Acad Psychiatry 30:426-429, October 2006
doi: 10.1176/appi.ap.30.5.426
© 2006 Academic Psychiatry
Review of Handbook of Psychiatric Education
James W. Lomax, II, M.D.
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INTRODUCTION
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This book review by Dr. Lomax was invited as a way to highlight a particularly salient resource for our readership. While Academic Psychiatry does not generally publish book reviews, in this case, an exception was made. The content of this work is closely tethered to the mission of the journal and represents concepts central to psychiatric education.
–The Editors
I was appreciative of the opportunity to conduct a focused, reflective reading of this Handbook of Psychiatric Education (1). I was somewhat unprepared, however, to be delighted by the myriad of ideas stimulated by contributions from the luminaries in psychiatric education. I will begin by agreeing with John Oldham’s statement on the back cover: "Handbook of Psychiatric Education ... should be essential reading for every director of psychiatric medical student education and residency training. ..." Furthermore, the Handbook can be used as a stimulus for promoting departmental discussions, as an aid for a variety of educational initiatives, and as a promoter of the department’s collective sense of an educational mission.
The book opens with a discussion of the preclinical undergraduate curricula. The authors distinguish the characteristics of a behavioral science course from a psychopathology course, highlighting the special obligation of the psychiatry department to compensate for the absent or uneven behavioral science backgrounds of medical students. The thoughtful use of "departmental super stars" is emphasized. There are valuable suggestions for the conduct of lectures and small group experiences and useful suggestions to manage the "antipsychiatry bias" of many medical students. The authors do not mention the use of preclinical electives to capture and sustain the interest of those precious students who enter medical school with a "pro-psychiatry bias." Examples are electives with a more conceptual focus, introducing the students to the notion of "models of the mind" (2) or an elective that helps develop narrative skills (3).
The ambitious treatment of the psychiatry clerkship offers clear goals and the good advice to the departmental medical student director to utilize the collective wisdom of a national peer group (e.g., the Association of Directors of Medical Student Education in Psychiatry objectives). The authors remind faculty that they function as administrators (not therapists) on evaluation committees. There is a useful section on psychiatric interviewing that emphasizes the importance of observing and providing feedback to students. This chapter might well be read prior to a meeting of the undergraduate education committee of the department with instructions for the group to reflect upon how the department clerkship fits with the content of this chapter. I contend that the psychiatry clerkship director should also proactively help the clinician educator faculty of the department to capture data necessary for promotion and inform faculty about criteria for promotion on educational tracks. Some recommendations of the chapter are a bit ambitious (visiting each site every month or two).
The chapter on undergraduate electives is particularly well done and addresses a topic more important than some educators realize. There are excellent recommendations in this chapter: get your chairman to do a regularly scheduled activity during the clerkship (such as "professors rounds"), develop electives that integrate psychiatry into the basic sciences, construct electives with independent practice psychiatrists or community health centers, have the student keep a daily narrative log of patient encounters (to reinforce how psychiatrists find meaning in medicine), and involve medical students in special departmental functions. The chapter conceptualizes electives as a synergism between education and recruitment. This chapter would provoke useful discussions at a special meeting of the undergraduate and residency education committees of the department. Another unmentioned elective is an experience designed for students who know they are going into another specialty but want to develop competency in the diagnosis of depression, anxiety, or substance abuse disorders in that specialty.
The overview of what and how to teach in the residency program will be interesting and valuable to program directors of all vintages. The section on setting goals is a helpful reminder that each department should focus on and enhance what it does well. The suggested sequencing of psychotherapy learning experiences is particularly good. Teaching about empathy and practicing truly empathic communication are of particular importance for PGY-II residents. This class tends to have a period of identity crisis and benefits from assistance to recapture and expand traits which may have been challenged during the trauma of becoming a doctor in the first postgraduate year (4). The section on becoming a psychotherapist appropriately emphasizes the importance of individual supervision but could offer more about how to develop faculty competence as individual supervisors.
The chapter on new teaching technologies provides good basic information for faculty with relatively modest amounts of technological sophistication. It offers particularly useful suggestions about Internet sites, software, and Internet links.
