La psychiatrie connectée,une psychiatrie augmentée ?

The use of digital technologies in medicine is constantly growing. The adoption of digital technologies in the clinical practice in psychiatry seems to be a question of when, not if. How can we use those tools effectively? To address those issues, this short review discusses three of the major contributions of digital psychiatry: 1/the assistance and improvement of current care; 2/the development of new treatments; 3/the production of scientific and medical knowledge.     

Academic and Private Practice Medicine and Health Service Delivery Systems: A Psychiatric Commentary

The author presents a commentary on the interactions and economic consequences of managed care, health service delivery systems, academic medicine, and psychiatry. The author recommends the creation of divisions of private practice psychiatry within academic psychiatry departments as a means to address the increasing financial pressures as well as to foster medical education, quality medical care, and clinical research.     

The influence of the curriculum in psychiatry residency education

Extraordinary economic forces are influencing graduate medical education in this country. Federal, state, and third party cost containment efforts, managed care, medical student loan indebtedness, and decreasing governmental and industry enthusiasm to support residency training are producing significant external pressures on academic health centers, recruitment into psychiatry, and on the practice of psychiatry. Other pressures on the psychiatry residency curriculum are being generated from the rapid expansion in our scientific knowledge base in clinical psychiatry and the influence of subspecialization. The future psychiatrist will be trained for a life long career in continuing education to accommodate for the explosive scientific contributions to our field. The residency training program will promote the ability to think scientifically, to teach others, to administrate and lead, and to achieve clinical competence in a more rigorous fashion. Regardless of the number and forms of emerging practice settings, it is best to train our residents for flexibility through emphasizing fundamental clinical and scientific excellence.     

Training in neurology

The training of clinical neurologists is undergoing profound change. Increasing subspecialization within neurology, the widening separation of clinical neurology from other branches of internal medicine, limitations of exposure to training in internal medicine, mandated restrictions in working hours, and attempts to shorten the training period are likely to have adverse effects on the next generation of clinical neurologists. Despite the need for a broad base in general medicine, discussed here, the exposure of neurology trainees to general medical disorders is diminishing. An emphasis on an algorithmic approach to patient management rather than on educating residents to use their reasoning faculties when applying new techniques and knowledge to clinical practice may adversely affect patient care. Neurologists require broad-based training in neurology, internal medicine, and psychiatry, to ensure excellence in clinical practice. It is time to question again whether they are receiving the training that they need.     

The Impact of Managed Care on Psychiatry

It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care. A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice. Some psychiatrists working in managed care have become increasingly involved in treatment teams. Other psychiatrists contracting with MCOs are reserved for medication management, consultation, or administration in carved-out mental health departments or agencies. Little is known about the extent to which managed care restrictions affect psychiatrists' patient care roles, collaborative relationships with other mental health professionals, and the degree to which psychiatrists are involved in administration of managed mental health care benefits. The era of managed care has constrained the clinical decision making of psychiatrists whose magnitude and impact on job satisfaction and labor market responses are unknown. Surveys of general physicians in MCOs have provided a framework for understanding some of the difficulties and opportunities faced by managed care psychiatrists, but have failed to shed much light on many aspects of medical practice specific to the provision of mental health care within the boundaries of managed care. Future research in this area would help fill this gap, and assist in shaping the roles of psychiatrists in managed mental health care organizations.     

Barriers to care

In elevating cost containment to a first principle, the current political debate about health policy in the U.S. and Canada has lost sight of what should be its primary concern: the health status of the population. The two need not be incompatible. Many current medical procedures are of uncertain value for health and entail sizable costs. The application of the knowledge obtained through randomized clinical trials to the practice of medicine can improve public health and at the same time save money for needed health purposes. Technology has come to dominate medical vision and has created conceptual barriers to responsive medical care. Doctors must attend to the illness experience of the patient as well as disease in organs and tissues. The limits of the biomedical model in psychiatry are illustrated by means of a hypothetical instrument: the PET/NMR cephaloscope. Clinical experience in psychiatry makes it abundantly clear that family and cultural environment are decisive determinants of functional status, even in disease conditions with a major organic component.     

