BRIEF
The
COMMUNICATIONS
Educational
BY JOEL
The
authors
educational
YA(;ER,
Objectives M.I).,
present
AND
ROBERT
a statement
ofthe
objectives
oftheir
program. This statement keep inJO(’115 the central provide thefticultv with curriculum
delineation can also
de s’elopment
oftheir contribute
.
0. PASNAU,
Through
tric
residency
to help residents training and to matrix for such
specific
objectives, residency programs to a clarification ofthe specialty.
CONFUSION ABOUNDS ABOUT the proper role of the psychiatrist and the legitimate arena of psychiatric activity (1-3). Psychiatric residents are acutely aware of this state of affairs and sometimes have great difficulty in knowing where to focus their attention (4). Several authors (5-8) have traced some of the emotional problems of psychiatric residents to the lack of clean goals in their educational programs. To counteract the tendency toward professional identity diffusion and to help residents keep the central tasks of training in focus, we have set forth specific educational objectives for each area ofthe residency at the University of California, Los Angeles. In this way we have operationally defined what we believe to be the cone of the psychiatnc specialty as a body of skills and knowledge. Our residents have found the delineation of the program’s expectations to be helpful, and training directors and residents in other programs have requested that our statement be made more widely available. Cone educational objectives have been developed for the first two years of the residency. In the third year residents are encouraged to pursue their individual areas of interest. During the core period residents are expected to become competent in skills and famil-
Dr.
Yager
is Assistant
Professor
in Residence
nau is Associate Professor aison Service, Department versity of California. Los
and
Director
of Resi-
Institute-Brentwood Program, and Dr. Pas-
in Residence and Chief, of Psychiatry, School Angeles, Calif. 90024.
Program
iar with specific areas of knowledge. These areas of ability and expertise should continue to grow through subsequent training and experience. The list is not intended to be exhaustive on exclusive but to serve as a guideline for study and professional development; although it appears to be comprehensive. it is not meant to deter interest in other aspects of psychiatry.
FIRST-YEAR
dency Education, UCLA Neuropsychiatric Veterans Administration Hospital Residency
Residency
M.D.
specific
psvchia
is designed tasks oftheir an organizing
of a Psychiatric
Consultation-Liof Medicine,
Uni-
EDUCATIONAL
OBJECTIVES
Our first-year program consists ofinpatient. day hospital, and emergency psychiatry services, as well as some outpatient and aftercare experiences in adult psychiatry. All residents have completed a prior internship. Seminars on basic psychiatry and the psychiatric literature are included in the curriculum. Skills By the end of the residents’ first year of training we expect them to be able to do the following: 1 Conduct a comprehensive psychiatric interview. 2. Make use of appropriate laboratory examinations, psychological testing, and other consultations as indicated in the workup of psychological problems. 3. Conduct a family interview. 4. Make accurate psychiatric diagnoses and thorough appraisals of the presenting problems. 5. Formulate a treatment plan and implement it through personal effort and appropriate referral (triage and disposition). 6. Usc all psychopharmacological agents well. 7. Conduct supportive therapy with increasing awareness of dynamic issues. 8. Have some understanding of the assumptions and values of dynamic, insight-oriented psychotherapy and begin to apply these principles in clinical work. 9. Become aware of their coumtertransfcrence problems and personal idiosyncrasies as they influence intcractions with patients and begin to learn to deal with them constructively. .
Ant J Psychiatry
133:2,
February
1976
217
BRIEF
COMMUNICATIONS
10. Work harmoniously within a milieu together with nurses, social workers, psychiatric technicians, and other mental health personnel in information gathering, treatment planning and implementation, and co.therapy; simultaneously learn from others and contribute to their development. 1 1 Conduct an inpatient group therapy meeting. 12. Administer elcctrocomvulsive therapy when required. .