A discussion of teaching psychiatry residents to become effective educators introduces the idea of a "teaching case conference" (analogous to the psychotherapy case conference). Though this activity would require a significant time investment, it seems to offer developmental potential for both residents and junior faculty. The chapter does not mention using the end-of-clerkship feedback session for students to obtain evaluation of resident teaching. Providing only an annual summary of student comments is too delayed for a useful feedback loop. Student comments about resident teaching should be distributed to the residency program director for regular feedback.
The chapter on the accreditation process provides a useful introduction to the Accreditation Council for Graduate Medical Education (ACGME) accreditation process. An additional recommendation is for the program director to meet with those participating in the site visit to be sure that everyone understands the Program Information Form (PIF) contents before it is sent to the Residency Review Committee. In my experience, inadequate evaluation of residents, lack of goals and objectives, failure of the rotation supervisor to go over goals and objectives with residents, and inadequate psychotherapy education are more common mistakes than those listed in the table of common mistakes found. Finally, the program director must systematically orient new faculty to ACGME expectations to ensure the accomplishment of requirements, many of which will be unfamiliar to new faculty.
The contribution on the evaluation of residents should stimulate lively discussion at the residency education committee (or a specific evaluation subcommittee). Helpful recommendations in this chapter include promoting self-evaluation by asking the residents to provide written personal goals. It was unclear to me whether the "process-folio" method entails something beyond the materials found in the two appendixes of the chapter. The chapter would benefit from attention to the concept of "feedback in medical education" (5) which is different than formative evaluation. Such feedback may be of a very personal nature and inappropriate for the resident’s permanent record. This chapter does not cite the work of Maxine Papadakis on professionalism, which documents that unprofessional behavior as a student is the most powerful predictor of severe professional problems as an independent practitioner (6). Designating professionalism as a required competency necessary for graduation and defining the elements of professionalism is of considerable usefulness to the program director when dealing with problem residents.
In some states, an important issue is the necessity for authentic discussions with residents about protecting trainees who are experiencing predictable developmental difficulties from being permanently stigmatized by a remediation experience. One suggestion is to work with the hospital and/or university’s legal council to designate a specific review entity (a "progressions" committee) as a peer review entity. Such a designation may protect and record discussions necessary to develop a paper trail (in unhappy outcomes) from discovery (when remediation leads to professional competency).
Many programs find it helpful to bring together all of the supervisors of a particular postgraduate year level at least twice a year to discuss the residents as a group. At such meetings, issues which have not reached the threshold of formal complaints sometimes become obvious. This and similar strategies are often discussed at American Association of Directors of Psychiatric Residency Training (AADPRT) workshops on evaluation. Many program directors find such workshops to be pivotal to their development. There are several points in this chapter in which the authors use more permissive language than allowed: the residency training director must conduct yearly examinations of cognitive knowledge. A final summary assessment of each resident is required. The residency training director must follow institutional policy on any official action such as probation and suspension.
The title of the chapter on special problems and challenges suggests a focus on issues that may or may not be of importance. It is a wonderful chapter, albeit more like "wisdom literature" than an operations manual. The residency program director must frequently balance conflicting roles: nurturing the development of residents, protecting the public interest and both preserving and transforming institutions and educational programs. The chapter makes the important distinction of knowing both what "to do" and when "to be" especially in regards to change (of program or personnel). The chapter authors emphasize the importance of both what one does and the perception of what one does. Developing the right amount of transparency is emphasized in this chapter. Like Emily Dickinson, the authors suggest "Tell all the truth, but tell it slant, success in circuit lies. The truth must dazzle gradually, or every man be blind" (6). Implicitly, the authors also communicate that good judgment comes from wisdom and wisdom comes from bad judgment. They advocate communication that balances providing adequate information to residents with compassionate privacy about personal and professional difficulties. Designating official communicators from the progression committee is helpful. One potential principle is that official actions regarding residents (like probation) which will have to be communicated to external bodies are generally communicated at least to the education committee of the department (which must have resident representation). The specific reasons for the official actions are generally discussed only in relatively small meetings (such as a progression subcommittee). A well functioning program generates enough trust in the work of the program administration and the resident representatives to manage anxiety evoked by negative progression actions.
