THE
AMERICAN
Some
Characteristics
BY
GUREL,
LEE
JOURNAL
of Psychiatric
Residency
THE PURPOSE of this study was to obtain quantitative descriptive data about psychiatric residency training programs. Conducted at a time when psychiatric practice and education are being subjected to criticism both from within (1, 2) and without (3, 4), the study was expected to bring to light findings that would be useful in understanding current emphases in training. A familiar truism holds that change is one of the unchanging facts of life. This study was conducted during a
This paper is abstracted from the monograph A Survey of Academic Resources in Psychiatric Residency Training, which is available from the Publications Services Division of the American Psychiatric Association. The study was conducted under provisions of contract HSM-4269-89 between APA and the National Institute of Mental Health; it was initiated under J.F. Whiting, Ph.D., former director of APA’s Manpower Division. Dr. Gurel is Director, Division of Manpower, Research opment, American Psychiatric Association. Address reprint 2723 Woodley Place, NW., Washington, D.C. 20008. wishes Nelson,
PSYCHIATRY
Training
Programs
PH.D.
The author summarizes responses to a major questionnaire survey ofpsychiatric residency training programs. In addition to providing objective data on residents, training staff, and on the training institution and its re/atedfacilities, the author presents information drawnfrom the narrative responses to questions on major issuesfacing psychiatry. These include training for dealing with critical social problems, recruitment of minority group trainees and faculty, and training in interdisciplinary collaboration and preparation for work with paraprofessionals. It is hoped that these data will facilitate answers to questions about the training psychiatrists should receive in the future by providing information about training programs in the immediate past.
The author rick, Carol
OF
to acknowledge and Ina Spaner.
the collaboration
of Mary
and Develrequests to Jane
Mer-
period of accelerated change in the conditions influencing the delivery of psychiatric services (5). As one psychiatrist expressed it, “We live in a time when nearly every psychiatric program in the country is undergoing critical evaluation and, in some cases, major changes” (6). This atmosphere of evaluation and change undoubtedly affected the conduct of the study. While our major purpose was to assemble heretofore unavailable “hard” data about the scope and nature of residency training, we also sought to address certain emerging and/or controversial issues; these issues will be identified and discussed.
METHOL)
All active programs approved by the AMA’s Residency Review Committee for training in general and/or child psychiatry (N 288) were sent questionnaires in two mailings in the spring and fall of 1972. The programs are categorized by program type, site, and sponsorship in table 1. To facilitate presentation, programs were grouped into the four categories indicated by the boxes in the table. It can be seen, for example, that one box encompasses the 28 programs offering child psychiatry training only and that another surrounds the 6+67+ 10+ 11+4=98 programs in psychiatric hospitals not operated in conjunction with a medical school. The four categories will be identified as child programs (N=28), mental hospital programs (N=98), medical school programs (N 97), and other programs (N =65) - the latter were in free-standing child/community clinics/centers or in general hospitals that were not medical school primary teaching sites. The questionnaires requested objective information about residents, training staff, and the training institution and its affiliated facilities. In addition, training directors were asked to provide narrative responses regarding a series of issues that were of particular interest to the Na=
=
An’ J Pst’chiatrv
/32:4. April
1975
363
CHARACTERISTICS
TABLE Psychiatric ship
OF
RESIDENCY
PROGRAMS
RESULTS
I Residency
Training
Programs
by
Type.
Type
Site
and
Child (N = 28)
Sponsorship
Psychiatric hospital, nonmedical school(N= 100) Federal Other public Private Psychiatric facility in medical school (N =99) In public university In private university Other Psychiatric unit in nonmedical school general hospital (N = 68) Federal Otherpublic Private Nonhospital clinic/center (N =21) Federal Otherpublic Private
6 67 II
1 1
and
Sponsor-
of Program
General (N = 162)
-
Site,
Combined Child/ General (N = 98)
Total (N = 288)
6 78 16
-
10 4 1
1 I -
16 13 2
38 27 1
13 13 19
2 3 11
-
7
-
-
-
1 1
8 9
I
41 3
15 16 37
-
2
11 10
tional Institute of Mental Health (NIMH) staff involved in initiating the study. These had to do with child mental health, community psychiatry, recruitment of minority group trainees and faculty, training for increased understanding of minority cultures, training in interdisciplinary collaboration and work with paraprofessionals, training to deal with critical social problems, and training in acquiring skills in community consultation, community organization, child advocacy, program administration, and program evaluation. Narrative responses were subjected to content analyses. Response
Rate
All of the 288 programs surveyed eventually responded with data on their residents. The information requested on staffing and other program characteristics was supplied by 234 programs; 32 more reported just the staffing information. Ratings of the quality and quantity of responses from the 234 programs with complete quantitative data indicated that 148 (63 percent) could be considered good or excellent, 31 percent fair, and 6 percent poor. The response to our request for narrative comments was considerably less satisfactory. Of the 234 programs with complete quantitative data, fewer than half (47 percent) had responses that were rated as satisfactory; more than one-third (37 percent) either did not respond or gave minimal and inadequate responses. The remaining 16 percent of the responses were considered minimal and barely adequate.
364
Am
J Psychiatry
132:4,
April
1975
Table I shows that of the 288 programs, 28 offered training only in child psychiatry, 162 only in general psychiatry, and 98 in both general and child psychiatry. Most programs were in psychiatric hospitals that were not part of a medical school (N= 100) or in psychiatric facilities that were functionally or administratively part of a medical school setting (N =99). The remainder were located in facilities associated with general hospitals that were not part of a medical school setting (N=68) or in clinics or centers not associated with a medical school or with either hospital setting (N 2 1). The type of training offered was related to program sponsorship and location. At the psychiatric hospitals (almost all of which were state mental hospitals) training was typically in general psychiatry only. Programs in general psychiatry also predominated, although to a lesser degree, in general hospitals that were not part of a medical school complex. On the other hand, two-thirds of the programs in medical school settings offered both basic training in general psychiatry and advanced training in child psychiatry. The 288 programs were located in 43 states, Puerto Rico, and the District ofColumbia. It is striking that almost half of the programs (47 percent) were located in the 1 1 northeastern states and the District of Columbia. Also of interest is the fact that mental hospital programs were more frequently located in this northeastern area than were medical school programs, whereas the reverse was true in the rest of the country. =
Residents A total of 4,750 residents were reported in training on September 1, 1972.’ Table 2 shows their placement by program type and by year of training. Fully 90 percent of the residents were in the first three years of training and 10 percent were in advanced training, mostly in child psychiatry. With respect to the four categories described previously, only 2.1 percent of the residents were in the 28 child programs; more than half (53 percent) were in the 97 programs in medical schools that were not exclusively child psychiatry programs. The number of residents varied from none in 6 programs (which did not, however, consider themselves inactive or in the process of closing down) to 110 in the case of a consolidated program comprised of 3 semiautonomous programs. The median number of residents per program was 12.5. Programs in New York State had 20.2 percent of all trainees and California had 12.5 percent. These were followed in descending order by Massachusetts, Pennsylvania, Ohio, Michigan, Illinois, Maryland, Connecticut, and Missouri. The programs in these 10 states had 3,344 residents, or 70.4 percent of the total.
‘Follow-up ambiguous
a year later indicated that several of the residents status and probably should not have been reported.
had
an
LEE
TABLE
GUREL
2
Distribution
ofResidents
by
Year
and
Type
of Program
Year First (N=l,54l) TypeofProgram Child(N=28) Mental hospital Medical school Other (N=65)
N 7 (N=98) (N=97)
438 820 276
Second (N=l,389) Percent
N
7.0 34.1 32.6 32.6
398 722 260
Third (N=l,345) Percent
9
of Training
9.0 31.0 28.7 30.7
Staffing
N
Percent
28 342 746 229
TABLE Number
Instructions for reporting teaching staff called for excluding staff who did not hold officially designated positions, who did not regularly do didactic or clinical teaching of psychiatric residents, and who possibly interacted only casually with residents. Consultants and lecturers were not to be reported unless they were both regularly scheduled and averaged at least one hour a week with residents. Data-handling procedures were designed to provide an unduplicated count ofstaffwithin the unit of a program and its associated facilities. However, a particular individual could have been reported by more than one program (e.g., a faculty member who worked part-time in more than one program). More than 8,000 psychiatrists were reported to be teaching in residency programs. Even though this figure does not necessarily reflect 8,000 separate individuals, particularly among the more than 5,000 part-time people, there can be little doubt that a considerable proportion of the nation’s psychiatric manpower is involved in the training of future psychiatrists. Table 3 presents a breakdown of psychiatrists in terms of board certification and full-time versus part-time involvement for the 266 programs that responded fully to the set ofstaffing items. Part-time appointments were relatively more frequent in child psychiatry training programs and least frequent, relatively speaking, in the case of mental-hospital-based programs. For the three program types other than those based in mental hospitals, both part-time and full-time faculty were more often board certified than not. In the mental-hospital-based programs, however, less than one-third of the full-time psychiatric teaching staff were certified. Only 302 full-time and 424 part-time neurologists were reported to be involved in psychiatric residency training. The neurologists were more likely than the psychiatrists to be board certified (76 percent versus 56 percent), and they were somewhat more often full-time (42 percent versus 37 percent). Data about other teaching staff are reported in table 4. The category of social scientist included social workers, sociologists, anthropologists, etc.; physical scientist included biologists, chemists, etc.; and other physicians included all M.D.s and D.O.s who were not psychiatrists or neurologists. Perhaps the most noteworthy finding re-
Fourth (N=348)
Fifth (N=l27)
N
28.0 26.6 29.6 27.1
39 58 192 59
Percent
N
39.0 4.5 7.6 7.0
17 49 39 22
Percent
Total (N=4,750)
17.0 3.8 1.5 2.6
100 1,285 2,519 846
3 of Psychiatrists
Teaching
in Residency
Type
Psychiatrists Faculty
on
certified Full-time Part-time Total Noncertified Full-time Part-time Total Both certified noncertified Full-time Part-time Total
Programs
of Program
Mental Hospital (N=94)
Medical School (N=95)
24 74 98
332 618 950
997 1,758 2,755
272 656 928
1,625 3,106 4,731
8 44 52
718 461 1,179
538 1,113 1,651
241 590 831
1,505 2,208 3,713
32 118 150
1,050 1,079 2,129
1,535 2,871 4,406
513 1,246 1,759
3,130 5,314 8,444
Child (N= 17)
Other (N=60)
Total (N=266)
Board
and
TABLE
4
Number Physical
of Other Scientists
Physicians. Teaching
Psychologists. Social in Residency Programs
Type
Classification Other physicians Full-time Part-time Total Psychologists Full-time Part-time Total Social scientists Full-time Part-time Total Physical scientists Full-time Part-time Total
Child (N= 17)
Scientists.
