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In Appreciation
W
e would
like
to extend
makingAcademic
our
Psychiatry
grateful
appreciation
an indispensable
to all those companion
who
gave
so much
for the psychiatric
to
educator.
Your consistently outstanding work as reviewers has created a superb standard for our peer-review system and the journal’s publication excellence. We would also like to extend our thanks to the journals’ staff at the American Psychiatric Press:John McDuffie, managing editor; Christopher Greene, assistant editor; and Bessie Jones, editorial assistant. Special acknowledgment also goes to our colleague Dr. Laura Roberts, who has graciously extended to us her time and expertise in manuscript review as well as in the administrative and management tasks involved in running a scholarly journal. Thank you again for your time and commitment to Academic Psychiatry. Our best wishes to you for the coming year. Samuel J. Keith, Paul C. Mohi,
Gerald
Adler, MD. Z. Altshuler,
Kenneth Jeifry Linda
Allan Tracy
M.D.
M.D.
Andresen, B. Andrews,
R. Dyer, M.D. Eells, Ph.D.
Ru S. El-Mallakh,
M.D.
Milton
Engel,
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Peter
M.D. M.D.
M.D. M.D.
S. Jensen,
James
Jensen,
Allan
Mark
M.D. M.D.
Paul Stuart Appelbaum, M.D. George W. Arana, M.D. Paul Balson, M.D., MPH. John Battaglia, M.D.
Javier Dwight
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Garfield,
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Gold,
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Litle,
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Roger Arthur
Barry
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Tamarin
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Morenz,
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Morrison,
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R. Muskin,
M.D. M.D.
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McCarty,
Lesly
M.D. M.D.
H, M.D. M.D.
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M.D.
M.D.
M.D. M.D.
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Albana Dassori, M.D. Paul A. Deci, M.D.
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Ph.D.
F. Lehman,
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M.D.
M.D.
Ellen Leibenluft, John Lisansky,
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Kiieg
Lambert, Landy,
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D.O.
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Kowatch, M.D. A. M. Kramer,
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HI, M.D.
Jo Kotrla,
Irving
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Gaufberg,
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Robert Thomas
Marcia
M.D.
H. Chan,
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M.D. M.D.
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0. Gabbard,
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Katzelnick,
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Lorian
Franchini,
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M.D.
L. Forster,
J.
David
Gregory
Alan
M.D.
Brotman,
Candilis,
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Bostwick,
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Fife,
Glen
M.D.
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Fauman,
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Paul
M.D.
Michael
R. Erickson, Escobar, Landis
Douglas M.D.
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D. Bloom,
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Brenda
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Linda David
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0.
Rieder,
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R. Robertson,
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Ph.D.,
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M.D.
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E. Taylor,
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J. Thienhaus,
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M. Schulte,
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Schwartz,
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Tischler,
Gary
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Ph.D.
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Teddye
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M.D.
Vargas,
Johan
II, M.D.
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Warner,
M.D.
Stephen
James
Weiler,
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Weissberg,
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M.D.
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H. Weissman,
Arnold
Werner,
Donald
Allan
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M.D. West,
M.D.
Deborah
Timothy
Kane
Sherwyn
M. Woods,
M.D.
Leonard
E. Sabin, M.D. H. Sack, M.D. Sajatovic,
Scannell,
Tasman,
M.D. M.D., Ph.D.
M.D.
James William Martha
Benito Santos, M.D. W. Santos, M.D.
Tardiff,
Allan
Tom Widiger, Ph.D. Thomas N. Wise, M.D.
L. Ruedrich,
Z. Sadler,
Kenneth
M.D.
Nathan Bert Smith, M.D. Zach Solomon, M.D.
Stephen
John
M.D.
M.D.
Rosenbaum, H. Rubin,
M.D.
Sally K. Severino, M.D. Pramod A. Shah, M.D. Stephen B. Shanfield, M.D.
M.D. M.D.
Paul Rodenhauser, Brenda Roman,
Milton Eugene
Alberto Cynthia
Stuart
H. Reid, M.D. Riba, M.D.
Brian Laura Carolyn
A. Sansone,
Harvey Michael
Elizabeth Rand, M.D. Alison Reeve, M.D.
William Michele
Sanders,
Randy
Stacy
Joseph
Harry Lucy
Richard
M.D. M.D.
Susan Stefan Ellen
Gordon Paul
Spitz, Jorve
M.D.
Stagno,
I. Stein, Stein, Stover,
M.D.
Philip Joel
M.D. Ph.D.
D. Strauss, Summergrad,
M.D.
Woollcott, Yager,
Kimberly
M.D.
Deborah
M.D.
Gwen
M.D.
Wolff,
M.D.,
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M.D. Yonkers, Zarin,
L. Zornberg,
M.D.
M.D. M.D.
Ph.D.
AcADIMIc PSYCHIATRY VOLUME
I 193
I 195
I
In Appreciation Samuel
I. Keith,
SPECIAL
M.D.,
The Role of the Time of Managed
Psychiatrist: Care
Verhulst,
205
Supervisor
Evaluation:From
Nathan Teaching
E. Hyler,
School
Geriatric
232
Psychiatry
Let
Hollywood Jaime
Electives
Training
and
in Adult
THE
T. Pichot,
EDUCATIONAL
Linda
Suicide
in the
Cinema
M.D. Into
Psychiatry:
Plaut,
Ph.D.,
Residency Ganzini,
A 20-Year
Eric
Weintraub,
Training
M.D.,
George
Experience M.D.
Programs A. Keepers,
M.D.
I Using
the
Internet
M.D.
by Dorthea
countermyths,
233
Testing
common
234
Feasibifity
of hospital-based
practicing
physicians
use
Psychiatry
Recruitment:
Myths,
The
in the
EDITOR
233
reasonable
Practice
I
ABSTRACTS
Abstracted
235
Help! Moore,
S. Michael
M.D.,
Residency
John
and
to Implementation
Recruitment
M.D.,
S. Levitte,
TO
Theories,
F.R.C.P.C.
M.D.,
Weintraub,
Susan
I
M.D.,
Psychiatry?
Walter
Methods,
Theory
Hemnann,
Steven Medical
Defining
I
ARTICLES
LETFER
M.D.
M.D.
REGULAR
I
C. Mohl,
I
.
226
Paul
ARTICLE
L
220
1996
APPRECIATION
Johan
212
NUMBER4.WINTER
20.
and
Juul,
Ph.D.
truths
about
use
of peer
inteffigence
sense
of cognitive or customary
taxonomies
ratings
in licensure
to evaluate
and
certification
the
performances
test
development:
of
I
VIDEO
236
Using
I
COLUMN Video
POINT
for
Psychiatric
Residency
Recruitment
I
& COUNTERPOINT
238
Point:
The
Top
241
Counterpoint:
I
EDUCATIONAL
242
Educational
10 Reasons
for Psychopharmacology
Psychopharmacology
Kramer,
I
DEPARTMENTS
244
Index
251
Statement
252
Information
Supervision
I
COMPUTING Computing:
Thomas
Supervision
Column M.D.,
Robert
Debut S. Kennedy,
M.A.
I
to Volume
20
of Ownership,
for Contributors
Management,
and
Circulation
Special The Role
Article
of the Psychiatrist
Defining Methods, Practice in the Time Johan
Theories, of Managed
Verhuist,
and Care
M.D.
This essay proposes that the division between biological and psychotherapy-oriented psychiatry originates in the discipline’s reliance on two fundamentally different methods of inquiry, that is, the medical-biological and the empathic-narrative. These terms are defined and distinguished from psychotherapy and psychodynamic psychiatry, as well as from general humanistic qualities in medicine. The division within the field may be fueled by a lack of clarity with respect to these concepts. The author argues that the essence of psychiatry is defined by a balanced combination of both methods. Psychiatry does not consist only of basic methods, but also of rules and guidelines for clinical practice, and of knowledge and theories used in the application of the methods. The role expectations for psychiatry in the managed care environment are examined and their effects upon methods, theory, and practice are analyzed. Some suggestions for dealing with the challenges of health care reform are offered.
(Academic
Psychiatry
1996;
20:195-204)
Le saint gu#{233}rit par l’amour, le magicien par le pouvoir, le m#{233}decinpar la m#{233}thode.
discipline. Practice is what the physician does, as reflected in clinical standards, protocols,
T
(The saint heals
through
through methods.)
the
power,
physician
and
of psychiatry external
inform
inter-
ods
care and
reform threaten scope of practice.
the psychiatrist’s To maintain some
atry
trol
over
a consensus
the
oped useful the
This
(1).
toward
future,
of the discipline essay
fostering in this
practice,
the discipline. The consists of the concrete peutic
activities
the
to be a first step It may be to distinguish between
consensus.
theories,
that
and
the
practice of diagnostic are characteristic
They
which
methods approach
that
what
the
two
to look clinical meth-
discipline
originally
(2), it is argued upon
other
Theories
sense of the the systematic
a distinction
based
different biological
instruct
upon
by Jaspers is
the
that
is pro-
psychi-
fundamentally
of inquiry: the medicaland the empathic-narra-
to be devel-
attempts
that
respect the
posed
on
of knowledge to possess.
to make there are
Following
role con-
about
needs
practice:
of inquiry,
founded.
body
needs
for and how data. Finally,
Internally,
Theory,
to the
psychiatrist
biological psychiatrists and psychotherapists are becoming increasingly polarized. Externally, socioeconomic changes and health
definition
guidelines.
refers
the
G. Buyse
is facing
challenges.
and
hand,
through -
he discipline nal
love, the sorcerer
methods
of
psychiatry and therafor the
Dr. Verhulst sociate professor try and Behavioral
is residency of psychiatry,
Seattle.
reprint
Address
partment
versity WA
Sciences,
of Psychiatry
of Washington
training director and asDepartment of Psychia-
University to Dr.
