Academic Psychiatry 26:257-261, December 2002
© 2002 Academic Psychiatry
Philosophy and Psychiatry
A New Curriculum for Child and Adolescent Psychiatry
Lloyd A. Wells, Ph.D., M.D.
Dr. Wells is Vice-Chair of Education in the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905.
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ABSTRACT
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Residents in psychiatry and child and adolescent psychiatry often seem to their preceptors to have difficulty with critical thinking. The author designed a curriculum for first-year (PGY-4) child and adolescent psychiatry residents with this perceived deficit in mind. The curriculum consisted of a blend of traditional first-year child and adolescent psychiatry didactic curriculum with a curriculum in philosophy. On the Cornell Critical Thinking Test, residents who took this course outscored residents who did not at a statistically significant level. The advantages of such a course are discussed.
Key Words: Philosophy and Psychiatry • Psychiatry Residency Curricula • Critical Thinking
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INTRODUCTION
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Critical thinking is not usually a major emphasis in the first-year child and adolescent psychiatry didactic curriculum at the start of the twenty-first century. It was not a major emphasis in psychiatry at the start of the twentieth century, either—and certainly not in child and adolescent psychiatry at that time, because the specialty did not exist.
At the start of the twentieth century, psychiatry was in some disarray, searching for a paradigm. Many psychiatrists were biologically oriented (1), but the state of biology was insufficient to support their theories or help their patients, for the most part. Furthermore, as biological causality was established for some disorders such as neurosyphilis, the disorders gradually "left" psychiatry to be treated by other specialties. This biological school gradually retreated in the early years of the century, and the two emerging paradigms were Freud's psychoanalytic model and Kraepelin's pragmatic, nonbiological, nonpsychodynamic approach. Several theorists attempted to create better paradigms. Adolf Meyer (2) devised an amalgam of psychodynamic and Kraepelinian psychiatry; much later, George Engel (3) introduced the biopsychosocial model. Both of these systems were helpful but had drawbacks and problems. Another approach was provided by Karl Jaspers (4) with the publication of his great textbook, General Psychopathology, in 1913. Implicit throughout this text, in keeping with Jaspers's role as a student of Heidegger and a significant philosopher in his own right, is the view that psychiatry can gain cohesion through the application of approaches inherent to philosophy. Unfortunately, this textbook, despite continuing through seven editions to 1959, had little effect on the theoretical structure of psychiatry until it was rediscovered by McHugh and others in the relatively recent past.
In psychiatry and child and adolescent psychiatry today, we face disarray not dissimilar to that at the opening of the twentieth century. We are dealing with an enormous volume of biological studies of great promise. Drugs have been developed that clearly ameliorate the course of several severe syndromes. The number of psychotherapies is multiplying, and several have a research base or at least heuristic promise. Disorders are of several types: those with demonstrable neuropathology and no known psychosocial etiology (e.g., organic brain syndromes); disorders with known social etiologies with concomitant neuropathology (e.g., posttraumatic stress disorders); disorders with putative neuropathology (e.g., schizophrenia); and disorders with no apparent neuropathology (e.g., dependent personality disorder).
This situation within the profession is rather baffling; though full of promise and intellectual excitement, it lends itself to confusion and fuzzy thinking. Psychiatrists have become physicians of the brain and of the mind. A medical model that is appropriate and useful in dealing with the brain becomes a less useful metaphor when applied to the mind of a patient. Mind is a metaphysical construct (5); how can we treat disorders of a metaphysical concept?
Factors from outside psychiatry that influence the specialty of child and adolescent psychiatry and psychiatry in general add to the difficulty. Managed care companies, for economic reasons, often seem to conceptualize all psychiatry, and especially psychiatric treatment, as biological, even though much of it is not. Reductionism, oversimplification, and post hoc ergo propter hoc arguments are rampant in this realm. The situation is confusing enough for experienced and knowledgeable psychiatrists, but it is more confusing for neophyte residents, some of whom complete their training without a real grasp of the current state of the field intellectually, and without the tools to evaluate the changing state of our knowledge and the changing scope of our practice (6).
It is apparent that we need to be able to construct paradigms that can embrace and incorporate biological psychiatry but that also recognize that psychiatry continues to deal with disorders of the mind as well as the brain.