and
of Program
Mental Hospital (N=94)
Medical School (N=95)
Other (N=60)
Total (N =266)
0 4 4
233 144 377
242 147 389
26 39 65
501 334 835
42 57 99
359 193 552
684 366 1,050
275 138 413
1,360 754 2,114
74 54 128
908 225 1,133
927 306 1,233
440 124 564
2,349 709 3,058
I 0 I
71 25 96
168 53 221
46 6 52
286 84 370
A m J Psychiatry
/32:4,
April
/975
365
CHARACTERISTICS
TABLE Number
OF
RESIDENCY
PROGRAMS
5 of Programs
Offering
Experience
with
Selected
Patient
Types/
Conditions
Type
Child (N=9) Patient
Type/Condition
Neurosis/behavior disorder, child/ adolescent Psychosis/autism, child/adolescent Juveniledelinquency Drug abuse, child/adolescent Psychophysiologic disorder, child/ adolescent Mental retardation Neurosis, adult Acute psychosis, adult Chronic psychosis, adult Organic brain syndrome Alcoholism Drug dependency, adult Personality disorders Disordersoftheaged Medical/surgical patients Other *Almost
exclusively
acute
situational
Percent
9 9 5 5
100 100 56 56
77 69 26 16
87 78 29 18
79 74 35 30
92 86 41 35
42 36 18 11
84 72 36 22
207 188 84 62
88 80 36 26
7 8 2 2
78 89 22 22
4 2 2 7
44 22 22 78
75 53 88 88 85 68 84 73 70 59 42 16
84 60 99 99 96 76 94 82 79 66 47 18
76 41 86 86 62 40 80 76 68 38 73 12
88 48 100 100 72 47 93 88 79 44 85 14
47 19 50 50 31 30 49 49 45 29 47 12
94 38 100 100 62 60 98 98 90 58 94 24
205 121 226 226 178 142 215 200 190 126 167 43
88 52 97 97 76 61 92 85 81 54 71 18
-
5 3
56 33
disorders.
Contact
A m J Psychiatry
132:4,
April
Percent
N
-
Percent
N
Percent
-
N
Total (N=234)
N
The availability to residents ofexperience with selected patient types and conditions was tabulated for the 234 programs that returned complete responses regarding this issue and the issues dealt with in the two following paragraphs. These data are presented in table 5, which indicates results generally in line with expectations for the particular program types. For example, with the exception of most of the child programs and 1 mental hospital program, all programs saw neurotic and acutely psychotic adults; all child programs saw neurotic and psychotic/autistic children. Alcoholic and drug-dependent adult patients were seen in a surprisingly high proportion of the non-child programs (92 percent and 85 percent, respectively). On the other hand, juvenile delinquents, young drug abusers, and patients with organic brain syndromes were seen in fewer programs than many authorities would probably have anticipated. It was found that an average of I 1 of the 16 listed conditions were seen in the 3 non-child program categories, with a range from 16 down to only 3 in the case of I mental hospital program. Thus it appears that some training programs are based in rather specialized settings and that arrangements for experiences in other settings are limited. However, it should be noted that these data reflect 366
Other (N=50)
Percent
flected in table 4 is the relatively large number of psychologists and social scientists reported to be involved in teaching residents. Especially remarkable is the relatively higher proportion of full-time appointments for these groups compared with psychiatrists and neurologists. Patient
Medical School (N=86)
N
-
or transient
of Program
Mental Hospital (N=89)
/975
the availability dents actually determined. Treatment
of certain saw patients
kinds ofthe
of patients; particular
whether resitypes was not
Modalities
A related issue involves the extent to which specified treatment methods were in use at the program and its associated facilities. It is evident from the data in table 6 that certain methods were practically universal-individual psychotherapy, group psychotherapy, psychotropic drugs, crisis intervention, and, to a slightly lesser extent, electroconvulsive therapy. On the other hand, insulin coma/subcoma therapy, carbon dioxide therapy, psychoanalysis (excluding psychoanalytically oriented psychotherapy), sensitivity training/training laboratories, and psychodrama were used very infrequently. The “other” category produced many responses, 90 percent of which reported either hypnosis or other somatic treatment. Affirmative responses ranged from 2 medical school programs reporting the use of 13 modalities to 2 child programs reporting 1 and 2 methods, respectively. The median number of modalities per program was approximately 8. Again, the reader is cautioned that the data reflect treatment methods in use at the program training site; the breadth or depth of experience of individual trainees is not known.2
2A reviewer of this manuscript suggested that these data her impression that programs overemphasize depth of few modalities at the expense of breadth of experience. as an example of this the extreme difficulty of finding an trained psychiatrist who is competent and available to troconvulsive therapyespecially on the east coast.
confirmed his/ experience in a He/she offered otherwise welladminister elec-
LEE
TABLE Number
6 of Programs
Offering
Experience
with
Selected
Treatment
Modalities
Type
Modality
N
Percent
Psychotropic drugs Electroconvulsivetherapy Insulin coma/subcoma therapy Carbon dioxide therapy Individual psychotherapy Psychoanalysis, classical and variants Behavior modification, token economy Group psychotherapy Sensitivity training/training laboratory Psychodrama Sociomilieu: self-government, attitude, etc. Conjoint/family Crisis intervention, walk-ins, etc. Alcoholism clinic/program Drug clinic/program Other
7 1
78 11
Number
-
-
-
-
9
100
-
-
3 8
33 89
-
-
-
-
I 7 7 I 2 3
11 78 78 II 22 33
N
Medical School (N=86) Percent
N
Other (N=50) Percent
N
Total (N=234) Percent
N
Percent
89 83 2 3 89 3 31 89 6 6
100 93 2 3 100 3 35 100 7 7
86 82 4 1 86 9 38 86 4 11
100 95 5 1 100 10 44 100 5 13
50 46 2 1 50 2 13 50 2 6
100 92 4 2 100 4 26 100 4 12
232 212
234 14 85 233 12 23
99 91 3 2 100 6 36 99 5 10
37 49 89 36 33 57
42 55 100 40 37 64
39 67 85 35 41 61
45 78 99 41 48 71
24 34 50 25 27 39
48 68 100 50 54 78
101 157 231 97 103 160
43 67 99 41 44 68
8 5
7 ofPrograms
Offering
Training
in Related
Fields
Type
Field
N
Percent
Nursingaffiliate Nursingclinicalspecialist Social work master’s/placement Psychology(doctoral) Mental health associate (A.A. degree) Medical internship Rehabilitation specialist Speech and hearing (MA., Ph.D.) Dietetics Other
2 I 5 4
22 II 56 44
6 2
67 22
Training
-
-
-
-
1 3
of Program
Mental Hospital (N=89)
Child (N=9)
Related
of Program
Mental Hospital (N=89)
Child (N=9)
TABLE
GUREL
11 33
N 61 13 48 50 6 53 27 I 2 29
Programs
One of the objectives of a residency is to train the future psychiatrist to work in the collaborative multidisciplinary arrangements that are increasingly common in mental health service delivery systems. Since shared training experiences are generally thought to foster the development of the skills and attitudes involved in effective multidisciplinary effort, we collected data on the extent to which training related to academic or professional requirements other than for medical specialists was offered at the program site and/or its associated facilities. The availability of8 such training programs and the medical internship is shown in table 7. The medical internship was the most frequently re-
Medical School (N=86)
Other (N=50)
Percent
N
Percent
69 15 54 56 7 60 30 I 2 33
57 10 59 63 2 83 27
66 12 69 73 2 97 31
-
-
1 37
1 43
N
Total (N=234) Percent
31 3 37 31 1 44 15 I
62 6 74 62 2 88 30 2
3 10
6 20
N
151 27 149 148 9 186 71 2 7 79
Percent
65 12 64 63 4 79 30 1 3 34
ported related training experience: it was offered at 79 percent of the programs and was almost universally available in medical school programs. A cluster of nursing, social work, and psychology programs was next in frequency. Dietetic, speech and hearing, and mental health associate programs were rare, and there were fewer rehabilitation-type programs than might have been expected. In retrospect, the item on related training should have specifically mentioned 2 or 3 additional groups. Included within the “other” category are 42 programs in pastoral counseling and similar ministerial training; 15 programs in vocational counseling, counseling and guidance, and/or subdoctoral psychology; and 7 programs in special education. A long list of other fields was com-
A m J Psychiatry
/32:4,
April
1 975
367
CHARACTERISTICS
RESIDENCY
OF
PROGRAMS
piled, but there were only I or 2 reports of each of these programs (law, pharmacy, hospital administration, etc.). In two-thirds of the programs, four or fewer kinds of related training programs were being conducted. As almost 20 percent of the residency programs had no related training (or none other than medical internship), such common-site training must be considered surprisingly infrequent, particularly in areas outside the traditional mental health professions.