A knowledge network for a dynamic taxonomy of psychiatric disease

Current taxonomic approaches in medicine and psychiatry are limited in validity and utility. They do serve simple communication purposes for medical coding, teaching, and reimbursement, but they are not suited for the modern era with its rapid explosion of knowledge from the “omics” revolution. The National Academy of Sciences published a report entitled Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease. The authors advocate a new taxonomy that would integrate molecular data, clinical data, and health outcomes in a dynamic, iterative fashion, bringing together research, public health, and health-care delivery with the interlinked goals of advancing our understanding of disease pathogenesis and thereby improving health. As the need for an information hub and a knowledge network with a dynamic taxonomy based on integration of clinical and research data is vital, and timely, this proposal merits consideration.     

Internet: an infrastructure of evidence-based medicine in neurology]

EBM is a cyclic process. Medical evidences are created in clinical trials, which are published in medical literatures. The medical literatures are converted to literature database, from which clinical practice guidelines are made. They are provided to the clinicians, from whom a new clinical research is born again. Information technology, especially the use of internet has deeply related to every process of EBM, which is shown above. In clinical trials, data are accumulated through internet and the process is controlled by a coordinator using internet. In Japan, University Hospital Medical Information System (UMIN) has successfully provided such a tool to the clinical researchers. For the literature search. IT is mandatory and clinical practice guidelines are created on the base of various secondary information database, which are edited using advanced information technology Clinical practice guidelines are provided to hospitals through internet and they reach to the clinicians using a function of hospital information system, especially electronic medical record. In recent days, IT is an indispensable tool for daily practice of evidence-based medicine. However, in Japan the evidence has not been accumulated in national level, and for the future, the creation of national database of medical data should be explored.     

Academic psychiatry and health care reform: strategic initiatives for sustaining the clinical mission

Health care reform has posed special challenges for departments of psychiatry in academic medical centers. This report describes one department's strategic responses to a marketplace with high penetration by managed care and provides examples of the kinds of faculty concerns that can arise when major departmental reorganizations are attempted. The department's successful adaptation to a radically altered professional environment is attributed to the following five initiatives: vertical integration and diversification of clinical programs, service line management, outcomes measurement, regional network development, and institutional managed care partnerships Although the authors did not design their adaptive efforts as a research study, they offer objective data to support their conclusion that the viability of their overall clinical enterprise has been sustained despite an external environment inhospitable to academic psychiatry.     

Child and adolescent psychiatry its problems and foresight]

Accompanying the fall in birth rate, problems pertaining to the child's mind such as school in attendance, bullying, violence in the school, intrafamilial violence, eating disorders, substance abuse, and child abuse have rocketed and diversified, in addition to affecting increasingly lower age groups. The importance of child and adolescent psychiatry has never been more profound, but our country, without a chair in Child and Adolescent Psychiatry in the medical school framework, and lacking recognition of Child and Adolescent Psychiatry as a clinical department has undoubtedly become an underdeveloped country in terms of child and adolescent psychiatric care. The medical schools have been in the process of review and reorganization these past few years. The range of mental science is wide, and despite being a major discipline constituting one of the two arms of medical science together with somatic medicine, it is regarded as a minor existence in our country. This is the time to re-establish mental science, with areas such as child and adolescent psychiatry, geriatric psychiatry, social psychiatry, and crime psychiatry placed on an equal footing with general psychiatry. Turning our eyes on the world, the children are being robbed of their mental health as refugees, through child labor, starvation, and civil war. The demand of this age is true symbiosis, surpassing differences in race, religion, language, and culture, which is probably the indispensable element in the quest for a happy future for the children of this age.     

Defining psychiatry in primary care: Origins,opportunities, and obstacles

Society's demand for more comprehensive health services, and psychiatry's pursuit of a more medical orientation, have together fueled interest in the psychiatric aspects of primary care medicine. We have begun to define the content of the field by transplanting selected aspects of existing clinical psychiatry into this new setting. Yet general medical patients present new types of psychiatric, interpersonal, and behavioral problems, and the psychosocial aspects of the medical care process are important in primary care. We need to acknowledge these characteristics in establishing a body of knowledge and clinical investigation that comprise the psychiatric aspects of primary care. Doing so will make our teaching and clinical care in primary care settings more valuable, will establish a solid academic foundation for the field, and will help to subject the “art” of medicine to more rigorous study.     