98195. Copyright
© 1996
of Washington,
Verhulst, Deand Behavioral Sciences, Uniat Seattle, Box 356560, Seattle, requests
Academic
Psychiatry.
tive approach. An analysis of both methods will lead to the conclusion that the essence of psychiatry as a discipline lies in the balanced combination of both methods. Confusing methods of inquiry with theoretical perspectives or clinical practice leads to misunderstandings and may be partially responsible for the polarization of the field. This proposition will be discussed. In the last section, I will review how psychiatric practice, theory, and methods may be affected by health care reform. Directions will be suggested for dealing with the challenge of a changing environment. First, a description of methods, theory, and practice is in order. METHODS: BIOLOGICAL Modem diseases
THE
MEDICALAPPROACH
medicine is based upon the idea as definable elements of reality.
disease is distinguished on the basis cific symptoms, a specific etiology
of A
of speand
pathogenesis, and a specific course of illness (3). Empirical and experimental research leads inductively to scientific descriptions of the disease and to “models” that correspond with increasing accuracy to real processes in the patient’s body. The medical-biological approach, characteristic for scientific medicine, takes an objective, observing stance and reaches a diagnosis by matching signs and symptoms with disease criteria. Such a diagnosis
relates
this
particular
case
to the
sionate attitude, empathy, and human warmth have been identified as the “humanistic qualities” that all physicians should possess (5). These qualities express personal care for the patient while the physician is objectively treating an impersonal disease. They are seen as basic traits that applicants to medical schools should be selected for and that can be influenced and reinforced during residency training (5). In psychiatry, the medical-biological approach can be defined as the formal method of objective observation, examination, and clinical scientific reasoning by which the psychiatrist identifies and treats disorders as defined by the Diagnostic and Statistical Manual (DSM). The method often involves semistructured interviews to match symptoms with DSM criteria, as well as medical and psychological tests. Because the ultimate goal of the DSM classification is to identify psychiatric diseases, the diagnosis already suggests the presence of a pathological process that all patients with the disorder would have in common. Treatment follows the diagnosis and is based upon the available empirical evidence. The medical-biological approach governs the somatic therapies. To use the medical-biological method effectively, the psychiatrist should possess the humanistic qualities of the physician. METHODS: NARRATIVE
clinical
experience and research with groups of similar patients. As the scientific method in medicine has developed increasingly objective and rational methods of observation, an inherent problem has come to the forefront: The patient feels treated as an object of examination rather than as a person. Consequently, the doctor-patient relationship tends to deteriorate, compliance to decrease, and iatrogenic complications to increase (4). To mitigate this problem, the medical-biological method requires a humanistic context. Sensitivity and respect for the patient, a caring and compas-
THE
EMPATHIC-
APPROACH
The empathic-narrative method is defined by an empathic interactional process: one tunes in to the patient and to one’s own reactions and associations to what the patient discloses; one looks for patterns and tries to make sense of all the information; and one formulates hypotheses of understanding tient
and
communicates
in a tactful
and
these helpful
way,
patient, in turn, gives feedback and associations (6). Theories of learning,
to the
pa-
and
the
further
development, cognitive processing, and interactional and social dynamics are used to extend
one’s understanding into the experiential world of the patient and to facilitate the process of translating this understanding into words. Empathic interactions lead to a meaningful story, a narrative, which can be summarized in the formulation of an explanatory hypothesis for the patient’s behavior and feelings (7). The empathic-narrative method governs the psychotherapeutic aspects of care. One will recall that one of the characteristics Yet
of the the
humanistic
empathic-narrative
be subsumed istic
physician
method
under
these
The
natural
qualities.”
is empathy.
general
cannot
“human-
empathy
of the
physician is intuitive and prescientific. The empathic-narrative approach, on the other hand, is a formal method of inquiry that requires systematic study and training. A surgeon, for instance, may be wonderfully “warm and empathic” toward her patients, yet she may have little skifi in developing narratives lyst could method,
of understanding. be a master yet
he
may
in
be rather
A psychoanathe narrative reserved
and
reticent in expressing human warmth. The empathic-narrative approach can be defined as a formal method of establishing and maintaining an empathic interactional process, by which both the psychiatrist and the patient gain a meaningful understanding of the patient’s symptoms, coping strategies, life experiences, and relationships. This method involves a degree of selfdisclosure and self-reflection on the part of the patient and a complex activity of listening, reflecting, and expressing hypotheses of understanding on the part of the psychiatrist. The narrative diagnostic formulation, which summarizes understanding, is unique for every patient, and this understanding is often in itself therapeutic. The therapeutic effect of the empathic narrative method seems related to the following: 1) being understood by another person restores one’s sense of belonging and connection to others; 2) feelings and experiences that were strange or unacceptable are
validated
and
can
now
be integrated
into
a
more realistic self-image; 3) the hypotheses of understanding provide a new perspective and suggest possibilities for change; and 4) empathic interactions strengthen the collaborative alliance between patient and psychiatrist. THEORIES
Each of these methods draws on a large pool of knowledge. To competently apply the medical-biological approach, one needs to have a thorough knowledge of biology and psychiatric
diseases,
as well
as their
epidemi-
ology, nosology, and psychopharmacology. Applying the empathic-narrative method requires sophisticated knowledge of how the mind works and theories about why people behave the way they do. It involves more than being a good listener. Even a natural good listener can easily be confused by a patient’s strange behavior, illogical ideas, or unusual feelings. What allows one to expand the range of what is generally understandable is knowledge: Theoretical constructs that offer a bridge between the inner world of the patient and one’s own. One will notice an important difference between the theories that inform the medical-biological method and those that inform the empathic-narrative method: Medicalbiological theories intend to accurately reflect an objective reality; empathic-narrative theories intend to facilitate a subjective understanding of the patient. Thus, in applying the empathic-narrative method, one can, to some extent, pragmatically choose a theoretical
perspective
that
“works”
or suits
the
subjective reality. Such flexibility is invaluable in times of transition, as will be shown next. In addition to knowledge that supports the clinical application of each method, there is also a body of knowledge about each method. One finds, in the literature, detailed descriptions of the objective, observing medical relationship (8). Major contributions
to our understanding tive
process
of the empathic-narra-
have
been
made
that
by psychoana-
research. It should be hard to reflect upon this method without key concepts, such as identification, transference, countertransference, and therapeutic alliance, to name just a few. The terms “empathic-narrative” and “medical-biological” can be abbreviated to lytic
simply
“narrative”
clinical practice the psychiatric called “narrative practice and method can be psychiatry.”
and
“medical.”
the danger
though
Also,
the
of the narrative method and knowledge related to it can be psychiatry”; and the clinical knowledge of the medical called “medical or biological
methods
can
be
is real,
inclined
trists tell us that the method is, in fact,
exclusive impossible
even
psychia-
practice of one (9,10). Both
distinguished,
and
one
can
dedicate oneself to the pursuit of one method only. For example, following the lead of medicine, biological psychiatry has made relatively successful efforts at replacing “subjective” elements of psychiatric assessment with more “objective” methods. Instead of construing a patient’s story, one attempts to reliably capture relevant information in a life-event questionnaire; instead of empathically exploring the patient’s experience of symptoms and illness, one matches a symptom checklist with diagnostic criteria. In the
PRACTICE
of reductionism
philosophically
future,
the
tic laboratory
push
tests
to use
may
shift
more the
diagnos-
emphasis
to
psychoanalytic perspective; others use learning theories. One can focus primarily on assessment or therapy, on crisis intervention, or long-term care, and so on. To define the range of what is acceptable
more objective criteria to establish psychiatric diagnoses. Clinicians are well aware of the limitations of such attempts to bring the whole of psychiatry under the medical-biological method. Despite major efforts to refine the diagnostic criteria, ambiguities keep emerging. This is especially true for the “neurotic”
practice,
disorders,
Psychiatric
practice
chiatrists may psychotherapists
the
of care practice
With
is varied.
prefer the
profession
develops
care
reform
set of values
and
priorities,
Adaptation
guidelines seems
for various conditions.
imposing
a different
standards
are being
reasonable,
a
standards
and clinical guidelines settings and clinical
practice
psy-
the medical method, narrative. Some favor
health
and
Biological
of care
adjusted.
as long
as the
the range of acceptable practice. Similarly, as there is some degree of flexibility in the use of theoretical constructs to inform the narrative method, one can choose theoretical perspectives that fit the new priorities and values. The core question, however, is: Will psychiatric practice hold the narrative and the medical methods in equilibrium, or will psychiatry be restricted to the humanistic application of the medical method only? I argue that psychiatrists cannot adequately provide service without a balanced combination of both methods. I also believe changes
stay
within
where
stantly
shifts
the with
symptomatology
ments, and where individual seem capable of generating pected syndromes. Another the fact that the patient’s tomatology used
is itself
to
evaluate
unusual
for
sciously
learn
con-
sociocultural
patients always new and unexlimitation lies in expressed symp-
shaped it. For
“borderline”
develop-
by instance, patients
to endorse
all the
the
method it is not to uncon-
symptoms
of, say, bipolar disorder in the course of repeated structured interviews in emergency room settings. The result can be the “iatrogenic” development of a pseudo-identity (11) as a manic-depressive patient and the adoption of a chronically mentally ill lifestyle.
Similarly, ented use the tivated
psychiatrists
psychotherapeutically sometimes
oriexclusively
narrative method. They may be moby a desire to always approach the
patient
as someone
man
who
condition
standable patient
in
way, as an
deals
with
the
and
under-
a unique
rather
than
“alienus,”
defining
a mind
huthe
requires
ever
more
for each
particular
NARRATIVE
complicated
case.
PSYCHIATRY,
PSYCHOTHERAPY,
AND
PSYCHODYNAMICS The
field
vided
of
psychiatry
between
the
one
or
“psychodynamic”
other.
hand It is,
is increasingly
“biological” and
di-
psychiatrists
on
“psychotherapy-oriented”
however,
psychiatrists narrative
on
the
psychiatry,
that is, the practice of the narrative method, that can be said to be the opposite as well as the complement of biological psychiatry, not psychotherapy or psychodynamics. This proposition requires Psychotherapy
further can be
examination. very broadly
the
patient.
illness “psychotherapy.”
called
theoretical constructs to expand reason into the realm of the irrational. Clinicians also know that the narrative method, by itself, can mask pathology, because both the psychiatrist and the patient tend to selectively pay attention to what fits with the evolving story. A formal, “objective” mental status examination may be needed to bring symptoms (e.g., alcohol abuse, “hearing voices,” or suicidal plans) into focus. One can say that any clinical assessment is incomplete unless an empathic narrative has been complemented by a medical-biological examination (12). Although both methods are very different, they do generate complementary information. However, this does not mean that the information gained by each method is equivalent. In some patients, the medical information is more relevant for treatment or prognosis, in others the narrative. There are few, if any, explicit criteria to help determine when to give priority to which method. Much of the art of psychiatry lies in knowing the proper balance of methods
with
a patient’s
disqualified
by a mental disease. Clinicians have learned, however, that exclusive use of the narrative method
fined. There seems to be a tendency the term to refer to any therapeutic
de-
An empathic
to use dialogue
exploration
experience
can
Even
of
then
be
the expression
of humanistic qualities during a medical evaluation, or any kind of supportive companionship, could be termed “psychotherapy.” Clearly, psychiatry a more narrow definition which pect
differentiates of
general
may
it from psychiatry:
wish to support of psychotherapy, the
narrative
as-
Psychotherapy
refers to formal treatment with a psychotherapeutic modality or with an eclectkz/integrative combination of modalities. A modality is defined by a specific theoretical framework from which specific therapeutic strategies are derived. Examples are psychoanalysis and cognitive therapy. Psychotherapy relies to a large extent on the empathic-narrative method but should be defined by its theories and practices if one wants to avoid confusion with the more encompassing narrative method of inquiry. For instance, a biological psychiatrist may very well believe that psychotherapy is no longer a viable part of the job description of the psychiatrist, yet he or she greatly values
the
derstanding experienced
narrative
method
of how and how the
in gaining
an
un-
symptoms illness fits into
are the
patient’s life story. Or a managed care company may take the “logical” steps of first assigning all “psychotherapy” to nonphysician providers and then restricting the psychiatrist to medical-biological tasks, believing that there is nothing else left. The distinction between narrative psychiatry and psychodynamic psychiatry is equally important. Psychodynamic psychiatry is the application of psychoanalytic theory and knowledge to general psychiatry (13). Described as a “way of thinking,” which complements the medical-biological approach and which endeavors to understand the patient (13), psychodynamic psychiatry can certainly be seen as a form of narrative
But not all narrative psychiatry is psychodynamic. In fact, many psychiatrists practice the narrative approach by means of nonpsychoanalytic theoretical perspectives, such as cognitive theories, systemic-interactional insights, or learning paradigms. The term “narrative psychiatry” encompasses all applications of the narrative method. Indeed, the narrative method is defined by a specific empathic interactional process, not by the explanatory theories that are used in it. The polarization between narrative and biological psychiatrists seems partially fueled by confusion between a particular psychodynamic theory and practice. Psychoanalytic thinking does not fit very well with the belief system of many biological psychiatrists. As for managed care, it is hard to imagine a perspective that appears more alien to its values and priorities than psychoanalysis. It would be most unfortunate if the narrative method as a whole would be rejected because it is associated with a treatment. psychiatsy.