As research results proliferate, residents are increasingly faced with a plethora of findings of this (hypothetical) type: the brains of children who were horrifically abused as children, studied in adult life, have a different level of  -aminobutyric acid activity, as measured very indirectly, than the brains of adults who were not abused as children. Such findings may be of great relevance, or they may be entirely epiphenomenal. Many residents have difficulty incorporating such studies into their conceptualization of psychiatry: they may ignore them, or they may inaccurately conclude that all posttraumatic stress disorder has been "shown" to be a disease of amygdaloid GABA hypersecretion. Residents (and their mentors) also cling to old heuristic models that are no longer accepted. Although the initial hypotheses about norepinephrine and serotonin have been largely discarded by neuroscientists in the last 15 years, at least in their simple form, many residents and attending physicians, attracted by the elegance and simplicity of such models and finding them still in the textbooks, view them as scientific fact. Finally, most textbooks continue to reflect some old concepts with little or no research base: residents in child and adolescent psychiatry continue to learn that borderline disorder is caused by difficulties in the rapprochement subphase of separation-individuation. The evidence to support this widely held belief comes from a very few studies (7,8) and much mere speculation about a culturally uncontrolled study done by Mahler and associates many years ago; it is not tenable as anything more than hypothesis—and it is not a heuristic hypothesis.
Such difficulties may be nearly incomprehensible to practitioners and educators in some other branches of medicine—although they are ubiquitous in muted forms, I believe. Perhaps they are prominent in psychiatry because the specialty is making a transition into a scientific mode. Furthermore, and paradoxically, this historically most "unscientific" of medical specialties is currently inundated with more scientific data than many other specialties, and this situation will be heightened in the next few years and decades. Interpretation of data about mind and brain requires a more rigorous analysis of data, hypotheses, and design of experiments than does data interpretation in many other fields, and at the same time, the practitioners of psychiatry and child and adolescent psychiatry are generally less well trained in the interpretation of data than are many other physicians.
Without training in dealing with this phenomenon, some residents rely on information from pharmaceutical company promotional representatives—demonstrated as inaccurate (9)—or managed care companies. Even trainees who make a good effort to master the current state of the art can be stymied in their future practice without training in evaluating the literature, which is and will be replete with new data and new hypotheses.
A possible approach to these difficulties is to introduce aspects of the ancient and modern discipline of philosophy into the psychiatric and child psychiatric curriculum. Although many people view philosophy as sage advice about old problems, philosophy is really about the approach to and evaluation of arguments and evidence. There is, in fact, an entire branch of modern philosophy—philosophy of mind—that devotes itself to the question of interpretation of data about mind and brain and their interface.
Some training programs have introduced aspects of philosophy into didactic curricula. An entire didactic curriculum at Johns Hopkins, for example, is based on the mind–brain problem (10). Schwartz (personal communication) is developing a highly sophisticated e-mail course on philosophy and psychiatry for residents and faculty. A journal of high quality, Philosophy, Psychiatry and Psychology (11), is devoted to the interface of these disciplines, as is its associated professional organization, the Association for the Advancement of Philosophy and Psychiatry.
At this point, however, the introduction of philosophy into psychiatric training and psychiatry as a field of knowledge is in its infancy. This approach was considered by Professor Nissl, at Heidelberg, nearly a century ago, and a compatible text was developed by Jaspers, as discussed above, but such a curriculum was never taught. I believe that the reason it was not taught, at least in the United States, may be related to the great influence of psychoanalysis on American psychiatry for many decades and the subsequent influence of a reductionistic psychopharmacology and, later, neurobiology. None of these models alone suffices for current clinical and theoretical situations, nor will they suffice in the near future (12).
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METHODS
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The curriculum for first-year (PGY-4) residents in child and adolescent psychiatry at Mayo Clinic had been as follows:
- Consultation-liaison psychiatry
- Emergency child and adolescent psychiatry
- History of child and adolescent psychiatry
- Psychotherapy
- Psychopharmacology
- Other treatment approaches
- Nosology
- Development
- Forensic child and adolescent psychiatry
- Natural history of syndromes
I designed a course that included all aspects of the above curriculum, but with a new, philosophical underpinning. The following philosophic topics were introduced, first in case-based discussions and then in readings in the philosophy literature:
- Ethics: Issues, behaviors, and choices
- Aesthetics: How do we integrate fragmented knowledge from different areas into a cohesive whole?
