , a n d q u i t e w r o n g to treat the anxiety ne ur otic by electroshock. T h e c o m p l e x task of fitting together a c u r r i c u l u m can b e simplified 1)y m a k i n g u se of two s u c c i n c t b l u e p r i n t s . T h e first is that wha t we propose to teach are facts, attitudes, a n d skills. In the first part of the c u r r i c u l u m , teaching s h o u l d b e p r e d o m i n a n t l y with respect to facts a n d attitudes, a n d in tim second part, o p p o r t u n i t y to pr a c tic e skills u n d e r supe r vision takes a prog r e ssi v e l y l a r g e r share. T h e secon(l 1)lueprint shows tim t e a c h i n g c u r r i c u l u m , a n d p a r t i c u l a r l y that 1)ased on se mina r s a n d lectures, as b e i n g c o m p r i s e d of t h r e e sections. First, c o n t i n u a t i o n subjects, i.e., s~l)jects w h i c h are t a u g h t in p r o g r e ssi v e form t h r ( m g h o n t tim w h o l e c u r r i c u l u m ; second, special subjects w h i c h a p p e a r in one or two years only, such as t e a c h i n g of e l e c t r o e n c e p h a l o g r a p h y ; third, electives. T u r n i n g to c o n t i n u a t i o n mlbjecls, three of t Il(se '" h a v e alrea(ly l)een me n tioned: p h e n o m e n o l o g y , psycl~otheral)y, a n d c o m m u n i t y l)sychiatry. To these sh o u l d 1)e a d d e d a fourth, n a m e l y , p s y c h o d y n a m i c s an(J ps~chfoatholo~z,~, a n d ....
TIIA IN I N(; Oi:
PSY(;i 11ATII ISTS
"9-31
a fifth con~prised of the s u p p o r t s y s t e m s , s u c h as b i o c h e m i s t r y , p h a r n a a c o l o g y , p s y c h o l o g y , sociologv, a n d genetics. E l e c t i v e s s e r v e to e n r i c h tile course, a n d g i v e d i v e r s i t y for those w h o h a v e a l r e a d y s h o w n an i n t e r e s t in special fields s u c h as i n d u s t r i a l psychiatrx;, a d m i n i s t r a t i v e p s y c h i a t r y , or a d v a n c e d child psychiatry. A m o n g tile special subjects m u s t b e i n c l u d e d i n s t r u c t i o n in t e a c h i n g . It is truly an e x t r a o r d i n a r y thing, b u t n o n e t h e l e s s true, t h a t the vastly, g r e a t e r n u m b e r of ~,niversitv t e a c h i n g c e n t e r s d o n o t h i n g to t e a c h t h e i r f u t u r e t e a c h ers, a n d it is a r a r e c e n t e r , i n d e e d , in w h i c h r e s e a r c h in t e a c h i n g has f o u n d e v e n a p r e c a r i o u s rooting. 3. l V h e r e ? T e a c h i n g s h o u l d lye c a r r i e d out in a n d t h r o u g h a c o m p l e x of clinical te;lching units, c o o r d i n a t e d u n d e r the direction of a u n i v e r s i t y , a n d s e r v i n g to express t h e r a n g e a n d r i c h n e s s of p s y c h i a t r i c e x p e r i e n c e . ~ P s y c h i a trists s h o u l d n o t be t r a i n e d e x c l u s i v e l y in a s t a t e hospital; t h e y s h o u l d ~ o t b e t r a i n e d exelusiveh, in the p s y c h i a t r i c d e p t ~ r t m e n t of a u n i v e r s i t y . N o single m e n t a l h o s p i t a l can give a d e q u a t e t r a i n i n g , a n d c o n t i n u e d a t t e m p t s to d o so u n d o u b t e d l y , a r e r e s p o n s i b l e , p a r a d o x i c a l l y e n o u g h , for a f u r t h e r g r o w t h in the n u m b e r s of those p e o p l e w h o u l t i m a t e l y e n d up in an otfice w i t h a little h a n d f u l of f a i t h f u l a n d affluent p a t i e n t s w h o m t h e y see y e a r a f t e r y e a r . T h o s e courses of t r a i n i n g w h i c h a r e strictly confined to t h e p s y c h i a t ric d e p a r t m e n t of a unix;ersit,~,, or to a single p s y c h i a t r i c d e p a r t m e n t of a g e n e r a l hospital, a r e likely t o ' p r o d u c e i n d i v i d u a l s w h o h a v e no i d e a of t h e r a n g e a n d v o h l m e a n d u r g e n c y of m e n t a l illness as it s p r e a d s a n d g r o w s t l a r o u g h o u t the p o p u l a t i o n . It is onb,' w h e n a g r o u p of such facilities is f o r m e d into a t r a i n i n g s y s t e m or n e t w o r k t h a t an a p p r o x i m a t i o n to a d e q u a t e e x p e r i e n c e a n d t e a c h i n g can be o b t a i n e d . Such a n e t w o r k s h o u l d b e u n d e r t h e a u s p i c e s a n d g e n e r a l d i r e c t i o n of t h e u n i v e r s i t y w h i c h a l o n e has t h e long t r a d i t i o n s of t e a c h i n g , a n d of t h e m a i n t e n a n c e of excellence, a n d m o r e o v e r , is in t h e b e s t p o s i t i o n to exercise re,;tr~tint on a t t e m p t s 1)y the clinical c e n t e r s u n d u l y to d i v e r t t h e m a n in t r a i n i n g from s t u d y to service. N,lodifications of tlais w h e r e b y i n d i v i d u a l s a r e t r a i n e d essentially, in a single u n i v e r s i t y t e a c h i n g hospital w i t h o c c a s i o n a l t w o or t h r e e xv,eek,- visits to the n e i g h b o r i n g m e n t a l h o s p i t a l s a r e useless. ,Y,l e n h a v e to be a s s i g n e d as i n t e g r a l m e m b e r s of the staff in t h e m e n t a l hospital, of tile p s y c h i a t r i c division of t h e g e n e r a l hospital~ o r a child p s y c h i a t r y c e n t e r , c f t h e staff of a m e n t a l h e a l t h clinic, a n d in thb c~0mmunity. A n d t h e v h a v e to b e a s s i g n e d for a long e n o u g h p e r i o d so t h a t t h e y can a n d do c o m e to t a k e responsibilities, u n d e r s u p e r v i s i o n , f o r t h e p a t i e n t s w h i c h a r e a s s i g n e d to t h e m . T h e m o r e a b l e a n d e n t e r p r i s i n g of t h e y o u n g m e n -those w h o a r e likely, l a t e r in t h e i r c a r e e r s to go f o r w a r d to the m a j o r positions in universities, hospitals, or in c o m m u n i t y p s y c h i a t r y s h o u l d b e e n c o u r a g e d to t a k e an e x t r a y e a r of t r a i n i n g a b r o a d . T i l e talents for a p p l i c a t i o n a n d o r g a n i z a tion w h i c h the U n i t e d States psy, chiatrist d e r i v e s as p a r t of his social h e r i t a g e , h a v e in a m e a s u r e b e c l o u d e d the f a c t t h a t m o s t of the b a s i c i d e a s p r e s e n t l y in operatio1~ in the p s y c h i a t r i c field c o m e f r o m E u r o p e . P a r a d o x i c a l l y , E u r o p e , or at least m a n ) , p a r t s of it, has b e e n q u i t e b a c k w a r d a b o u t t r a n s l a t i n g t h e s e
0,30
D. E'~VEN C A S [ E I I O N