Knowledge By the end of the residents’ first year of training we expect them to be able to discuss the following: 1 The theory and nature of both individual and family interview techniques. 2. The nature of psychiatric data, including phenomenology and frames of reference. 3. Indicatioms, values, and limitations of psychological testing. 4. Methods for distinguishing between organic and functiomal processes. 5. The differential diagnosis of psychiatric symdromes with appropriate criteria. 6. Evaluation and management of psychiatric emergencies. 7. Patients’ rights, indications for involuntary psychiatnic hospitalization, and other basic legal issues. 8. Indications and comtraimdicatioms for full hospitalizatiom, day hospitalization, family intervention, crisis intervention, supportive psychotherapy behavior thenapy, intensive long-term dynamic psychotherapy, group psychotherapy, and ECT. 9. Indications and contraindications for common psychopharmacological agents, as well as dosages, side effects, and drug interactions. 10. Alternative etiological explanations for the psychoscs. 1 1 Basic psychoanalytic concepts. 12. Basic concepts of family organization and communication. 13. Basic principles of learning theories. 14. Basic concepts of group dynamics. 15. Basic concepts of social psychiatry and epidemiology, including concerns and treatment issues with specific ethnic, minority, and disadvantaged populations. 16. A perspective on the different psychotherapeutic schools of thought. 17. Neurobiological basic science, including genetics; biogcnic amines; the anatomy, physiology, and pathology of the limbic system; sleep physiology and pathology; and memory. 18. How to critically evaluate the merits and lirnitations of scientific literature. .
,
.
SECOND-YEAR
EDUCATIONAL
The second-year consultation-liaison,
218
AmiPsychiatry’
program child
OBJECTIVES
consists psychiatry,
133:2,
February
of assignments and adult
1976
to out-
patient services. Some patients are followed throughout the residency, and new cases are added as indicated. A weekly clinical neurology seminar covering pertinent neurological topics, a seminar in psychophysiological medicine, and a child psychiatry seminar are included in the curriculum. In addition, during the second year the resident continues to develop skills in evaluation and in briefand long-term treatment of mdividuals, couples, families, and groups. Increasing attentiom is paid to dynamic issues in psychotherapy and the immediate environment of the doctor-patient interaction including process, coumtertransference, specific techniques of intervention, and nonspecific effects of the psychotherapy process. Consultation-Liaison Skills By the end of the residents’ notation on consultation-liaisom psychiatry we expect them to be able to do the following: 1 Assess the specific intentions of the referring physician for any given request for consultation. 2. Conduct a comprehensive interview of a physically ill patient and a thorough assessment of each case, making appropriate use of information from the referring physician, other hospital personnel, the hospital chart, and the patient’s family. 3. Construct a comprehensive formulation of the patient’s problems that includes attention to the life setting and specific circumstances leading to the illness and the request for consultation; the present and past significance of the illness and problems, including primany impact and secondary effects on the patient and significant others; psychosomatic and somatopsychic considerations; and the specific influences of the patient’s personality on the manifestations of the illness and illness behavior. 4. Define and implement appropriate interventions, addressing the problems that initiated the request for consultation. 5. Undertake the psychotherapeutic treatment, for am extended period of time, of at least one dying patient and one patient with a psychophysiological illness. 6. Effectively communicate with the referring physiciam, both verbally and through concise, nontechnically worded motes, about the assessment, offering practical suggestions for management. These suggestioms may include how the physician might interact with and counsel the patient and his family; ward management by the hospital staff; other environmental manipulatiom; the appropriate use of psychopharmacological agents in the physically ill; and furthen recommendations for referral, disposition, and treatment. 7. Develop a good liaison relationship with physiciams, nurses, social workers, and the other staffon the service to which the resident is assigned and, using consultation models ofcommumity psychiatry, help assess and meet the needs of the staff as mental health educator, facilitator, and resource person. .
.
BRIEF
Knowledge. By the end ofthe residents’ rotation on consultation-liaison psychiatry we expect them to be able to discuss the following: I Models of consultation. 2. Social psychology of patient role behavior. 3. Psychological aspects ofstress, coping and adaptation, including the dying process, bereavement, transition states, and life crises. 4. Psychiatric interventions in liaison settings. 5. Psychosomatic psychopharmacology. 6. Specific syndromes of special importance in liaison settings, including conversion reactions, pain, gross stress reactions, postpartum psychiatric problems, postoperative psychoses, psychoses in the intcnsive care unit, psychiatric evaluations for special medical procedures, compensation neurosis, and malingering. 7. Theories of psychosomatic contributions to the pathogenesis of illness. .