- Politics: Managed care and other systems of care; the ways mentally ill children are treated in society and by social agencies
- Logic: Formal rules of reasoning with examples of common, classic logical errors
- Ontology: Our basic body of knowledge
- Epistemology: How do we know what we know?
Following this introduction of philosophy, the course followed a syllabus that combined curricular topics of child and adolescent psychiatry with a consideration of ethics, aesthetics, politics, logic, ontology, and epistemology relevant to each topic.
A topic such as attention deficit disorder would be analyzed over a few weeks according to all these dimensions—a rigorous and very interesting exercise. In the case of attention deficit disorder, for example, the residents and I would discuss a few cases and read papers and textbook articles about it. We considered the basic body of knowledge and then broke down what was actually known. Research methodology and findings were discussed, with an emphasis on how we know what we know and how we may not know what we think we know. Logical errors in our assumptions about the topic were examined in detail. Ethical issues were discussed, such as the ethics of treating mild cases with medicines that have definite adverse effects. Political aspects of the disorder were also discussed—"best treatment" versus the treatment an insurance company will pay for, and parents' reactions to the lay debate about Ritalin, for example. In the "aesthetic" component, we attempted to integrate the knowledge gained into a pragmatic and heuristic approach to assessment and treatment. This process was used with the other syndromes encountered in child and adolescent psychiatry and was also used to address other topics.
Before taking this course, the PGY-4 residents in child and adolescent psychiatry (N=3) took the Cornell Critical Thinking Test–Level Z (13) under supervised conditions with a 1-hour time limit. This instrument has good test-retest reliability (9).
Control subjects were 14 residents from the PGY-5 child and adolescent psychiatry group and the PGY-3 adult psychiatry group. All residents in these two groups were enlisted as control subjects. Under the same conditions as the study group, these control subjects took the Cornell Critical Thinking Test–Level Z.
At the end of the course (1 week after its completion), both groups again took the Cornell Critical Thinking Test–Level Z. This time, all 3 members of the study group and 8 of the original control subjects took the examination.
The null hypothesis was that there would be no difference in the clinical reasoning performance on the Cornell test between those who took the course and those who did not. A two-tailed t-test was used to analyze the data.
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RESULTS
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Scores for the administrations of the Cornell Critical Thinking Test–Level Z before and after the course for the 3 residents and the control subjects are displayed in Table 1.
The analysis of variance indicated that those who took the course had significantly higher scores on the Cornell Critical Thinking Test–Level Z than those who did not take the course (standard deviation: control subjects, pretest 4.69, posttest 5.85; those who took the test, pretest 7.51, posttest 5.00; P=0.006).
There is a significant difference in change between the pretest and posttest results between the course and control groups. A two-sample t-test on the change scores (post minus pre) shows that the data do not support the null hypothesis that the change in the score from pre to post is the same between the two groups. There is a 95% confidence level that the amount of change from pre to post is different in the two groups (P=0.0006).
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DISCUSSION
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One must question the control group, since PGY-3 adult psychiatry residents have less training than child and adolescent psychiatry residents. The selection was based on the accessibility of the PGY-3 residents, whom I was teaching in a seminar. Although they have less training than child and adolescent psychiatry residents, the difference is not great. The small number of residents in our child and adolescent psychiatry training program presented an obstacle to controlling the study with only residents in child and adolescent psychiatry. This led to a control group that was not random, in the pure sense, but was interesting in that the less trained residents outperformed the sample residents before the course.
Aside from the formal statistical findings, I was impressed by comments of residents who took the course, which have been more frequent as time has gone on. One resident said, "The readings and discussion have had a real impact on me. I really question what people say at meetings now, and I have a lot of questions about some of the studies I read." One of the residents who took this course progressed from a Child Psychiatry Resident In-Training Examination (Child PRITE) score of 33rd percentile to the second highest in the nation. Whether this marvelous improvement was related to the course is, of course, debatable.
