Training psychiatrists to diagnose and treat substance abuse disorders

Addiction training in psychiatric residency programs needs expansion. Epidemiology research has shown that patients with substance use disorders and co-occurring mental health disorders are the norm in nearly all clinical settings. Unfortunately, traditional training approaches built around brief rotations on detoxification or intensive substance abuse rehabilitation units do not adequately train psychiatrists in long-term management skills, and may reinforce misperceptions that these patients do not respond to treatment. An enhanced addiction curriculum coupled with an extended outpatient clinic rotation is an ideal model for teaching the skills needed to successfully care for these patients. Training must include an adequate knowledge base, an opportunity to cultivate positive attitudes toward these patients, and recognition that psychiatrists must take responsibility for treating the addiction problem and any co-occurring psychiatric disorders. The program developed at Boston University Medical Center successfully integrates expanded addiction psychiatry training into the general psychiatry residency.     

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.     

The role of the physician in addiction prevention and treatment.

With increasing pressure on general physicians by managed care organizations and the public to treat and advocate for drug and alcohol addicted patients, it is more necessary than ever that physicians have the knowledge and skills to appropriately address this segment of the population. Specifically, physicians need a better understanding of the prevalence of alcohol and drug dependence in a variety of populations, along with increased awareness of the economic impact of addictive illnesses on our society. Routine screening questions should be incorporated into patient encounters, and physicians should be able to identify environments that may pose a risk for the development of addiction. Physicians need training and practice in referring patients to treatment teams, monitoring patients in recovery, and providing interventions that will eliminate or reduce substance abuse before it becomes addiction. The treatment outcomes in abstinence-based programs, particularly those combined with referral to AA, have been encouraging, demonstrating that addiction is a treatable illness and not a character defect. In addition, several studies provide evidence that addiction treatment is cost-beneficial, resulting in reduced medical costs, lowered absenteeism, and increased productivity. Despite these encouraging results, there is still room for improvement. Treatment is not always effective, and it is not sufficiently available to everyone who needs it. Addicted individuals are both stigmatized and marginalized, and many are too ill to advocate for themselves. Widespread recognition in the medical community of addiction as a treatable illness will contribute to a greater understanding of addictive disorders and reduce the stigma attached to the diagnosis and treatment of addiction. For this to occur, better training for physicians in the recognition and management of addictive disorders, starting at the medical school level, is necessary. The approval of addiction medicine as a clinical specialty by the American Medical Association also has helped to advance the legitimacy of addiction as a treatable illness, and provides a focal point for the synthesis and integration of clinical, teaching, and research activities central to addiction medicine. The combination of knowledge, skills, and attitudes outlined in the article will go a long way toward increasing physicians' abilities to assist their patients with recovery from addiction.     

A questionnaire survey of the neurology training program in Japan]

A questionnaire survey was performed in order to see the current trends of the neurology training program in Japan. A questionnaire was sent out to 81 neurology program directors of the medical schools and large hospitals. 72 program directors answered the questionnaires. According to the summed results, each program had an average of 37 inpatient beds, 7 teaching staffs with the neurology board certification. The program had an average of 4 residents annually, and they served as junior neurology residents for 1.8 years, and as chief residents for 1 year with 6 months of hospital consultation. 1.4 years training in the internal medicine was prerequisite for the neurology program. The training of clinical neurophysiology was done mainly by the own faculty staff in each program, but the training of neuroradiology and neuropathology varied. A quarter of the training programs had their own teaching staffs of neuroradiology and the rest of three quarters asked for training to the neuroradiology department. 32 of 72 programs had their own teaching neuropathologists and 26 programs asked the training in the pathology department and 14 programs did not have any teaching staffs of neuropathology. It seems that these numerical data are quite similar to those of the American standard of Accreditation Councils. We must still improve the real contents of the neurology training program with more capable teaching staffs.     

Training residents to care for the mentally ill

Recent changes in Royal College training requirements have highlighted the need for residency programs to be able to offer challenging and worthwhile experiences to their trainees in caring for the chronically mentally ill. This training should bring them into contact with patients at each stage of their illness and recovery and expose them to the different settings in which treatment or management takes place. Postgraduate programs face many problems in organizing this teaching that arise from the nature and course of long-term psychiatric illnesses, the organization of residency training programs, attitudes and preconceptions of residents and teachers and competing time demands. The authors review these problems, identify specific goals for the training and suggest strategies for achieving these goals. Expectations of postgraduate programs, clinical placements, supervisors and residents themselves are outlined.     

Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence.

OBJECTIVE: The changing effectiveness of a treatment program for dual-diagnosis patients was evaluated over a 2-year period with the use of a sequential study group design. METHOD: The treatment outcome of 179 consecutively enrolled patients with chronic psychotic illness and comorbid substance dependence who entered a specialized day hospital dual-diagnosis treatment program from Sept. 1, 1994, to Aug. 31, 1996, was evaluated. The 24 months were divided into four successive 6-month periods for comparing the evolving effectiveness of the program for groups of patients entering the day hospital during these four periods. Treatment attendance, hospital utilization, and twice weekly urine toxicology analyses were used as outcome measures. RESULTS: The initial treatment engagement rate, defined as at least 2 days of attendance in the first month, increased significantly from group 1 to group 4, more than doubling. Thirty-day and 90-day treatment retention rates also substantially increased from group 1 to group 4. More patients had no hospitalization in the 6 months after entering the day hospital program than in the 6 months before entering the day hospital program. Urine toxicology monitoring indicated that the patients in group 4 were more likely than those in group 1 to remain abstinent at follow-up. CONCLUSIONS: The evolving clinical effectiveness of a developing program can be quantified by using a sequential group comparison design. The sequential outcome improvements may be related to the incremental contributions of assertive case management and skills training for relapse prevention.     

Combined outpatient alcoholism therapy and occupational rehabilitation on welfare recipients--results of a pilot study

This study tested the feasibility of outpatient abstinence treatment among alcohol dependent subjects on welfare. Patients had a long history of alcohol dependence and prolonged unemployment. Over a period of six months a total of 250 patients were approached by the social welfare office and asked to participate in the program. The program involved detoxification and a three month combined alcohol treatment and personal job training. Of the 250 persons approached 96 patients (about 40 %) appeared for the initial examination, 19 patients (13 %) finished detoxification and a total of 5 patients completed the program. The majority of a group of patients considered to be highly therapy resistant did not complete the program. Still it was important to demonstrate that a subgroup of patients did successfully complete this program. We consider this pilot project a successful starting point for further development of treatment approaches targeted more specifically at this group of patients.     

Influence of experience on major clinical decisions. Training implications.

We studied 779 walk-in psychiatric patients presenting to 32 first- or second-year residents and 772 patients presenting to 25 third-year residents or attending physicians as to the decision to admit to the hospital or to administer medication to those not admitted. There were no significant demographic or clinical differences between patients presenting to the two groups. The more experienced staff admitted half as many patients and treated serious depression with tricyclics twice as frequently. Inexperienced psychiatrists used hospitalization more frequently when these patients suffered from suicidal ideation, hallucinations, delusions, and inability to cope. When the training procedure was modified and second-year residents were introduced into a more structured setting, their decision-making quickly approached that of third-year residents and attending physicians. We suggest that specific training can modify decision-making, where general clinical experience may not. Implications for resident and medical student training are discussed.     

The neurology training in the United States and Japan]

The practice of neurology, like many other fields of medicine, currently faces a number of critical problems in the United States mostly by cumbersome restrictions designed to contain rapidly escalating medical costs. Fortunately, however, the residency training has maintained the spirit of the time-tested tradition, which has served the medical community well ever since its inception in 1910. The system has continued with little modifications after a switch of internship to Basic Residency Program (PG1) in the late 1960s. In comparison, the neurology training in Japan suffers from following deficiencies: 1) a paucity of bedside teaching in most medical schools, necessitating the initiation of unprepared residents into patient care; 2) an insufficient number of staff, especially at a governmental school, precluding an adequate coverage of neurological subspecialities such as electrophysiology and neuropathology; 3) absence of a tutorialship from senior to junior residents, and from interns to medical students, mostly for the lack of organization and logistics; and 4) no incentive to specialize without board certification by the governmental agencies or proper recognition by insurance providers. We must address these fundamental issues to promote neurology as an independent discipline for improved care of patients with neurological disorders.     