SOME
SPECIAL
ISSUES
The status of certain aspects of residency training content can be adequately inferred from the quantitative data presented in the preceding section. Our results suggested that I) opportunities for experience with certain patient conditions vary, 2) some content is essentially universal, 3) some content has been largely phased out (e.g., insulin coma and carbon dioxide therapies), and 4) still other content (e.g., behavior modification and sociomilieu methods) is available in only a small number of the programs. To complement those data, narrative resonses were elicited about what we perceived to be emerging emphases, points of controversy, or areas of suspected deficiency in psychiatric residency training. The reader is cautioned that the findings in the following paragraphs are subject to limitations of response bias. The kind of extended speculation that was included in the parent monograph on the possible reasons for (and the impact of) the lowered rate of response to this part of the survey cannot alter this central fact. There is simply no way of knowing how respondent and nonrespondent programs differ and what influences operated to produce the selective response. What follows is based on the 162 programs (56 percent) that returned usable responses on the seven issues. These responses varied from the single word “none” to 44 pages on one issue. Child
Mental
Health
We initially assumed that because all of the programs surveyed were accredited, their didactic and clinical content would meet the accreditation requirements of sufficient
experience
general of
psychiatry
human
process
in child
an
growth
and
development
in infancy
and
childhood
and by the sociocultural This
psychiatry
to acquire
knowledge
should
instruction and through children. (7, p. 373)
milieu be
.
.
.
for
the
understanding and as
of
influenced
of which
resident
of the
the
imparted
through
supervised
clinical
the
in
biology
maturational by
family
the
family
is a part.
formal
experience
didactic
with
Our tabulations support the conclusion that the programs varied widely in interpretation of the “sufficient experience” requirement. The responses ranged from that of I program which explicitly reported no child mental health content and no provision for placement at child facilities, through 2 programs in which such instruction was elective, to 40 programs with teaching and experience throughout all three years. Although didactic in-
368
Am
J Psychiatry
/32:4.
April
/975
struction in normal development was frequently reported, only 8 programs reported provision for actual experiences with normal children; e.g., experience in well-baby clinics and observation ofand/or participation in nursery school programs. One program reported experience with normal children throughout all three years of the basic residency, and 5 programs indicated opportunities for research in child psychiatry. There was little indication of experimentation with the child mental health curriculum; the few reported instances could not be considered major departures from the conventional. We do not know to what extent the programs simply did not report innovative curriculum developments because they were not directly requested to do so, but this could hardly explain the almost total absence of references to innovative approaches. The fact that child mental health content headed the list of issues of special concern in the survey suggests that the APA and NIMH personnel who planned the study may have questioned how well this content was being covered in basic psychiatry training programs. The data suggest that such doubts may be well founded. It appears that there is reason to doubt not only the adequacy of coverage of child mental health but even whether some programs continue to meet the minimum standards for approval. Interdisciplinary
Collaboration
Responses concerning the issue of interdisciplinary collaboration in psychiatric training were placed in five categories, as follows: I) collaboration with other medical specialties, e.g., “resident may be asked to consult to other parts of the hospital” (N=7); 2) joint seminars and/or conferences, i.e., participation in common didactic activities (N= 15); 3) common assignment with other disciplines to patient care situations, e.g., admission, patient planning, case review, or discharges (N=44); 4) an explicitly designed team approach to patient care involving joint decision making and shared responsibility (N =59); and 5) a strongly emphasized commitment to an explicitly designed team approach, with reciprocal training and supervision (N = 33). There were 3 instances of no response and I negative response. We found that 43 percent of the programs reported only a very rudimentary level ofinterdisciplinary collaboration, whether with medical colleagues or members of allied nonmedical professions. In spite of the fairly large numbers of nonmedical personnel and of nonpsychiatrist physicians involved in psychiatric education, it appears that systematic preparation for, exposure to, and involvement in interdisciplinary collaboration is quite mmimal for many psychiatric residents. This finding is consistent with our previously noted findings on the relative infrequency of common-site training. Working
with
Paraprofessionals
Having noted the limited preparation of residents for interdisciplinary collaboration, we do not find it surprising that preparation for work with paraprofessionals was reported to be even more limited. In fact, it was often un-
LEE
clear whether the respondents distinguished the unique connotation of the term “paraprofessional” -some obviously equated “paraprofessional” with “multidisciplinary” and reported material on social workers, psychologists, and other physicians.3 Despite these misunderstandings, program responses clearly indicated little if any systematic preparation of residents for work with paraprofessionals. In fact, not one response could be interpreted as describing such preparation. Many respondents did report the availability of opportunities for working with paraprofessionals by virtue of on-the-job contact and daily interaction. Several respondents turned the issue around and described situations in which residents were teaching paraprofessionals rather than being taught to work with the paraprofessional. Clearly, training programs provide little systematic preparation for residents to work collaboratively with cither the more traditional multidisciplinary mental health team or the newer paraprofessional. This is not to say that the contributions of nonpsychiatrist groups were unrecognized or denigrated-in fact, a number of respondents offered testimonials to their importance. Rather, it appears that there is a widespread albeit implicit assumption that simple exposure to other mental health workers is all that is necessary to enable the resident to work effectively with them. Alternatively, it is possible that the importance of explicit training for work with other professionals and paraprofessionals is recognized but is not considered sufficiently important to warrant inclusion in an already heavy training regimen. Whatever the cxplanation, it is clear that preparation of residents to work with other personnel is at best informal and more often than not nonexistent. Recruitment Cultures
ofMinorities
and
Understanding
Other
Content analyses in this area were organized within three general categories of response: mechanisms for recruitment, numbers of minority residents and faculty, and efforts to promote understanding of minority subcultures. Recruitment. Five types of responses regarding recruitment efforts could be distinguished: I) statements that no special effort was being made but that discrimination was not practiced (N =42); 2) generalized, unspecific statements that efforts to recruit minorities had been made (N =56); 3) statements that a minimal level of affirmative action was being implemented, e.g., advertising in professional and/or minority publications or letters to medical schools and to graduating medical students (N = 16); 4) statements indicating a strong affirmative action 3This paper follows the convention of defining the paraprofessional role as working directly with clients, under general (as opposed to close, continuing) professional supervision, and for which brief, intensive, specialized training is usually required, typically at the sub-baccalaureate level, as opposed to a role requiring possession of(or working toward) a terminal degree defining a journeyman level for a given field. Typically regarded as paraprofessionals are physician assistants, indigenous mental health workers, new careerists (usually with the A.A. degree), drug counselors, etc.
GUREL
program, evidenced by recruitment efforts directed specifically toward medical schools with large minority populations by letters to deans, visits to the schools, and discussions with their students, and by personal contact with other minority psychiatrists (N = I 2); and 5) no response (N =36). Numbers of minority residents andfaculty. Although they were not specifically asked to do so, 27 programs volunteered specific numbers of minority trainees and faculty. These data are at best suggestive-we do not know, for example, whether other programs could have responded with numbers or whether foreign medical graduates were reported as blacks, Spanish-speaking, etc. The desirability of more systematic data in this area is obvious. Understanding ofminority subcultures. There were 52 programs that did not address this issue and 5 that simply indicated no efforts in the direction of furthering residents’ understanding of minority groups or foreign cultures. Among the remaining 105 respondents, 46 indicated that residents were exposed ‘0 experiences with minority group members in the course of everyday contact with patients and other staff and/or as a result of placements in community settings. Fifty-nine programs indicated an explicit effort in this area either through didactic instruction alone (N=29) or instruction plus the kinds of exposure just described (N=30). Instructional mechanisms included informal discussions, lectures, scmmars, and workshops. A recurring theme among the respondents was that in spite of their efforts and good intentions they had not been able to recruit women and minority group members simply because they were not available. A common observation concerned the necessity for increasing the number of minority group applicants to medical schools before there could be an increase in minority persons in the basic psychiatry residency program. Other comments suggested that although the area of minority group recruitment is being addressed with less than universal and vigorous attention, there is a growing awareness of the issues, and a few attempts have been made to resolve them. For example, several programs indicated that they provided or were planning to provide opportunities for residents to learn Spanish. Six programs noted special scheduling provisions for women residents. Training
To Deal
with
Social
Problems
Responses to this item separated the issue of social problems into three components: I) alcoholism and drug dependency as medical problems: 2) alcoholism and drug dependency as social problems; and 3) racism, poverty, etc., as related but separable problems. Alcohol and drug abuse. Training programs accepted responsibility for preparing residents to deal with alcohol and drug abuse-in sharp contrast to other issues dealt with in this section. Excluding several ambiguous responses and nonresponses, there was clear indication that instruction in the medical management of alcoholism and drug dependency was offered. The content of such instruction consisted for the most part of emergency man-
Am
J Psychiatry
132:4,
April
1975
369
CHARACTERISTICS
OF
RESIDENCY
PROGRAMS
