Teaching psychiatry to nonpsychiatrists: II. A model curriculum

It is becoming increasingly clear that psychiatric and psychosocial needs of medical patients are not being adequately met. This need has led to an increasing emphasis on the psychiatric education of nonpsychiatrists at varying levels of experience. Given the many problems involved in these educational efforts, as well as the paucity of evaluation studies and the uncertainty of results, the authors argue that the systematic application of empirically-validated educational principles may lead to greatly improved effectiveness. In the first section of a two-part series, the authors reviewed educational methodology as it relates to the development of objectives, the selection of teaching procedures, and the use of evaluation techniques. The present paper, part-two, describes in detail a “model” curriculum for primary care residents that was developed according to these principles of educational methodology.     

Training outcome in liaison psychiatry : Literature review and methodological proposals

This paper reviews training outcome studies in liaison psychiatry. The author located nine evaluation studies, only four of which were controlled and only two of which included trainee-related patient outcomes. The author suggests a typology of evaluation dimensions with specific methodological proposals which may be useful for future assessment research.     

Medication noncompliance: Systematic approaches to evaluation and intervention

Medication noncompliance is a significant problem in medical practice, but many intervention strategies developed for noncompliant patients (such as tangible rewards, contingency contracting) are not practical for the large numbers of patients seen by private practitioners on an ongoing basis. Based upon a review of the literature concerning the key determinants affecting compliance, the authors have developed a practical, rational, and systematic approach to assessing medication compliance that may serve as a guide for psychiatrists in formulating consultation recommendations, in liaison teaching activities, and in clinical psychiatric practice. Special emphasis is placed upon the identification of psychiatric syndromes that may negatively affect compliance. Implications for compliance-related research in consultation-liaison psychiatry are also discussed.     

An oral examination of the psychiatric knowledge of medical housestaff: Assessment of needs and evaluation baseline

To assess the psychiatric knowledge of medical housestaff, the authors devised an oral examination based on two simulated clinical encounters and administered it to 26 medical residents. The case material embodied those psychiatric problems known to be common in medical populations, namely depression, delirium, dementia, and “psychogenic” pain. The stan-dardized simulations were punctuated by standardized “open” questions with followup probes. A panel of experienced clinicians developed rating criteria for each question such that responses could be categorized as “good,” “adequate,” “inadequate,” or “poor,” in terms of “what an internist needs to know,” Blind raters of the exam achieved an interrater reliability of 0.88. The results indicated major deficits in the knowledge needed for assessment and treatment of these common problems. Only 16% of answers were “good,” whereas 42% were “inadequate” or “poor.” For example, 88% of the doctors could not name three factors that help distinguish organic from “functional” psychosis, and 88% could not list three side-effects of tricyclic antidepressants. The doctors' level of experience was not correlated with test scores, either overall or question by question. These results, together with measures of attitude and skill, have been used to develop a needs-based liaison psychiatry curriculum and to evaluate the effectiveness of that curriculum.     

Models for evaluating teaching in consultation-liaison psychiatry: I. An overview.

In this paper two useful models are introduced for evaluation of teaching in consultation-liaison psychiatry: decision-oriented and conclusion-oriented research. These models, based on previous studies of educational evaluation, are defined here in terms of their purpose for liaison psychiatry. To clarify the models' usefulness, the methodologic requirements for each model are presented while the unique characteristics of the liaison environment are described in terms of their effect on conclusion-oriented evaluation.     

The clinical specialty unit: The use of the psychiatry inpatient unit to treat chronic pain syndromes

The authors describe a 15-bed psychiatry inpatient unit, the Clinical Specialty Unit (CSU), designed to treat patients with chronic pain syndromes. They argue that the use of psychiatry beds for this purpose is appropriate, given the nature of the chronic pain disorder, but is not without its liabilities. The administrative structure and roles of the multidisciplinary team are described.     

