Teaching psychiatry to non-psychiatrists: I. The application of educational methodology

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 empiricall validated educational principles may lead to greatly improved effectiveness. In this first section of a two-part series, the authors review educational methodology as it relates to the development of training objectives, the selection of teaching procedures, and the use of evaluation techniques. Part two presents a detailed “model” curriculum for primary care residents, developed according to the 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.     

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.     

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.     

A curriculum for the psychiatric training of family physicians

Recognizing the important role of family physicians in mental health care, psychiatry and family medicine faculty developed a psychiatric curriculum for family medicine residents. The collaborative effort utilized graduate interviews, literature review, and specialized group techniques to develop a competency-based curriculum that begins early in the residency, is integrated longitudinally into the remainder of the curriculum, and utilizes seminars, clinical experience, and liaison with a mental health team in the training design.     

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.     

Adaptation of residents to consultation-liaison psychiatry: II. Working with the nonpsychiatric staff

When working with the staff in a general hospital, psychiatry residents may be overly competitive, solicitous, or detached. These defensive reactions often arise because of the special challenges of performing a consultation, including the skepticism about the value of psychiatry and the demeaning or unrealistic expectations about what the psychiatrist can do. Furthermore, the psychiatry resident feels even more challenged if the attitudes and behavior of the staff must be changed for the patient's benefit. To affect this influence on the staff the psychiatry resident may need to assume a “liaison stance.” This stance involves not only establishing a collegial alliance but also using modified therapeutic maneuvers to alter staff behavior. By applying psychodynamic knowledge to understand and potentially to influence the staff, psychiatry residents, as participant observers, can feel less helpless and frustrated by difficult liaison situations.     

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.     

Psychiatric treatment in severe brain injury: A case report

A patient with severe, penetrating brain injury is presented. The patient was in psychiatric treatment for four years, starting two months after the injury; psychological tests were administered four times. By most criteria, the patient recovered completely. The case confirmed earlier observations that intelligence measured by verbal subtests, recovers faster than that measured by performance subtests. The latter continued to improve during the two to four year period after injury. The case clearly indicates the emotional and psychological problems that arise in the presence of severe brain damage. These reactions may hamper rehabilitation, although the gross psychological disabilities caused by the brain injury have improved. It is suggested, therefore, that brain damaged patients should receive psychiatric treatment. Some of the problems of such psychotherapeutic treatment are briefly 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.     

Tablets and talking—A spurious contrast in psychiatry

Pharmacotherapy and psychotherapy of psychiatric patients are not given equal appreciation. Particularly in syndromes with marked psychogenic or psychosocial overtones, psychotherapy is regarded as the causal therapy par excellence. In these cases (the vast majority), psychotropic drugs are believed to have at best a symptomatic importance and to entail the risk of effacing the true causes. I consider this view to be as unfelicitous as it is wrong, because: (1) Psychosocially determined behavior disorders, too, have a neurochemical substrate; (2) It is by all means sensible to make an attempt to normalize behavior by correction of this substrate; (3) Normalization of the cerebral substrate with the aid of pharmacotherapy is no less a causal type of therapy than is reduction of the pathogenic input with the aid of psychotherapy; (4) This means that pharmacotherapy and psychotherapy are complementary, and that each separately is an incomplete therapy.This argument is valid where psychotropic drugs with a relatively specific effect are available, as they are for the vital depressions and psychoses of the schizophrenic type. In these groups of patients, empirical findings confirm the theoretical expectation formulated (4) above. It is postulated that, for the treatment of neuroses which has so far been based entirely on psychotherapeutic intervention, much is yet to be expected of future developments in psychopharmacology.     

Relating literature to medicine: Blending humanism and science in medical education

There is a need to add a humanistic component to scientific aspects of medical education. It must be adequately organized and evaluated to compete successfully in an already overcrowded curriculum. This study reports an educational experiment involving three consecutive freshman classes in a new community-based medical school. A specialist in literature and a psychiatrist teach a two-week course to first-year students in which themes and topics relevant to medical practice are explored through selected readings and patient interviews that are integrated into daily experiential groups. The outcome of the course and similarities and differences between years are explored inrelation to group sessions, class composition, reading assignments, and patient interviews.     

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.     

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.     

Humanizing the student-cadaver encounter

In a recently accredited medical school, the curriculum, which emphasizes the psychologic and social aspects of disease, includes innovative features aimed toward training students to provide humanistic health care in underserved areas. As part of this curriculum, an educational experiment was designed to explore issues concerning the medical student's first exposure to a cadaver. The authors describe the experiment as it evolved over a three-year period, and they discuss its value based on student evaluation and faculty opinion.