i d e a s into p r a c t i c a l a p p l i c a t i o n . T h e l e a d i n g c e n t e r s in Z u r i c h , in L o n d o n , in Paris, a n d in V i e n n a , h o w e v e r , h a v e m u c h to t e a c h t h e s c h o l a r l y a n d those w h o a r e a t t r a c t e d b v v e n t u r e s in ideas. 4. ~Vhen? T u r n i n g to t h e q u e s t i o n of w h e n , w e m a y a n s w e r this very. s i m p l y b y s a y i n g t h a t t h e b e s t t i m e to c o m m e n c e t r a i n i n g in p s y c h i a t r y is i m m e d i a t e l y a f t e r t h e i n t e r n s h i p . O n e hears, h o w e v e r , to a d e c r e a s i n g d e g r e e , of t h e necessity, u s u a l l y u r g e d b y g e n e r a l p r a c t i t i o n e r s , t h a t m e n s h o u l d first h a v e a y e a r or t w o of e x p e r i e n c e in g e n e r a l m e d i c i n e in a d d i t i o n to t h e i n t e r n s h i p . I n v i e w of t h e f a c t t h a t w e h a v e n o t y e t felt t h a t w e c o u l d a d d an e x t r a );ear to t h e s c a n t y t h r e e },ears t h a t w e d i v e to t r a i n i n g in p s y c h i a t r y , this s e e m s q u i t e i m p r a c t i c a l . \ V e can, h o w e v e r , t a k e a g o o d d e a l of t h e f o r c e o u t of t h e criticism if w e m a k e it a b t m d a n t l y c l e a r to o u r m e n in t r a i n i n g througla t h e p r o c e d u r e s w h i c h w e set u p , t h a t t h e y a r e m e d i c a l m e n . I t m u s t be f u n d a m e n t a l to the t e a c h i n g on o u r w a r d r o u n d s , in o u r s e m i n a r s a n d c o n f e r e n c e s , a n d in o u r l e c t u r e s , t h a t t h e s e m e n a r e p r e p a r i n g t h e m s e l v e s f o r life in m e d i cine, a n d n o t in a p a r a - m e d i c a l c a r e e r w h i c h d o e s not r e q u i r e its f o l l o w e r s to p a y a n y a t t e n t i o n to t h e p h y s i c a l h e a l t h of t h e i n d i v i d u a l , to t a k e responsibility f o r h i m o u t s i d e t h e t h e r a p e u t i c h o u r , or to m a i n t a i n a n y r e a s o n a b l e p r o f e s sional r e l a t i o n w i t h his c o l l e a g u e s in o t h e r fields of m e d i c i n e . 5. H o w ? L e t us s t a r t off b y e m p h a s i z i n g t h a t t e a c h i n g m u s t n o t p r e c l u d e l e a r n i n g . T e a c h i n g a n d l e a r n i n g a r e b r o t h e r s , a n d if t e a c h i n g is safer, l e a r n i n g is w i s e r . B o t h a r e essential. T h e r e h a s b e e n an a m a z i n g l a c k of p r o g r e s s in t h e d e v e l o p m e n t of n e w t y p e s of t e a c h i n g i n s t r u m e n t s , a l t h o u g h m a n y of t h e l o n g e s t a b l i s h e d m e t h o d s of t e a c h i n g h a v e b e e n g r e a t l y i m p r o v e d b y a d j u v a n t s . T h i s is r a t h e r s t r i k i n g in v i e w of t h e f a c t t h a t g r e a t p r o g r e s s h a s b e e n m a d e in t h e m a t e r i a l to b e l e a r n e d . T h e t r a d i t i o n a l t e a c h i n g i n s t r u m e n t s a r e s o m e ten in n u m b e r : A. T h e l e c t u r e w h i c h h a s b e e n d e c l i n i n g in f a v o r for a l m o s t a g e n e r a t i o n h a s n o w b e c o m e a m u c h m o r e vital t h i n g . N e w aids, s u c h as t a p e rec o r d i n g , s o u n d m o v i e s , a n d television, h a v e b r o u g h t n e w life. T h e g r o w i n g k n o w l e d g e of g r o u p d y n a m i c s , i n i t i a t e d b y K u r t L e w i n a h a v e c r e a t e d a n e w i m a g e of the l e c t u r e . \ V e see t h e s e r r i e d s t u d e n t s n o l o n g e r as r o w s of r e c e p t o r s a r r a n g e d b e f o r e a b r o a d c a s t e r . N o w w e see t h e s t u d e n t s a n d l e c t u r e r in c o n s t a n t i n t e r a c t i o n in a d)naamic field w h i c h h a s p l e n t y of h i d d e n p o t e n t i a l i t i e s w i t h w h i c h to e x p e r i m e n t . B. S e m i n a r s . T h e s e r e m a i n t h u s f a r t h e m o s t e x c i t i n g of o u r t e a c h i n g i n s t r u m e n t s . G r o u p i n t e r p l a y is m o s t e a s i l y s t u d i e d h e r e . E a c h s e m i n a r l e a d e r c a n m o s t r e a d i l y w o r k o u t his m o s t effective m o d e of i n t e r a c t i o n with the students. C. G r o u p discussions. T h i s is an a r o a in w h i c h a g r e a t d e a l of experimentation with the group d y n a m i c i d e a s ~ d i s c u s s i o n leaders, observers, r e c o r d e r s ........h a s b e e n c a r r i e d out. D. T h e tutorial, w h i l e a c t u a l l y i n t r o d u c e d b y S o c r a t e s , is r e l a t i v e l y unk n o w n in A m e r i c a n m e d i c a l schools. It is costly in t e r m s of f a c u l t y time. b u t t h e r e is no d o u b t t h a t it r a n k s h i g h a m o n g the effective i n s t r m n e n t s . F o r a s t u d e n t to b e al)le to discuss his d i a g n o s t i c a n d t r e a t m e n t diHiculties,
TBAIN.1NG OF PSYCIIIAq'BISTS
~33
to e x p l o r e t h e r e a c h e s of t h e l i t e r a t u r e , to c o n s i d e r t h e s t r u c t u r e of his r e s e a r c h p l a n , w i t h a s e n i o r m e m b e r of t h e f a c u l t y f o r an h o u r or t w o a w e e k , c o n s t i t u t e s for h i m all a r e a of m o s t a c t i v e a n d r a p i d l e a r n i n g . As the r a n g e a n d poteiltial of t h e n e w c h e m o t h e r a p y c o n t i n u e s to exp a n d , a n d as o u r k n o w l e d g e of p s y c h o p h a r m a c o l o g y a n d n e u r o p h y s i o l o g y g r o w s a p a c e , it is absolutely, e s s e n t i a l t h a t the y o u n g m a n w h o m a y look f o r w a r d to h a v i n g m o r e a n d m o r e p o w e r f u l tools p l a c e d in his h a n d s s h o u l d h a v e c o n s t a n t l y a v a i l a l ) l e to h i m , t h e g u i d a n c e of a s e n i o r coll e a g u e . M o r e o v e r , the g r o w i n g p r o m i s e of p h a r m a c o l o g i c a l a g e n t s req u i r e s t h a t a n i n c r e a s i n g s h a r e of t e a c h i n g t i m e s h o u l d b e g i v e n to ins t r u c t i o n n o t o n l y in o u r k n o w l e d g e of s u c h d r u g s , b u t also to t h e i r p r a c t i c a l a p p l i c a t i o n . T h i s is d e m a n d e d n o t o n l y b y t h e r e c o r d of t h e i r e f f e c t i v e n e s s , b u t also b y o u r u r g e n t n e e d to b r i n g i m m e d i a t e r e l i e f to g r e a t e r n u m b e r s of p a t i e n t s w h o p r e s e n t l y can r e c e i v e no t r e a t m e n t it o n l y t r a d i t i o n a l m e t h o d s a r e to b e u s e d . I t is m o s t i m p o r t a n t to s e e to it, h o w e v e r , t h a t t h e t u t o r d o e s n o t become a therapist, or a general counsellor, but that he remain an instructor, a d v i s e r , a n d a s s o c i a t e in d e a l i n g w i t h the difficult c a s e s w i t h w h i c h tile y o u n g m a n h a s to w o r k . E. T h e c o n f e r e n c e s h o u l d b e r e s e r v e d for s p e c i a l topics r a t h e r t h a n as a r e g u l a r m e a n s of i n s t r u c t i o n w h i c h is m o r e easily c a r r i e d o u t in discussioYl g r o u p s a n d s e m i n a r s . F. \ V a r d r o u n d s . T h i s h a s n e v e r b e e n p r o p e r l y d e s c r i b e d t h o u g h it is o n e of t h e m o s t i m p o r t a n t a r e a s for l e a r n i n g . I n d e e d it is a m a z i n g to d i s c o v e r it, b u t it is n o n e t h e l e s s t r