and a shift in the theoretical paradigms. Drastic changes could even affect the basic methods the
of the
discipline,
very
identity.
latter’s
Conceivably, health care reform wifi lead to “capitated” or managed care systems, whose pnmaly purpose appears to be to control health care costs. Strategies to meet that goal include an emphasis on medical necessity and on time-effective, empirically validated interventions, as well as the development of a multidisciplinary approach in which the most expensive providers are assigned as narrow a segment of the care as possible. We will see that the changes that are being imposed on psychiatry by the managed care environment have profound effects upon the discipline. Consider the distinction between the methods, theories, and practice of a medical discipline. Minor changes are likely to be absorbed at the level of practice, and without much effect upon theory or methods. More profound changes may
also
require
a different
way
of thinking
altering argue
that
health care reform requires changes in psychiatry that go beyond the level of clinical practice and also involve the discipline’s theoretical perspectives. Even the basic methods of inquiry, constituting the identity of the psychiatrist, seem to be affected: The use
of the
narrative
method
as an
essential
aspect of psychiatric care may be in peril in this new environment. To argue these points, I will first briefly review the model of psychiatric practice that seems to be envisioned by managed care. I will indicate how it differs from traditional psychiatry and whether the changes that would need to be made to accommodate the new model involve the discipline’s practice, theories, or methods. Finally, I will argue that psychiatry may benefit not only from adjusting ance with
its practice managed
it is imperative THE CHALLENGE OF HEALTH CARE REFORM
thereby I wifi
method
to maintain
in patient
of all psychiatric
and theories in accordcare values, but also that care
the
narrative
as an essential
aspect
work.
CHARACTERISTICS OF MANAGED CARE: MEDICAL NECESSITY, TIME, AND COST EFFECTIVENESS In managed care, the gathering of diagnostic information is limited to what one needs to 1) develop a reasonable treatment plan, and 2) to justify the expenditure of the resources one is planning to commit. Psychiatrists may find it difficult to adapt to such a “utilitarian” philosophy.
Traditional
training
has
always
emphasized completeness and comprehensiveness: A really good evaluation consists of a multi-axial diagnosis and an in-depth psychodynamic formulation, which uncovers the underlying issues and the root causes of the problems. Furthermore, in managed care the goal of treatment is to alleviate symptoms and to improve the patient’s level of functioning.
ment cannot be reached without addressing such problems. Managed care fosters a highly practical and pragmatic approach, and demands time and cost-effective, empirically validated treatments and explicit outcome expectations. In traditional psychiatric practice, the outcome expectations tended to be vague. The goal of treatment
Many psychiatrists perceive the restriction of their role to purely medical-biological work as a threat to their professional identity: Their narrative skills, honed through years of training and practice, seem to be disqualified and may ultimately atrophy. A deep concern about the consequences of this model for patient care exists. And indeed, when the medical method is not complemented with a narrative approach, diagnostic errors and iatrogenic complications are
was
likely
One needs complaints, treating
to stay close to the patient’s overt and one should only consider “underlying”
often
problems
“personality
reconstruction”
rather than symptom managers are skeptical bitious
therapeutic
ment plans psychiatrist’s
relief. Care system about vague and amgoals,
that
if improve-
seem ideological
and
about
based
upon position
treatthe and
unique interests rather than upon scientific evidence. The managed care model differs considerably from traditional practice. Simply adopting a new style of practice will not be enough. What is also needed is a different way that
of thinking supports,
and a theoretical framework informs, and guides such clini-
cal practice. CHARACTERISTICS CARE:
OF MANAGED
A MULTIDISCIPLINARY
APPROACH In solo practice, roles: signs
the psychiatrist
He or she the treatment
conducts
the
psychotherapy, control and
managed
provides plan, somatic
fulfills
the diagnosis, negotiates the treatments
and
many defees, the
and is responsible for quality utilization management. In
these roles are decentralized among many players. All too often, the psychiatrist is left with the role of team DSM-diagnostician and psychopharmacologist. Other members of the mental health team perform the “nonmedical” clinical tasks, such as case management, psychoand
care,
divided
therapy,
counseling
establishing support take on administrative tion
review
and
quality
to
families,
and
systems. Still others tasks, such as utiliza-
control.
to occur. A managed
care
administrator
may
very
well agree with the need for both approaches, but that person may propose that the narrative assessment be conducted by a less expensive team member, such as the social worker or psychotherapist. However, if one team member exclusively uses the medical method and another exclusively the narrative, they both risk construing an incomplete and distorted image of the problem and its etiology. The patient’s disorder should not be disconnected from the patient’s story. For one person to use both methods and to integrate the information in a coherent clinical picture is a matter of medical necessity. That one person is, by virtue of training and experience, the psychiatrist. In some managed care environments, this problem is solved by giving psychiatry a more central role in the team structure: The psychiatrist offers both a descriptive and a narrative formulation; he or she oversees and coordinates the care and provides supervision as needed. This role requires the psychiatrist to constantly use both methods of inquiry. To competently play such a central role, the psychiatrist needs to also possess specific additional skills. For instance, he or she needs to be able to negotiate, among all team partners, a common understanding of 1) what the problems are; 2) how they, presumably, came about; 3) what one can do about them; and 4) what outcomes one can expect and pursue. A shared image of the problems, their etiology, the treatment options, and the
outcome expectations is essential for tive teamwork. Note that the utilization reviewer,
effec-
strategies fessionals, ministrators
who
represents the task of cost control, and the primary care gatekeeper should collaborate as members of the treatment team. As much as possible, the patient and the patient’s family should also be engaged as full team partners, who help define the problems and participate in the treatment plan. The establishment of a collaborative partnership with the patient and the family is of foremost importance in managed care (14). Traditional training may not fully prepare the psychiatrist to take on such a central role. One needs to be able to both perform a structured diagnostic
evaluation
in a limited
ration
to be able
and
a narrative
amount
to integrate
of time; the
explo-
one needs
bio-psycho-social
data and to develop a clear and jargon-free formulation that can be shared with the team; and one needs to know how, and to what extent, to negotiate the formulation and the treatment plan with the patient and other team members. Consequently, clear thinking and common sense have priority over sophisticated conceptual nuances. Many of the traditional theoretical frameworks
used
in narrative
suited to support to play a central
seem
ill
these tasks. If psychiatry is role in managed care,
changes
in “theory”
changes
in “practice.”
ADAPTING
psychiatry
should
complement
TO MANAGED
the
CARE
The analysis of the effects of health care reform on the practice, theories, and methods of psychiatry leads to some initial recommendations. The balanced combination of the medical and be
the narrative
psychiatry’s
contribution
methods
of inquiry
most
unique
and
to patient
care.
To defend
may
valuable such
a core value, the profession should consider 1) developing research programs to demonstrate the importance for patient care of combining both methods; 2) developing
for educating policymakers, about
exclusively and the
mental health proand health care adthe danger of an
medical-biological
approach;
3) encouraging psychiatrists to support medical necessity of combining both
methods role
of inquiry
and
to demand
for
the
psychiatrist
in the
As
for
adjustments
in
a central
mental
health
team. the
discipline’s
theories, some general considerations and directions for change can be offered. The narrative method uses theories to expand one’s capacity for empathic understanding. In contrast, medical-biological theories purport to describe an objective reality and laws of nature, which makes them somewhat less adaptable to socioeconomic changes. Health care reform challenges narrative psychiatry to adapt current conceptualizations and to develop and
new
priorities
ones.
cepts and theories ple, so that they
patient
and
change
and
Considering
of managed
care,
that 1) are clear can be understood
the treatment team; utilize the therapeutic
of the narrative method ment of the interview;
empathic laborative
the
connection partnership
values
we need
con-
and by
simthe
2) promote potential
from the first and 3) support
and, hence, the between patient
mo-
the coland
physician.
Conceivably, these three criteria can be made operational, and they can be used to objectively evaluate theoretical constructs and interventions. For instance, the concept of projective identification, which carries sophisticated nuances that can be helpful in psychoanalysis, may need to be translated into a clear interactional language in order to be useful in general psychiatry. (People acquire
the
cognitive
schema
of the
interaction
patterns that are prevalent in their culture. Thus, when someone in a relationship displays one “half” of a particular interaction pattern, the same schema is triggered in the partner who will feel inclined to respond with the complementary role.) Similarly, the image of a patient being “fixated in,” or “re-
gressed create
to,” early unnecessary
developmental distance
answered unambiguously. One should that a clear awareness of the challenge creases the likelihood of success.
stages may contrasting
by
the patient’s immaturity with the therapist’s superior growth. In contrast, a conceptualization in terms of patterns that were learned in the past is not only less judgmental but also offers the hope that these patterns can be unlearned. At first glance, it may seem that psychiatry should be able to adjust to managed care by changing practice guidelines and narrative
theories.
The
flexibility
of narrative
CONCLUSION In the debate about the future of psychiatry, a lot of attention seems directed at the question of whether psychiatrists will still be able to conduct psychotherapy. bate between narrative
con-
ceptualizations is limited, however. Medical-biological theories can be said to be limited by “facts and data”; narrative theories are limited by the belief systems of the psychiatrist and the patient. Indeed, it is important that the theory on which the psychiatrist’s empathic understanding rests “rings true.” Conceptualizations can only serve as a bridge between the inner world of the patient and one’s own if they resonate with one’s world view and belief system. A practitioner who has, over the years, successfully identified with a particular theoretical perspective may no longer be able to question it. As for the patient, the therapist’s perspective needs to be new to facilitate change but can-
chiatrists
not
be too
partnerships
tion
“Are
the
new
to be incorporated.
psychiatrists
new
role
The
capable
demands?”
can
of
ques-
meeting
therefore
not
hope in-
be
centers
psychotherapy. that
the
real
argues
be
issue
is whether
a “straw
the
depsy-
value that
of psy-
person”
and
psychiatry
can
practiced without a balanced of the narrative and the medimethod.
At the
same
in ways
of thinking
by managed mately
the
essay
may
be adequately combination cal-biological and
around This
chotherapy
Similarly, biological
and
time,
care.
benefit
changes
in practice
are being
demanded
These the
changes
field
as
could
the
ulti-
traditional
emphasis on defining “underlying problems,” on idealistic but vague treatment goals,
on sophisticated
alizations, placed
and by an
but
private
on ideological emphasis on and
on
change
and
that
tal, and
understandable.
conceptupurity is recollaborative
a language
that
is respectful,
fosters
nonjudgmen-
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Regular
Articles
Supervisor From
Theor,i
Nathan
Evaluation to Implementation
Herrmann,
M.D.,
F.R.C.P.C.
