The clinical quality of U.S. physicians, the unevenness in their attention to the care of psychiatric patients, and their awareness of the importance of the ability to handle the psychological aspects of nonpsychiatric medical care are of great consequence. Therefore, education regarding the behavioral and psychiatric aspects of medical care as well as education of physicians who specialize in the treatment of psychiatric patients deserves careful study.
The authors of the papers in this special issue of Academic Psychiatry refer back to the 1960s, when psychiatric education was widely considered an afterthought. During that period, the amount of research on psychiatric disorders and the cumulative size of U.S. research effort were modest. Few schools had substantial research programs as part of their psychiatric departments. Further, psychiatry was considered a less desirable specialty, and departments of psychiatry were considered secondary to departments of other specialties. Psychiatry was frequently characterized as a specialty with people who were, to say the least, “idiosyncratic.” Such generalizations about the field were made not only in curbside conversation but overtly.
Today, the overall research effort on psychiatric disorders has increased substantially. Many would describe the questions being addressed in psychiatry and brain science and behavior as constituting one of the most critical areas in medical research. Moreover, psychiatry is frequently ranked first, second, or third among departments in the amount of research conducted in a given medical school.
Additionally, psychiatric leaders have increasingly been appointed to positions of consequence in academia. Whereas in the early 1960s, there was hardly a dean in the U.S. who was a psychiatrist; in recent years, psychiatry has been the discipline of as many as 10% to 12% of U.S. medical school deans. Further, psychiatrists have occupied positions such as hospital president; university president; academic medical center chancellor; academic medical center vice president; associate dean; Institute of Medicine president; and, most recently, Association of American Medical Colleges president.
This is not to say that denigration of psychiatry by academia has disappeared. However, this denigration takes its place along with that aimed at other medical disciplines, since all disciplines seem to have their occasional critics and naysayers. As a field that contends with some of society’s most sensitive problems (e.g., HIV, competency, suicide), psychiatry, naturally, is subject to considerable debate and sharp scrutiny. Recently, however, criticism of the field by some has been accompanied by increasing respect from others.
Realization of the large share of the global burden of illness that has been identified by the World Health Organization along with recognition of psychiatric medical problems in the treatment of nonpsychiatric medical illnesses, such as heart disease, diabetes, and asthma, has increased attention toward the field. Moreover, the awarding of the Nobel, Lasker, and other distinguished recognition to investigators in psychiatry increases the general acknowledgement of the field as a legitimate medical discipline.
In the process of becoming a more full-fledged member of the medicine family, however, psychiatry encounters more problems of academic medicine. Increased assumption of responsibilities in medicine overall is evident in the selection of more psychiatrists to leadership positions in broader arenas that contend with problems in medicine.
Such problems include the sometimes inadequate attention to teaching throughout medical education, the need for more rewards for those who teach, the problem of finding enough faculty, the paucity of attention to performance feedback regarding student interviews of patients, and the need for more rigorous evaluation of students.
With increased societal regard for psychiatry, the recognition and need for interdisciplinary collaborations in research, teaching of human behavior, and medical care of the multitude of complex illnesses, it becomes critical for psychiatry to resist its own tendencies to function as a silo in a general medical center.
The papers in this special edition cover a wide area. Niedermier et al. (1) report on the positive attitude toward the psychiatric clerkship by those who choose psychiatry as their specialty and by those who do not. Niedermier et al. maintain that the benefits of nonpsychiatrists valuing the psychiatric clerkship would result in the nonpsychiatrist physician approaching psychiatric aspects of medicine more effectively.
Cutler et al. (2) review ways in which the field of psychiatry is viewed both positively (e.g., intellectual content, lifestyle) and negatively (e.g., status, earnings). This critical and analytical paper enlightens educators about the stressful experience students describe in working with psychiatric patients. The authors also describe efforts designed to contend with this stress and attempts to alleviate its negative effects. Cutler et al. maintain that acknowledging this stress and providing opportunity to discuss it may not only benefit the student but also foster recruitment. This suggests that educators should engage in more critical and constructive examination.
The inclination for greater rigor in evaluation reported by Roman and Trevino (3) is a significant indicator of recognition of the psychiatry clerkship as a serious endeavor. Roman and Trevino discuss the complex issue of clinical skills evaluation, which is a formidable problem. Although arduous, assuring that clinical skills are part of the medical student evaluation should help to avert the development of “checklist robots” and encourage comprehensiveness in the examination of patients and the ultimate formulation of patients’ problems. Attention to clinical skills should lead to an expectation of a coexisting knowledge base that is augmented with clinical skills. Evaluating communication and interview skills can be achieved through supervised clinical interviews by the student. All of these factors contribute to the development of psychiatrists and nonpsychiatric physicians who are well informed about psychiatry.
An appropriate companion paper by McIlwrick et al. (4) tackles the intriguing and sensitive issue of performance feedback. The authors hypothesize reasons for the uneven handling of the need for performance feedback in psychiatric education and call for increased “thought and discussion” on the topic. It is noteworthy that when one surveys students, one finds a desire for such feedback. Likewise, preceptors seem to desire greater training in how to provide feedback as well as more help with various methods of student evaluation.
The growing problem of addressing necessary teaching time and adequate numbers of teaching faculty is discussed by Pessar et al. (5). The willingness to find, describe, and undertake ways of addressing these concerns is an indicator of constructive engagement by psychiatric educators. Pessar et al. maintain that with funding in academic health centers becoming increasingly scarce, viable solutions include 1) suggestions of Chairs serving as models in teaching, 2) assistance for teachers with eligibility for continuing medical education and other less costly perquisites, and 3) more reasonable consideration of promotional criteria. It remains to be seen, however, whether teaching academies that have cropped up recently will become widespread and effective solutions in addressing the problems of education and teaching. Teaching should be more valued and rewarded by universities and medical schools.
I find it beneficial to examine our field longitudinally. Over the years, initial blushes of excessive enthusiasm regarding the allegedly all-encompassing ability to solve problems by psychoanalysis, then deinstitutionalization, then psychiatric medication, then community mental health centers, and then brain research have led to spurts of excitement intermingled with periods of drift and/or pessimism.
However, our field has strengthened, and the steady increase of therapeutics, the strengthening of research, the progressive destigmatizing, and the increasing documentation of the global mental health burden along with the emergence of psychiatric leadership in general medicine and academic leadership are all promising indications. In this context, quality individuals are needed in the field. We must train first-rate psychiatrists and nonpsychiatric physicians who are well informed about psychiatry, and we need greater rigor and attention to the educational processes that produce these greatly needed practitioners and academicians.
The papers in this issue reveal an increasing number of academicians who exceed daily educational duties in that they ask questions, suggest hypotheses, and try new ideas. The snapshot of psychiatric education emerging in 2006, as a result, is one with many serious challenges, like other medical disciplines. However, the minds and attitudes to tackle these challenges exist.