agement of toxic conditions, pharmacological methods to treat alcoholism and drug abuse, and psychotherapeutic emphases in longer-term management. The programs indicated (specifically, in some cases) that alcoholism and drug abuse had long been recognized as among the problems psychiatrists deal with and need to be trained for. Surprisingly, most of the training and experience in these areas occurred either in the classroom or in a hospital-based setting; for every instance of teaching/experience in a nonhospital community setting there were three instances in the classroom and/or hospital. In contrast to training in medical management, little mention was made of training to deal with drug and alcohol abuse as social problems-granting, of course, that the distinction between medical and social problems is necessarily arbitrary. Attention to alcoholism and drug abuse as social problems could be discerned only in reports of the involvement of residents in walk-in crisis clinics, “hot line” services, halfway houses, etc. Racism, poverty, etc. Responses regarding racism and poverty generally fell into two categories, one that questioned whether these were legitimate concerns of psych iatric training, and another that took the position that these problems were simply too broad and too pervasive to be addressed by psychiatry. The only affirmative responses reflected programs that conveyed information to residents about the availability of welfare resources, both social and financial, and the complexities of welfare systems. Other problems. Eleven programs extended their narrative descriptions of training in critical social problems beyond the issues suggested in the question. Six of these reported didactic content in the areas of suicide, aging, unemployment, unwed mothers and unwanted pregnancy, therapeutic abortion, women’s liberation, criminal or antisocial and aggressive behavior, and the psychiatric role in draft deferment. Three of the II programs reported the availability of clinical experience in geriatric settings. Community
Psychiatry
Responses to this item were classified within a series of categories of increasing involvement: I. No content in community psychiatry (N =2). 2. General, unspecified statements of content (N = 5). 3. Didactic training only (N = 10). 4. Didactic training plus clinical experience in hospital service areas (N= 13). Community involvement in this category was so classified largely as a result of dealing with families of patients and with community agencies referring patients. 5. Didactic training and hospital-based experience, plus service and/or consultation with agencies such as schools, jails, prisons, other general hospitals, visiting nurses, courts, children’s centers, etc. (N = 58). These served a specific community program rather than a broader geographic area. 6. Didactic training, in-hospital service, contact with community agents, and experience at comprehensive mental health centers serving entire catchment areas
370
Am
J Psychiatry
/32.4,
April
/ 975
(N =43). Opportunities for training at this level included not only center services but also the outreach programs they conducted. 7. All of the training options in the previous category plus additional elective experience in community psychiatry in extensive and/or innovative areas (N=3l). This category included opportunities in evaluation and development of mental health delivery systems, in health maintenance organ izations, industrial consultation, multiple outreach or satellite clinics, research and evaluation, training programs for paraprofessionals, innovative treatment approaches, and programs unique by virtue of size, geography, and/or multiplicity of services. About half of the respondents (46 percent) reported a level of training in community psychiatry beyond what could be considered the traditional pattern ofdidactic instruction, hospital-associated experience, and consultation with community agencies. Other evidence lends support to the impression that the movement into the community is increasing. One respondent stated, “The concepts of community psychiatry’ have not been central in the development of our training program to date. The pressures of the current events are moving us in that direction now.” It is probable that the 46 percent of the programs reporting extensive community involvement represent the cutting edge of a trend. Seven programs reported that their residents received part of their training at 1 of 3 training programs in community psychiatrythe Center for Training in Community Psychiatry and Mental Health Administration at the University of California, Berkeley, the Laboratory for Community Psychiatry at Harvard, and the Community Psychiatry Training Program at Yale. Teaching
ofNew
Skills
Under the heading of”new skills,” the program directors were asked to describe training content in five areas: community consultation, community organization, child advocacy, administration, and program evaluation. With the partial exception of community consultation, there were far fewer affirmative responses on these items than on the preceding issues. The low level of the responses could have resulted from the fact that these issues were addressed at the end of a time-consuming task to which many respondents had obviously devoted considerable thought. In addition, a number of respondents explicitly questioned whether two of the areas in this section, cornmunity organization and child advocacy, had a legitimate place in the basic residency program. Community consultation. Responses to the issue of community consultation were generally in line with our earlier finding that fewer than half of the programs had moved beyond a fairly traditional pattern of involvement with community-based agents and agencies. Of the I 62 programs (one of which did not respond) 82 indicated little or no training content or experience in community consultation. The largest single type of involvement was rotation in community-based clinics and community mental health centers (N =61). Twenty-four programs reported consultation or other participation by
LEE
their residents in the schools, and 20 reported involvement of residents in some facet of the legal-judicialprison system. In all, 46 programs (28 percent) were rated as reporting substantial involvement and/or cxplicit didactic content in community consultation. Community organization. This area was rarely reported as being covered in training program curriculums. As already noted, several respondents volunteered the opinion that community organization was not an area of psychiatric expertise and/or concern. The 14 affirmative responses indicated that coverage was achieved largely through practicum assignments rather than didactic instruction. Placement sites included satellite and outreach activities of a teaching hospital, advisory councils of community mental health centers, a health maintenance organization, a metropolitan health planning agency, and a military community. Child advocacy. Only six programs cited specific instances of residents’ participation in child advocacy efforts; interestingly, only I instance was within a school system. Other activities included consultation to legislators and lobbying for legislation, consultation with legal personnel about the civil rights of children, and involvement in a child advocacy program funded by an Offlee of Economic Opportunity grant. It is difficult to know how much of the involvement in child advocacy represented an emphasis on the part of the training program and how much reflected an individual’s pursuit of his/her personal interests. Because the distinction was not always clear, essentially personal activities that reflected the resident’s role as a citizen rather than as a psychiatrist in training (e.g., letter writing, speaking to activist groups, etc.) were not tabulated as afflrmative responses. Administration. The inclusion ofadministration in this section reflects the fact that there has to date been little formal preparation of psychiatrists to assume administrative responsibilities. Data abstracted from program responses-over one-fourth simply ignored the issue-indicate that only 8 programs offered didactic material oriented toward developing administrative skills. An additional 28 programs reported that experience requirements were structured to increase the resident’s administrative know-how above what would normally be learned by assignment as a ward administrator or as chief resident. That formal training in administration was not commonly seen as a component ofthe residency program could also be inferred from respondents’ references to the availability of such training at the Harvard and Berkeley facilities. Program evaluation. Response to this question was similar to the responses for training in community organization, child advocacy, and administration. Only 13 of the 27 programs responding affirmatively addressed program evaluation in any direct sense; the others responded in terms of teacher evaluation and self-assessment. Participation in activities that might reasonably be considered evaluation took place primarily within the teaching hospital setting. Activities consisted of’ participation in programs of consumer evaluation and of apprenticeship-
type assignments in efforts under a grant or contract.
to evaluate
service
GUREL
agencies
COMMENT
It has been said that the transition from the l960s to the l970s was marked by a general disillusionment with science and technology as a basis for improving the human condition. The parallel growth ofhumanistic philosophies brought an increased concern with the quality of human life and a view of health as one of the basic rights of people. These emphases, among others, have resulted in an increased demand for mental health services in general and for psychiatric services in particular. However, social change has done more than merely expand the public’s demand for an increased quantity of psychiatric services. Attempts to make these services more available and accessible have emerged from the crucible of governmental-professional interaction. They have been expressed in the form of differential government support for certain kinds of programs and mental health delivery’ systems. The results of these efforts, to mention only a few examples, are evident in the expansion of the community mental health center program, the development of storefront services in the inner city and satellite clinics in rural areas, the sharing of psychiatric expertise with paraprofessionals, and a decreased emphasis on hospital treatment, with a concomitant emphasis on outpatient services and community-based alternatives to institutionalization. It is as yet unclear whether these developments represent progress or merely another swing of the pendulum. There may be a lesson in the fact that whereas Dorothea Dix labored to get the mentally ill out of the community and into hospitals, we now labor to get them out of hospitals and into the community (8). What is clear is that many psychiatrists who are attempting to meet the challenge of the newer forms of service delivery feel inadequately prepared to meet the demands of the roles they have been pioneering. Most were trained in postWorld War II models that tended to prepare psychiatrists for the practice of psychoanalytically oriented mdividual psychotherapy in solo office practice. Doubts about the utility of this training were soon reinforced by the criticisms of coworkers and of the intended recipients of their services. The validity of these misgivings and criticisms is not especially relevant here. What is important is that they served to focus attention on what psychiatrists do, what they should do, and how appropriately and adequately they are trained for their professional roles. A host of influences has subsequently reinforced concerns about psychiatric training and the underlying question ofwhat the potential psychiatrist is being trained for. While much ofthe stimulus for examining such issues has come from outside psychiatry-judicial critics, minority groups, the women’s movement, government budget officials, etc. -psychiatrists themselves have become increasingly concerned with the question, “What is a psychiatrist?” As this is being written, an official body of the
Am
J
Psychiatry
132.4.
April
/ 975
371
CHARACTERISTICS
OF
RESIDENCY
PROGRAMS
American Psychiatric Association is attempting to provide an answer to this question. Psychiatrists, like other professionals, are to a large extent what they have been trained to be, and they do in practice what they have been trained to do. But as delivery systems and emphases in psychiatric practice change, one can hope that the structure and content of training programs will be adjusted to better prepare residents for their changing roles. The study reported here was conceived as an attempt to provide certain baseline information about the nature and scope of the training offered in approved residency training programs. In focusing on the totality of residency training, this report and the parent monograph serve as companion pieces to an earlier APA publication (9) stressing the uniqueness of individual training programs. The data presented here are offered in the hope that they will facilitate answers to questions about the training psychiatrists should receive in the future by providing at least limited information about training and training programs in the immediate past.
372
Am
J Psychiatry
/32:4,
April
/ 975
REFERENCES
I. Szasz TS: The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement. New York, DelI Publishing Co. 1970 2. Torrey EF: The Death of Psychiatry. Radnor, Pa, Chilton Book
Co. 1974 3. 4. 5. 6.
7.
8.
9.