Expansion of the consultation-liaison psychiatry paradigm at a university medical center: integration of diversified clinical and funding models

The perspective of the contemporary Consultation-Liason Service (CLS) psychiatrist is increasingly one of consultant to medical and surgical colleagues in models other than inpatient medical and surgical units. Simultaneously, the need for a clinically and educationally robust inpatient CLS persists despite funding pressures. The University of California, Davis Medical Center Department of Psychiatry has made use of creative organizational and financial models to accomplish the inpatient CLS clinical and educational missions in a fiscally responsible manner. In addition, the department has in recent years expanded the delivery of psychiatry consultation-liaison clinical and educational services to other models of care delivery, broadening the role and influence of the CLS. Several of the initiatives described in this paper parallel an overall evolution of the practice of consultation-liaison psychiatry in response to managed care influences and other systems pressures. This consultation-liaison paradigm expansion with diversified sources of funding support facilitates the development of consultation-liaison psychiatry along additional clinical, administrative, research, and educational dimensions. Other university medical centers may consider adaptation of some of the initiatives described here to their institutions.     

What should non‐US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.     

Psychiatry and primary care medicine in Canada

Summary Primary care medicine has developed rapidly in Canada as elsewhere during the last 25 years. It is a natural sequela to the trend to specialization following World War II and primary practice itself has now reached the status of a specialty. The result has been a longer and more thorough educational process and this process has invited psychiatry to introduce the bio-psychosocial model to medical practice. Although Canadian psychiatry has not itself developed a primary practice frame of health care delivery, it has contributed to primary care residency education. The Canadian national health insurance scheme has facilitated the development of the non-psychiatric physician's interest in the psychological and social issues of health and illness by offering medical coverage in most provinces for psychotherapy. In addition, the generally unlimited payment for all forms of psychiatric care allow ready consultation by physicians to psychiatrists.     

Psychiatry clerkship directors: Who they are,what they do,and what they think

We mailed questionnaires to ascertain biographic, academic and attitudinal data about psychiatry clerkship directors in the U.S. The average director is 46 years old, has been in academic medicine for 13 years, and has directed the clerkship for 5.9 years. Most are associate or full professors and hold one or more additional administrative positions, most often director of medical student education in psychiatry. Most view their role as fulfilling and want to direct the clerkship for the rest of their careers. However, most also perceive that their medical school does not provide enough support, that faculty don't teach enough, and that the current economic climate impedes learning. Unless medical student education is supported under managed care, the quality of clerkships and job satisfaction for clerkship directors will decline.     

QEEG and brain mapping. Historial develoment,clinical practices and epistemological issues

Although it has been more than two decades since brain mapping was introduced in medicine, its scientific value and clinical practice have not been proved. This paper makes an overview about the historical development of brain mapping, its usefulness in psychiatry and lays epistemological issues concerning the role of technology in medical settings. Both historical and technological development of qEEG gives us the opportunity to think about complexity between ethics, science, technology and medicine.     

Psychiatry--family practice liaison: a collaborative approach to clinical training

In view of the growing need for effective liaison between psychiatry and family practice programs, some of the models for educational and clinical liaison are discussed, and a clinical training program is described in which psychiatry and family practice educators work collaboratively in the training of both family practice and psychiatry residents and medical students. The program is offered as a model for providing comprehensive clinical training to residents and students and comprehensive clinical care to patients.     

Status of behavioral medicine in American and Canadian medical training

This article reports a survey of attitudes and current practices regarding behavioral medicine in American and Canadian medical school departments of psychiatry. Participants were eighty-two chairpersons of departments of psychiatry. Five major areas were addressed concerning the existence, location, and composition of behavioral medicine faculty and their contribution to training and research programs. Results indicate that behavioral medicine is represented in the majority of medical schools and teaching hospitals. Faculty tended to be located in psychiatry. A majority of the respondents did not think that behavioral medicine should be considered a separate clinical specialty area, but in actual practice behavioral medicine was distinct from consultation/liaison psychiatry as often as integrated with it. The analysis of subjects and methods taught in residency training programs suggested a meaningful trend in the data. The implications of these results for models underpinning traditional medical education and psychosomatic medicine are discussed.