Child
Psychiatry
Skills. By the end of the residents’ notation in child psychiatry we expect them to be able to do the following: I Conduct a thorough evaluation of children and their families, properly assessing the nature and sigmificance of presented problems. 2. Appropriately use psychological and physiological assessment techniques to augment the clinical evaluation. 3. Work as a team with psychologists, social workens, and other professionals to obtain a complete evaluation and to formulate appropriate interventions. 4. Appreciate the dynamic and developmental aspects of disturbing behavior in children and adolescents and the extent to which those behaviors are nespomsive on refractory to environmental contingencies. Knowledge. By the end ofthe residents’ rotation in child psychiatry we expect them to be able to discuss the following: 1 Principles of the evaluation of children and their families. 2. Major theories of child development, including psychodynamic, cognitive, and biological issues. 3. Common psychiatric problems of childhood and current concepts in the classification of childhood disorders. 4. Mental retardation, including evaluation and treatment planning. 5. Adolescence, with a focus on personality developmental issues. 6. Principles of intervention in child and adolescent psychiatry. .
.
Adult
Psychiat
Skills By the end of the second year we expect the residents to be able to treat individuals, couples, familics, and groups as indicated, with supervision. Knowledge. By the end of the residents’ second
year of training the following: 1. Alternative
we
expect
them
COMMUNICATIONS
to be
able
to discuss
of therapy, including basic and contraindications for the use of different psychotherapeutic techniques for brief or long periods of time, as well as something about available outcome evidence. 2. Characteristics of and explanations for neurotic, charactenological, and borderline conditions. 3. Psychiatrically pertinent aspects of neurology. assumptions,
theories
indications
,
DISCUSSION
The educational objectives we have outlined are not meant to be static. They are intended to be rethought, updated, and altered, reflecting the evolving perception of the psychiatrist’s role by the faculty and residents. Specific educational objectives at other residency programs may differ from ours in substance or in emphasis. Endow and Weinstein (9) have recently published a report on the detailed goals and objectives for psychiatric residency education. Their objectives and ours, developed independently of one another, both stress mastery of specific areas of knowledge and skill. There are many similarities-and differencesbetween these two sets of objectives. Such diversity, reflecting psychiatry’s broad scope, is commendable. Each program can contribute to a clarification of the specialty by defining its own educational objectives as precisely as possible. Statements of educational objectives offer advantages to applicants, residents, and faculty. We include the statement in the descriptive material sent to applicants, many of whom have commented favorably that such statements cam provide applicants with additional means by which to compare and contrast training programs. The statement is distributed at the beginning of each year to new residents and those continuing in the program as part of the orientation manual and can be referred to when the resident starts a new rotation. For the faculty, the definition of educational objectives provides an organizing matrix around which both the didactic and clinical experience in the curriculum can be constructed. Seminars and clinical experiences that compete for limited amounts of resident time cam be viewed against their potential contribution to the objectives. These objectives also have proven to be useful in the development of assessment procedures for the residents and for the program as a whole. By enumerating objectives for specific skill and knowledge areas for psychiatric residency education and by using these as a basis for discussion in the profession, residency programs may help to determine the viability and definition of our specialty in the future.
.
REFERENCES I
.
American Washington,
Psychiatric DC, APA,
AmfPsvchiatrv
Association: 1968
133:2,
What
February
is
a
1976
Psychiatrist?
219
BRIEF
COMMUNICATIONS
2. Holland
B, Stoller
chiatry:
R: The psychiatrist’s
Education
and
Brunner/Mazeh,
Image.
Grinker R: The future educational Psychiatry 132:259-262, 1975
4.
Yager J: A survival guide for Psychiatry 30:494-499, 1974
5.