The evaluation of supervisors demic psychiatry programs.
and assessment of teaching effectiveness are vital for acaThe literature on teaching evaluation in classroom settings reviewed briefly, followed by a summary of the available literature on supervisor evaluation in clinical medicine and psychiatry. While student evaluation forms of supervisor’s teaching ability may be reliable and valid, this popular form of assessment is insufficient fulfill
all the purposes
required
of such
evaluations.
The development
and
of a new process for supervisor evaluation is described for the University partment of Psychiatry. (Academic Psychiatry 1996; 20:205-211)
T
he evaluation of teaching effectiveness in clinical medicine is essential if instructors are to improve their skills, educational directors are to strengthen programs, and deans are to promote faculty members (1). Despite these crucial functions, surprisingly little has been written about the evaluation of teaching effectiveness in medicine as a whole, and almost nothing pertaining to psychiatry in particular, While several studies have attempted to examine the process of evaluating supervisors in clinical medicine, these attempts have paled in comparison to the systematic implementation and thorough research of teacher evaluations in the dassroom setting (1). Furthermore, a recent review concludes that what literature exists deals almost exdusively with studies that have focused on the use of student evaluations (2). While an exhaustive review of the education literature is beyond the scope of this article, it is worthwhile to examine some of the themes of these studies before considering the work in clinical medicine.
Education there are
OF THE
researchers essentially
LITERATURE have two
recognized that ways to judge
to
implementation
of Toronto’s
De-
teaching effectiveness: 1) use of an “objective criterion” based upon what students have learned from their teachers, and 2) use of a “subjective criterion” based upon students’ evaluations (3). While ratings in education and clinical medicine have often focused on student evaluations, faculty resistance to this aspect is well documented. The following concerns predominate: 1) evaluation forms are often prepared by persons who are unqualified to construct such instruments, 2) student ratings are unreliable, 3) student ratings might favor an “entertainer”-style teacher, 4) student ratings are highly correlated with expected grades, and 5) students are not competent judges of educators since the long-term benefits of a particular course may not be clear at the time it is rated (4). While most research has shown a weak positive
correlation
between
student
is postgraduate
ratings
and
education coordinaCentre, and assistant professor of psychiatry, Department of Psychiatry, University of Toronto, Ontario, Canada. Address reprint requests to Dr. Herrmann, Sunnybrook Health Science Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. Dr. Herrmann
tor,
REVIEW
is
Sunnybrook
Health
Copyright
© 1996
Science
Academic
Psychiatry.
other indices of teaching effectiveness, such as class performance (5,6), some have questioned whether good teaching can be measured at all by using the typical criteria in student
rating
by Rodin
forms.
A controversial
and Rodin
study
(3), for example,
a negative correlation between ings of teaching performance
showed
student ratand objective
of student learning, prompting the authors to report, “Students rate most highly instructors from whom they learn least.” Hyratings
pothesizing
about
their
results,
the
authors
suggest that students may resent instructors who force them to work too hard and learn more
than
they
wish.
Rodin
and
Rodin
also
postulate that the more students learn, better they are able to detect weaknesses teaching
ability,
important teachers
to consider when of senior residents and
search
such
phor
a suggestion
as this
of student
that
suggests
might
be
evaluating fellows. Re-
that
as consumer
the in
the
is not
metaalways
not always know what is best. Despite these concerns, a comprehensive review of the education literature suggests that student ratings are reliable, with good stability (test-retest appropriate-that
is, the
reliability) and rater reliability)
customer
internal
does
consistency
(inter-
seven
dimensions
guished
that
the best
were
from
enthusiasm,
significantly worst
distin-
clinical
teachers
organization/clarity,
clini-
cal competence, modeling, group instructional skills, clinical supervision, and knowledge. With some modifications, Irby and colleagues used these dimensions to design a rating form later tested in a follow-up study (I). They found that the form was highly reliable, as assessed by interrater reliability
and
internal
consistency.
Irby
et al.
also used factor analysis to determine construct validity based on the literature and concluded that the ratings were specific enough to identify individual strengths and weaknesses in a sample of obstetrics-gynecology
staff
recently,
rated
Irby
acteristics
by
clinical
et al. have
shown
of clinical
teachers
clerks. that
More the
char-
in ambulatory
care settings were similar to those found in prior studies of ward teaching (8). These results may be important because they suggest that
different
rating
forms
may
needed
for evaluating clinicians in different services or milieus. Other
studies
on the
cal (9) and internal sicians (10) further
evaluation
medicine confirm
not
who
be
teach
of surgi-
attending the reliability
phyand
(4). These authors also conclude that while student ratings “fall far short of a complete assessment of an instructor’s teaching contribution,” they do provide valid data based upon their review of studies examining content, criterion, and construct
validity of student evaluations. al. (9), however, have suggested need to be grouped according
Tortolani et that ratings to postgradu-
ate
and
validity.
evaluating
David ment
Irby,
of Medical
of Washington,
a professor
in
Education
at the
Seattle,
much to the literature teaching effectiveness
the
has
Depart-
cine,
University
contributed
on the evaluation in clinical medicine.
Over the past two decades, Irby leagues have attempted to study
and the
year
of
his colcharac-
(PGY)
to reduce
bias
error
re-
lated to rater education. In an interesting description of the measurement process for clinical
asks supervisors formance, Irby’s items brief ual
form
teachers
in internal
medi-
et al. (10) describe a form that students and residents to rate
Guyatt medical
according to 14 domains of permany of which incorporated (11). While concluding that this effectively
supervisors’
differentiated
strengths
and
individweaknesses,
teristics of clinician educators and how to assess their teaching validly and reliably. In an early study (7), the medical students and
they
directors residents’
did not always review individual evaluation forms. Instead, the
residents
and
training
directors
of di-
feedback
to supervisors
worst mensions.
were
clinical The
asked
to rate
their
teachers
on
a number
results
suggested
best that
the
also
noted
of the trainees.
that,
in practice,
based
Guyatt
their
the
training
ratings
on group
et al. suggest
and
interviews that
the
reluctance
to use
evaluation
forms
is based
Psychiatry.
Each
hospital
or teaching
site has
upon the following factors: 1) the difficulty of getting house staff to complete forms consistently and carefully, 2) the reluctance of house staff to give low ratings even when confidentiality is assured, and 3) the possibility that house staff may make idiosyncratic ratings. While the validity of these assumptions was not addressed, it is difficult to argue in favor of evaluation forms if they were
a local postgraduate education coordinator (i.e., the hospital coordinator), who is a member of the medical school faculty and reports to the director. In 1991, the director of postgraduate education formally convened the Supervisor Evaluation Committee (SEC), with a chairperson (the author) and repre-
not
SEC
being
used
by the
training
directors.
Although several studies have addressed the evaluation of teaching effectiveness in psychiatry, they have dealt only with psychotherapy supervision (12-17). Ratings of videotaped supervision have been used to determine which factors distinguish outstanding psychotherapy supervisors from good or average ones (12,13). The reliability of a standardized rating scale for psychotherapy supervision has been demonstrated by Shanfield and his colleagues (14), who found that supervisors judged to be excellent were empathic and focused on the concerns of trainees (15). In a survey study by Pate and Wolff (17) that examined supervision in psychotherapy, the residents’ ranking of the supervisor’s
ability
to
teach,
the
rapport
between supervisor and trainee, and the supervisor’s fund of knowledge were by far the most important features that distinguished satisfactory from unsatisfactory supervision. These studies seem to suggest that it is possible to design generic forms for evaluation of all psychiatry supervisors without the need for modification to account for what might be considered special circumstances in psychotherapy
THE
supervision.
UNWERSITY
OF TORONTO
sentation
from
grams
as well
was
asked
evaluation the
sisted
of a 6-page
of submitting graduate
Department
of
At
evaluation
the
with
of that
form
con-
major
sec-
forms
directly
Office
to the
without
Posthaving
to show it to their supervisor. While the director of postgraduate education reviewed all the forms, there was no formal process for identifying poor supervisors, notifying their hospital postgraduate education coordinator, or dealing with the negative evaluations.
forms
university’s
system.
document
Education
ation
to the
The
process
supervisory relationship (12 aspects of supervision (7 in specific areas (13 items), and psychotherapy supervision (17 items). These 49 items were rated on a 5-point Likert-type scale, ranging from unsatisfactory to excellent, without criterion references. The last page of the form included sections for narrative comments on the strengths and weaknesses of the supervisor, as well as another 5-point Likert-scale rating for “overall evaluation.” While there was no written policy for the process, the expectation was for residents to complete this form every 6 months, discuss it with their supervisor (who was to sign it), and submit the form to the Postgraduate Education Office. Because of resident concerns, this unwritten policy was changed in 1991 to allow residents the option
described
sponsible
pro-
tions, including items), practical items), teaching
ture
re-
the
the
supervisor
single
education
and
representation.
revise
time,
For
of postgraduate
divisions
to review
and
The psychiatry residency program at the University of Toronto has over 130 residents (PGY-1-PGY-5) and about 30 fellows. The residency program occurs at 16 training sites. The program is highly centralized, with a director
major as resident
tee’s
the
yearly
academic
meeting,
scores
of the
narrative The
the
promotion
director
evaluations
would and
commitpool
summarize
the the
comments. SEC began before
used
by reviewing and
by other
examining
departments
the literaevalu-
in the
faculty of medicine cine) and by other
internal mediof psychiatry. A new form was developed, with the goals of making it shorter and easier to complete. To ensure that the form could evaluate characteristics that determine the quality of supervision, the committee borrowed heavily from the literature, especially the work of Irby and colleagues (1,7,8,11). The new form had three brief sections. Section One used a critical-incident approach to evaluation, asking the following three questions: 1) On the average, how many hours of regularly scheduled supervision did you have per week with this supervisor? 2) How many observed (live or taped) interviews did you have with this supervisor per 6 months? and 3) How many times during the rotation did your supervisor provide detailed feedback about your progress? Section Two asked residents to rate their supervisors in six categories: enthusiasm, organization/clarity, knowledge, clinical supervision, availability, and modeling. Each category contained a detailed description of the factors residents should use when rating a supervisor. For example, under the category of modeling, the
resident
supervisor professional
(surgery, departments
is asked
to consider
1) is an appropriate role
model;
whether
the
clinical
and
2) is an appropriate
role model as a teacher; 3) is responsible, self-confident, flexible, respectful, and nondogmatic; 4) relates to the resident as a colleague; and 5) is sensitive to gender, ethical, cultural, and socioeconomic issues. A seventh
question
assign an overall All 7 elements
asks
rating of the use a 5-point
scale, ranging from poor tion Three is a full page, tions requesting narrative the supervisor’s major weaknesses, ing
supervision
and
the
(A
to
supervisor. Likert-type
to excellent. with three comments strengths,
suggestions quality.
resident
Secqueson major
for
improv-
copy
of
the
complete “Supervisor Evaluation Policy and Procedure Manual,” including the rating form, is available from the author upon request.)