u e , t h a t a n u m b e r of p r o f e s s o r s of p s y c h i a t r y a c t u a l l y n e v e r m a k e w a r d r o u n d s ; the)" m e r e l y p r e s i d e in t h e i r offices or a t o c c a s i o n a l c o n f e r e n c e s . T h i s is o n e of t h e c o n s e q u e n c e s of a p p o i n t i n g as c h a i r m a n of tile d e p a r t m e n t , i n d i v i d u a l s w h o h a v e h a d little or n o e x p e r i e n c e in d e a l i n g w i t h t h e c e a s e l e s s p r e s s u r e on t i m e a n d i n g e n u i t y c o n s t i t u t e d b y r e s p o n s i l ) i l i t y for a clinical s e r v i c e . XVard rounds should be conducted by the entire medical team, psychiatrist, p s y c h o l o g i s t , social w o r k e r , o c c u p a t i o n a l t h e r a p i s t , n u r s e , a n d t h e r e s i d e n t s t a f f a s s i g n e d to w o r k w i t h t h e p a r t i c u l a r c h i e f of s e r v i c e . H e r e t h e s t u d e n t h a s all u n r i v a l e d o p p o r t u n i t y to f o l l o w t h e t h i n k i n g of t h e c h i e f of s e r v i c e as h e is c o n f r o n t e d x~dth p r o b l e m a f t e r p r o b l e m a n d to p a r t i c i p a t e w i t h h i m as a m e m b e r o f t h e m e d i c a l t e a m in w o r k i n g o u t t h e d i a g n o s i s , in p l a n n i n g , a n d in t h e e x e c u t i o n of t r e a t a n e n t . -~ S e r v i c e in t h e o u t - p a t i e n t d e p a r t m e n t or in t h e c o m m u n i t y is n o t m e n t i o n e d s e p a r a t e l y s i n c e i n s t r u c t i o n in t h e s e a r e a s c a n 1)e c a r r i e d o u t b y the same instruments which are already mentioned. G. T h e r e m a i n i n g i n s t r u m e n t s a r e of lesser s i g n i f i c a n c e - -the j o u r n a l c l u b , s o c i o d r a m a , t h e h o m e visit a n d t h e i n f o r m a l s e t t i n g -staff r o o m o v e r a p o t of coffee, t h e d o c t o r s ' d i n i n g r o o m , a n d in t h e e v e n i n g w h e n t h e stlzdcnts m e e t t o g e t h e r to d i s c u s s t h e annoyance:~, t h e f r u s t r a t i o n s , a n d t h e clinical t r i u m p h s of t h e d a y . T h e a c t u a l a d j u v a n t s w h i c h c a n b e u s e d in t e a c h i n g will n o t l)e d i s c u s s e d in d e t a i l in this s h o r t p a p e r . I t
~34
D. E-xVI,'_.N C A ~ I E R O N
is here, i n t e r e s t i n g l y enough, that the m a j o r a d v a n c e s are b e i n g m a d e , as f ar as t e a c h i n g is c o n c e r n e d the provision of audio-visual aids, the o n e - w a y screen, tire use of television, t e a c h i n g tapes, a n d the like. Teachi n g m a c h i n e s , i n t r o d u c e d by Skinner 4 h a v e thtxs far failed to establish themselves ira the p s y c h i a t r i c field. In order to control one's teaching, one must know the results, a n d here tire e x a m i n a t i o n still plays a part. An e-xamination is r e q u i r e d at the erad of the first y e a r to w eed out those who are clearly unfitted, or to correct those w h o m i g h t h a v e d o n e better, to e n c o u r a g e those who h a v e shown promise. A second e x a m i n a t i o n is r e q u i r e d at the end of the last ye a r to d e t e r m i n e those fit to be given the seal of a p p r o v a l of the t e a c h i n g institution. Of still more i m p o r t a n c e , however, is the assessment of the s t u d e n t a s se ssm e n t b y the chief resident, b y his tutor, b y his c h i e f of service, b y the chiefs of the clinical t r a i n i n g units through w h i c h lae passed. This a s s e s s m e n t ( w h i l e it is m o r e difficult to obtain from it a satisfactory-looking, r o u n d figure than is the erase w ith e x a m i n a t i o n s ) nonetheless, is c o n s i d e r a b l y m o r e F(~netrating in its evaluation of the student. F r o m it we not oral), obtain an evaluation of the r a n g e of facts w h i c h he has tat his disposal a n d the skills w i t h w h i c h to use these facts, b u t s o m e t h i n g w h i c h the e x a m i n a t i o n ne ve r does reveal, n a m e l y , his attitudes. 6. A n d lastly, w e come to the que stion of why? A n d this is so s i m p l e that it seems h a r d l y , at first sight, necessary to pose. A n d yet, w h y do we n e e d to train so man), m o r e psychiatrists? \~Te n e e d to train t h e m obviously b e c a u s e w e h a v e as yet x'e~, little idea of pr e ve ntion, a n d the p r o b l e m gr ows apace. Secondly, w e n e e d to train a great m a n y mor e b e c a u s e we are g r a d u a l l y coming to realize that p s y c h i a t r y is not just a d e p a r t m e n t of m e d i c i n e b u t it is the m i s s i n g h e m i s p h e r e of m e d i c i n e . P s y c h i a t r y m a y verx, well lye on the eve of b r e a k i n g up into a n u m b e r of aiiied areas: c hild psyc hia tr y, m e n t a l retardation, i n d u s t r i a l p s y c h i a t r y , c o m m u n i t y psychiatr.v, a n d a d m i n i s t r a t i v e psychiatry. "~Ve n e e d m o r e ps,'chiatrists a n d far b e t t e r t r a i n e d psychiatrists, b e c a u s e u n d o u b t e d l y m a n y p s y c h i a t r i c illnesses are not yet even r e c o g n i z e d , let alone treated a p p r o p r i a t e l y . A n d the p r o b l e m of m e n t a l deviation in all its m y r i a d forms is one w h i c h q u i t e fairly is b e g i n n i n g to bog down the w h o l e f o r w a r d progress of m a n ' s efforts. R ECO3I.~IENDATIONS
1. T h a t every step should b e taken to s t r e n g t h e n a n d e m p h a s i z e a m o n g ourselves, w i t h our colleagues, a nd with the g e n e r a l public, the p a r a m o u n t r e s p o n s i b i l i t y of p s y c h i a t r y for a s s e m b l i n g , a u g m e n t i n g , teaching, a n d a p p ly ing, the o r g a n i z e d b o d y of k n o w l e d g e c o n c e r n i n g the m e n t a l l y ill. 2. T h a t r e c o g n i t i o n s h o u l d be w i t h d r a w n from the present i n a d e q u a t e a n d i n c o m p l e t e single unit t r a i n i n g areas. 3. T h a t r e s p o n s i b i l i t y for t r a i n i n g psychiatrists should lye taken b y university-directed, m u l t i p l e unit networks. 4. T h a t tire present core ctrrriculum should move with the p r e s e n t l y emerging needs, to give p r o p e r r e p r e s e n t a t i o n to t r a i n i n g in c o m m u n i t y p s y c h i a t r y
235
TRAINING OF I~SYCIlIA'rlllSTS
and to give an equal weight and status to all the major therapies, including chemotherapy, the physical therapies, the group therapies, and milieu therapies. 5. That teaching should be taught. 6. That research on se]ection, teaching, and learning, as well as on assessment should be fostered. REFERENCES 1. Cameron, D. E.: The psychiatric training network of McGill University. Amer. J. Psychiat. 120(11):1039-1044, 1964. 2. ~ : Medical rounds. Bombay Medical Digest, pp. 377-378, July, 1964. 3. Lewin, K.: Frontiers of group dynamics.