The chapter on special events is an extremely useful starting point to develop program-specific variations of the events covered. The orientation packet described might also include the APA pamphlet on Resident as a Teacher. The template for the orientation meeting offers a useful foundation upon which individual modifications can be added. The authors do not mention how residents are oriented for on-call responsibilities. One element of becoming chief resident not mentioned but commonly observed is how rapidly the resident peer group perceives the chief resident elect as becoming "part of them" instead of "one of us." Use of the "No Free Lunch" website as a discussion piece for residents with respect to industry support is a helpful idea (7). The short section on disasters and terrorism may have enduring salience for residency program directors. The relatively smooth functioning of communication systems in New York contrasts sharply with the much greater difficulties related to Hurricane Katrina. The reasons for the differences are probably important to discern as both 9/11 and Katrina may indeed be harbingers of future disasters.
The chapter on recruitment of residents is invaluable for both the new and veteran residency program director. Understanding and communicating your particular niche as a program is the key theme of this chapter. An annual review of the departmental website is useful. It can also be an initiative of the residency program director that can serve as a "community building" activity for the department. The authors recommend the use of resident interviewers who have graduated from the applicant’s medical school. The program director might also read the applicant’s personal statement looking for professional (psychotherapy) and nonprofessional (music or literature) interests or experiences (military service, being an exchange student, etc.) to pick interviewers. The authors recommend avoiding "manipulating" the National Resident Matching Program (NRMP) list in order to "look better" to your GME peers. However, the residency program director should have final authority over the list to arbitrate disputes about whether a particular applicant is a good "fit" for the program. The development and use of "audition electives" (remembering that the audition is frequently bilateral) are important considerations. It is hard to establish communications between the medical student and residency director to be sure the program director knows when "outside" students are taking electives. Both authors are particularly experienced with international medical graduates and provide good advice for their selection.
The book closes with a chapter on major issues in psychiatric education. If you enjoy "futurist" pieces, you will find it more useful than "fuzzy." Outsourcing of psychotherapy is a theoretical possibility, but the outsourcing of pharmacotherapy already exists on the Internet and is an immediate threat to good medical care. The author suggests the development of a video library showing the treatment course of common psychiatric disorders. Such a library could increase the promotability of the clinician educator faculty who produce them and enhance the education of resident clinicians at the same time. This and other chapters advocate a psychiatry "interest group" or "club" to nurture nascent interest in our field. Inviting students to the home of a senior faculty member is a very generous offering that almost certainly increases the recruitment success of any hospital or university.
In closing, the Handbook is a wonderful contribution of value to individual faculty and to the educational mission of any psychiatry department. The next edition might include a chapter on interdisciplinary collaboration in education. I am concerned that the new edition will need to help us continue to think about our roles in national disasters and terrorism. I hope it will help us to consider our role in a nation with reconsidered priorities and a more vigorous commitment to health care and education.
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ACKNOWLEDGMENTS
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Dr. Lomax is affiliated with the Baylor College of Medicine, Houston, Texas.
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REFERENCES
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- Kay J, Silberman EK, Pessar LF (eds): Handbook of Psychiatric Education. Arlington, VA, American Psychiatric Publishing, 2005
- Ghaemi SN: The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness. Baltimore, Johns Hopkins University Press, 2003
- Verghese AC: The physician as storyteller. Ann Intern Med 2001; 4;135:1012-1017
- Nemiah JC: The Idea of a Psychiatric Education. Proceedings of the American Association of Directors of Psychiatric Residency Training. Harvey Shein Memorial Lecture, The Journal of Psychiatric Education, Vol. 5, 1981, pp 183-194
- Ende J: Feedback in clinical medical education. JAMA 1983; 250:777–781[Abstract]
- Papadakis MA, Hodgson CS, Teherani A, et al: Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Psychiatry 2004; 79:244–249
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