One mission of the academic psychiatrist is education. During the course of supervising trainees, references to "classic" psychiatry articles or literature will often arise. For example, "Taking care of the hateful patient" by James Groves is a popular citation (1). This article was published in 1978 and is not available in an online electronic journal format. Faculty members may possess a photocopy of this article in their office filing cabinet, but if one can be found, it will probably be in poor condition.
Another useful teaching article is George Vaillant’s practical "The beginning of wisdom is never calling a patient a borderline" (2). A MEDLINE search performed in October 2003 returned 93 references for the author "Vaillant, GE," but none of the references contained the aforementioned article. Perhaps the publication of the article in the first volume of a then new journal precluded its inclusion in MEDLINE.
Ralph Kahana and Grete Bibring’s chapter "Personality Types in Medical Management," from Norman Zinberg’s 1964 text Psychiatry and Medical Practice in a General Hospital, is as useful today as it was 40 years ago. But the generation of psychiatrists for whom this text was a standard, however, is moving on, and they do not always bequeath their old tomes to junior colleagues (3).
These three examples illustrate how teaching materials might be difficult to procure. In the second example, the trainee must search various databases to find the correct reference. In all of these examples, the trainee will likely need to trudge to the university library to photocopy original materials. If the trainee does not make extra effort to locate the information, a teaching opportunity will be lost.
Today’s trainees are more proficient in the use of computers. In 2001, Patel found that academic psychiatrists and psychiatry residents used the Internet for psychiatric information 16.2% more than in the previous 5 years (4). Trainees now search for the latest articles in full text or Adobe Acrobat PDF format through their university library web site. The days of trekking to the library barefoot and through the snow no longer need to exist.
But what about older teaching materials that are not available electronically? Computers can also be used to efficiently organize these materials. We report a pilot project to 1) create a collection of "classic" psychiatry literature and 2) create a computer program for the easy storage and on-demand retrieval of such frequently used teaching materials.
Reading lists for psychiatry trainees have been previously published but not recently updated (5, 6). In 1968, Woods et al. provided a list of the 307 (out of 4,024) articles most recommended by 140 training programs (5). Malmquist and Soth updated this list almost 20 years later and identified 36 (out of 853) articles from 16 training programs (6). In the field of consultation-liaison psychiatry, a basic reading list of 86 articles was identified by a task force and subsequently used in a pilot program to teach residents consultation-liaison psychiatry (7, 8). Strain et al. have 2,748 article annotations in their 1996 Consultation-Liaison Literature Database, which includes a subset of important papers for trainees (9).
Compiling a list of "classic" or basic articles in general psychiatry is a daunting and ambitious task. As Woods et al. wrote, "the psychiatric literature is overwhelming in volume and most difficult to evaluate …" and that was over 35 years ago (10)! Such a list would need to be a multisite collaboration in order to maximize the number of expert opinions, and it would also risk obsolescence unless it was periodically updated.
One approach to compiling a list of important teaching articles is to start with what is commonly used at the local level. This "bottom up" approach, in contrast to the "top down" approach of surveying the entire field to arrive at a comprehensive list, has practical advantages: 1) it requires less effort; 2) it results in a smaller, more manageable list; and 3) faculty members will be able to use what they are most familiar with to make their teaching points. The "top down" comprehensive approach can be used at a later time to fill gaps from the "bottom up" approach.
We all organize, store, and retrieve paper teaching materials in a traditional filing cabinet. Technological advances over the last decade have made it possible to place and share such materials on web sites. Scanners, as easy to use as photocopying machines, accurately replicate documents into PDF format at approximately 100 kilobytes per page. Assuming that an 80 gigabyte hard disk costs $160, one could store 800,000 pages of text at the cost of 2 cents per 100 pages.
The idea of storing documents on web sites is not new. However, practicalities such as the need for a webmaster limit the convenience of using a web site as a personal electronic filing cabinet. Software that allows clinicians to upload, download, and search for their own documents is necessary. Such software, which combines self-serviceable web site and database features, has become more available and can implement this new use of existing technology to create a sharable web database for teaching materials as familiar as a standard piece of office furniture.
Commercial document management software, ranging from off-the-shelf packages for personal use to customized software for corporate use, can store articles and teaching materials. Some universities are moving toward digital institutional repositories to retain the intellectual output of their research faculty. The DSpace Federation (http://www.dspace.org), started in 2000 as a joint venture between the Massachusetts Institute of Technology (MIT) Libraries and the Hewlett-Packard Company, is now offering their repository software free of charge to research institutions. Their software requires a Unix server and local technical expertise.