The relevance of a staff-oriented approach in consultation psychiatry: A preliminary study

According to the literature, a patient-staff conflict or intra-staff conflict is often the hidden reason for requesting a psychiatric consultation. This study is specifically directed at determining the percentage of consultations in which such “staff problems” play a clinically relevant role. Indications of staff problems were found in one-third of 313 consultations investigated. These problems occurred significantly more frequently in patients admitted to surgical wards and in patients referred because of psychological disturbances related to their physical disorder, with a diagnosis of “transient situational disturbance” or “no psychiatric disorder”. Consultants with relatively less experience diagnosed significantly more staff problems. In about half of the consultations with staff problems, a staff-oriented approach was applied. Lack of communication with the ward staff in question was the most frequent obstacle to applying such an approach.     

The consultee-attended interview: an approach to liaison psychiatry.

The consultee-attended (C-A) interview, a format in which the liaison psychiatrist interviews the patient in the consultees' presence, is described. The background, strategy, concepts and methods, obstacles and resistances, and countertransference difficulties of C-A interview are discussed. The C-A interview is an experiential teaching instrument with which to facilitate consultees' "participant-observation," a clinical posture that complements other approaches to the care of sick people.     

The application of Kohutian self psychology to consultation--liaison psychiatry

Explanations of emotional and behavioral response to illness seen by consultation--liaison psychiatrists include crisis theory, stress theory, classical Freudian theory, grief, and alexithymia. Recent developments in self psychology are also useful. Kohut identifies empathy as central to the establishment and maintenance of a sense of personal integrity, self-esteem, tolerance, and administration of others; deficits may cause feelings of shame, humiliation, rage, emptiness, and hypochondriasis. Persons who experience insufficient empathy during development are particularly vulnerable to these findings at the slightest hint of decreased concern, support, or empathy from parent surrogates. They attempt to compensate with a grandiose self-image, or by attachment to an idealized other. Prior formulations have considered illness a real or threatened object loss, with the lost object assuming symbolic significance in the individual's emotional or behavioural experience. However, illness may also be understood as a threat to the integrity of the self. This helps explain the range of emotional reactions observed and the disturbances in the doctor-patient relationship. Intervention is directed toward reconstitution of the self. Cases are presented to illustrate the application of this theory to formulation and treatment.     

Liaison psychiatry: A model for medical care on a general hospital psychiatric unit

Liaison psychiatry is traditionally practiced on the medical and surgical floors of the general hospital. The need for liaison psychiatry on the inpatient psychiatric unit as opposed to its usual setting was realized when the medical care requirements of hospitalized psychiatric patients was assessed. In many general hospitals this medical care is provided by a psychiatrist in consultation with medical and surgical colleagues. Over a three-year period at the Medical Center Hospital of Vermont 563 medical/surgical consultations were provided to the inpatient psychiatric unit. To utilize these consultations most effectively, the role best suited for the psychiatrist was that of liaison-consultee. Case examples are used to demonstrate the effectiveness of employing liaison skills in the treatment of somatic problems on the inpatient psychiatric unit. The educational implications of learning the liaison model in this context are discussed.     

Consultation evaluation: I. Psychotropic drug recommendations.

A follow-up chart review was undertaken of 100 consecutive patients seen in psychiatric consultation for whom psychotropic medication was recommended. Significant differences in implementation (P less than 0.01) by class of drugs (neuroleptics, tricyclics, benzodiazepines) were found. Most often no discernible reason for consultee disagreement could be found or inferred. The importance of such follow-up studies for consultation work is stressed.     

Models for evaluating teaching in consultation-liaison psychiatry: III. Conclusion-oriented research

This paper reviews the purposes and methodologic requirements of conclusion-oriented research for evaluating outcomes of consultation-liaison (C-L) teaching in psychiatry. Requirements for replicating educational methods and outcomes, and for demonstrating cause-effect relationships between program inputs and program outcomes include: careful definition of educational methods; selection of valid and reliable outcome measures; and use of sound experimental designs. Barriers to meeting these methodologic criteria in C-L settings are identified, and methods for overcoming them are suggested. In addition, useful guidelines are provided for the educator wishing to conduct conclusion-oriented C-L research to determine teaching effectiveness.     