Halheck
6.
Woods
dents.
The
Woods
5:
Psychiatry S.
Pasnau
Effect
by
ofhis
Usdin
G.
role,
in Psy-
New
York,
151-164
1973, pp
3.
5,
image
Edited needs
of psychiatrists.
psychiatric
residents.
problems
25:339-346,
1962
R,
A,
Cohman
of
et al:
M.D., PH.D.
problems
on
DONALD
resiof
OF
W. GOODWIN,
between hunger and in man, early investigators looked effect of the drug; they found none
THE
ASSOCIATION
marijuana smoking for a hypoglycemic
Drs. Permutt, Goodwin, ty School of Medicine, fessor, Department of
63110,
Assistant
Medical
Investigator,
Mo. Dr. University,
Schwin Palo
This
research
Scientist
Health
220
supported
Development
marijuana
Institute
placebo
St. Louis,
this research
(awarded
was
done.
to Dr. Goodwin) and
Alcohol Abuse and Alcoholism, RR-00036 from the National
for this study Alcohol,
Rockvilhe,
133:2,
were supplied Drug
Abuse,
Md.
February
1976
Metabolism
M.D.,
ROBERT
SCHWIN,
M.D.,
(1-3). These studies did not specify how long before the marijuana was administered the volunteer subjects had eaten. The concentration of glucose in the blood is maintained in sufficient quantities to prevent hypoglycemia predominantly by gluconeogenesis from the liven after glycogen stores have been used up (4). After a period of starvation liver glycogen becomes depleted, and any substance that impairs gluconcogenesis. e.g. alcohol (5), can cause hypoglycemia. An effect of marijuana on gluconcogenesis might be more readily apparent in subjects who had fasted; the effect might be to produce hypoglycemia. For this rcason we observed a sample of marijuana users who had fasted for 24-72 hours before administration of marijuana for subsequent hypoglycemia. The effect of marijuana on carbohydrate metabolism after eating has also not been evaluated. If marijuana potentiates insulin secretion on action, it might produce reactive hypoglycemia 2-5 hours after a meal. We therefore studied the effects of marijuana on canbohydrate tolerance during a 5-hour oral glucose tolenance test. ,
METHOD
Stanford
by
AA-47325
Health,
Am J Psychiatry
Institute,
of Psychiatry,
Alcohol, Drug Abuse, and grants DA-4RG-008 and DA-00282 on Drug Abuse, AA-4732R and Research on grant
of Mental
Administration,
Medical
in part
Award Institute Center
and
Hughes
with the Department Calif. , at the time
Administration Institute
from the National Clinical Research tutes of Health.
tional
and Hill St. Louis, Medicine,
Howard was Alto,
was
Mental Health from the National
The
are with the Washington UniversiMo. Dr. Perrnutt is Assistant Pro660 South Euclid, St. Louis, Mo. is Professor of Psychiatry, and Dr. Hill is Professor of Psychiatry. Dr. Permutt is also a
Dr. Goodwin
Research
Russell A. Pasnau R, Taintor Z: Emotional problems of residents in psychiatry. Am J Psychiatry 132:263-267. 1975 Endow A. Weinstein H: Goals and objectives ofresidency education. in The Integration of Child Psychiatry into the Basic Residency Program. Edited by Madow L. Malone C. Hilhsdahe, NJ, Town House Press, 1975. pp 14-24
Carbohydrate
The authors observed the effect ofmarijuana on carbohydrate metabolism infed andfasting states in chronic marijuana users. Theyfound no hypoglycemia in 7patients who were given marijuana after fasting for24-72 hours. They alsofoundno significant difference in carbohydrate tolerance and no hypoglycemia during an oral glucose tolerance test in lOpatients who smokedplacebo or marijuana on alternate days. They conclude that marijuana has no effect on carbohydrate metabolism in thefed or the f asted state in well-nourished chronic marijuana users.
BECAUSE
8.
Gen
psychiatric
Emotional
of Marijuana
BY M. ALAN PERMUTF, SHIRLEY Y. HILL,
Arch
7.