more
Having useful
designed what and efficient
was felt instrument,
to be a the
SEC turned to the task of formalizing a process of evaluation. This task was far more difficult than the committee members could have imagined, largely as a result of a number of diametrically opposed opinions on both the process and philosophy of evaluation. The residents were extremely concerned about the possible repercussions of giving negative evaluations to supervisors. The residents felt that because of the power imbalance
in
the
resident-supervisor
rela-
tionship, anonymity had to be safeguarded to collect meaningful, honest, and impartial assessments. Residents’ concerns extended not only to the consequences of negative evaluations on their training, but also to implications for their future careers. Residents did not feel that the current system that allowed them the option of submitting the forms directly to the postgraduate director was
suitable
sors
might
“protection,” assume
because
(often
correctly)
supervithat
they
had chosen that route because of a negative evaluation. Many supervisors were concerned about a process of evaluation that was not face-to-face in nature. Concerns were expressed about the availabffity of evaluations for promotion purposes, as well as their right to view information collected on them immediately, with the opportunity to respond quickly to negative evaluations. Members of the Postgraduate Education Committee argued that the principles of education theory, including
dealing
negotiation, ment with inconsistent
communication, and reassessstudent and teacher (18), seemed with a process that did not en-
courage
face-to-face
believed
that
with
a situation
problems
evaluation. in which
through
This
group
a resident
would provide personal feedback about supervision was valuable, if not essential, to an educational experience that has the goal of preparing residents for their future careers. In the end, however, the most persuasive argument came from the associate dean of
postgraduate medical education of the university. He noted that it was university policy to maintain confidentiality of evaluations by trainees. According to this perspective, the process was unacceptable if there was even a perception on the part of the trainee that a poor supervisor evaluation could lead to later poor evaluations of the trainee. In light of these concerns, the SEC proposed a formal process documented in the “Supervisor Evaluation Policy and Procedures Manual.” All residents are expected to provide verbal feedback to all their supervisors at least every 3 months; however, this type of evaluation is recognized as separate from the formal written evaluation done before the end of a rotation that is included in the supervisor’s teaching record. Residents evaluate their primary clinical supervisor (the
service’s
attending
physician)
and
their
psychotherapy supervisor. A resident’s rotation is not considered completed until such time as the Postgraduate Education Office has received the feedback forms. All residents are responsible for submitting these forms directly to the Postgraduate Education Office at least 2 weeks prior to the end of their rotation and prior to receiving their individual evaluation from their supervisor. The supervisor evaluation form has a face sheet with the resident’s name and a statement indicating the resident has evaluated the supervisor prior to receiving his/her own evaluation. This is the only location on the evaluation form that contains the resident’s name or signature. After documenting receipt of the supervisor evaluation forms from each resident, the director’s administrative assistant removes and destroys the face sheets. Hospital dinators and pooled
postgraduate individual
evaluations
from
education supervisors the
previous
coorreceive 4 6-
month blocks. The SEC reviews all forms after each 6-month period for “negative” evaluations, defined by specific criteria. When a supervisor receives 2 negative evaluations in any 2-year period, the individual
supervisor,
hospital
coordinator,
and
hospi-
tal chief are notified. It is the responsibility of the hospital postgraduate education coordinator
to submit
a written
report
to the
SEC
detailing the circumstances of the evaluations, the supervisor’s responses, and the actions
(remedial
taken
or
if necessary.
otherwise)
that
were
maintain the any evalu-
Supervisors
right to file a grievance regarding ation or the process, according to the university’s grievance procedure. The supervisor evaluation
forms
are
the
purpose
request
for
teaching
dossier
made
available of
for promotion
upon
inclusion
in
a
procedures.
OUTCOME One
of the most
ing July
introduction of 1993 was
number
dramatic
outcomes
follow-
of the new procedure in a significant increase in the
of evaluation
forms
submitted
by
the residents. Before 1991, 56% of the residents submitted evaluation forms. Between July 1991 and June 1993 this figure increased to 76%, coincident with the policy that allowed residents the option of sending in forms without showing them to their supervisors. From July 1993 to June 1994, when all forms
were
sent
directly
to the
postgraduate
education coordinator, 89% (189/212) of the residents submitted these forms (most residents in this program change rotations every 6 months). Of the 11% who did not submit their forms, the vast majority were senior residents
graduating
or leaving
the program.
Over the course of 7 evaluation periods between 1991 and 1994, 44 negative evaluations from a total of 619 (7%) were identified. Only four represented multiple negative evaluations, necessitating formal review by the SEC. While all the reviews were painful and difficult for both the supervisors and the committee, the outcome was positive in three cases. In these instances, the hospital coordinators carefully reviewed the causes
of the
poor
evaluations
with the supervisors, initiated changes, such as ensuring that
and,
together
important the residents
received clarification scheduling of more stance,
better orientation to the service, of expectations and roles, better of supervision, and the provision observed interviews. In one in-
the
negative
evaluations
were
based
almost exclusively on lack of supervisor availability caused by the supervisor’s heavy clinical load. These evaluations were then helpful in encouraging the hospital chief to reduce the clinical load and provide more supported teaching time for this supervisor. In the one review that the SEC did not feel resulted in a positive outcome, the hospital coordinator, siding with the supervisor, attributed the negative evaluations (in this instance
more
conflicts”
and
dents.” satisfied
than
two)
“the
prejudices
to
Because the hospital that the supervisor
emplary
job,
the
SEC
“personality of
the
coordinator was doing
requested
resi-
was an ex-
CONCLUSIONS process
programmatic process can
useful?
For
improvement, be quite helpful
the
purpose
of
it appears this for both training
directors and individual supervisors. With respect to faculty development, it is unlikely that feedback provided by these forms is used by individual supervisors to improve specific more,
the
aspects 2-year
of their pooled
teaching. evaluations
Furtherare re-
ceived too infrequently to reinforce teaching improvement. A study by Skeff (19) of internal medicine supervisors demonstrated that teaching improvement occurred only when the supervisors received intensive feedback (trainee evaluations, videotapes, self-assessment) and not student evaluation-form feedback alone. Skeff’s study is supported by research of college teaching, which also demonstrated back
by
that
student
questionnaire
itself
seldom
improved
effectiveness (20). With respect these ratings have
ing effectiveness all levels, there elements
sions
feedteaching
promotion, as one piece
teaching on
inform
deci-
(21). He suggests
teaching
should
be de-
upon scholarly evidence (papers, attractive evidence (recruitment
and subsequent evidence (invited
honorific cludes,
should
promotion
based
pendent chapters);
success lectures,
evidence (prizes, “Such evidence
of
trainees); symposia);
peer
and He cona more
awards). provides
compelling argument for a teacher’s promotion than a local reputation or an accumulation of testimonials from students” (p. 879).
The be
University tremely
generalizability of limited. As described of large
Toronto and highly
this process before, the
program centralized.
is
exThis
helps ensure anonymity of the residents and provides for multiple evaluations over short periods of time. Programs with fewer residents and supervisors may need to consider modifications, such as longer periods to
pool
evaluations,
or
the
use
of
group
evaluations. The
student
evaluation
form,
the
most
popular method of assessing supervisor teaching effectiveness, is not only simple and economical, but also appears to demonstrate acceptable reliability and validity. Exclusive use of this form, however, cannot effectively address all the previously described needs of academic departments. This conclusion is echoed by a recent study of the Association of American Medical Colleges’ Group on Educational Affairs (22). In this survey of 110 medical schools, the faculty and administration listed inadequate methods to evaluate teaching evaluations evaluation.
be to academic been helpful
of
effectiveof faculty McHugh of teach-
is essential for promotion at is still debate about which
regarding
promotion
may
a face-to-face
meeting with both the supervisor and the hospital coordinator to discuss the evaluations.
Is this
of objective evidence of teaching ness. However, in a recent review promotions in medical schools, notes that while the documentation
directed
and
specific as the Future
problems
with
major problems research must,
at developing
more
methods for evaluating teaching demic medical departments.
student in faculty therefore,
effective for all aca-
References 1.Irby
D, Rakestraw
medicine. 56:181-186
MB,
instructors
Woolliscroft
by
1989;
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in
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B: Student
evaluations
1972; 177:1164-1166 F, Greenough WT, of college
fulness.
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and
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PK:
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1973;
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PG,
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clinical
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GM,
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SB, MohI
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MK,
Kline
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su-
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psychiatric
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Psychiatry
1984;
in inter-
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KM:
in Clinical
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observed.
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the
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per-
14:122-128
45:67-86
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performance
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Am
1983; 75:465-470
20. Kulik
A, McKeachie
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RG, Biilson JM: The social context of teachlearning. New Directions for Teaching and 1991;
19. Skeff Med
TK:
Academic
teaching
clinical
in medicine,
17. Pate
Learning
care
for Medical Residents: Roles, Techniques, and Programs, edited by Edwards JC, Marier RL. New York, Spnnger, 1988, pp.255-260 12. Goin
of the
18. Tibenus ing and
53:808-815
DA, Rosati RJ: Resident evaluation of surgical faculty. J Surg Res 1991; 51:186-191 10. Guyatt GH, Nishikawa J, Wifian A, et al: A measure-
11. Irby
SB, MohI
assessment
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AJ, Risucci
9. Tortolani
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16. Perez
1971;
158:208-213 MK, Zimmerman
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14. Shanfield
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64:159-164
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better
2. Donnelly Med
P: Evaluating
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21. McHugh
by
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RF,
Froom
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ID:
Faculty
in faculty
and evaluation.
administration Acad
Med
Teaching
Psychiatry?
Let Hollywood
Suicide
Help!
in the Cinema
Steven
E. Hyler,
Jaime
Moore,
M.D. M.D.
Commercial films on videotape may be helpful in teaching medical students and residents about psychiatry. Recommendations are made on the use of specific films to illustrate various aspects of suicide, including depression, posttraumatic stress disorder, adolescent pressures and suicide, suicide gesture vs. suicide attempt, and the spiritual and philosophical aspects of suicide. In the Appendix, the authors list several dozen films depicting suicide that might be used for teaching purposes. (Academic Psychiatry 1996; 20:212-219)
ecently, Fidler has reported on “the diemma of unavailable videotapes for psychiatric education” (1). We describe the usefulness of videotaped commercial movies in teaching medical students and about psychiatry. Such videotapes
residents
are readily available and have been used successfully by the senior author in teaching such topics as psychopathology, psychiatric diagnosis (2), personality disorders, and transference and countertransference (3). For the past several years, the senior author has been the director of the “Teaching Psychiatry? Let Hollywood Help!” course at the annual meetings of the American Psychiatric Association. Along with the course faculty, the senior author has demonstrated how commercial film depictions can be used as adjunct aids to enhance teaching. It should be emphasized that the majority of commer-
available film depictions of psychiatry and related topics are often dreadful. Many are unrealistic and misleading at best, and serve to stigmatize our profession and our patients (4) at worst. We report on the use of selected commercial films to teach about suicially
cide,
and
we
recommend
specific
SUICIDE, DEPRESSION, POSTFRAUMATIC STRESS Dr.
Hyler
is associate
professor
of clinical
the
in
AND DISORDER
psychia-
of Psychiatry, Columbia University, and on the staff of the New York State Psychiatric Institute, New York. Dr. Moore is a graduate of the Columbia University College of Physicians and Surgeons, New York. Address reprint requests to Dr. Hyler, Unit #112, WHCS, New York State Psychiatric Institute, 722 West 168th Street, New York, NY 10032. try,
scenes
films that we believe are useful in educating students about the topic. The number of films that portray suicidal ideation and behavior is considerable. Aside from sex and violence, there are few topics as powerful in their impact that can be portrayed on the screen. A search of movies on the Cinemania ‘94 CD-ROM computer ifimography (5) revealed over 100 films that depict suicide. Appendix 1 presents a selection of films that include suicide and/or references to suicide. selected
Department
Copyright
C 1996
Academic
Psychiatry.