The scores of the residents who took the course increased significantly. The scores of those who did not take the course fell slightly. This may be related to a hurried attitude toward the retest, with a sense of "nothing to lose." Nevertheless, 5 of the 8 control subjects who took the test a second time took the full hour for the test, compared with 2 of the 3 residents who took the course.
A second concern is that 6 of the initial control group did not take the test the second time: 3 of them could not do so for logistic reasons, and 3 of them apparently chose not to do so. The statistical analysis, however, included only the 8 control subjects who took the test and the retest.
A third concern is that the Cornell Critical Thinking Test–Level Z may not truly reflect critical reasoning skills in the clinical situation. An exhaustive review of the literature has not provided an exemplary test of clinical reasoning skills. The Cornell test does have several items that clearly attempt to measure appreciation of design of experiments and conclusions from clinical-type experiments.
The data and statistical analysis strongly suggest that the course described above helped trainees learn some skills that are helpful in assessing data. The subjective response of the three persons who took the course was very positive: they felt that it gave them a broader picture of the field, an appreciation of its ethical issues, and, especially, an ability to read and criticize the literature with a high degree of comfort. Perhaps unrelated to the course, scores on the Child PRITE were very high for this group following the course, after an essentially average performance before the course.
There are several approaches to percentile scores on the Cornell test. I chose the ZD, one of many percentile rankings. It is of concern that the percentile scores of good child and adolescent psychiatry residents and good adult psychiatry residents were initially so low—around the 5th percentile for the persons taking the course. It is gratifying that these percentile scores increased to a mean at the 65th percentile after the course. But the question occurs: why are advanced residents in a cerebral medical specialty ranking so low? One can only speculate, but it is my hypothesis that lengthy medical training fosters an approach of rote learning of facts with little emphasis on synthesis or critical skills. This hypothesis can be investigated in further detail. It would be interesting to examine critical thinking skills of premedical students, medical students early and late in their training, residents in various fields, and practicing physicians, comparing them with control groups of other students and professionals. If the low scores initially found in this sample are not an anomaly, there is reason for concern about the reasoning skills of the medical profession.
A course on child psychiatry with philosophical overtones seemed helpful in the acquisition of critical thinking skills and did not seem to have a deleterious effect on acquiring child psychiatry skills, as assessed by the PRITE. I would urge that such a course can be extremely helpful to trainees.
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ACKNOWLEDGMENTS
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The author acknowledges the consultation of Dr. John Sadler in the attempt to begin this project. This work was supported by a Clinician Educator Award from Mayo Foundation. This topic was briefly presented in a poster presentation at the meeting of the American Association of Directors of Psychiatric Residency Training, Seattle, WA, March 1–4, 2001.
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REFERENCES
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- Shorter E: A History of Psychiatry. New York, Wiley, 1997, pp 69-112
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- Jaspers K: General Psychopathology. Baltimore, Johns Hopkins University Press, 1997
- Heil J: Philosophy of Mind: A Contemporary Introduction. New York, Routledge, 1998
- Wells LA: Psychiatry, managed care, and crooked thinking. Mayo Clin Proc 1998; 73:483-487[Medline]
- Zeanah CH, Anders TF, Seifer R, et al: Implications of research on infant development for psychodynamic theory and practice. J Am Acad Child Adolesc Psychiatry 1989; 28:657- 668[Medline]
- Stern DN: The Interpersonal World of the Infant: A View From Psychoanalysis and Developmental Psychology. New York, Basic Books, 1985
- Ziegler MG, Lew P, Singer BC: The accuracy of drug information from pharmaceutical sales representatives. JAMA 1995; 273:1296-1298[Abstract]
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- Philosophy, Psychiatry and Psychology (journal). Baltimore, Johns Hopkins University Press
- Chalmers D: The Conscious Mind: In Search of a Fundamental Theory. New York, Oxford University Press, 1997
- Ennis RH, Millman J, Tomko TN: Cornell Critical Thinking Tests Level X and Level Z Manual, 3rd edition. Pacific Grove, CA, Critical Thinking Books and Software, 1985
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ABSTRACT
INTRODUCTION