Human Relations. 1:1, 1947. 4. Skinner, B. F.: Teaching Machines. Science 128:969-977, 1958. 5. Medical education in the United States. Survey by the Staff of the Council on Medical Education. J. A. M. A. 190: 626, 1964.
D. Ewen Cameron, M.D., Directm, Psychiatry and Aging Research Laboratories, Veterans Administration HosT~ital, Albany, New York; Research Professor, Department of Psychiatry, Albany Medical College, Albany, N. Y.
227 CO.%Ii'III.;IlI.;~Sl'*'I'; ]'SY(;IIIATltYt V()I,, 13, SO. 4 (Atr(;Us'r). 1965
first s e a r c h , the o n l y c h a r a c t e r i s t i c w h i c h t h e y s h a r e is t h a t t h e i r a d h e r e n t s r a r e l y talk to t h e i r p a t i e n t s . T h e c l a s s i c a l a n a l y s t was, a n d still is, a m a n w h o p r e s i d e s r a t h e r t h a n p a r t i c i p a t e s , w h o n e v e r talks to t h e f a m i l y , has n o t h i n g to s a y to, or l e a r n from, t h e social w o r k e r a n d p s y c h o l o g i s t . On the f a r left s t a n d s the o r g a n i e i s t w i t h his f i n g e r on the e l e c t r i c s w i t c h . H e will talk to t h e p a t i e n t "'lie d o w n , " "'o'o up," "'take t h e s e t h r e e t i m e s a day.'" But as far as t a l k i n g to u n d e r s t a n d , that's not for h i m . H e is t r e a t i n g a disease, not a p a t i e n t , a n d e l e c t r o s h o c k is the v e r y t h i n g for it. O u r t r a i n i n g p r o g r a m s s h o w e v e r y w h e r e the s p e c t r a l p r e s e n c e o f the past. T r a d i t i o n d u l l s a l i k e both their c o n t e n t "_and t h e i r m e t h o d . K r a e p e l i n , Bleuler, a n d F r e u d w e r e m e n of g r e a t i n f l u e n c e ip, the-it day. P a s s i n g t i m e s h o u l d h a v e a l l o w e d us b y n o w to w i n n o w out w h a t w a s g o o d a n d w h a t w a s f a u l t y . But t o a n a m a z i n g e x t e n t t h e s e t h r e e m e n still ~.~rently m"fluenec" w h a t w e t e a c h a n d h o w w e t e a c h . T h e r e is p.otlfing t e m p o r a l ) I t in t h e rest of m e d i c i n e . Safe s u r g e r y s t a r t e d w i t h Lister, b u t nobod'; n o w w o u l d teach the a n t i s e p t i c p r e c e d u r e s L i s t e r d e v i s e d . O s i e r d e s c r i b e d the a n e m i a s as he k n e w t h e m , b u t w h o w o u l d t e a c h his classification of a n e m i a s t o d a y ? \Ve can u n d e r s t a n d t h a t our field is full of so m u c h u n c e r t a i n t y , so h a r d to g r a s p , so h a r d to w o r k in, t h a t i n s e c u r i t y is h i g h , a n d that it is p e r h a p s for this r e a s o n t h a t t e a c h i n g is so d o m i n a t e d b v d e f e r e n c e to authority'. B u t t h o s e w h o h a v e so t a u g h t , w h o ]rove 'been i n t e n t not u p o n a w a k e n i n g m e n ' s m i n d s , b u t u p o n i n d o c t r i n a tion, h a v e s e r v e d to b l o c k a n d s t u l t i f y t h e i n i t i a t i v e a n d e n t e r p r i s e of two g e n e r a t i o n s of y o l m g ps)'ehiatrists. L e t us t a k e a look at a n d ask six q u e s t i o n s a b o u t p r e s e n t d a y t r a i n i n g o f p s y c h i a t r i s t s a n d see w h e t h e r f r o m t h a t w e can d r a w s o m e c o n c l u s i o n s . T h e q u e s t i o n s a r e c o m p r e s s e d into t h o s e little w o r d s w h i c h m e n , s e e k i n g h a r d facts, h a v e u s e d f r o m e a r l i e s t times. 1. W h o ? \ V i m is to b e t a u g h t , a n d w h o is to do tim t e a c h i n g ? In r e g a r d to t h e first it can r e a s o n a b l y b e s a i d t h a t t h e r e is g e n e r a l a g r e e m e n t that m e n entering training must have passed through accredited m e d i c a l schools and i n t e r n s h i p s . \ V h e n w e c o m e to the q u e s t i o n of s e l e c t i o n of t h o s e w h o m i g h t b e e x p e c t e d to do p a r t i c u l a r l y w e l l in p s y d f i a t r v , w e e n c o u n t e r two m a j o r clitfieulties. T h e first is that w e h a v e no g e n e r a | a g r e e m e n t as to w h a t k i n d of f i e l d a m a n is to b e fitted for. A n d t h e s e c o n d d i f f i c u l t y is o n e w h i c h , in f a i r n e s s to o u r s e l v e s , w e m u s t s a y w e s h a r e w i t h m a n y others, a n d t h a t is t h e r e d o n o t exist at t h e p r e s e n t t i m e r e a l l y g o o d m e t h o d s of p e r s o n a l i t y t e s t i n g w h i c h w o u l d e n a b l e us to s a y this is an i m a g i n a t i v e , p e r c e p t i v e , s t a b l e p e r s o n , w i t h g o o d g r o w t h p o t e n t i a l s . D e a n s h a v e b e e n t r y i n g to find this sort of t h i n g s i n c e s e l e c t i o n b e c a m e o n e of t h e facts of life in m e d i c a l schools, anti t h e y h a v e not s u c c e e d e d p a r t i c u l a r l y well. N o r d i d the a r m e d forces. ~Vc'. t a n select out the gross things, t h e p s y c h o n e u r o t i c , the p s y c h o t i c . \Ve c e r t a i n l y can't g u a r a n t e e that our s e l e c t e e will n e v e r h a v e a p s y c h o s i s or a n e u r o s i s in his l i f e t i m e . T h e s e c o n d p r o l ) l e m w h i c h resides in tile qllestion "\VIle'.a'' is '~vllf) shall d o tim t e a c h i n g . T i m a n s w e r v e r y s i m p l y is those w h o are g o o d t e a c h e r s . A n d g o o d teaclu;rs a r e nc)t o n l y tlmse wh¢) can stir ancl i n s p i r e t h e s t u d e n t s , b u t
"I'RAIN1N(; 0 1 " I > S Y ( . ' I I I , - t T I I I S ' I ' S
2290
also those who can give a truly balanced account of what the student must know. A n d h e r e one llltlSt l)anish all extremists. You c a nnot have s o m e o n e take r e s p o n s i b i l i t y for a t e a c h i n g p r o g r a m w h o is p r e e o n l m i t t e d . If he has a l r e a d y show n that his l x let is that the u l t i m a t e solution of all p s y c h i a t r i c ills is b i o c h e m i c a l , let him 1)3, all m a t t e r of m e a n s teach the b i o c h e m i s t r y of 1)sychiatry", an i n t e r e s t i n g a n d v a h l a b l e field. But let h i m not take the h e l m of the w h o l e program. If lie is a psychoanalyst, let him fetich psychoanalysis. L o n g e x p e r i e n c e has fully shown that those m e n who ,,,,,ere t r a i n e d in psychoanalysis early in their careers, a n d who h a v e then r e t u r n e d to work in the p s y c h i a t r i c field, new>¢.1 fully .. recover from their initial indoctrination. T h e r e fore, t h e p r o g r a m should be d i r e c t e d by a b r o a d l y tr a ine d person not tills y m p a t h e t i c either to o r g a n i c or p s y c h o a n a l y t i c viewpoints, b u t f u l l y pers u a d e d t h at tim a n s w e r to p s y c h i a t r i c prol)tems is to be f ound in psyc hia tr y . This is s o m e t h i n g w h i c h requires tile firmest possible e mpha sis. O u r m e d i c a l c¢ll(:ae, ue. w ho constitute the m e m b e r s h i p of the selection c o m m i t t e e s for n e w c h a i r m e n ot7 p s y c h i a t r y , t)ewildered u n d o u l ) t e d l y b y our own confusion, h a v e in the htst d e c a d e or two passe(:l through fashions in w h i c h only those w h o w e r e p r e d o m i n a n t h , neurologists, biochemists, or endocrinologists, ,,,,,ere seriously c o n s i d e r e d for these pivotal posts, or equall.v as foolish, only those w h o w e r e ps.x,ehoanalysts. All such types of selection are q u i t e disasterous to a large modern university ps)'ehiatrie program. 