J
9.
Emotional
AND
Am
psychiatric residents. Panel discussion at the 125th annual meeting of the American Psychiatric Association, Dallas, Tex, May 1-5, 1972 Pasnau R, Russell A: Psychiatric resident suicide: an analysis of five cases. Am J Psychiatry 132:402-406, 1975
Insti-
by the Naand Mental
For this study 10 nonobese male volunteers ranging in age from 23 to 3 1 who had smoked marijuana at least once a week for one year were admitted to the Clinical Research Center of Washington University Medical School the night before the first ofoun tests was made. These patients fasted overnight. On the morning of day 1 of the study a fasting plasma for glucose and insulim was drawn from each patient, then either I g of marijuana containing 1 .5% L\-9-tetrahydnocannabinol
The
COMMUNICATIONS
Educational
BY JOEL
The
authors
educational
YA(;ER,
Objectives M.I).,
present
AND
ROBERT
a statement
ofthe
objectives
oftheir
program. This statement keep inJO(’115 the central provide thefticultv with curriculum
delineation can also
de s’elopment
oftheir contribute
.
0. PASNAU,
Through
tric
residency
to help residents training and to matrix for such
specific
objectives, residency programs to a clarification ofthe specialty.
CONFUSION ABOUNDS ABOUT the proper role of the psychiatrist and the legitimate arena of psychiatric activity (1-3). Psychiatric residents are acutely aware of this state of affairs and sometimes have great difficulty in knowing where to focus their attention (4). Several authors (5-8) have traced some of the emotional problems of psychiatric residents to the lack of clean goals in their educational programs. To counteract the tendency toward professional identity diffusion and to help residents keep the central tasks of training in focus, we have set forth specific educational objectives for each area ofthe residency at the University of California, Los Angeles. In this way we have operationally defined what we believe to be the cone of the psychiatnc specialty as a body of skills and knowledge. Our residents have found the delineation of the program’s expectations to be helpful, and training directors and residents in other programs have requested that our statement be made more widely available. Cone educational objectives have been developed for the first two years of the residency. In the third year residents are encouraged to pursue their individual areas of interest. During the core period residents are expected to become competent in skills and famil-
Dr.
Yager
is Assistant
Professor
in Residence
nau is Associate Professor aison Service, Department versity of California. Los
and
Director
of Resi-
Institute-Brentwood Program, and Dr. Pas-
in Residence and Chief, of Psychiatry, School Angeles, Calif. 90024.
Program
iar with specific areas of knowledge. These areas of ability and expertise should continue to grow through subsequent training and experience. The list is not intended to be exhaustive on exclusive but to serve as a guideline for study and professional development; although it appears to be comprehensive. it is not meant to deter interest in other aspects of psychiatry.
FIRST-YEAR
dency Education, UCLA Neuropsychiatric Veterans Administration Hospital Residency
Residency
M.D.
specific
psvchia
is designed tasks oftheir an organizing
of a Psychiatric
Consultation-Liof Medicine,
Uni-
EDUCATIONAL
OBJECTIVES
Our first-year program consists ofinpatient. day hospital, and emergency psychiatry services, as well as some outpatient and aftercare experiences in adult psychiatry. All residents have completed a prior internship. Seminars on basic psychiatry and the psychiatric literature are included in the curriculum. Skills By the end of the residents’ first year of training we expect them to be able to do the following: 1 Conduct a comprehensive psychiatric interview. 2. Make use of appropriate laboratory examinations, psychological testing, and other consultations as indicated in the workup of psychological problems. 3. Conduct a family interview. 4. Make accurate psychiatric diagnoses and thorough appraisals of the presenting problems. 5. Formulate a treatment plan and implement it through personal effort and appropriate referral (triage and disposition). 6. Usc all psychopharmacological agents well. 7. Conduct supportive therapy with increasing awareness of dynamic issues. 8. Have some understanding of the assumptions and values of dynamic, insight-oriented psychotherapy and begin to apply these principles in clinical work. 9. Become aware of their coumtertransfcrence problems and personal idiosyncrasies as they influence intcractions with patients and begin to learn to deal with them constructively. .
