As a psychiatry training director for the past 9 years, I have been impressed by the stated preferences of candidates for residency. An overwhelming number of applicants, either verbally or in writing, express their desire for "balance" as the priority they seek in training. This balance is generally defined as "psychotherapy" or "psychoanalysis" or "psychodynamics" on the one hand and "biological psychiatry" or "psychopharmacology" on the other. The prevalence of this notion suggests that throughout American medical schools, students are being taught to look at programs from a perspective of even-handedness.

In the competitive world of resident recruitment, a convenient strategy is to emphasize your program's own perfect blend of the biological and psychological, while denigrating rival institutions as "too dynamic" or "too research-oriented." It is not only training directors who reinforce the idea of such dichotomies; medical student applicants are presumably deriving their information from many quarters within our field.

If our training programs are to be judged by their degree of balance, and if academic medical centers are purveying this standard, then American psychiatry must define this concept with greater clarity than currently exists.

The education of psychiatrists today incorporates a wide array of experiences and emphases. The Residency Review Committee (RRC) delineates a complex host of essential requirements. Any program could potentially provide "=uivalence" between biological/psychopharmacologic issues and psychotherapy but be markedly deficient in meeting RRC minimal standards and in providing a well-rounded foundation for the practice of psychiatry. For example, such a residency might fail to prepare students to care for chronic and persistently mentally ill patients in the community or to be cognizant of major forensic and ethical issues. Another error would involve limited concepts of either side of the hallowed balance. The psychotherapy—psychological curriculum might be too heavily weighted toward one particular approach, for example, psychoanalysis, at the expense of other valid therapeutic modalities, such as cognitive/behavioral or family therapy. Such an imbalance (within the "balance") often reflects a "gold standard" approach that posits one type of psychotherapy as the yardstick by which others are measured.

The basic questions, then, are whether we can create some sort of parity or proportionality, and how do we achieve this goal? There are vocal critics on both sides of the scale who advocate greater emphasis on their own specialized approaches. Reiser (+1) has decried the "loss of mind" in psychiatric education, encouraging the preservation of "solid psychodynamic…skills." This sentiment was echoed by Wilson (+2), who fears "a loss of the concept of the depth of mind, a loss of the concept of the unconscious." There is concern about a medicalization of our approach to patients, with a consequent de-emphasis of more nuanced, longitudinal, and social aspects of their problems. On the other hand, Detre (+3) advocates training clinical neuroscientists and phasing psychoanalysis and much of psychology out of the curriculum. It is interesting to note a generational difference on the question of "biology vs. psychology." Berman et al. (+4) found that a group of psychiatrists trained within the previous 15 years valued these two aspects of practice equally, but an older group trained more than 15 years earlier attributed greater significance to psychological methods. Adding fuel to these debates, Kandel (+5,+6) has eloquently portrayed a sophisticated interaction of neuroscience and "the mind," appealing to psychoanalysts to expand the scientific underpinnings of their field. This vision implies an ultimate science of psychiatry that would abandon mind—brain dichotomies, either an ideal or an unduly utopian view of "balance," depending on one's perspective.

There are also concrete and specific elements to consider as part of a "balance" in psychiatric education. Should programs provide equal allotments of time in their curricula to instruction in psychopharmacology and psychotherapy? Must there be equivalence between the numbers of teachers versed in these fields or a critical mass of faculty proficient in both?

Clearly, if balance were to be measured so formally, real educational needs could not be met. Mohl (+7) portrayed fundamental components of balance: didactic and experiential psychodynamic psychotherapy, a systematic approach to short-term psychotherapy, neuroscience in addition to psychopharmacology and phenomenology, transcultural training, and an integrative approach by faculty. These are sound recommendations, but they overlook some major residual issues.

Many residency candidates refer to balance in a way that suggests "blind justice" carrying psychopharmacology in one scale and psychotherapy in the other, perfectly symmetrical. In fact, the harmony among approaches, bodies of knowledge, and subspecialties is complex, influenced by the phase of training, resident choices, scientific advances, and the changing healthcare system.

The structure of rotations has a major impact on the teaching of various models. During the first 2 years of training, experience is centered on inpatient units, emergency rooms, and medical/neurological services. A medical-model approach is critical in these settings, particularly in an era of more stringent criteria for hospitalization and brief lengths of stay. The advances of psychopharmacology, biological psychiatry, and neuroscience should be unequivocally emphasized. Lessons of a more psychological focus cannot be central during this phase. This issue can be complicated, and argued, of course, by psychiatric practitioners of all persuasions. Efforts should be made to introduce first- and second-year residents to intrapsychic, unconscious, and interpersonal issues, including transference and countertransference. However, rather than dominating the curriculum, these concerns should be background material. Faculty who are more psychodynamically oriented often convey their impatience with medical models, undermining other teachers' approaches and residents' morale. It is vital that trainees in this phase learn about psychologically relevant concepts from faculty who accept the idea of an introduction of their views within a medical-model framework. In the first 2 years, then, balance is a chimera.