Ordinary People is the 1980 Oscar-winning film adapted from the Judith Guest novel. It stars Timothy Hutton as Conrad Jarret, the survivor of a boating accident that killed his older brother. The film depicts the effects of the tragedy on Conrad and his parents
(played by Donald Tyler Moore). The itial suicide attempt, atric hospitalization, particularly
moving.
attempts
to
trasted by and deny Conrad’s of the tant
Sutherland
effects and
his any
the
father’s
and
and
stress disorder) illustrates vivor guilt. A particularly involves Conrad’s attempt that
he
knew
covering templates he
from
that she cutting
chooses
Berger
the
trauma (resul-
of surscene a girl
Upon
dis-
psychiatrist,
Hirsch),
to see him immediately. come to a breakthrough
and
of their
films
Together, of insight
patients
depict
negatively.
tion
in patients
ifim
provides
a
accurate portrayal traumatic stress that lends itself
how
the
lack
of
to suicidal ideawith other risk factors. The highly detailed and relatively of major depression, postdisorder, and teen suicide well to teaching purposes. contribute
ADOLESCENT
Heathers
psychiatrists In
illustrates can
they in a
addition,
film provides an excellent illustration of a number of typical suicide risk factors, as outlined recently by Buzan and Weissberg (6). The foremost of these factors is the intimate correlation between affective disorders and suicidal tendency, with depressed patients having a 25-fold greater suicide risk. In the film, Conrad exhibits most of the classic symptoms of a major depression, including decreased sleep and appetite, lack of interest in school and extracurricular activities, latent guilt about his brother’s death, and suicidal ideation. Conrad’s relationship problems with his girlfriend Jeanine (played by Elizabeth McGovern), his dispute with a former best friend, and his previous suicide attempt are all high-risk factors often seen in teenage suicide. the
support
is able
session.
that
attempt,
social
Dr.
who
Even though this film may be criticized for its overly simplistic view of the psychotherapy process, the positive portrayal of the dedicated psychiatrist, as well as the sympathetic portrayal of the troubled patient, serves as an effective counterbalance to the majority
Particularly pertinent to the feelings of hopelessness experienced by many who are driven to suicide is Conrad’s description of what drove him to his first attempt: “It’s like faffing into a hole, and the hole keeps getting bigger and bigger and suddenly you’re inside and you’re trapped and you’re the hole.” Finally, Conrad’s sense of isolation from his mother, because of her inability to talk about his brother’s death or his initial suicide
posttraumatic
the topic graphic to phone
hospital.
his
by Judd
cathartic
con-
to avoid Similarly,
has killed herself, he conhis wrists. Fortunately,
to contact
(played
powerful
are
to minimize the its aftereffects
depression
Mary
halting
incident
mother’s attempts such discussion.
attempt accident
major
His
discuss
and
of Conrad’s inresultant psychion the family is
the
is the
careers
PRESSURES
AND
SUICIDE
1989
film
of
that
Winona
helped
Ryder,
launch Christian
Slater, and Shannen Doherty. The film is a black comedy of adolescent suicide that manages, often in spite of itself, to portray the
effects
of suicide
able high school Early in the film,
on
a cohort
students Veronica
of vulner-
and their parents. (Ryder) is induced
and seduced by her boyfriend J.D. (Slater) into murdering the tyrannical leader of the school’s most powerful social clique while making it look like a suicide. This “suicide” initially generates a lot of confusion within the
school
as
to
how
the
issue
should
be
addressed. However, when J.D. subsequently tricks Veronica into murdering two of the school’s football players and making it seem like a double suicide, the school and surrounding community rally under the banner of teen angst to acknowledge the inherent stresses of teenage life. Unfortunately, the overzealous faculty organizer of this movement goes so far as to promote the notion that suicide is sometimes an unavoidable sequelae of teen problems: At one point, he states, “whether to kill yourself or not is one of the most important decisions a teen-
ager
can
make.”
The
promotion
of this
atti-
real suicide attempts, one by a popular cheerleader, the other by one of the school’s social outcasts. It is then that Veronica recognizes the hysteria of the “suicide frenzy” occurring around her and takes action to diffuse it. While this film promotes the dangerous misconception that talking about suicide can influence an individual’s overall suicide risk, it does retain some educational value. First, the film spothghts the notion of “copycat tude
later
suicides.” nomenon timated
to two
leads
While the is somewhat that
from
evidence for controversial, 1%
to
2%
this
of
pheit is es-
all
teen
suicides do occur in clusters (7); therefore, this factor merits consideration in the proper context. A second strength of the ifim is its portrayal of many of the ship stressors experienced
social by
and relationteens. While
the ramifications of peer confficts and dating problems are often downplayed by parents as minor concerns, they can play a significant role as risk factors in teen suicide. The portrayal of these confficts and problems, along with the reactions of the film’s characters, lends important insight into the severe stresses teens experience. SUICIDE SUICIDE
GESTURE
disorder. Forest
Glenn
ATFEMPT
demonstrates
Close’s the
portrayal DSM-IV
wrists.
that
help
Here
we
have
distinguish
attempt:
the
pulsive
nature
all the
the
dramatic
to ifiustrate
personality of
Alex
diagnostic
criteria of impulsivity, self-destructiveness, affective instability, and frantic attempts to avoid being abandoned, as well as idealizatiorildevaluation. The film can also be used to highlight the distinction between “suicidal gestures” and suicide attempts. Following a weekend of passionate lovemaking with Dan Gallagher (Michael Douglas’s character), a married man looking for sexual excitement (and himself an example of a narcissistic personality), Alex, in a desperate attempt to prevent him from leaving, slashes
ingredients
gesture
from
presentation;
of
the
act;
the
the
the
im-
choice
of
method (superficial wrist cuts, being less lethal than firearms, jumping, or hanging); readily available assistance; and clear-cut secondary gain (Dan stays to help tend to her wounds). Alex even goes so far as to ensure discovery by engaging him in a goodbye embrace during which she smears the blood from her cut wrists over his face. A somewhat older movie with a parallel plot and a similarly staged suicide attempt is the 1971 film Play Misty For Me. In the ifim, Clint Eastwood plays a disc jockey in a small Pacific-coast town who is pursued by a obsessed fan (Jessica Walter). After a brief physical relationship he tries to break things off and discovers she is willing to do anything to keep him, including slashing her wrists. As with Fatal Attraction, this effort is aimed more at gaining his attention and forcing her way into his life than representing a serious
wish
to die.
An Officeranda the
other
suicide.
end David
Gentleman of the
Keith
(1982) presents
spectrum, plays
Blount) presents he can
completed
Sid Worley,
commissioned officer going through ors of naval flight school training new girlfriend Lynette (played
VS.
Fatal Att raction (1987) can be used a “textbook case” of borderline
her
a nonthe
when by
rig-
his Lisa
tells him she is pregnant. The news him with two very difficult options: forget about her, remain loyal to the
code of his military family, complete his training, and marry the woman they have chosen for him, or he can forsake his family, quit naval training, and many Lynette. He acts on the second of these choices, but is scorned by Lynette who has lied about the pregnancy because of her dream to be the wife of a navy aviator. The abrupt loss of support from his family, the loss of his future goal of becoming a pilot, and the rejection he experiences by Lynette are all strong risk factors for suicide in someone of his age rigid
group. His ultimate suicide illustrates characteristics of a serious attempt: a method
with high lethality potential (hanging), a solitary location (a motel room), a swiftly executed plan with little chance for second thoughts, and a failure to tell anyone of his
serious
whereabouts
tranged room);
or intentions.
A similarly fatal involving a character sented
in the ifimA
character (played self
in the
Lt. Colonel
when
faced
with
is pre-
(1992). The Markinson
Matthew the
again
military, Men
chooses
his military
commanding
attempt,
Few Good
by J.T. Walsh)
dishonoring his
suicide
to shoot
dilemma
service
him-
of either
or betraying
officer.
Another film that highlights many of the risk factors of a completed suicide is ‘Night Mother (1986), from the Pulitzer Prize-winning play by Marsha Norman. Sissy Spacek portrays a young woman who is bent on self-destruction
following
a series
of
per-
sonal disappointments. Her mother, played by Anne Bancroft, is shown to be powerless to prevent the ultimate outcome. The entire film is a study of the careful preparations for the
deed.
sions
Particularly
between
futility
the
of trying
now
that
the
mother
she
has threatens
moving
are the
protagonists
discus-
involving
the
to stop Spacek’s character made up her mind. When to call
her
daughter’s
psychiatrist, a family member, or the police, the mother is told, “Go ahead and while you make the call, I will shoot myself now rather than later.” Similar careful preparations leading ultimately to suicide are seen in Ironweed (1987). Jack Nicholson plays Francis Phelan, an alcoholic vagabond, who is a grief-stricken father who blames himself for the accidental death of his infant son. Many in the audience will be moved following the final days of his life, where he is shown paying one last visit to the wife that he abandoned, before committing suicide by jumping out of a moving train. In the recent ifim Scent of a Woman (1992), we witness the elaborate preparations of the blind Lt. Col. Frank Slade (played by Al Pacino), who decides on a last fling in New York City prior to taking his life. Here again, we see
a number
of factors
associated
with
planned
suicide
attempt:
gunshot
a lethal
to
the
method
head);
thought-out plan; the placing order (including a final visit brother); an isolated a last fling (complete
(a
a well-
of affairs to see his
in es-
location (a hotel with limousine
and an expensive hotel, dinner, and call girl); and a lack of future plans (buying a one-way ticket to New York). The deed is prevented only by the timely intervention of his compassionate travel companion (played by Chris O’Donnell), who gives him the strength to live on in the face of his vision loss. SPIRITUAL AND PHILOSOPHICAL ASPECTS OF SUICIDE Any discussion plete without
of suicide would be incomsome efforts to portray the spiritual aspect. In It’s a Wonderful Life (1947), George Bailey (played by James Stewart) decides to end his life because of desperation over forces that he cannot control. He is shown by Clarence (his guardian angel) that his life, indeed, has value and that his existence has enhanced the lives of all those with whom he has had contact Though it is unlikely that any potential suicide victim will respond
to the
cheer
and
goodwifi
espoused
in the film, it makes a wonderful case for remaining optimistic in the face of overwhelming odds. Many a therapist, or potential therapist, should find much to relate to in this classic film. The film Thelma and Louise (1991) also illustrates more of a philosophical perspective on the issue of suicide. In the final scene, the two protagonists (played by Geena Davis and Susan Sarandon) are faced with the choice of either continuing to live in a maledominated world and being judged for a murder committed in an act of self-defense against
women selves. valuable a
illustrating
rape,
with
or
dying
as
no one to answer this film is not
While teaching
common
aid from suicide
two
liberated
to but
them-
a particularly the perspective risk
factors,
of it
provide
does
an
example
excellent
strength
of human us that in certain sons would sooner
conviction circumstances sacrifice
than
their
compromise
and
of the reminds some perown lives
their
video
is not
“pirated,”
tional
rather
than
the
clip
is relatively
and if the nounced.
beliefs.