Ant J Psychiatry
133:2,
February
1976
217
BRIEF
COMMUNICATIONS
10. Work harmoniously within a milieu together with nurses, social workers, psychiatric technicians, and other mental health personnel in information gathering, treatment planning and implementation, and co.therapy; simultaneously learn from others and contribute to their development. 1 1 Conduct an inpatient group therapy meeting. 12. Administer elcctrocomvulsive therapy when required. .
Knowledge By the end of the residents’ first year of training we expect them to be able to discuss the following: 1 The theory and nature of both individual and family interview techniques. 2. The nature of psychiatric data, including phenomenology and frames of reference. 3. Indicatioms, values, and limitations of psychological testing. 4. Methods for distinguishing between organic and functiomal processes. 5. The differential diagnosis of psychiatric symdromes with appropriate criteria. 6. Evaluation and management of psychiatric emergencies. 7. Patients’ rights, indications for involuntary psychiatnic hospitalization, and other basic legal issues. 8. Indications and comtraimdicatioms for full hospitalizatiom, day hospitalization, family intervention, crisis intervention, supportive psychotherapy behavior thenapy, intensive long-term dynamic psychotherapy, group psychotherapy, and ECT. 9. Indications and contraindications for common psychopharmacological agents, as well as dosages, side effects, and drug interactions. 10. Alternative etiological explanations for the psychoscs. 1 1 Basic psychoanalytic concepts. 12. Basic concepts of family organization and communication. 13. Basic principles of learning theories. 14. Basic concepts of group dynamics. 15. Basic concepts of social psychiatry and epidemiology, including concerns and treatment issues with specific ethnic, minority, and disadvantaged populations. 16. A perspective on the different psychotherapeutic schools of thought. 17. Neurobiological basic science, including genetics; biogcnic amines; the anatomy, physiology, and pathology of the limbic system; sleep physiology and pathology; and memory. 18. How to critically evaluate the merits and lirnitations of scientific literature. .
,
.
SECOND-YEAR
EDUCATIONAL
The second-year consultation-liaison,
218
AmiPsychiatry’
program child
OBJECTIVES
consists psychiatry,
133:2,
February
of assignments and adult
1976
to out-
patient services. Some patients are followed throughout the residency, and new cases are added as indicated. A weekly clinical neurology seminar covering pertinent neurological topics, a seminar in psychophysiological medicine, and a child psychiatry seminar are included in the curriculum. In addition, during the second year the resident continues to develop skills in evaluation and in briefand long-term treatment of mdividuals, couples, families, and groups. Increasing attentiom is paid to dynamic issues in psychotherapy and the immediate environment of the doctor-patient interaction including process, coumtertransference, specific techniques of intervention, and nonspecific effects of the psychotherapy process. Consultation-Liaison Skills By the end of the residents’ notation on consultation-liaisom psychiatry we expect them to be able to do the following: 1 Assess the specific intentions of the referring physician for any given request for consultation. 2. Conduct a comprehensive interview of a physically ill patient and a thorough assessment of each case, making appropriate use of information from the referring physician, other hospital personnel, the hospital chart, and the patient’s family. 3. Construct a comprehensive formulation of the patient’s problems that includes attention to the life setting and specific circumstances leading to the illness and the request for consultation; the present and past significance of the illness and problems, including primany impact and secondary effects on the patient and significant others; psychosomatic and somatopsychic considerations; and the specific influences of the patient’s personality on the manifestations of the illness and illness behavior. 4. Define and implement appropriate interventions, addressing the problems that initiated the request for consultation. 5. Undertake the psychotherapeutic treatment, for am extended period of time, of at least one dying patient and one patient with a psychophysiological illness. 6. Effectively communicate with the referring physiciam, both verbally and through concise, nontechnically worded motes, about the assessment, offering practical suggestions for management. These suggestioms may include how the physician might interact with and counsel the patient and his family; ward management by the hospital staff; other environmental manipulatiom; the appropriate use of psychopharmacological agents in the physically ill; and furthen recommendations for referral, disposition, and treatment. 7. Develop a good liaison relationship with physiciams, nurses, social workers, and the other staffon the service to which the resident is assigned and, using consultation models ofcommumity psychiatry, help assess and meet the needs of the staff as mental health educator, facilitator, and resource person. .