2. W h a t ? "~Vhat s h o u l d be t a u g h t ? Prot)ably, the best x,'ay to a p p r o a c h this is to ask ourselves, w h a t are the e n d u r i n g facts of p s y c h i a t r y a n d w h a t are. the n e w d e m a n d s . Tile e n d u r i n g facts are that the t r a i n e d psve hia tr is t 111ust h a v e a clear and c o m p l e t e grasp of the different p a t t e r n s of d e v i a n t behavior. Hence phenomenology in the sense of syniptonmtolog.x" iniist be well alid thoroughl)- [aright. T h e trained psx,chialrisl lllllSl ])e able to diagnose w i t h a(,cilracy and o~er a SOtlild prognosis. This is Fllndamental to all medicine. F r o m l i m e i m n l e m o r i a l lllell lid'v-e tried to hel l) each othe r 1)v. persuadin,~. discussing, taking counsel together, exl)laining, and comforting. D o w n the ages this h a s a p p e a r e d as one form or a n o t h e r of p s y c h o l h e r a p y . I t is b a s i c an d is p e r h a p s tile most w i d e l y u s e d form of t r e a t m e n t in p s y c h i a t r y . It must be g i v e n a p l a c e of major a n d c o n t i n u i n g i m p o r t a n c e thro~lghout the entire teachi n g c u r r i c u l u m . T h o u g h its p o t e n c y as a t h e r a p e u t i c p r o c e d u r e still r e m a i n s love, it has g r e a t p r o m i s e a n d ab ove all things, it is Hie w a y in w h i c h the y o u n g m a n gets to k n o w the facts of h u m a l l nature. T h e s e are t h e e n d u r i n g r e q u i r e m e n l s for the w e l l - t r a i n e d psychiatrist, b u t ours is a d a y of revolution in t h e r a p y a nd facility. T h e one to one t h e r a p e u t i c r e l a t i o n s h i p is b e i n g i m n l e n s e l y e x p a n d e d by g r o u p work, by. w o r k i n g w i t h families, 1)y w o r k i n g in teams, and liv the utilization of a tremendous range Of eolnnltlllitv facilities w h i c h have b e e n 1)rought into b e i n g in the last two or three decades, t t e n c e , the psychiatrist in t r a i n i n g m u s t l e a r n to work not only w i t h c o m m u n i t y resources, b u t also in the c o m m u n i t y ; lie must learn to h n d a c o m m o n l a n g u a g e w ith the psychologist, the social worker, social psychiatrist, the visiting nliirse organizations, the eoinnlnnity mental healtl, faeililies, lhe jllv('ni]e eOlll'l personnel, lind lluit ,Tro;ll ;ll'ra~ of pt,liph~. ;ill
~30
D. Ir~.VEN CA,'NIEItON
of whona h a v e come into b e i n g to deal with the vast eomplexities of m e n t a l illness. A firm g r o u n d i n g in the n a t u r e of the h u m a n or ga nism is essential. Behavioral functions, w h i l e possessed of a high d e g r e e of a u t o n o m y , carmet exist without, and are a s s u r e d l y m u c h affected b,,, tim supl)ort systems, . physiological, b i o c h e m i c a l , a n d endocrinologieal. T h e organism is h i g h l y integrated. It functions in a u n i t a r y m a n n e r , yet c a n n o t act c o m p l e t e l y with respect to all its functions save ira r e l a t i o n s h i p to others, e.g., sexual functions. And moreover, the ]roman b e i n g is, of necessity, in constant interaction with its immediate environment. Partial a n d ad hoe concepts of h u n m n nature, such as the "id, ego," "superego" st n l c tures, o p e r a t i n g in terms of a v a r i e t y of drives, or the reflex-mounted m o n s t e r d e r i v e d from our k n o w l e d g e of c onditioning, are of the most limite d v a l u e for the purposes of m o d e r n p s y c h i a t r y . T h e w o r k i n g m o d e l of w h i c h the y o u n g m a n ml,st possess h i m s e l f is one w h i c h will free him to take into consideration a n y kind of force w h i c h bears upon the patient ...........genetic, chilclhood trauma, the i m m e d i a t e reality situation, conflict, insecurity, endoerinological, a n d b i o c h e m i c a l dysfunctions, the pressures of the family, a n d work. F i r m possession of such a m o d e l will also free h i m to m a k e use of each and e ve r y k i n d of t h e r a p y w h i c h x~dll serve to a m e l i o r a t e a n d t e r m i n a t e m e n t a l illness. A n d so he must b e c o m e expert, not only, in p s y c h o t h e r a p y , g r o u p work, and c o m m u n i t y skills, but also in the u n d e r s t a n d i n g a n d use of the so-called somatic theral)ies. It is n e c e s s a r y for us to b e a r in m i n d that b y far, the most potent tools we ha ve at the p r e s e n t t i m e are the somatic therapies , w h e n used for the a p p r o p r i a t e cases. N o t h i n g t h a t we n o w have a p p r o a c h e s the old t h e r m a l t r e a t m e n t of general paresis ira terms of p e r c e n t a g e recoveries, and the recovery rate of severe r e t a r d e d depressions treated b y electroshock is far h i g h e r than the recovery rate of severe p s y c h o n e u r o t i c illness in patien ts trealed b y psyclaotherapy. A1)ove all, they m u s t be t a u g h t w i s d o m ira the a p p r o p r i a t e use of these therapies. It is q u i t e w r o n g to treat the d e e p l y r e t a r d e d de pr e ssion 1)y p s y c h o t h e r a p y , a n d q u i t e w r o n g to treat the anxiety ne ur otic by electroshock. T h e c o m p l e x task of fitting together a c u r r i c u l u m can b e simplified 1)y m a k i n g u se of two s u c c i n c t b l u e p r i n t s . T h e first is that wha t we propose to teach are facts, attitudes, a n d skills. In the first part of the c u r r i c u l u m , teaching s h o u l d b e p r e d o m i n a n t l y with respect to facts a n d attitudes, a n d in tim second part, o p p o r t u n i t y to pr a c tic e skills u n d e r supe r vision takes a prog r e ssi v e l y l a r g e r share. T h e secon(l 1)lueprint shows tim t e a c h i n g c u r r i c u l u m , a n d p a r t i c u l a r l y that 1)ased on se mina r s a n d lectures, as b e i n g c o m p r i s e d of t h r e e sections. First, c o n t i n u a t i o n subjects, i.e., s~l)jects w h i c h are t a u g h t in p r o g r e ssi v e form t h r ( m g h o n t tim w h o l e c u r r i c u l u m ; second, special subjects w h i c h a p p e a r in one or two years only, such as t e a c h i n g of e l e c t r o e n c e p h a l o g r a p h y ; third, electives. T u r n i n g to c o n t i n u a t i o n mlbjecls, three of t Il(se '" h a v e alrea(ly l)een me n tioned: p h e n o m e n o l o g y , psycl~otheral)y, a n d c o m m u n i t y l)sychiatry. To these sh o u l d 1)e a d d e d a fourth, n a m e l y , p s y c h o d y n a m i c s an(J ps~chfoatholo~z,~, a n d ....