Ennis BJ: Prisoners of Psychiatry: Mental Patients, Psychiatrists, and the Law. New York, Harcourt Brace Jovanovich, 1972 Chu FD, Trotter 5: The Madness Establishment. New York, Grossman Publishers, 1974 Freedman AM: The presidential address: creating the future. Am J Psychiatry 131:749-754, 1974 Fleckles CS: The making of a psychiatrist: the resident’s view of the process of his professional development. Am J Psychiatry 128:1111-IllS, 1972 Essentials of approved residencies, in Directory of Approved Internships and Residencies, 1972-1973. Chicago, American Medical Association, 1972 Gurel L: Dorothea Dix revisited: extended care in the community as an alternative to hospitalization. Read at the 21st annual meeting of the Gerontological Society, Denver, Oct 31-Nov 2, 1968 Gurel L (ed): A Descriptive Directory of Psychiatric Training Programs in the United States, l972-73. Washington, DC, American Psychiatric Association, 1973
AMERICAN
Some
Characteristics
BY
GUREL,
LEE
JOURNAL
of Psychiatric
Residency
THE PURPOSE of this study was to obtain quantitative descriptive data about psychiatric residency training programs. Conducted at a time when psychiatric practice and education are being subjected to criticism both from within (1, 2) and without (3, 4), the study was expected to bring to light findings that would be useful in understanding current emphases in training. A familiar truism holds that change is one of the unchanging facts of life. This study was conducted during a
This paper is abstracted from the monograph A Survey of Academic Resources in Psychiatric Residency Training, which is available from the Publications Services Division of the American Psychiatric Association. The study was conducted under provisions of contract HSM-4269-89 between APA and the National Institute of Mental Health; it was initiated under J.F. Whiting, Ph.D., former director of APA’s Manpower Division. Dr. Gurel is Director, Division of Manpower, Research opment, American Psychiatric Association. Address reprint 2723 Woodley Place, NW., Washington, D.C. 20008. wishes Nelson,
PSYCHIATRY
Training
Programs
PH.D.
The author summarizes responses to a major questionnaire survey ofpsychiatric residency training programs. In addition to providing objective data on residents, training staff, and on the training institution and its re/atedfacilities, the author presents information drawnfrom the narrative responses to questions on major issuesfacing psychiatry. These include training for dealing with critical social problems, recruitment of minority group trainees and faculty, and training in interdisciplinary collaboration and preparation for work with paraprofessionals. It is hoped that these data will facilitate answers to questions about the training psychiatrists should receive in the future by providing information about training programs in the immediate past.
The author rick, Carol
OF
to acknowledge and Ina Spaner.
the collaboration
of Mary
and Develrequests to Jane
Mer-
period of accelerated change in the conditions influencing the delivery of psychiatric services (5). As one psychiatrist expressed it, “We live in a time when nearly every psychiatric program in the country is undergoing critical evaluation and, in some cases, major changes” (6). This atmosphere of evaluation and change undoubtedly affected the conduct of the study. While our major purpose was to assemble heretofore unavailable “hard” data about the scope and nature of residency training, we also sought to address certain emerging and/or controversial issues; these issues will be identified and discussed.
METHOL)
All active programs approved by the AMA’s Residency Review Committee for training in general and/or child psychiatry (N 288) were sent questionnaires in two mailings in the spring and fall of 1972. The programs are categorized by program type, site, and sponsorship in table 1. To facilitate presentation, programs were grouped into the four categories indicated by the boxes in the table. It can be seen, for example, that one box encompasses the 28 programs offering child psychiatry training only and that another surrounds the 6+67+ 10+ 11+4=98 programs in psychiatric hospitals not operated in conjunction with a medical school. The four categories will be identified as child programs (N=28), mental hospital programs (N=98), medical school programs (N 97), and other programs (N =65) - the latter were in free-standing child/community clinics/centers or in general hospitals that were not medical school primary teaching sites. The questionnaires requested objective information about residents, training staff, and the training institution and its affiliated facilities. In addition, training directors were asked to provide narrative responses regarding a series of issues that were of particular interest to the Na=
=
An’ J Pst’chiatrv
/32:4. April
1975
363
CHARACTERISTICS
TABLE Psychiatric ship
OF
RESIDENCY
PROGRAMS
RESULTS
I Residency
Training
Programs
by
Type.
Type
Site
and
Child (N = 28)
Sponsorship
Psychiatric hospital, nonmedical school(N= 100) Federal Other public Private Psychiatric facility in medical school (N =99) In public university In private university Other Psychiatric unit in nonmedical school general hospital (N = 68) Federal Otherpublic Private Nonhospital clinic/center (N =21) Federal Otherpublic Private
6 67 II
1 1
and
Sponsor-
of Program
General (N = 162)
-
Site,
Combined Child/ General (N = 98)
Total (N = 288)
6 78 16
-
10 4 1
1 I -
16 13 2
38 27 1
13 13 19
2 3 11
-
7
-
-
-
1 1
8 9
I
41 3
15 16 37
-
2
11 10
tional Institute of Mental Health (NIMH) staff involved in initiating the study. These had to do with child mental health, community psychiatry, recruitment of minority group trainees and faculty, training for increased understanding of minority cultures, training in interdisciplinary collaboration and work with paraprofessionals, training to deal with critical social problems, and training in acquiring skills in community consultation, community organization, child advocacy, program administration, and program evaluation. Narrative responses were subjected to content analyses. Response
Rate
All of the 288 programs surveyed eventually responded with data on their residents. The information requested on staffing and other program characteristics was supplied by 234 programs; 32 more reported just the staffing information. Ratings of the quality and quantity of responses from the 234 programs with complete quantitative data indicated that 148 (63 percent) could be considered good or excellent, 31 percent fair, and 6 percent poor. The response to our request for narrative comments was considerably less satisfactory. Of the 234 programs with complete quantitative data, fewer than half (47 percent) had responses that were rated as satisfactory; more than one-third (37 percent) either did not respond or gave minimal and inadequate responses. The remaining 16 percent of the responses were considered minimal and barely adequate.
364
Am
J Psychiatry
132:4,
April
1975
Table I shows that of the 288 programs, 28 offered training only in child psychiatry, 162 only in general psychiatry, and 98 in both general and child psychiatry. Most programs were in psychiatric hospitals that were not part of a medical school (N= 100) or in psychiatric facilities that were functionally or administratively part of a medical school setting (N =99). The remainder were located in facilities associated with general hospitals that were not part of a medical school setting (N=68) or in clinics or centers not associated with a medical school or with either hospital setting (N 2 1). The type of training offered was related to program sponsorship and location. At the psychiatric hospitals (almost all of which were state mental hospitals) training was typically in general psychiatry only. Programs in general psychiatry also predominated, although to a lesser degree, in general hospitals that were not part of a medical school complex. On the other hand, two-thirds of the programs in medical school settings offered both basic training in general psychiatry and advanced training in child psychiatry. The 288 programs were located in 43 states, Puerto Rico, and the District ofColumbia. It is striking that almost half of the programs (47 percent) were located in the 1 1 northeastern states and the District of Columbia. Also of interest is the fact that mental hospital programs were more frequently located in this northeastern area than were medical school programs, whereas the reverse was true in the rest of the country. =
Residents A total of 4,750 residents were reported in training on September 1, 1972.’ Table 2 shows their placement by program type and by year of training. Fully 90 percent of the residents were in the first three years of training and 10 percent were in advanced training, mostly in child psychiatry. With respect to the four categories described previously, only 2.1 percent of the residents were in the 28 child programs; more than half (53 percent) were in the 97 programs in medical schools that were not exclusively child psychiatry programs. The number of residents varied from none in 6 programs (which did not, however, consider themselves inactive or in the process of closing down) to 110 in the case of a consolidated program comprised of 3 semiautonomous programs. The median number of residents per program was 12.5. Programs in New York State had 20.2 percent of all trainees and California had 12.5 percent. These were followed in descending order by Massachusetts, Pennsylvania, Ohio, Michigan, Illinois, Maryland, Connecticut, and Missouri. The programs in these 10 states had 3,344 residents, or 70.4 percent of the total.
‘Follow-up ambiguous
a year later indicated that several of the residents status and probably should not have been reported.
had
an
LEE
TABLE
GUREL
2
Distribution
ofResidents
by
Year
and
Type
of Program
Year First (N=l,54l) TypeofProgram Child(N=28) Mental hospital Medical school Other (N=65)
N 7 (N=98) (N=97)
438 820 276
Second (N=l,389) Percent
N
7.0 34.1 32.6 32.6
398 722 260
Third (N=l,345) Percent
9
of Training
9.0 31.0 28.7 30.7
Staffing
N
Percent
28 342 746 229
TABLE Number
Instructions for reporting teaching staff called for excluding staff who did not hold officially designated positions, who did not regularly do didactic or clinical teaching of psychiatric residents, and who possibly interacted only casually with residents. Consultants and lecturers were not to be reported unless they were both regularly scheduled and averaged at least one hour a week with residents. Data-handling procedures were designed to provide an unduplicated count ofstaffwithin the unit of a program and its associated facilities. However, a particular individual could have been reported by more than one program (e.g., a faculty member who worked part-time in more than one program). More than 8,000 psychiatrists were reported to be teaching in residency programs. Even though this figure does not necessarily reflect 8,000 separate individuals, particularly among the more than 5,000 part-time people, there can be little doubt that a considerable proportion of the nation’s psychiatric manpower is involved in the training of future psychiatrists. Table 3 presents a breakdown of psychiatrists in terms of board certification and full-time versus part-time involvement for the 266 programs that responded fully to the set ofstaffing items. Part-time appointments were relatively more frequent in child psychiatry training programs and least frequent, relatively speaking, in the case of mental-hospital-based programs. For the three program types other than those based in mental hospitals, both part-time and full-time faculty were more often board certified than not. In the mental-hospital-based programs, however, less than one-third of the full-time psychiatric teaching staff were certified. Only 302 full-time and 424 part-time neurologists were reported to be involved in psychiatric residency training. The neurologists were more likely than the psychiatrists to be board certified (76 percent versus 56 percent), and they were somewhat more often full-time (42 percent versus 37 percent). Data about other teaching staff are reported in table 4. The category of social scientist included social workers, sociologists, anthropologists, etc.; physical scientist included biologists, chemists, etc.; and other physicians included all M.D.s and D.O.s who were not psychiatrists or neurologists. Perhaps the most noteworthy finding re-
Fourth (N=348)
Fifth (N=l27)
N
28.0 26.6 29.6 27.1
39 58 192 59
Percent
N
39.0 4.5 7.6 7.0
17 49 39 22
Percent
Total (N=4,750)
17.0 3.8 1.5 2.6
100 1,285 2,519 846
3 of Psychiatrists
Teaching
in Residency
Type
Psychiatrists Faculty
on
certified Full-time Part-time Total Noncertified Full-time Part-time Total Both certified noncertified Full-time Part-time Total
Programs
of Program
Mental Hospital (N=94)
Medical School (N=95)
24 74 98
332 618 950
997 1,758 2,755
272 656 928
1,625 3,106 4,731
8 44 52
718 461 1,179
538 1,113 1,651
241 590 831
1,505 2,208 3,713
32 118 150
1,050 1,079 2,129
1,535 2,871 4,406
513 1,246 1,759
3,130 5,314 8,444
Child (N= 17)
Other (N=60)
Total (N=266)
Board
and
TABLE
4
Number Physical
of Other Scientists
Physicians. Teaching
Psychologists. Social in Residency Programs
Type
Classification Other physicians Full-time Part-time Total Psychologists Full-time Part-time Total Social scientists Full-time Part-time Total Physical scientists Full-time Part-time Total
Child (N= 17)
Scientists.