DISCUSSION
not
choose just
them
to use
videotape
commercial
a series
teaching
to illustrate
and
psychopathology,
use
psycho-
or any related topic, like suicide? response is that videotapes of actual are quite useful and, if available,
therapy, The best patients
should indeed ing purposes, various
be used. commercial
topics
can
often
be
superior
to the
tapes of actual patients. First, a good deal of thought (and money) has gone into the often high
production
values
ing
in graphic,
typic
ifiustrations
“real
life.”
patient
of these
films,
Second,
when is played
students, or trainees, tient relating a story
a videotape
are
allowed
their lives ing to the
of
what is seen is the pa(or history) after the fact.
up
attempt,
themselves,
emotions sider the
Scent
as well
and share difference
terview
of,
say,
the
events
fateful reasons tapes
we
can
view
leading
the
as experience
Al Pacino
several as compared
attempt,
of the
experience
the desperation. between viewing
of a Woman
tive
and
as they unfold. Rather than listenteffing of a story of events leading
to a suicide
events
the Conan in-
character
in
days after his aborwith watching all
up to and
including
the
day. Third, it might be difficult for of confidentiality to present videoof
students. ethical The cial
to observe
films
beyond the “fair
actual
patients
Using issue.
commercial
legality
of using
is controversial, the use
to an
audience
films clips and
from
article
or several
supply
of material
is available
knows
which can
tape
to rent a film
of
for example, pages
of
to advertise the Finally, a large to anyone
who
a video
store
from
wealth
of
movies aired each week by the dozens commercial and cable television stations.
from
the
of All
the films mentioned the Appendix, should
in on
earlier, or included be readily available
videotape.
Suggestions Depictions
for Use of Commercial Film for Teaching Psychiatry
of a
to an audience
By contrast, in the film portrayals we are able to view the protagonists in context: that is, we
include,
materials payment
result-
dramatic, and often protothat are not easily found in
interview
the
be ifiegal admission.
films
if
5 minutes),
film is clearly andoctrine” allows
a book.) It would movie or to charge
or who
However, for teachfilm depictions of
(under
copyrighted
would of an
for educapurposes,
without
This
photocopies
Why
film?
of patients
certain
to use
in
their
short
identity of the (The “fair use
teachers
royalties. Why
if it is used commercial
avoids
of this
commer-
a discussion
is
scope of this article. However, doctrine” is likely to apply if the
The senior author has used clips of commercial ifim depictions to teach psychiatry to medical students, psychiatric residents, and faculty, as well as to other mental health professionals, including psychiatric nurses and occupational therapy students. For instance, film clips demonstrating the stigmatization of the mentally ill in the movies have been used by the author at professional meetings and at meetings hosted by allied groups of families of the mentally ifi. The courses
that
annual
meetings
the
author
has
of the American
taught
at
the
Psychiatric
Association have been extremely well received, as judged from the course evaluations and personal contacts with the participants.
To follow
are
some
suggestions
for using the film clips discussed earlier. Beginning a lecture with a brief film clip is a good way to capture the attention of the audience. The scene from Ordinary People where Conrad cuts his wrists after discovering that his friend from the hospital has committed suicide is effective in this regard. Alternatively, the lecturer can conclude alec-
ture by presenting a film clip that summarizes key points of the lecture, such as ‘Night Mother, or a clip that leaves the audience with a topic to discuss in small groups following the lecture, such as the final scene from Thelma and Louise. Films clips are also useful in small
group
cussion.
Choosing
what
discussions
to stimulate
clip
a film
ambiguous
that
in its content,
dis-
is some-
or message,
is a good way to the audience to has always been ating discussion.
excite interest and provoke participate. Fatal Attraction a potent stimulus in generAnother particularly effec-
tive
is
technique
assignment
to illustrate sion
to
to bring (e.g.,
the
group
an
videocips of a potential discus-
an aspect
topic
give
in their
suicide).
own
The
author
has
been
continually students
impressed by how creative the can be in finding film clips to illustrate a variety of topics in psychiatry. It was through an exercise of this type that the coauthor of this paper was rate on this article. Though this paper cide,
psychiatric
dance
of
has
focused
clips
selected
ifim
to collaboon
sui-
will find an abun-
educators
illustrative
commercial films that juncts in teaching about psychiatry. The teacher present
recruited
available
from
may be used as adalmost any aspect of may find it useful to clips
to ifiustrate
the
various aspects of psychopathology as would be reported in a mental status examination: the Joker, from Batman (1989), to focus on appearance; the Kevin Costner character from Field of Dreams (1989) to dis-
cuss auditory hallucinations (“If you build it, he will come”); and the psychiatric examination scene from The Terminator (1984) to ifiustrate the definition of delusion. Scenes including Kevin Kline’s character in Sophie’s Choice (1982) or Peter Finch’s character from Network (1976) can be used to illustrate various aspects of mania. The hospital scene from Vertigo (1958) showing James Stewart in a state of catatonic stupor can be used to illustrate marked psychomotor retardation found in serious depression. In either large lectures or small groups, the teacher can present a film clip and ask how the students would arrive at a certain diagnosis or formulate a treatment plan for the character. An excellent case study is to be found in the character of Travis Bickle, the Robert DeNiro character in Taxi Driver (1976). Indeed, a series of scenes from that film have been incorporated
in an interactive
to teach
a systematic
computer approach
program to evaluating
a patient’s mental status (8). To take advantage of this vast, nearly untapped teaching resource, educators need only learn to shift their perspective when viewing films toward keeping an eye open for scenes
or characters
that
may
be useful
to
their teaching. The author has accumulated a personal collection of some 1,200-plus ifims that are regularly used for teaching. Of course, a system for cataloging and indexing such film clips is highly recommended. The list of potential ifims that can be useful in teaching about psychiatry is almost endless.
References 1. Fidler
DC: The
for psychiatric
dilemma
of unavailable
education.
Academic
videotapes
Psychiatty
1993;
17:171-173 2. Hyler
SE:
DSM-III
movies.
Compr
3. Gabbard
GO,
at
the
cinema:
Psychiatry Gabbard
1988; K:
madness
parasites:
mentally
movies.
atry
1991;
ill in the
42:1044-1048
therapeutic
29:195-201
Countertransference
the movies. Psychoanal Rev 1985; 72:171-184 4. Hyler SE, Gabbard G, Schneider I: Homicidal acs to narcissistic
in the
the Hosp
stigmatization Community
5. Microsoft Corporation: Cinemania ‘94 (CD-ROM) Interactive Movie Guide. Seattle, WA, Microsoft Corporation, 1994 6. Buzan RD, Weissberg MP: Suicide: risk factors and
in
considerations
emergency
Med 1992; 10:335-343 MS. Wallenstein S, Kleinman
7. Gould mani-
ride
clusters:
of the
Am
J Public
Psychi-
in the
depart-
J Emerg
ment.
8. Hyler cation.
an
examination
MH,
of age-specific
Health 1990; 80:211-212 SE, Bujold AE: Computers in psychiatric Psychiatric
Annals
1994;
24:13-19
et al: Sineffects.
edu-
APPENDIX #{149} Absence Melinda whose paper
1.
Selected
movie
depictions
of Malice (1981) Dillon as a helpful, frightened life is ruined by a thoughtless story
of suicide
news-
#{149}After Hours (1985) Roseanne Arquette’s character overdoses unclear reasons in lower Manhattan #{149}And Justice Jack Warden judge bent
for All (1979) portrays a mentally on self-destruction
#{149}The Bell Jar (1979) The Sylvia Plath autobiographical picts the mental breakdown
paign
to find
that
his
#{149}Hamlet (1948 and Both Sir Laurence
for
spectively,
drama of a young
dewoman
beloved
has
cam-
war killed
herself
#{149}Captain Newman, M.D. (1963) Eddie Albert plays a psychotic, manic Army officer who jumps off a water tower when confronted #{149}The Jaye
with
his illness
Crying Game (1992) Davidson’s portrayal
volved
in a
IRA terrorist leads native to unrequited
relationship
to suicide love
with
attempt
#{149}Dead Poets Society (1989) A student kills himself rather than the will of his domineering father,
him to become
a doctor
rather
#{149}The Deer Hunter (1978) Russian roulette turns deadly Walken’s character following
would
an actor
War
experiences #{149}Down and Out in Beverly Nick Nolte, as a bum, tries the swimming pool of the a Beverly Hills mansion #{149}The End (1978) Burt Reynolds attempts kill himself, after being
Hills
(1986)
to drown unhappy
himself owners
in of
capable
Nikita punk
to change his life, or given a fatal diagnosis
prison
(1990) chooses
#{149}The Godfather, Part Imprisoned Mafioso well-being
over
an ines-
term
#{149}A Few Good Men (1992) J.T. Walsh’s character chooses honor
the
death
2 (1974) chooses
of his family
death
suicide
before
to ensure
(1971) Harold
Mel
Gibson,
ceases
the even
re-
of existence
more
simulating eccentric
suicide and attempts community to cope
jump from save him?
the ledge?
Will
have
been
like if George
had
never
#{149}Last Tango in Paris (1973) After his wife commits suicide, Marlon gets to play an “American in Paris” #{149}Lethal Weapon (1987) Mel Gibson plays a suicidal a nervous breakdown after
Brando
cop on the verge of the death of his wife
#{149}Meet John Doe (1941) Gary Cooper plays an unemployed man duped by a fascist newspaper magnate #{149}Network (1976) A third-rate TV network ings after its anchorman self on-screen
dis-
a
been
who
is
gets a boost in the ratthreatens to kill him-
#{149}‘Night Mother (1986) A young woman is determined to kill herself ter a series of personal disappointments
#{149}Fatal Attraction (1987) Glenn Close’s character, Alex, responds poorly to rejection and makes a desperate suicide attempt to maintain her relationship with Michael Douglas’s character #{149}La Femme Ultra-violent
meaning
#{149}It’s a Wonderful Life (1947) Savings & Loan President George Bailey is saved by his guardian angel from despair and suicide attempt by showing him what life born
as an alter-
for Christopher his Vietnam
the
the suicide by the Hol-
#{149}I Never Promised You a Rose Garden (1977) A disturbed 16-year-old experiences command hallucinations to kill herself
in-
succumb to who wants
than
examine
#{149}Hero (1992) Will Andy Garcia Dustin Hoffman
an
of a transvestite
complicated
versions) and
#{149}Heathers (1989) Film illustrates adolescent of the school officials and
housemates folof the group
(1992) his successful
Olivier
1991
#{149}Harold and Maude Eccentric 20-year-old suicide after meeting 79-year-old Maude
unbalanced
#{149}The Big ChilI (1983) The reunion of former college lowing the suicide of a member #{149}Bram Stoker’s Dracula The count returns from
#{149}Guilty by Suspicion (1991) Robert DeNiro’s character witnesses of an actress whose life is destroyed lywood blacklist
woman
#{149}An Officer and a Gentleman A young Navy cadet chooses honor following abandonment
af-
(1982) death over disby his girlfriend
#{149}Ordinary People (1980) Timothy Hutton’s character attempts suicide following the death of his older brother in a boating accident. His psychiatrist, portrayed by Judd Hirsch, interprets his survivor guilt and heals him #{149}The Prince of Tides (1991) A suicide attempt by Nick Nolte’s troubled twin sister Savannah brings him to New York to work with his sister’s psychiatrist, Barbra Streisand
APPENDIX
1.