.
BRIEF
Knowledge. By the end ofthe residents’ rotation on consultation-liaison psychiatry we expect them to be able to discuss the following: I Models of consultation. 2. Social psychology of patient role behavior. 3. Psychological aspects ofstress, coping and adaptation, including the dying process, bereavement, transition states, and life crises. 4. Psychiatric interventions in liaison settings. 5. Psychosomatic psychopharmacology. 6. Specific syndromes of special importance in liaison settings, including conversion reactions, pain, gross stress reactions, postpartum psychiatric problems, postoperative psychoses, psychoses in the intcnsive care unit, psychiatric evaluations for special medical procedures, compensation neurosis, and malingering. 7. Theories of psychosomatic contributions to the pathogenesis of illness. .
Child
Psychiatry
Skills. By the end of the residents’ notation in child psychiatry we expect them to be able to do the following: I Conduct a thorough evaluation of children and their families, properly assessing the nature and sigmificance of presented problems. 2. Appropriately use psychological and physiological assessment techniques to augment the clinical evaluation. 3. Work as a team with psychologists, social workens, and other professionals to obtain a complete evaluation and to formulate appropriate interventions. 4. Appreciate the dynamic and developmental aspects of disturbing behavior in children and adolescents and the extent to which those behaviors are nespomsive on refractory to environmental contingencies. Knowledge. By the end ofthe residents’ rotation in child psychiatry we expect them to be able to discuss the following: 1 Principles of the evaluation of children and their families. 2. Major theories of child development, including psychodynamic, cognitive, and biological issues. 3. Common psychiatric problems of childhood and current concepts in the classification of childhood disorders. 4. Mental retardation, including evaluation and treatment planning. 5. Adolescence, with a focus on personality developmental issues. 6. Principles of intervention in child and adolescent psychiatry. .
.
Adult
Psychiat
Skills By the end of the second year we expect the residents to be able to treat individuals, couples, familics, and groups as indicated, with supervision. Knowledge. By the end of the residents’ second
year of training the following: 1. Alternative
we
expect
them
COMMUNICATIONS
to be
able
to discuss
of therapy, including basic and contraindications for the use of different psychotherapeutic techniques for brief or long periods of time, as well as something about available outcome evidence. 2. Characteristics of and explanations for neurotic, charactenological, and borderline conditions. 3. Psychiatrically pertinent aspects of neurology. assumptions,
theories
indications
,
DISCUSSION
The educational objectives we have outlined are not meant to be static. They are intended to be rethought, updated, and altered, reflecting the evolving perception of the psychiatrist’s role by the faculty and residents. Specific educational objectives at other residency programs may differ from ours in substance or in emphasis. Endow and Weinstein (9) have recently published a report on the detailed goals and objectives for psychiatric residency education. Their objectives and ours, developed independently of one another, both stress mastery of specific areas of knowledge and skill. There are many similarities-and differencesbetween these two sets of objectives. Such diversity, reflecting psychiatry’s broad scope, is commendable. Each program can contribute to a clarification of the specialty by defining its own educational objectives as precisely as possible. Statements of educational objectives offer advantages to applicants, residents, and faculty. We include the statement in the descriptive material sent to applicants, many of whom have commented favorably that such statements cam provide applicants with additional means by which to compare and contrast training programs. The statement is distributed at the beginning of each year to new residents and those continuing in the program as part of the orientation manual and can be referred to when the resident starts a new rotation. For the faculty, the definition of educational objectives provides an organizing matrix around which both the didactic and clinical experience in the curriculum can be constructed. Seminars and clinical experiences that compete for limited amounts of resident time cam be viewed against their potential contribution to the objectives. These objectives also have proven to be useful in the development of assessment procedures for the residents and for the program as a whole. By enumerating objectives for specific skill and knowledge areas for psychiatric residency education and by using these as a basis for discussion in the profession, residency programs may help to determine the viability and definition of our specialty in the future.