and
of Program
Mental Hospital (N=94)
Medical School (N=95)
Other (N=60)
Total (N =266)
0 4 4
233 144 377
242 147 389
26 39 65
501 334 835
42 57 99
359 193 552
684 366 1,050
275 138 413
1,360 754 2,114
74 54 128
908 225 1,133
927 306 1,233
440 124 564
2,349 709 3,058
I 0 I
71 25 96
168 53 221
46 6 52
286 84 370
A m J Psychiatry
/32:4,
April
/975
365
CHARACTERISTICS
TABLE Number
OF
RESIDENCY
PROGRAMS
5 of Programs
Offering
Experience
with
Selected
Patient
Types/
Conditions
Type
Child (N=9) Patient
Type/Condition
Neurosis/behavior disorder, child/ adolescent Psychosis/autism, child/adolescent Juveniledelinquency Drug abuse, child/adolescent Psychophysiologic disorder, child/ adolescent Mental retardation Neurosis, adult Acute psychosis, adult Chronic psychosis, adult Organic brain syndrome Alcoholism Drug dependency, adult Personality disorders Disordersoftheaged Medical/surgical patients Other *Almost
exclusively
acute
situational
Percent
9 9 5 5
100 100 56 56
77 69 26 16
87 78 29 18
79 74 35 30
92 86 41 35
42 36 18 11
84 72 36 22
207 188 84 62
88 80 36 26
7 8 2 2
78 89 22 22
4 2 2 7
44 22 22 78
75 53 88 88 85 68 84 73 70 59 42 16
84 60 99 99 96 76 94 82 79 66 47 18
76 41 86 86 62 40 80 76 68 38 73 12
88 48 100 100 72 47 93 88 79 44 85 14
47 19 50 50 31 30 49 49 45 29 47 12
94 38 100 100 62 60 98 98 90 58 94 24
205 121 226 226 178 142 215 200 190 126 167 43
88 52 97 97 76 61 92 85 81 54 71 18
-
5 3
56 33
disorders.
Contact
A m J Psychiatry
132:4,
April
Percent
N
-
Percent
N
Percent
-
N
Total (N=234)
N
The availability to residents ofexperience with selected patient types and conditions was tabulated for the 234 programs that returned complete responses regarding this issue and the issues dealt with in the two following paragraphs. These data are presented in table 5, which indicates results generally in line with expectations for the particular program types. For example, with the exception of most of the child programs and 1 mental hospital program, all programs saw neurotic and acutely psychotic adults; all child programs saw neurotic and psychotic/autistic children. Alcoholic and drug-dependent adult patients were seen in a surprisingly high proportion of the non-child programs (92 percent and 85 percent, respectively). On the other hand, juvenile delinquents, young drug abusers, and patients with organic brain syndromes were seen in fewer programs than many authorities would probably have anticipated. It was found that an average of I 1 of the 16 listed conditions were seen in the 3 non-child program categories, with a range from 16 down to only 3 in the case of I mental hospital program. Thus it appears that some training programs are based in rather specialized settings and that arrangements for experiences in other settings are limited. However, it should be noted that these data reflect 366
Other (N=50)
Percent
flected in table 4 is the relatively large number of psychologists and social scientists reported to be involved in teaching residents. Especially remarkable is the relatively higher proportion of full-time appointments for these groups compared with psychiatrists and neurologists. Patient
Medical School (N=86)
N
-
or transient
of Program
Mental Hospital (N=89)
/975
the availability dents actually determined. Treatment
of certain saw patients
kinds ofthe
of patients; particular
whether resitypes was not
Modalities
A related issue involves the extent to which specified treatment methods were in use at the program and its associated facilities. It is evident from the data in table 6 that certain methods were practically universal-individual psychotherapy, group psychotherapy, psychotropic drugs, crisis intervention, and, to a slightly lesser extent, electroconvulsive therapy. On the other hand, insulin coma/subcoma therapy, carbon dioxide therapy, psychoanalysis (excluding psychoanalytically oriented psychotherapy), sensitivity training/training laboratories, and psychodrama were used very infrequently. The “other” category produced many responses, 90 percent of which reported either hypnosis or other somatic treatment. Affirmative responses ranged from 2 medical school programs reporting the use of 13 modalities to 2 child programs reporting 1 and 2 methods, respectively. The median number of modalities per program was approximately 8. Again, the reader is cautioned that the data reflect treatment methods in use at the program training site; the breadth or depth of experience of individual trainees is not known.2
2A reviewer of this manuscript suggested that these data her impression that programs overemphasize depth of few modalities at the expense of breadth of experience. as an example of this the extreme difficulty of finding an trained psychiatrist who is competent and available to troconvulsive therapyespecially on the east coast.
confirmed his/ experience in a He/she offered otherwise welladminister elec-
LEE
TABLE Number
6 of Programs
Offering
Experience
with
Selected
Treatment
Modalities
Type
Modality
N
Percent
Psychotropic drugs Electroconvulsivetherapy Insulin coma/subcoma therapy Carbon dioxide therapy Individual psychotherapy Psychoanalysis, classical and variants Behavior modification, token economy Group psychotherapy Sensitivity training/training laboratory Psychodrama Sociomilieu: self-government, attitude, etc. Conjoint/family Crisis intervention, walk-ins, etc. Alcoholism clinic/program Drug clinic/program Other
7 1
78 11
Number
-
-
-
-
9
100
-
-
3 8
33 89
-
-
-
-
I 7 7 I 2 3
11 78 78 II 22 33
N
Medical School (N=86) Percent
N
Other (N=50) Percent
N
Total (N=234) Percent
N
Percent
89 83 2 3 89 3 31 89 6 6
100 93 2 3 100 3 35 100 7 7
86 82 4 1 86 9 38 86 4 11
100 95 5 1 100 10 44 100 5 13
50 46 2 1 50 2 13 50 2 6
100 92 4 2 100 4 26 100 4 12
232 212
234 14 85 233 12 23
99 91 3 2 100 6 36 99 5 10
37 49 89 36 33 57
42 55 100 40 37 64
39 67 85 35 41 61
45 78 99 41 48 71
24 34 50 25 27 39
48 68 100 50 54 78
101 157 231 97 103 160
43 67 99 41 44 68
8 5
7 ofPrograms
Offering
Training
in Related
Fields
Type
Field
N
Percent
Nursingaffiliate Nursingclinicalspecialist Social work master’s/placement Psychology(doctoral) Mental health associate (A.A. degree) Medical internship Rehabilitation specialist Speech and hearing (MA., Ph.D.) Dietetics Other
2 I 5 4
22 II 56 44
6 2
67 22
Training
-
-
-
-
1 3
of Program
Mental Hospital (N=89)
Child (N=9)
Related
of Program
Mental Hospital (N=89)
Child (N=9)
TABLE
GUREL
11 33
N 61 13 48 50 6 53 27 I 2 29
Programs
One of the objectives of a residency is to train the future psychiatrist to work in the collaborative multidisciplinary arrangements that are increasingly common in mental health service delivery systems. Since shared training experiences are generally thought to foster the development of the skills and attitudes involved in effective multidisciplinary effort, we collected data on the extent to which training related to academic or professional requirements other than for medical specialists was offered at the program site and/or its associated facilities. The availability of8 such training programs and the medical internship is shown in table 7. The medical internship was the most frequently re-
Medical School (N=86)
Other (N=50)
Percent
N
Percent
69 15 54 56 7 60 30 I 2 33
57 10 59 63 2 83 27
66 12 69 73 2 97 31
-
-
1 37
1 43
N
Total (N=234) Percent
31 3 37 31 1 44 15 I
62 6 74 62 2 88 30 2
3 10
6 20
N
151 27 149 148 9 186 71 2 7 79
Percent
65 12 64 63 4 79 30 1 3 34
ported related training experience: it was offered at 79 percent of the programs and was almost universally available in medical school programs. A cluster of nursing, social work, and psychology programs was next in frequency. Dietetic, speech and hearing, and mental health associate programs were rare, and there were fewer rehabilitation-type programs than might have been expected. In retrospect, the item on related training should have specifically mentioned 2 or 3 additional groups. Included within the “other” category are 42 programs in pastoral counseling and similar ministerial training; 15 programs in vocational counseling, counseling and guidance, and/or subdoctoral psychology; and 7 programs in special education. A long list of other fields was com-
A m J Psychiatry
/32:4,
April
1 975
367
CHARACTERISTICS
RESIDENCY
OF
PROGRAMS
piled, but there were only I or 2 reports of each of these programs (law, pharmacy, hospital administration, etc.). In two-thirds of the programs, four or fewer kinds of related training programs were being conducted. As almost 20 percent of the residency programs had no related training (or none other than medical internship), such common-site training must be considered surprisingly infrequent, particularly in areas outside the traditional mental health professions.