The effects of a psychiatric liaison program on the utilization of psychiatric consultations: an evaluation by chart audit.

The effects of a psychiatric liaison program were studied by a chart audit examination of psychiatric consultations on a medical service. A comparison of the full liaison ward with the other wards revealed significant differences in the use of emergency consultation and psychiatric follow-up treatment. The results indicated improved psychologic management of medical patients on wards with intense liaison involvement but no measurable change in attitude toward the psychiatrist. Evaluation methodology and implications of the results are discussed.     

Admissions to a South African general hospital psychiatric unit

In a study of adminssions to the psychiatric unit of a general hospital from December 1, 1977, to November 30, 1978, data obtained from all 478 admitted patients were analyzed; the most prevalent condition was found to be the neuroses, followed by organic brain syndromes. Most patients admitted fell into the 19–39 age group, with a preponderance of male admissions between the ages of 6–39, but more admissions of females above 40. A significant difference in the occurrence of conditions between the sexes was noted: the most prevalent condition for males between the ages of 6–39 years was schizophrenia, while more females suffered from the neuroses. Males 40 years and older presented predominantly with organic brain syndromes; females in that age group presented predominantly with affective psychoses. The average length of stay for both sexes was eight days. Schizophrenia required the longest hospital stay, an average of 11 days. Seventy-eight patients (16.3%) were admitted more than once during the period of study. Conditions commonly associated with readmission were affective psychoses and schizophrenia. The role of the general hospital psychiatric unit and its advantages and shortcomings are discussed.     

A review of systems approaches to consultation-liaison psychiatry: The need for synthesis

Five applications of systems theories to liaison psychiatry are reviewed. “Systems” is noted to have three distinct meanings as applied to consultation-liaison psychiatry: as a metatheoretical construct, as a decision-making process, and as an organizing construct for social variables. It is proposed that the time is ripe for synthesis of the social systems theories, reduction to the most parsimonious use of variables, and empirical testing of their importance. General systems theories are seen as needing further development before they will be routinely useful in consultation-liaison psychiatry.     

Emergency psychiatry training: the new old problem

Unevenness in emergency psychiatry training is still an issue as borne out by a recent literature review. An emergency setting in a general hospital is described with its attendant problem areas for psychiatric residents' function and learning. An adaptable curriculum is reported that takes into account limits of time, finances, and faculty.     

The significance of biological factors in the diagnosis of depressions: II hormonal variables

The reasons behind the recent upswing in psychoendocrinology are discussed, with reference also to the relation between MA research and hormone studies. The question is raised whether hormonal research has yielded data of diagnostic value. Data that warrant predictions about the choice of antidepressant and the prognosis of the depression considered.Three function tests are discussed in this context: the DST, the TRH/TSH test, and growth hormone responses to various stimuli. These three “tests” can all be disturbed in depressions, but probably in particular in some of the endogenous (vital) depressions. These findings, like the biochemical data, support the concept of the pathogenetic heterogeneity of the vital depressions. We do not know whether the disturbances described are all observed in the same patients or are characteristic for various subgroups. DST disturbances were found to be highly specific: characteristic for the subgroup of endogenous depressions. The specificity of the other “tests” had not yet been adequately studied. Data on their therapeutic and prognostic significance, although promising as such, are still scantly. Any conclusion concerning their value in psychiatric practice would therefore be premature.     

Interdiscimplinary differences on a general hospital psychiatry unit.

A questionnaire was distributed to staff members of a 28-bed general hospital psychiatry unit to determine and compare staff perceptions of the value of psychotherapies and the role of the disciplines in conducting treatments. Marked interdisciplinary differences were reported in attitudes toward the use of psychopharmacologic agents, the importance of diagnostic evaluation, the value of psychotherapy in the treatment program, the role of various disciplines in the program, and the therapeutic community approach. Clinical implications of the magnitude of interdisciplinary differences are discussed, and recommendations are made for resolving intergroup conflict.