Selected
movie
depictions
of suicide
#{149}Saturday Night Fever (1977) An unplanned pregnancy and an inferiority complex lead John Travolta’s disco buddy to “fall” to his death from the Verrazano Bridge #{149}The Shrike Jose Ferrer tor whose overdose
(1955) plays a depressed Broadway tyrannical wife drives him
#{149}The Slender Thread Sidney Poitier plays line who attempts to a suicidal woman at line
directo a drug
(1965) a volunteer at a suicide hottrack down the location of the other end of the phone
(continued) #{149}Sophie’s Choice (1982) Meryl Streep is the concentration camp survivor who is led back to life, and then to death, by her “manic-depressive” boyfriend Kevin Kline #{149}Splendor Natalie
in the Grass (1961) Wood’s conflict between her Warren Beatty and her moral values to attempt suicide
love leads
#{149}What’s New Pussycat? (1965) Peter Seller’s hilarious attempt to commit cide is thwarted by Woody Allen
for her
sui-
Medical
Electives and Into Psychiatry
School
Recruitment A 20-Year Walter
Experience
Weintraub,
S. Michael Eric
Plaut,
Weintraub,
M.D. Ph.D. M.D.
Part of psychiatry’s recruitment problem is a result of defections among students who were planning careers in psychiatry when they entered medical school. The authors present data from a 20-year (1974-1993) experience at the University of Maryland that shows that students who expressed a preference for psychiatry as a career in the freshman year were four times more likely to enter psychiatric residency training after graduation if they participated in the Combined Accelerated Program in Psychiatry (CAPP), a 4-year psychiatric elective program, than if they pursued the regular undergraduate psychiatric program. More than 20% of the CAPP students who preferred non psychiatric careers as freshmen were “converted” to psychiatry and later entered psychiatric residency programs. Recent changes in the ideology and economics of our profession have neither lessened the popularity of the CAPP nor diminished its apparent ability to shelter students preferring psychiatry from the stigmatizing experiences of medical school. (Academic Psychiatry 1996; 20:220-225)
D
uring the past few years, recruitment of American medical graduates into psychiatry has taken a downward turn. While
taking fewer candidates interested in psychiatry (2). These explanations of the recruitment
problem
the
since
the
reasons
for
psychiatry’s
losses
are
not
known, educators have offered a number of speculations. We have been told that psychiatry has a gloomy future under managed care (1), that our profession has been unfairly portrayed in the press and movies, and that medical
Dr.
school
admissions
W. Weintraub
associate
professor;
professor; versity
of
committees
is clinical and
Dr.
Baltimore, Department Street, Baltimore, MD Copyright
© 1996
Dr.
E. Weintraub
all are in the Department Maryland School of
Maryland. Address reprint traub, School of Medicine,
professor,
Academic
Plaut
is
is assistant
of Psychiatry, UniMedicine, Baltimore,
requests University
of Psychiatry, 21201-1549.
are
to
Dr. W. Weinof Maryland at
645W.
Psychiatry.
Redwood
outside
may
causes our
and
be
termed
proposed
professional
activities.
“alloplastic,” solutions
are
“Alloplas-
tic” theorists, for example, suggest influencing admissions committees’ decisions, improving psychiatry’s image in the community, and trying to ameliorate our economic future. There is, unfortunately, no evidence that such praiseworthy efforts have any influence on recruitment into psychiatry. The “autoplastic” approach to psychiatric recruitment focuses on changes within the medical school, specffically in the medical school environment. This approach assumes that many more students enter medical school with the ing careers in psychiatry
intention
than
of pursu-
actually
do so
after lieve
graduation. “Autoplastic” that large-scale defections
educators befrom psychi-
are attributable to an unfriendly medical school environment (3,4). Of the various specialties, only psychiatry is viewed in a consistently negative way by nonpsychiatric faculty and house staff. The “autoplastic” approach to recruitment is to use the re-
atry
of medical
schools’
departments
of
psychiatry to create a friendlier environment for students interested in psychiatry as well as for potential “converts”-that is, students with an aptitude for psychiatry who are open-minded about their future careers. Educators do not agree among themselves with respect to which experiences may influence a student’s choice of psychiatry. It is apparently possible to offer medical students a well-integrated series of lectures and clinical experiences of high quality without
ing
increasing the likelihood of their psychiatry as a career (5). We describe an undergraduate
chooselective
program, the Combined Accelerated Program in Psychiatry (CAPP), which has had remarkable success in recruiting medical students into psychiatric residency programs over a 20-year span (1974-1993). After briefly describing the CAPP, we report recruitment data for the first 20 graduating
factors
dasses
that caused THE
COMBINED
PROGRAM The idea Department
and the
try to account
program’s
for the
success.
ACCELERATED
IN PSYCHIATRY
for the CAPP was initiated by the of Psychiatry of the University of Maryland in 1970. In a sense, the program was a response to the student revolt of the 1960s, a movement that was sharply critical of the content and manner of medical school teaching. A behavioral science and psychiatry track, the CAPP enables selected medical students to enroll in a specialty program while continuing in the usual curriculum. Traditionally, 12 students are selected from approximately twice that number of applicants. No pledge of a career interest in psychi-
and
students all applicants
spring
no preference
planning
CAPP
atry
sources
is required,
to applicants
is given in psychiatry.
careers are chosen accepted
as follows. to the next
Each fresh-
school dass are sent letters deCAPP and inviting interested students to apply. During the first freshman psychiatry dass in the autumn, the director of CAPP speaks about the program and extends a second invitation to interested students. Applicants are evaluated in two stages.
man medical scribing the
First, the program director all candidates and screens seem
unsuited
who
have
plicants they
to
the
may
and
those
its goals. Some apat this point when
withdraw that
interviews those who
program
misunderstood
realize
briefly out
participation
requires
more
time than they are willing to give. The second stage of the selection process consists of two lengthy interviews, one with a faculty member and one with an upperciass CAPP student. The interviewers report their impressions of the applicants to a committee that makes the final selections. A student’s chances
for acceptance
are enhanced
if he or
she has an unusually brilliant college record; has a special accomplishment or aptitude (Ph.D., published research, high MCAT socres etc.); belongs to a minority group; and comes from rural Western Maryland or the Eastern Shore. Although there have been some minor changes in the CAPP curriculum, it has remained fundamentally unaltered throughout the 20-year period. Students are expected to be familiar with the general culture of the psychiatric profession by the middle of the junior year of medical school. Reading seminars are scheduled during the first 2 years to guide students in their mastery of basic psychiatric concepts. The clinical part of the CAPP is highly structured and consists of a sequentially arranged series all participants semester
are
taught
interviewees,
of experiences must pass.
of the
how
freshman
through year,
to establish
using
first
which the first
During
each
the
students
a rapport
with
other
then
and
ward patients as subjects. During the second semester, the students learn to elicit and describe the signs and symptoms of psychiatric
ration
illness. In addition to the interviewing seminar, CAPP students spend a block of 4 hours a week on 1 of the psychiatric inpatient units. They become familiar with a ward commu-
uted to the program. Summer stipends for CAPP students remaining in the Baltimore
nity
and
mental
submit
status
reports
to be
evaluated by a faculty member. CAPP students who desire personal treatment are offered psychotherapy at a fee they can afford by members of the local psychoanalytic society.
During man
the
year,
spend
at least
atric
The
into
the junior
London,
the
students faculty.
is done
CAPP
students
attention preference
in
is supervised
get in other by the
senior
a great
faculty.
deal
ways, too. Department
the
20-year
of Psychiatry atry had sciences
combined
of perThey are of Psy-
discussion
A 6-week
outpatient
and
Data
complete a specialty 1970, the year the groups of students
effects of the program significant for students
found
in prior
publications
(6,7).
Program funding plished in several ways. is done faculty
by fullfree
tor possessing tion. Early
and
of charge.
has Most
part-time
been of the
accomteaching instruc-
a rare skill receives remunerain the program’s development, costs and defrayed
tute
Health
summer fellowship by a National Instigrant.
After
the
expi-
inpatient
assign-
requirements.
to
and entered We have
residency included
in
trainour
who completed at the possible positive are not likely who spend
to be only a
few months in the program. Of the 244 students admitted into the program during the 20-year span, 224 completed at least 1 year and
departmental
An occasional
administrative stipends were of Mental
about the can be
and
preference form. Since program was started, 20 have graduated from
those students in the CAPP;
1 year
lectures
after their acceptance students are asked
faculty. Additional goals and strategies
least
Psychibehavioral during the
Collection
Within 2 weeks the CAPP, the
study only
the
groups were used junior derkship, which
the formal
completed
Department
students.
Large group
years.
postlecture for instruction.
medical school ing programs.
CAPP
local, contrib-
undergradu-
hours to teach psychopathology
small
into
the
a strong
for non-CAPP 150 and
preclinical
ments,
period,
offered
chiatry when applying for fellowships and jobs, are invited into professors’ homes for dinners and parties, and often develop close relationships with many of the psychiatric information of the
hospitals
TRAINING IN PSYCHIATRY FOR NON-CAPP UNIVERSITY OF MARYLAND MEDICAL STUDENTS
supervision from and mentoring
by full-time
Affairs
office;
and
to go elsewhere.
adults and children. do psychotherapy, the
receive individual Much of the teaching
in CAPP sonal given
with they
time
beginning
year,
choosing
ate program
and Turkey.
program,
sophomore
psychotherapy During the
rotations
they train. They stipends and are
Switzerland,
Veterans
the dean’s
Psychiatry;
area are provided by those institutions to which the students are assigned. Departmental funds provide stipends for students
During in-
in the world. Since 1970, gone as far as San Fran-
of the
student’s
psychiatry
and
of
to
psychi-
are generally
in which modest
Italy,
heart
with
grant,
Department
state,
fresh-
required
working
free to go anywhere CAPP students have The
the
are
students
of the institutions are provided with
cisco,
following
students
8 weeks
patients.
tegrated
summer
CAPP
of the federal
the
graduated
224 students, psychiatry preferred In freshman complete
from
medical
school.
Of these
98 indicated a preference early in the freshman year;
another specialty. 1972, 1973, and 1974, medical the same
students specialty
all
for
126
entering
were asked to preference form
given
to
CAPP
completed
students.
within
academic
the
year.
Of
the
dents who entered land
School
years,
405
of
indicated
forms
few
446
of the
non-CAPP
stu-
an initial
former
the specialty 405 students, 20
entered graduation.
for psychiatry. records
kept
and Office of Student school, we were able to
ascertain
the
specialty
choices
students expressed the early
and 20 non-CAPP students a preference for psychiatry part of the freshman year.
of the
of the
veals (15%)
that 68 (69.4%) of of the latter entered
the
and 3 resi-
18.29;
=
recent
de-
cline in interest in psychiatric affected the CAPP’s effect
specialization on recruitment,
we compared first 10 years
figures (1974-1983)
those
results
the recruitment of the program 10 years identical.
of the second are almost
10 years,
69.1%
psychiatry chiatric vs. 70%
in the freshman
year
training second
the
“Converts” Of the specialties
During
students
residency during
of the with
(1984-1993).
of CAPP
The the
other
than
entered
classes
P