TIIA IN I N(; Oi:
PSY(;i 11ATII ISTS
"9-31
a fifth con~prised of the s u p p o r t s y s t e m s , s u c h as b i o c h e m i s t r y , p h a r n a a c o l o g y , p s y c h o l o g y , sociologv, a n d genetics. E l e c t i v e s s e r v e to e n r i c h tile course, a n d g i v e d i v e r s i t y for those w h o h a v e a l r e a d y s h o w n an i n t e r e s t in special fields s u c h as i n d u s t r i a l psychiatrx;, a d m i n i s t r a t i v e p s y c h i a t r y , or a d v a n c e d child psychiatry. A m o n g tile special subjects m u s t b e i n c l u d e d i n s t r u c t i o n in t e a c h i n g . It is truly an e x t r a o r d i n a r y thing, b u t n o n e t h e l e s s true, t h a t the vastly, g r e a t e r n u m b e r of ~,niversitv t e a c h i n g c e n t e r s d o n o t h i n g to t e a c h t h e i r f u t u r e t e a c h ers, a n d it is a r a r e c e n t e r , i n d e e d , in w h i c h r e s e a r c h in t e a c h i n g has f o u n d e v e n a p r e c a r i o u s rooting. 3. l V h e r e ? T e a c h i n g s h o u l d lye c a r r i e d out in a n d t h r o u g h a c o m p l e x of clinical te;lching units, c o o r d i n a t e d u n d e r the direction of a u n i v e r s i t y , a n d s e r v i n g to express t h e r a n g e a n d r i c h n e s s of p s y c h i a t r i c e x p e r i e n c e . ~ P s y c h i a trists s h o u l d n o t be t r a i n e d e x c l u s i v e l y in a s t a t e hospital; t h e y s h o u l d ~ o t b e t r a i n e d exelusiveh, in the p s y c h i a t r i c d e p t ~ r t m e n t of a u n i v e r s i t y . N o single m e n t a l h o s p i t a l can give a d e q u a t e t r a i n i n g , a n d c o n t i n u e d a t t e m p t s to d o so u n d o u b t e d l y , a r e r e s p o n s i b l e , p a r a d o x i c a l l y e n o u g h , for a f u r t h e r g r o w t h in the n u m b e r s of those p e o p l e w h o u l t i m a t e l y e n d up in an otfice w i t h a little h a n d f u l of f a i t h f u l a n d affluent p a t i e n t s w h o m t h e y see y e a r a f t e r y e a r . T h o s e courses of t r a i n i n g w h i c h a r e strictly confined to t h e p s y c h i a t ric d e p a r t m e n t of a unix;ersit,~,, or to a single p s y c h i a t r i c d e p a r t m e n t of a g e n e r a l hospital, a r e likely t o ' p r o d u c e i n d i v i d u a l s w h o h a v e no i d e a of t h e r a n g e a n d v o h l m e a n d u r g e n c y of m e n t a l illness as it s p r e a d s a n d g r o w s t l a r o u g h o u t the p o p u l a t i o n . It is onb,' w h e n a g r o u p of such facilities is f o r m e d into a t r a i n i n g s y s t e m or n e t w o r k t h a t an a p p r o x i m a t i o n to a d e q u a t e e x p e r i e n c e a n d t e a c h i n g can be o b t a i n e d . Such a n e t w o r k s h o u l d b e u n d e r t h e a u s p i c e s a n d g e n e r a l d i r e c t i o n of t h e u n i v e r s i t y w h i c h a l o n e has t h e long t r a d i t i o n s of t e a c h i n g , a n d of t h e m a i n t e n a n c e of excellence, a n d m o r e o v e r , is in t h e b e s t p o s i t i o n to exercise re,;tr~tint on a t t e m p t s 1)y the clinical c e n t e r s u n d u l y to d i v e r t t h e m a n in t r a i n i n g from s t u d y to service. N,lodifications of tlais w h e r e b y i n d i v i d u a l s a r e t r a i n e d essentially, in a single u n i v e r s i t y t e a c h i n g hospital w i t h o c c a s i o n a l t w o or t h r e e xv,eek,- visits to the n e i g h b o r i n g m e n t a l h o s p i t a l s a r e useless. ,Y,l e n h a v e to be a s s i g n e d as i n t e g r a l m e m b e r s of the staff in t h e m e n t a l hospital, of tile p s y c h i a t r i c division of t h e g e n e r a l hospital~ o r a child p s y c h i a t r y c e n t e r , c f t h e staff of a m e n t a l h e a l t h clinic, a n d in thb c~0mmunity. A n d t h e v h a v e to b e a s s i g n e d for a long e n o u g h p e r i o d so t h a t t h e y can a n d do c o m e to t a k e responsibilities, u n d e r s u p e r v i s i o n , f o r t h e p a t i e n t s w h i c h a r e a s s i g n e d to t h e m . T h e m o r e a b l e a n d e n t e r p r i s i n g of t h e y o u n g m e n -those w h o a r e likely, l a t e r in t h e i r c a r e e r s to go f o r w a r d to the m a j o r positions in universities, hospitals, or in c o m m u n i t y p s y c h i a t r y s h o u l d b e e n c o u r a g e d to t a k e an e x t r a y e a r of t r a i n i n g a b r o a d . T i l e talents for a p p l i c a t i o n a n d o r g a n i z a tion w h i c h the U n i t e d States psy, chiatrist d e r i v e s as p a r t of his social h e r i t a g e , h a v e in a m e a s u r e b e c l o u d e d the f a c t t h a t m o s t of the b a s i c i d e a s p r e s e n t l y in operatio1~ in the p s y c h i a t r i c field c o m e f r o m E u r o p e . P a r a d o x i c a l l y , E u r o p e , or at least m a n ) , p a r t s of it, has b e e n q u i t e b a c k w a r d a b o u t t r a n s l a t i n g t h e s e
0,30
D. E'~VEN C A S [ E I I O N
i d e a s into p r a c t i c a l a p p l i c a t i o n . T h e l e a d i n g c e n t e r s in Z u r i c h , in L o n d o n , in Paris, a n d in V i e n n a , h o w e v e r , h a v e m u c h to t e a c h t h e s c h o l a r l y a n d those w h o a r e a t t r a c t e d b v v e n t u r e s in ideas. 4. ~Vhen? T u r n i n g to t h e q u e s t i o n of w h e n , w e m a y a n s w e r this very. s i m p l y b y s a y i n g t h a t t h e b e s t t i m e to c o m m e n c e t r a i n i n g in p s y c h i a t r y is i m m e d i a t e l y a f t e r t h e i n t e r n s h i p . O n e hears, h o w e v e r , to a d e c r e a s i n g d e g r e e , of t h e necessity, u s u a l l y u r g e d b y g e n e r a l p r a c t i t i o n e r s , t h a t m e n s h o u l d first h a v e a y e a r or t w o of e x p e r i e n c e in g e n e r a l m e d i c i n e in a d d i t i o n to t h e i n t e r n s h i p . I n v i e w of t h e f a c t t h a t w e h a v e n o t y e t felt t h a t w e c o u l d a d d an e x t r a );ear to t h e s c a n t y t h r e e },ears t h a t w e d i v e to t r a i n i n g in p s y c h i a t r y , this s e e m s q u i t e i m p r a c t i c a l . \ V e can, h o w e v e r , t a k e a g o o d d e a l of t h e f o r c e o u t of t h e criticism if w e m a k e it a b t m d a n t l y c l e a r to o u r m e n in t r a i n i n g througla t h e p r o c e d u r e s w h i c h w e set u p , t h a t t h e y a r e m e d i c a l m e n . I t m u s t be f u n d a m e n t a l to the t e a c h i n g on o u r w a r d r o u n d s , in o u r s e m i n a r s a n d c o n f e r e n c e s , a n d in o u r l e c t u r e s , t h a t t h e s e m e n a r e p r e p a r i n g t h e m s e l v e s f o r life in m e d i cine, a n d n o t in a p a r a - m e d i c a l c a r e e r w h i c h d o e s not r e q u i r e its f o l l o w e r s to p a y a n y a t t e n t i o n to t h e p h y s i c a l h e a l t h of t h e i n d i v i d u a l , to t a k e responsibility f o r h i m o u t s i d e t h e t h e r a p e u t i c h o u r , or to m a i n t a i n a n y r e a s o n a b l e p r o f e s sional r e l a t i o n w i t h his c o l l e a g u e s in o t h e r fields of m e d i c i n e . 