Debate: is the neurology residency program of Japan to be standardized?: "Yes"]

Japanese Neurological Association (JNA) should establish the standardized nationwide neurology residency program, and JNA should disclose the minimal requirements of both knowledge and practice for the board of neurology to the public and guarantee the quality of the neurology specialists. Standardization of the residency program will facilitate not only standardization of the knowledge, skill and art of the neurology specialists but also inter-institutional cooperation among the individual teaching hospitals in completing the training programs for the residents. Neurology professionals whose quality is guaranteed by JNA will satisfy the demands of the patients who want excellent neurological services of high quality and safety, and will be favorably accepted by high level hospitals which supply medical services of high quality. Nationwide standardized neurology residency program will thus be welcomed by both residents who aim for the board of neurology and teaching hospitals which accept the residents. It will facilitate to efficiently educate neurology residents for specialists, and will benefit the patients and hospitals. JNA should establish the standardized neurology residency program as soon as possible and go to action to socially and economically improve the condition and treatment of the specialists (for example; approval of doctor's fee by the government).     

Psychiatry and internal medicine resident education in an acute care medical-psychiatry unit

A Medical-Psychiatry Program has been developed at the University of Iowa. It includes a medical-psychiatry unit, a medical-psychiatry lecture series, a medical-psychiatry residency program, and a medical-psychiatry fellowship. The program enables residents pursuing straight psychiatry or internal medicine training to participate in a rotational experience requiring that they evaluate and treat patients for illnesses in both specialties under the supervision of both a staff psychiatrist and internist. During the rotation the resident learns how psychiatric and medical disease in the same patient complicates patient care and the skills needed to diagnose and treat such patients in the climate of their own specialty. The rotation is considered a valuable training experience by the majority of residents going through the rotation.     

The teaching of psychotherapy in Canadian psychiatric residency programs: residents' perceptions

In order to determine the residents' perceptions toward their psychotherapy training, a questionnaire was distributed to 400 residents in the 16 Canadian psychiatric residency programs. The main areas studied were: the resident's demographic and educational characteristics; the residency program characteristics; the type of training available in different psychotherapeutic modalities; the analysis of quality and quantity of attention given to different elements of psychotherapy supervision (patient assessment, diagnostic formulation of treatment approach and goals); the degree of importance attributed by the residents to the above mentioned elements of psychotherapy supervision; and the residents' perception of their supervisor's attributes (examples: teaching ability and rapport). Forty-two percent of the residents completed the questionnaire. Residents mentioned that the most adequate supervision was for long-term individual psychotherapy cases and that behavioral and group therapy supervision was the least adequate. The three most essential qualities in a supervisor's profile were judged to be: capacity for the development of a good rapport with the trainee; ability to pinpoint residents' psychotherapy shortcomings and his willingness to help residents to overcome them; ability to teach. Three factors that significantly influenced the trainees perception of their psychotherapy training were: resident's age, a seminar in individual psychotherapy in the residency core program; having received more than one hour weekly of psychotherapy supervision. The understanding of patient's psychodynamics was the most adequately taught element during psychotherapy supervision.     

Is it still necessary to teach community psychiatry to the psychiatric resident?

After having defined his conception of what community psychiatry is, where it is situated in the line of evolution of modern psychiatry, the author weighs the pertinence of teaching residents knowledge pertaining to a sector in full identity crisis. The effort is worthwhile, since this crisis has permitted the community psychiatrist to better define himself, namely in regard to the other health professionals, and it is therefore easier to determine what kind of knowledge should be transmitted to the resident in this particular field. A tentative teaching program is outlined. In such a program, education aspects should take precedence of training aspects, making the future psychiatrist more prepared to face eventual changes in that field. Such a program should take place in the final part of the residency course following a solid preparation in basic clinical psychiatric knowledge.     

Barriers to care for patients with neurologic disease in rural Zambia

The awesome burden of treatable yet untreated neurologic disease in the developing world presents a humanitarian crisis to those of us with neurologic expertise from more privileged situations. Although increased economic resources are critically needed, a shortage of personnel to care for these patients is as great a problem. It is neither feasible nor desirable to propose training neurologists to work in these regions. However, COs could be selected to receive additional training and return to their home regions to serve as resources for referrals and as community educators. Such a training program would not require massive financial commitments. A handful of dedicated neurologists could conceivably accomplish this in 6- to 8-week training sessions. Ideally, educational materials, such as posters and pamphlets in both English and the native language of the various regions, would be provided at no cost. Existing textbooks in neurology are written for physicians and often focus on diagnostic evaluations and therapies far beyond the services available in developing countries. A text for practical use by COs and community health workers that discusses the application of available medicines and therapies for common neurologic problems would be invaluable. Similar books exist that address general medical and obstetrical problems (for example, Where There Is No Doctor: A Village Health Care Handbook). Where There Is No Neurologist could be developed as a primary teaching tool and a valuable reference for COs with neurologic expertise. Neuroscience researchers, clinical neurologists, and neurology residents from industrialized countries have much to offer and to gain by working in the Third World. Research to monitor the incidence and resource utilization of emerging problems such as stroke is needed to influence public policy. The economic burden and lost productivity caused by neurologic disease in this part of the world has not been appreciated or explored. Disease beyond the scope of Western experience manifests daily in places like Chikankata. Entities such as tabes neurosyphilis, which previous generations of neurologists used as the basis for their training, still abound in Zambia. Much personal satisfaction can be gained in providing care to this vulnerable and underserved population.     