SOME
SPECIAL
ISSUES
The status of certain aspects of residency training content can be adequately inferred from the quantitative data presented in the preceding section. Our results suggested that I) opportunities for experience with certain patient conditions vary, 2) some content is essentially universal, 3) some content has been largely phased out (e.g., insulin coma and carbon dioxide therapies), and 4) still other content (e.g., behavior modification and sociomilieu methods) is available in only a small number of the programs. To complement those data, narrative resonses were elicited about what we perceived to be emerging emphases, points of controversy, or areas of suspected deficiency in psychiatric residency training. The reader is cautioned that the findings in the following paragraphs are subject to limitations of response bias. The kind of extended speculation that was included in the parent monograph on the possible reasons for (and the impact of) the lowered rate of response to this part of the survey cannot alter this central fact. There is simply no way of knowing how respondent and nonrespondent programs differ and what influences operated to produce the selective response. What follows is based on the 162 programs (56 percent) that returned usable responses on the seven issues. These responses varied from the single word “none” to 44 pages on one issue. Child
Mental
Health
We initially assumed that because all of the programs surveyed were accredited, their didactic and clinical content would meet the accreditation requirements of sufficient
experience
general of
psychiatry
human
process
in child
an
growth
and
development
in infancy
and
childhood
and by the sociocultural This
psychiatry
to acquire
knowledge
should
instruction and through children. (7, p. 373)
milieu be
.
.
.
for
the
understanding and as
of
influenced
of which
resident
of the
the
imparted
through
supervised
clinical
the
in
biology
maturational by
family
the
family
is a part.
formal
experience
didactic
with
Our tabulations support the conclusion that the programs varied widely in interpretation of the “sufficient experience” requirement. The responses ranged from that of I program which explicitly reported no child mental health content and no provision for placement at child facilities, through 2 programs in which such instruction was elective, to 40 programs with teaching and experience throughout all three years. Although didactic in-
368
Am
J Psychiatry
/32:4.
April
/975
struction in normal development was frequently reported, only 8 programs reported provision for actual experiences with normal children; e.g., experience in well-baby clinics and observation ofand/or participation in nursery school programs. One program reported experience with normal children throughout all three years of the basic residency, and 5 programs indicated opportunities for research in child psychiatry. There was little indication of experimentation with the child mental health curriculum; the few reported instances could not be considered major departures from the conventional. We do not know to what extent the programs simply did not report innovative curriculum developments because they were not directly requested to do so, but this could hardly explain the almost total absence of references to innovative approaches. The fact that child mental health content headed the list of issues of special concern in the survey suggests that the APA and NIMH personnel who planned the study may have questioned how well this content was being covered in basic psychiatry training programs. The data suggest that such doubts may be well founded. It appears that there is reason to doubt not only the adequacy of coverage of child mental health but even whether some programs continue to meet the minimum standards for approval. Interdisciplinary
Collaboration
Responses concerning the issue of interdisciplinary collaboration in psychiatric training were placed in five categories, as follows: I) collaboration with other medical specialties, e.g., “resident may be asked to consult to other parts of the hospital” (N=7); 2) joint seminars and/or conferences, i.e., participation in common didactic activities (N= 15); 3) common assignment with other disciplines to patient care situations, e.g., admission, patient planning, case review, or discharges (N=44); 4) an explicitly designed team approach to patient care involving joint decision making and shared responsibility (N =59); and 5) a strongly emphasized commitment to an explicitly designed team approach, with reciprocal training and supervision (N = 33). There were 3 instances of no response and I negative response. We found that 43 percent of the programs reported only a very rudimentary level ofinterdisciplinary collaboration, whether with medical colleagues or members of allied nonmedical professions. In spite of the fairly large numbers of nonmedical personnel and of nonpsychiatrist physicians involved in psychiatric education, it appears that systematic preparation for, exposure to, and involvement in interdisciplinary collaboration is quite mmimal for many psychiatric residents. This finding is consistent with our previously noted findings on the relative infrequency of common-site training. Working
with
Paraprofessionals
Having noted the limited preparation of residents for interdisciplinary collaboration, we do not find it surprising that preparation for work with paraprofessionals was reported to be even more limited. In fact, it was often un-
LEE
clear whether the respondents distinguished the unique connotation of the term “paraprofessional” -some obviously equated “paraprofessional” with “multidisciplinary” and reported material on social workers, psychologists, and other physicians.3 Despite these misunderstandings, program responses clearly indicated little if any systematic preparation of residents for work with paraprofessionals. In fact, not one response could be interpreted as describing such preparation. Many respondents did report the availability of opportunities for working with paraprofessionals by virtue of on-the-job contact and daily interaction. Several respondents turned the issue around and described situations in which residents were teaching paraprofessionals rather than being taught to work with the paraprofessional. Clearly, training programs provide little systematic preparation for residents to work collaboratively with cither the more traditional multidisciplinary mental health team or the newer paraprofessional. This is not to say that the contributions of nonpsychiatrist groups were unrecognized or denigrated-in fact, a number of respondents offered testimonials to their importance. Rather, it appears that there is a widespread albeit implicit assumption that simple exposure to other mental health workers is all that is necessary to enable the resident to work effectively with them. Alternatively, it is possible that the importance of explicit training for work with other professionals and paraprofessionals is recognized but is not considered sufficiently important to warrant inclusion in an already heavy training regimen. Whatever the cxplanation, it is clear that preparation of residents to work with other personnel is at best informal and more often than not nonexistent. Recruitment Cultures
ofMinorities
and
Understanding
Other
Content analyses in this area were organized within three general categories of response: mechanisms for recruitment, numbers of minority residents and faculty, and efforts to promote understanding of minority subcultures. Recruitment. Five types of responses regarding recruitment efforts could be distinguished: I) statements that no special effort was being made but that discrimination was not practiced (N =42); 2) generalized, unspecific statements that efforts to recruit minorities had been made (N =56); 3) statements that a minimal level of affirmative action was being implemented, e.g., advertising in professional and/or minority publications or letters to medical schools and to graduating medical students (N = 16); 4) statements indicating a strong affirmative action 3This paper follows the convention of defining the paraprofessional role as working directly with clients, under general (as opposed to close, continuing) professional supervision, and for which brief, intensive, specialized training is usually required, typically at the sub-baccalaureate level, as opposed to a role requiring possession of(or working toward) a terminal degree defining a journeyman level for a given field. Typically regarded as paraprofessionals are physician assistants, indigenous mental health workers, new careerists (usually with the A.A. degree), drug counselors, etc.
GUREL
program, evidenced by recruitment efforts directed specifically toward medical schools with large minority populations by letters to deans, visits to the schools, and discussions with their students, and by personal contact with other minority psychiatrists (N = I 2); and 5) no response (N =36). Numbers of minority residents andfaculty. Although they were not specifically asked to do so, 27 programs volunteered specific numbers of minority trainees and faculty. These data are at best suggestive-we do not know, for example, whether other programs could have responded with numbers or whether foreign medical graduates were reported as blacks, Spanish-speaking, etc. The desirability of more systematic data in this area is obvious. Understanding ofminority subcultures. There were 52 programs that did not address this issue and 5 that simply indicated no efforts in the direction of furthering residents’ understanding of minority groups or foreign cultures. Among the remaining 105 respondents, 46 indicated that residents were exposed ‘0 experiences with minority group members in the course of everyday contact with patients and other staff and/or as a result of placements in community settings. Fifty-nine programs indicated an explicit effort in this area either through didactic instruction alone (N=29) or instruction plus the kinds of exposure just described (N=30). Instructional mechanisms included informal discussions, lectures, scmmars, and workshops. A recurring theme among the respondents was that in spite of their efforts and good intentions they had not been able to recruit women and minority group members simply because they were not available. A common observation concerned the necessity for increasing the number of minority group applicants to medical schools before there could be an increase in minority persons in the basic psychiatry residency program. Other comments suggested that although the area of minority group recruitment is being addressed with less than universal and vigorous attention, there is a growing awareness of the issues, and a few attempts have been made to resolve them. For example, several programs indicated that they provided or were planning to provide opportunities for residents to learn Spanish. Six programs noted special scheduling provisions for women residents. Training
To Deal
with
Social
Problems
Responses to this item separated the issue of social problems into three components: I) alcoholism and drug dependency as medical problems: 2) alcoholism and drug dependency as social problems; and 3) racism, poverty, etc., as related but separable problems. Alcohol and drug abuse. Training programs accepted responsibility for preparing residents to deal with alcohol and drug abuse-in sharp contrast to other issues dealt with in this section. Excluding several ambiguous responses and nonresponses, there was clear indication that instruction in the medical management of alcoholism and drug dependency was offered. The content of such instruction consisted for the most part of emergency man-
Am
J Psychiatry
132:4,
April
1975
369
CHARACTERISTICS
OF
RESIDENCY
PROGRAMS
agement of toxic conditions, pharmacological methods to treat alcoholism and drug abuse, and psychotherapeutic emphases in longer-term management. The programs indicated (specifically, in some cases) that alcoholism and drug abuse had long been recognized as among the problems psychiatrists deal with and need to be trained for. Surprisingly, most of the training and experience in these areas occurred either in the classroom or in a hospital-based setting; for every instance of teaching/experience in a nonhospital community setting there were three instances in the classroom and/or hospital. In contrast to training in medical management, little mention was made of training to deal with drug and alcohol abuse as social problems-granting, of course, that the distinction between medical and social problems is necessarily arbitrary. Attention to alcoholism and drug abuse as social problems could be discerned only in reports of the involvement of residents in walk-in crisis clinics, “hot line” services, halfway houses, etc. Racism, poverty, etc. Responses regarding racism and poverty generally fell into two categories, one that questioned whether these were legitimate concerns of psych iatric training, and another that took the position that these problems were simply too broad and too pervasive to be addressed by psychiatry. The only affirmative responses reflected programs that conveyed information to residents about the availability of welfare resources, both social and financial, and the complexities of welfare systems. Other problems. Eleven programs extended their narrative descriptions of training in critical social problems beyond the issues suggested in the question. Six of these reported didactic content in the areas of suicide, aging, unemployment, unwed mothers and unwanted pregnancy, therapeutic abortion, women’s liberation, criminal or antisocial and aggressive behavior, and the psychiatric role in draft deferment. Three of the II programs reported the availability of clinical experience in geriatric settings. Community