5. H o w ? L e t us s t a r t off b y e m p h a s i z i n g t h a t t e a c h i n g m u s t n o t p r e c l u d e l e a r n i n g . T e a c h i n g a n d l e a r n i n g a r e b r o t h e r s , a n d if t e a c h i n g is safer, l e a r n i n g is w i s e r . B o t h a r e essential. T h e r e h a s b e e n an a m a z i n g l a c k of p r o g r e s s in t h e d e v e l o p m e n t of n e w t y p e s of t e a c h i n g i n s t r u m e n t s , a l t h o u g h m a n y of t h e l o n g e s t a b l i s h e d m e t h o d s of t e a c h i n g h a v e b e e n g r e a t l y i m p r o v e d b y a d j u v a n t s . T h i s is r a t h e r s t r i k i n g in v i e w of t h e f a c t t h a t g r e a t p r o g r e s s h a s b e e n m a d e in t h e m a t e r i a l to b e l e a r n e d . T h e t r a d i t i o n a l t e a c h i n g i n s t r u m e n t s a r e s o m e ten in n u m b e r : A. T h e l e c t u r e w h i c h h a s b e e n d e c l i n i n g in f a v o r for a l m o s t a g e n e r a t i o n h a s n o w b e c o m e a m u c h m o r e vital t h i n g . N e w aids, s u c h as t a p e rec o r d i n g , s o u n d m o v i e s , a n d television, h a v e b r o u g h t n e w life. T h e g r o w i n g k n o w l e d g e of g r o u p d y n a m i c s , i n i t i a t e d b y K u r t L e w i n a h a v e c r e a t e d a n e w i m a g e of the l e c t u r e . \ V e see t h e s e r r i e d s t u d e n t s n o l o n g e r as r o w s of r e c e p t o r s a r r a n g e d b e f o r e a b r o a d c a s t e r . N o w w e see t h e s t u d e n t s a n d l e c t u r e r in c o n s t a n t i n t e r a c t i o n in a d)naamic field w h i c h h a s p l e n t y of h i d d e n p o t e n t i a l i t i e s w i t h w h i c h to e x p e r i m e n t . B. S e m i n a r s . T h e s e r e m a i n t h u s f a r t h e m o s t e x c i t i n g of o u r t e a c h i n g i n s t r u m e n t s . G r o u p i n t e r p l a y is m o s t e a s i l y s t u d i e d h e r e . E a c h s e m i n a r l e a d e r c a n m o s t r e a d i l y w o r k o u t his m o s t effective m o d e of i n t e r a c t i o n with the students. C. G r o u p discussions. T h i s is an a r o a in w h i c h a g r e a t d e a l of experimentation with the group d y n a m i c i d e a s ~ d i s c u s s i o n leaders, observers, r e c o r d e r s ........h a s b e e n c a r r i e d out. D. T h e tutorial, w h i l e a c t u a l l y i n t r o d u c e d b y S o c r a t e s , is r e l a t i v e l y unk n o w n in A m e r i c a n m e d i c a l schools. It is costly in t e r m s of f a c u l t y time. b u t t h e r e is no d o u b t t h a t it r a n k s h i g h a m o n g the effective i n s t r m n e n t s . F o r a s t u d e n t to b e al)le to discuss his d i a g n o s t i c a n d t r e a t m e n t diHiculties,
TBAIN.1NG OF PSYCIIIAq'BISTS
~33
to e x p l o r e t h e r e a c h e s of t h e l i t e r a t u r e , to c o n s i d e r t h e s t r u c t u r e of his r e s e a r c h p l a n , w i t h a s e n i o r m e m b e r of t h e f a c u l t y f o r an h o u r or t w o a w e e k , c o n s t i t u t e s for h i m all a r e a of m o s t a c t i v e a n d r a p i d l e a r n i n g . As the r a n g e a n d poteiltial of t h e n e w c h e m o t h e r a p y c o n t i n u e s to exp a n d , a n d as o u r k n o w l e d g e of p s y c h o p h a r m a c o l o g y a n d n e u r o p h y s i o l o g y g r o w s a p a c e , it is absolutely, e s s e n t i a l t h a t the y o u n g m a n w h o m a y look f o r w a r d to h a v i n g m o r e a n d m o r e p o w e r f u l tools p l a c e d in his h a n d s s h o u l d h a v e c o n s t a n t l y a v a i l a l ) l e to h i m , t h e g u i d a n c e of a s e n i o r coll e a g u e . M o r e o v e r , the g r o w i n g p r o m i s e of p h a r m a c o l o g i c a l a g e n t s req u i r e s t h a t a n i n c r e a s i n g s h a r e of t e a c h i n g t i m e s h o u l d b e g i v e n to ins t r u c t i o n n o t o n l y in o u r k n o w l e d g e of s u c h d r u g s , b u t also to t h e i r p r a c t i c a l a p p l i c a t i o n . T h i s is d e m a n d e d n o t o n l y b y t h e r e c o r d of t h e i r e f f e c t i v e n e s s , b u t also b y o u r u r g e n t n e e d to b r i n g i m m e d i a t e r e l i e f to g r e a t e r n u m b e r s of p a t i e n t s w h o p r e s e n t l y can r e c e i v e no t r e a t m e n t it o n l y t r a d i t i o n a l m e t h o d s a r e to b e u s e d . I t is m o s t i m p o r t a n t to s e e to it, h o w e v e r , t h a t t h e t u t o r d o e s n o t become a therapist, or a general counsellor, but that he remain an instructor, a d v i s e r , a n d a s s o c i a t e in d e a l i n g w i t h the difficult c a s e s w i t h w h i c h tile y o u n g m a n h a s to w o r k . E. T h e c o n f e r e n c e s h o u l d b e r e s e r v e d for s p e c i a l topics r a t h e r t h a n as a r e g u l a r m e a n s of i n s t r u c t i o n w h i c h is m o r e easily c a r r i e d o u t in discussioYl g r o u p s a n d s e m i n a r s . F. \ V a r d r o u n d s . T h i s h a s n e v e r b e e n p r o p e r l y d e s c r i b e d t h o u g h it is o n e of t h e m o s t i m p o r t a n t a r e a s for l e a r n i n g . I n d e e d it is a m a z i n g to d i s c o v e r it, b u t it is n o n e t h e l e s s t r u e , t h a t a n u m b e r of p r o f e s s o r s of p s y c h i a t r y a c t u a l l y n e v e r m a k e w a r d r o u n d s ; the)" m e r e l y p r e s i d e in t h e i r offices or a t o c c a s i o n a l c o n f e r e n c e s . T h i s is o n e of t h e c o n s e q u e n c e s of a p p o i n t i n g as c h a i r m a n of tile d e p a r t m e n t , i n d i v i d u a l s w h o h a v e h a d little or n o e x p e r i e n c e in d e a l i n g w i t h t h e c e a s e l e s s p r e s s u r e on t i m e a n d i n g e n u i t y c o n s t i t u t e d b y r e s p o n s i l ) i l i t y for a clinical s e r v i c e . XVard rounds should be conducted by the entire medical team, psychiatrist, p s y c h o l o g i s t , social w o r k e r , o c c u p a t i o n a l t h e r a p i