On the Edge of Life, I: Assessment of, Reaction to, and Management of the Terminally Ill Recorded in an Intensive Care Unit Journal

BACKGROUND: In a general hospital, few clinical settings match the intensity of the intensive care unit (ICU) experience. Clinical rotations in ICUs elicit and emphasize the struggles house officers face on a daily basis throughout their training. METHOD: These struggles were recorded by hundreds of residents in a journal maintained in the Massachusetts General Hospital's Medical ICU for the past 20 years. We systematically reviewed these unsolicited entries to define and to illustrate how house officers respond to caring for terminally ill patients. The 3 overarching topics that surfaced repeatedly were assessment of terminally ill patients, reaction to their prognosis, and management of their disease or their eventual demise. RESULTS: House officers record affective reactions and cognitive assessments to cope with the stress and dysfunction associated with the care of the critically ill and to facilitate their management of these patients. Journal entries by residents reveal a deep concern for the welfare of their patients, conflict about the technological advances and limitations of the system, and reflection on how involved physicians should become with their patients. CONCLUSION: House officer journal entries reflect a combination of newly gained medical knowledge and coping strategies in managing terminally ill patients. House officers also demonstrate a deep concern for the welfare of their patients. Insight from years of reflection from past house officers can help prepare trainees and residency programs for the breadth and intensity of the ICU experience and for work in clinical practice settings that follow completion of training.     

Importance of communication training for psychiatric residents and mental health trainees

Through the illustration of a clinical vignette and excerpts from interviews with trainees, this paper suggests that communication and communication disorders are essential issues in child psychiatry training. The vignette shows how communication issues pervade a multidisciplinary psychoeducational day treatment program. The importance of communication in the clinical experience and its impact on the professional preparation of psychiatry residents and mental health trainees are examined, and conclusions and recommendations for the goals of a training program in child psychiatry are presented which expand upon those findings.     

General psychiatry residents' perceptions of specialized training in the field of mental retardation

This study examined the perceptions of general psychiatry residents about the utility of specialized training that they received on an inpatient unit for patients with mental retardation and co-occurring psychiatric disorders. An anonymous questionnaire was sent to 58 former and current residents, and 43 questionnaires were returned. Views about the educational components of the training program were rated by Likert scale. A total of 98 percent of respondents strongly agreed or agreed that training was useful. Most respondents (56 percent) rated the training as sufficient preparation to treat patients with mental retardation; 84 percent reported that the training should be required during psychiatric residencies. Psychiatry residents were very satisfied with their specialized educational experience and found it to be a valuable component of their training.     

Preparing psychiatry residents for the certification exam: a survey of residency and exam experiences.

OBJECTIVE: To determine which methods best prepare psychiatry residents for the certification exam, and ultimately for practice, to facilitate appropriate residency program curriculum changes. METHOD: We sent an anonymous survey to all final year (that is, PGY5) Canadian university-affiliated psychiatry residents, regarding frequency and diversity of observed interviews, form of feedback delivery, research and other training experiences, self-perception of preparedness and knowledge base, and management strategies for exam anxiety 6 months before and immediately after the certification exam. RESULTS: There was a 52% response rate. Residents from across Canada identified the following factors as enabling successful exam completion: regular mock orals supervised by Royal College examiners, clinical experience with exposure to a wide spectrum of pathologies, individual and group study time, and appropriate anxiety management. Preparation for the oral exam involving sample case vignettes with presentation and formulation skills training was considered to be essential but was identified as an area of educational and experiential weakness in some programs. CONCLUSIONS: To prepare psychiatry residents for successful completion of their certification exam, programs should incorporate regular mock orals observed by Royal College examiners throughout residency training (not just in PGY2 and PGY5). Programs should also incorporate training in case vignettes, training in oral exam skills, and teaching of anxiety-management strategies.