Even without intricate software, one can use the computer as a simple filing cabinet. Clinicians already scan and save important articles on their computers, but remembering numerous filenames for the various articles may become difficult. Bibliography management software such as Endnote (http://www.endnote.com, approximately $200 academic pricing) can be used to store references and a link to a specific article. This approach is a good alternative to document management software, especially if an institution has a site license, so that an individual can access the bibliography software and database from any networked computer.
In our pilot project, we used the "bottom up" approach to collecting articles and other teaching materials. The materials were not limited to "classic" articles; instructive institutional protocols, neuroscience images, and faculty presentations were also included. Faculty and residents were asked to list the materials frequently referenced in discussions during rounds and in supervision sessions. These materials were obtained and, if appropriate, scanned into PDF format with a Hewlett-Packard 9100c Digital Document Sender (www.hp.com, approximately $3,000). An inexpensive generic scanner with Adobe Acrobat software (www.adobe.com, approximately $100 academic pricing) was also undertaken, but found to be less convenient. Materials already in electronic format, such as images (JPG or GIF), presentations (PPT), text files (PDF or DOC), spreadsheets (XLS), or movie clips (MPG), were used directly. We classified each item according to its broad teaching category (e.g., psychotherapy, mood disorders, personality disorders) and assigned up to five keywords that could identify the item for later retrieval. We then entered the relevant bibliographic data, category, and keywords for the item and specified its file directory location. The entire entry was then submitted to the electronic filing cabinet.
For several reasons, we developed our own electronic filing cabinet software. Our institution already had web database software (Macromedia’s Cold Fusion and Microsoft’s SQL Server), and one of the authors (S.K.) had programming skills that allowed us to customize the filing cabinet. The equivalent of two full-time work weeks was spent in programming efforts. However, this estimated time included familiarity with the local development environment and project specifications. Because of the degree to which our electronic filing cabinet was customized, our software is not easily portable to other institutions, but we would be happy to share our experience with those interested in creating their own electronic filing cabinet.
Located on an internal psychiatry webpage, our electronic filing cabinet can be accessed from any computer within our institution’s intranet. Users can list the contents by various fields (category, bibliographic data, keywords, etc.) and, they can conduct a search by those same fields. Both faculty and trainees can access the filing cabinet and add their own items without relying on a webmaster.
Preliminary feedback indicated that the electronic filing cabinet was a beneficial teaching tool. For example, one faculty member was able to print an article related to a patient’s management for the trainee even before morning rounds concluded. Use of the electronic filing cabinet also appears to promote resource sharing among the department’s educators, as they now are able to view the materials that their colleagues use with trainees and can incorporate those resources into their own teaching. It is our desire to, after full implementation, track the number of "hits" to the web site and determine the number of times each item has been accessed.
Copyright issues are a major area of concern in the implementation of article repositories. The copyright fair use guidelines allow an educator to make a single copy of an article for educational or research purposes (11). All of us have saved a copy of a good article for future teaching. The storing of that article in digital format for internal sharing, even in a nonprofit educational setting, presents a gray area. Many universities have license agreements with journal publishers that allow for latitude in the use of their online articles throughout their institution. However, these licenses may not extend to older articles that are not available online. In such a case, the safest route is to obtain permission to store the article in digital format for educational use. For example, one of our requests for permission was promptly granted, although with restrictions, while we have not yet received a response from one publisher concerning a permission request. Nevertheless, we will keep a copy of the request to document that a good-faith attempt to obtain permission was made.
Ideally, a repository of "classic" teaching articles could be shared nationally among interested teaching departments. The benefits would included collaboration, decreased individual effort, and increased utilization. However, copyright concerns make this goal less realizable. Indeed, a database of article references and annotations could be shared, but it would not provide the desired article content at one’s fingertips. Optimistically, these issues can be surmounted in the future.
It is not necessary to limit the electronic filing cabinet to "classic" articles. Current online articles and materials can be stored for easy and reliable access, and not exclusively for teaching. For example, the system can be employed to store articles for references used in manuscript preparation or even for an individual’s own publications. Because content is not limited to text files, nor is an audience limited to psychiatrists, the electronic filing cabinet can also be used in other settings such as an image teaching databank for internal medicine.
We created an electronic filing cabinet for frequently used teaching materials that can be shared by department members. The filing cabinet is easy to use and allows on-demand retrieval of documents from any computer on an internal network. The idea of the electronic filing cabinet extends beyond teaching psychiatry. The goal of this project, however, was to utilize computer technology for a specific application in the field: to help make psychiatric education more efficient. We would encourage others to try to do the same.