s t , n u r s e , a n d t h e r e s i d e n t s t a f f a s s i g n e d to w o r k w i t h t h e p a r t i c u l a r c h i e f of s e r v i c e . H e r e t h e s t u d e n t h a s all u n r i v a l e d o p p o r t u n i t y to f o l l o w t h e t h i n k i n g of t h e c h i e f of s e r v i c e as h e is c o n f r o n t e d x~dth p r o b l e m a f t e r p r o b l e m a n d to p a r t i c i p a t e w i t h h i m as a m e m b e r o f t h e m e d i c a l t e a m in w o r k i n g o u t t h e d i a g n o s i s , in p l a n n i n g , a n d in t h e e x e c u t i o n of t r e a t a n e n t . -~ S e r v i c e in t h e o u t - p a t i e n t d e p a r t m e n t or in t h e c o m m u n i t y is n o t m e n t i o n e d s e p a r a t e l y s i n c e i n s t r u c t i o n in t h e s e a r e a s c a n 1)e c a r r i e d o u t b y the same instruments which are already mentioned. G. T h e r e m a i n i n g i n s t r u m e n t s a r e of lesser s i g n i f i c a n c e - -the j o u r n a l c l u b , s o c i o d r a m a , t h e h o m e visit a n d t h e i n f o r m a l s e t t i n g -staff r o o m o v e r a p o t of coffee, t h e d o c t o r s ' d i n i n g r o o m , a n d in t h e e v e n i n g w h e n t h e stlzdcnts m e e t t o g e t h e r to d i s c u s s t h e annoyance:~, t h e f r u s t r a t i o n s , a n d t h e clinical t r i u m p h s of t h e d a y . T h e a c t u a l a d j u v a n t s w h i c h c a n b e u s e d in t e a c h i n g will n o t l)e d i s c u s s e d in d e t a i l in this s h o r t p a p e r . I t
~34
D. E-xVI,'_.N C A ~ I E R O N
is here, i n t e r e s t i n g l y enough, that the m a j o r a d v a n c e s are b e i n g m a d e , as f ar as t e a c h i n g is c o n c e r n e d the provision of audio-visual aids, the o n e - w a y screen, tire use of television, t e a c h i n g tapes, a n d the like. Teachi n g m a c h i n e s , i n t r o d u c e d by Skinner 4 h a v e thtxs far failed to establish themselves ira the p s y c h i a t r i c field. In order to control one's teaching, one must know the results, a n d here tire e x a m i n a t i o n still plays a part. An e-xamination is r e q u i r e d at the erad of the first y e a r to w eed out those who are clearly unfitted, or to correct those w h o m i g h t h a v e d o n e better, to e n c o u r a g e those who h a v e shown promise. A second e x a m i n a t i o n is r e q u i r e d at the end of the last ye a r to d e t e r m i n e those fit to be given the seal of a p p r o v a l of the t e a c h i n g institution. Of still more i m p o r t a n c e , however, is the assessment of the s t u d e n t a s se ssm e n t b y the chief resident, b y his tutor, b y his c h i e f of service, b y the chiefs of the clinical t r a i n i n g units through w h i c h lae passed. This a s s e s s m e n t ( w h i l e it is m o r e difficult to obtain from it a satisfactory-looking, r o u n d figure than is the erase w ith e x a m i n a t i o n s ) nonetheless, is c o n s i d e r a b l y m o r e F(~netrating in its evaluation of the student. F r o m it we not oral), obtain an evaluation of the r a n g e of facts w h i c h he has tat his disposal a n d the skills w i t h w h i c h to use these facts, b u t s o m e t h i n g w h i c h the e x a m i n a t i o n ne ve r does reveal, n a m e l y , his attitudes. 6. A n d lastly, w e come to the que stion of why? A n d this is so s i m p l e that it seems h a r d l y , at first sight, necessary to pose. A n d yet, w h y do we n e e d to train so man), m o r e psychiatrists? \~Te n e e d to train t h e m obviously b e c a u s e w e h a v e as yet x'e~, little idea of pr e ve ntion, a n d the p r o b l e m gr ows apace. Secondly, w e n e e d to train a great m a n y mor e b e c a u s e we are g r a d u a l l y coming to realize that p s y c h i a t r y is not just a d e p a r t m e n t of m e d i c i n e b u t it is the m i s s i n g h e m i s p h e r e of m e d i c i n e . P s y c h i a t r y m a y verx, well lye on the eve of b r e a k i n g up into a n u m b e r of aiiied areas: c hild psyc hia tr y, m e n t a l retardation, i n d u s t r i a l p s y c h i a t r y , c o m m u n i t y psychiatr.v, a n d a d m i n i s t r a t i v e psychiatry. "~Ve n e e d m o r e ps,'chiatrists a n d far b e t t e r t r a i n e d psychiatrists, b e c a u s e u n d o u b t e d l y m a n y p s y c h i a t r i c illnesses are not yet even r e c o g n i z e d , let alone treated a p p r o p r i a t e l y . A n d the p r o b l e m of m e n t a l deviation in all its m y r i a d forms is one w h i c h q u i t e fairly is b e g i n n i n g to bog down the w h o l e f o r w a r d progress of m a n ' s efforts. R ECO3I.~IENDATIONS
1. T h a t every step should b e taken to s t r e n g t h e n a n d e m p h a s i z e a m o n g ourselves, w i t h our colleagues, a nd with the g e n e r a l public, the p a r a m o u n t r e s p o n s i b i l i t y of p s y c h i a t r y for a s s e m b l i n g , a u g m e n t i n g , teaching, a n d a p p ly ing, the o r g a n i z e d b o d y of k n o w l e d g e c o n c e r n i n g the m e n t a l l y ill. 2. T h a t r e c o g n i t i o n s h o u l d be w i t h d r a w n from the present i n a d e q u a t e a n d i n c o m p l e t e single unit t r a i n i n g areas. 3. T h a t r e s p o n s i b i l i t y for t r a i n i n g psychiatrists should lye taken b y university-directed, m u l t i p l e unit networks. 4. T h a t tire present core ctrrriculum should move with the p r e s e n t l y emerging needs, to give p r o p e r r e p r e s e n t a t i o n to t r a i n i n g in c o m m u n i t y p s y c h i a t r y
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and to give an equal weight and status to all the major therapies, including chemotherapy, the physical therapies, the group therapies, and milieu therapies. 5. That teaching should be taught. 6. That research on se]ection, teaching, and learning, as well as on assessment should be fostered. REFERENCES 1. Cameron, D. E.: The psychiatric training network of McGill University. Amer. J. Psychiat. 120(11):1039-1044, 1964. 2. ~ : Medical rounds. Bombay Medical Digest, pp. 377-378, July, 1964. 3. Lewin, K.: Frontiers of group dynamics.
Human Relations. 1:1, 1947. 4. Skinner, B. F.: Teaching Machines. Science 128:969-977, 1958. 5. Medical education in the United States. Survey by the Staff of the Council on Medical Education. J. A. M. A. 190: 626, 1964.
D. Ewen Cameron, M.D., Directm, Psychiatry and Aging Research Laboratories, Veterans Administration HosT~ital, Albany, New York; Research Professor, Department of Psychiatry, Albany Medical College, Albany, N. Y.