The third and fourth years of residency are the time for emphasis of psychodynamics, cognitive and behavioral theory and practice, family and group therapy, public/community issues, hypnosis, and other short-term psychotherapies. Outpatient pharmacologic management is also a vital element of the latter half of the training period. So the challenge of the last 2 years is to teach a variety of approaches, to have faculty with strengths in these areas, and to produce graduates who are capable of providing state-of-the-art treatment. Does this mean that balance is essential at this phase? It certainly means that all these components should be taught well, but slavish adherence to a concept of parity is simplistic. Many approaches complement each other. Modern psychiatrists must be able to choose from a variety of potential treatments to determine the most feasible plan. Within the course of treating any patient, different therapeutic priorities may emerge, requiring flexibility and comprehensiveness in style and substance. Thus, our trainees should graduate with substantial knowledge and experience in varied facets of psychiatry. But the educational process in our field should not be harnessed by an "=uivalence" formula any more than cardiology programs should care about the relative time spent in teaching pharmacologic as opposed to invasive approaches. Thus, our PGY-3 and PGY-4 residents need to fulfill the requirements of becoming a psychiatrist without a superimposed forced effort at attaining the elusive "balance."

Residents may begin training with or may develop interests in specific areas of psychiatry, which then may or may not lead to career choices. The best education, while meeting RRC essential requirements, affords opportunity for pursuit of intellectual interests and personal priorities. Tracks within a residency are one way of achieving this goal, tailoring an individualized rotational schedule allowing the trainee to satisfy these needs. Abundant elective time can serve the same purpose. Residents who wish to sort out their interests in two or three areas of practice can certainly benefit from such opportunities.

Tracking and elective time are methods that may be considered antithetical to balance. If most residents in one program decide to take electives in research, does that mean the program lacks sufficient psychotherapy credentials? If a majority pursue a child-and-adolescent track, does this imply weakness in geriatrics? If balance requires bean-counting, tracks and electives are to be avoided; but I believe we would be mistaken if we sought to produce only "generalist" psychiatrists and de-emphasized subspecialized interests.

Every medical field evolves constantly in response to new scientific discoveries. The past 50 years have witnessed an unparalleled series of quantum leaps in our understanding of behavior and the brain. The pace of discovery seems to be increasing, creating an exciting environment for our specialty. One such development is the recent finding of a critical enzyme (β-secretase) with significant potential for the study and treatment of Alzheimer's disease (+8). There is also great interest in a report suggesting a vital role for oscillating groups of thalamic neurons in the control of a host of mental functions (+9). As these advances increase, leading to a multitude of new experiments, training programs must keep pace, incorporating state-of-the-art knowledge into the curriculum. The science and practice of psychotherapy are not evolving at the same rate as neuroscience/biological psychiatry. Hence, balance can be viewed as reactionary in this context.

In recent years American medicine has changed radically as a result of the advent of managed care. This has had a negative impact on medical education in general (+10), and psychiatry has not been spared. A dramatic de-emphasis on hospitalization and pressures for streamlined, "cost-effective" delivery of care are beginning to alter the face of our profession. Training programs, however, must prepare their residents to practice in the real world. Greater efficiency in treatment may be developed at the expense of established methodologies. If this change were to undermine our notions of "balance," we would be forced to adjust specific aspects of our curriculum to reflect the new realities.

Balance, as a term denoting absolute or near-absolute equity among psychiatric approaches, is an idealized concept that is inconsistent with the realities of training. Balance should not be considered the most vital element of a psychiatric department or residency. The fact that the RRC requirements for psychiatry are more extensive than almost all other specialties is more a reflection of the politics of our field than its science and practice. In this context, it is interesting to note that the RRC plans to require demonstrated "competence" in several forms of psychotherapy but not in pharmacotherapy.

We may wish to be an inclusive branch of medicine, continuing to foster both psychology and biology; but we should also embrace the expression of individualized strengths within this context. A department with particular strengths in neuroscience or psychoanalysis would do better to emphasize these areas than suppress or deny them for fear of being labeled "unbalanced." They may teach other areas, perhaps very well, without diluting their strengths. A training program must also be cognizant of the appropriate body of knowledge to be taught at various points, the priorities of its residents, and changes in psychiatric and medical practice in general. Anchoring psychiatry to the concept of balance, well-intentioned as it is, could submerge us rather than stabilize us. It is time for more intellectual flexibility.

Perhaps the concept of balance should be replaced by one of minimal standards, allowing for enhanced experiences, which may vary from program to program. A number of therapeutic approaches, subspecialty fields, and theoretical and scientific areas may be universally recognized as deserving of inclusion in the educational corpus. However, suprathreshold emphases should be encouraged, promoted, and celebrated.

People who fear the loss of humanism overlook the most humanistic aspects of medicine. Alleviating human suffering is not the sole province of any single approach. Achieving this goal is the most vital element of training and should not be subordinated to politicized concepts such as balance. Methods that clearly demonstrate limitations in therapeutics must be eliminated or limited; new developments must be fostered. If this leads to less "balance," our field would do well to accept that result.