Psychiatry
Responses to this item were classified within a series of categories of increasing involvement: I. No content in community psychiatry (N =2). 2. General, unspecified statements of content (N = 5). 3. Didactic training only (N = 10). 4. Didactic training plus clinical experience in hospital service areas (N= 13). Community involvement in this category was so classified largely as a result of dealing with families of patients and with community agencies referring patients. 5. Didactic training and hospital-based experience, plus service and/or consultation with agencies such as schools, jails, prisons, other general hospitals, visiting nurses, courts, children’s centers, etc. (N = 58). These served a specific community program rather than a broader geographic area. 6. Didactic training, in-hospital service, contact with community agents, and experience at comprehensive mental health centers serving entire catchment areas
370
Am
J Psychiatry
/32.4,
April
/ 975
(N =43). Opportunities for training at this level included not only center services but also the outreach programs they conducted. 7. All of the training options in the previous category plus additional elective experience in community psychiatry in extensive and/or innovative areas (N=3l). This category included opportunities in evaluation and development of mental health delivery systems, in health maintenance organ izations, industrial consultation, multiple outreach or satellite clinics, research and evaluation, training programs for paraprofessionals, innovative treatment approaches, and programs unique by virtue of size, geography, and/or multiplicity of services. About half of the respondents (46 percent) reported a level of training in community psychiatry beyond what could be considered the traditional pattern ofdidactic instruction, hospital-associated experience, and consultation with community agencies. Other evidence lends support to the impression that the movement into the community is increasing. One respondent stated, “The concepts of community psychiatry’ have not been central in the development of our training program to date. The pressures of the current events are moving us in that direction now.” It is probable that the 46 percent of the programs reporting extensive community involvement represent the cutting edge of a trend. Seven programs reported that their residents received part of their training at 1 of 3 training programs in community psychiatrythe Center for Training in Community Psychiatry and Mental Health Administration at the University of California, Berkeley, the Laboratory for Community Psychiatry at Harvard, and the Community Psychiatry Training Program at Yale. Teaching
ofNew
Skills
Under the heading of”new skills,” the program directors were asked to describe training content in five areas: community consultation, community organization, child advocacy, administration, and program evaluation. With the partial exception of community consultation, there were far fewer affirmative responses on these items than on the preceding issues. The low level of the responses could have resulted from the fact that these issues were addressed at the end of a time-consuming task to which many respondents had obviously devoted considerable thought. In addition, a number of respondents explicitly questioned whether two of the areas in this section, cornmunity organization and child advocacy, had a legitimate place in the basic residency program. Community consultation. Responses to the issue of community consultation were generally in line with our earlier finding that fewer than half of the programs had moved beyond a fairly traditional pattern of involvement with community-based agents and agencies. Of the I 62 programs (one of which did not respond) 82 indicated little or no training content or experience in community consultation. The largest single type of involvement was rotation in community-based clinics and community mental health centers (N =61). Twenty-four programs reported consultation or other participation by
LEE
their residents in the schools, and 20 reported involvement of residents in some facet of the legal-judicialprison system. In all, 46 programs (28 percent) were rated as reporting substantial involvement and/or cxplicit didactic content in community consultation. Community organization. This area was rarely reported as being covered in training program curriculums. As already noted, several respondents volunteered the opinion that community organization was not an area of psychiatric expertise and/or concern. The 14 affirmative responses indicated that coverage was achieved largely through practicum assignments rather than didactic instruction. Placement sites included satellite and outreach activities of a teaching hospital, advisory councils of community mental health centers, a health maintenance organization, a metropolitan health planning agency, and a military community. Child advocacy. Only six programs cited specific instances of residents’ participation in child advocacy efforts; interestingly, only I instance was within a school system. Other activities included consultation to legislators and lobbying for legislation, consultation with legal personnel about the civil rights of children, and involvement in a child advocacy program funded by an Offlee of Economic Opportunity grant. It is difficult to know how much of the involvement in child advocacy represented an emphasis on the part of the training program and how much reflected an individual’s pursuit of his/her personal interests. Because the distinction was not always clear, essentially personal activities that reflected the resident’s role as a citizen rather than as a psychiatrist in training (e.g., letter writing, speaking to activist groups, etc.) were not tabulated as afflrmative responses. Administration. The inclusion ofadministration in this section reflects the fact that there has to date been little formal preparation of psychiatrists to assume administrative responsibilities. Data abstracted from program responses-over one-fourth simply ignored the issue-indicate that only 8 programs offered didactic material oriented toward developing administrative skills. An additional 28 programs reported that experience requirements were structured to increase the resident’s administrative know-how above what would normally be learned by assignment as a ward administrator or as chief resident. That formal training in administration was not commonly seen as a component ofthe residency program could also be inferred from respondents’ references to the availability of such training at the Harvard and Berkeley facilities. Program evaluation. Response to this question was similar to the responses for training in community organization, child advocacy, and administration. Only 13 of the 27 programs responding affirmatively addressed program evaluation in any direct sense; the others responded in terms of teacher evaluation and self-assessment. Participation in activities that might reasonably be considered evaluation took place primarily within the teaching hospital setting. Activities consisted of’ participation in programs of consumer evaluation and of apprenticeship-
type assignments in efforts under a grant or contract.
to evaluate
service
GUREL
agencies
COMMENT
It has been said that the transition from the l960s to the l970s was marked by a general disillusionment with science and technology as a basis for improving the human condition. The parallel growth ofhumanistic philosophies brought an increased concern with the quality of human life and a view of health as one of the basic rights of people. These emphases, among others, have resulted in an increased demand for mental health services in general and for psychiatric services in particular. However, social change has done more than merely expand the public’s demand for an increased quantity of psychiatric services. Attempts to make these services more available and accessible have emerged from the crucible of governmental-professional interaction. They have been expressed in the form of differential government support for certain kinds of programs and mental health delivery’ systems. The results of these efforts, to mention only a few examples, are evident in the expansion of the community mental health center program, the development of storefront services in the inner city and satellite clinics in rural areas, the sharing of psychiatric expertise with paraprofessionals, and a decreased emphasis on hospital treatment, with a concomitant emphasis on outpatient services and community-based alternatives to institutionalization. It is as yet unclear whether these developments represent progress or merely another swing of the pendulum. There may be a lesson in the fact that whereas Dorothea Dix labored to get the mentally ill out of the community and into hospitals, we now labor to get them out of hospitals and into the community (8). What is clear is that many psychiatrists who are attempting to meet the challenge of the newer forms of service delivery feel inadequately prepared to meet the demands of the roles they have been pioneering. Most were trained in postWorld War II models that tended to prepare psychiatrists for the practice of psychoanalytically oriented mdividual psychotherapy in solo office practice. Doubts about the utility of this training were soon reinforced by the criticisms of coworkers and of the intended recipients of their services. The validity of these misgivings and criticisms is not especially relevant here. What is important is that they served to focus attention on what psychiatrists do, what they should do, and how appropriately and adequately they are trained for their professional roles. A host of influences has subsequently reinforced concerns about psychiatric training and the underlying question ofwhat the potential psychiatrist is being trained for. While much ofthe stimulus for examining such issues has come from outside psychiatry-judicial critics, minority groups, the women’s movement, government budget officials, etc. -psychiatrists themselves have become increasingly concerned with the question, “What is a psychiatrist?” As this is being written, an official body of the
Am
J
Psychiatry
132.4.
April
/ 975
371
CHARACTERISTICS
OF
RESIDENCY
PROGRAMS
American Psychiatric Association is attempting to provide an answer to this question. Psychiatrists, like other professionals, are to a large extent what they have been trained to be, and they do in practice what they have been trained to do. But as delivery systems and emphases in psychiatric practice change, one can hope that the structure and content of training programs will be adjusted to better prepare residents for their changing roles. The study reported here was conceived as an attempt to provide certain baseline information about the nature and scope of the training offered in approved residency training programs. In focusing on the totality of residency training, this report and the parent monograph serve as companion pieces to an earlier APA publication (9) stressing the uniqueness of individual training programs. The data presented here are offered in the hope that they will facilitate answers to questions about the training psychiatrists should receive in the future by providing at least limited information about training and training programs in the immediate past.
372
Am
J Psychiatry
/32:4,
April
/ 975
REFERENCES
I. Szasz TS: The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement. New York, DelI Publishing Co. 1970 2. Torrey EF: The Death of Psychiatry. Radnor, Pa, Chilton Book
Co. 1974 3. 4. 5. 6.
7.
8.
9.
Ennis BJ: Prisoners of Psychiatry: Mental Patients, Psychiatrists, and the Law. New York, Harcourt Brace Jovanovich, 1972 Chu FD, Trotter 5: The Madness Establishment. New York, Grossman Publishers, 1974 Freedman AM: The presidential address: creating the future. Am J Psychiatry 131:749-754, 1974 Fleckles CS: The making of a psychiatrist: the resident’s view of the process of his professional development. Am J Psychiatry 128:1111-IllS, 1972 Essentials of approved residencies, in Directory of Approved Internships and Residencies, 1972-1973. Chicago, American Medical Association, 1972 Gurel L: Dorothea Dix revisited: extended care in the community as an alternative to hospitalization. Read at the 21st annual meeting of the Gerontological Society, Denver, Oct 31-Nov 2, 1968 Gurel L (ed): A Descriptive Directory of Psychiatric Training Programs in the United States, l972-73. Washington, DC, American Psychiatric Association, 1973