.
REFERENCES I
.
American Washington,
Psychiatric DC, APA,
AmfPsvchiatrv
Association: 1968
133:2,
What
February
is
a
1976
Psychiatrist?
219
BRIEF
COMMUNICATIONS
2. Holland
B, Stoller
chiatry:
R: The psychiatrist’s
Education
and
Brunner/Mazeh,
Image.
Grinker R: The future educational Psychiatry 132:259-262, 1975
4.
Yager J: A survival guide for Psychiatry 30:494-499, 1974
5.
Halheck
6.
Woods
dents.
The
Woods
5:
Psychiatry S.
Pasnau
Effect
by
ofhis
Usdin
G.
role,
in Psy-
New
York,
151-164
1973, pp
3.
5,
image
Edited needs
of psychiatrists.
psychiatric
residents.
problems
25:339-346,
1962
R,
A,
Cohman
of
et al:
M.D., PH.D.
problems
on
DONALD
resiof
OF
W. GOODWIN,
between hunger and in man, early investigators looked effect of the drug; they found none
THE
ASSOCIATION
marijuana smoking for a hypoglycemic
Drs. Permutt, Goodwin, ty School of Medicine, fessor, Department of
63110,
Assistant
Medical
Investigator,
Mo. Dr. University,
Schwin Palo
This
research
Scientist
Health
220
supported
Development
marijuana
Institute
placebo
St. Louis,
this research
(awarded
was
done.
to Dr. Goodwin) and
Alcohol Abuse and Alcoholism, RR-00036 from the National
for this study Alcohol,
Rockvilhe,
133:2,
were supplied Drug
Abuse,
Md.
February
1976
Metabolism
M.D.,
ROBERT
SCHWIN,
M.D.,
(1-3). These studies did not specify how long before the marijuana was administered the volunteer subjects had eaten. The concentration of glucose in the blood is maintained in sufficient quantities to prevent hypoglycemia predominantly by gluconeogenesis from the liven after glycogen stores have been used up (4). After a period of starvation liver glycogen becomes depleted, and any substance that impairs gluconcogenesis. e.g. alcohol (5), can cause hypoglycemia. An effect of marijuana on gluconcogenesis might be more readily apparent in subjects who had fasted; the effect might be to produce hypoglycemia. For this rcason we observed a sample of marijuana users who had fasted for 24-72 hours before administration of marijuana for subsequent hypoglycemia. The effect of marijuana on carbohydrate metabolism after eating has also not been evaluated. If marijuana potentiates insulin secretion on action, it might produce reactive hypoglycemia 2-5 hours after a meal. We therefore studied the effects of marijuana on canbohydrate tolerance during a 5-hour oral glucose tolenance test. ,
METHOD
Stanford
by
AA-47325
Health,
Am J Psychiatry
Institute,
of Psychiatry,
Alcohol, Drug Abuse, and grants DA-4RG-008 and DA-00282 on Drug Abuse, AA-4732R and Research on grant
of Mental
Administration,
Medical
in part
Award Institute Center
and
Hughes
with the Department Calif. , at the time
Administration Institute
from the National Clinical Research tutes of Health.
tional
and Hill St. Louis, Medicine,
Howard was Alto,
was
Mental Health from the National
The
are with the Washington UniversiMo. Dr. Perrnutt is Assistant Pro660 South Euclid, St. Louis, Mo. is Professor of Psychiatry, and Dr. Hill is Professor of Psychiatry. Dr. Permutt is also a
Dr. Goodwin
Research
Russell A. Pasnau R, Taintor Z: Emotional problems of residents in psychiatry. Am J Psychiatry 132:263-267. 1975 Endow A. Weinstein H: Goals and objectives ofresidency education. in The Integration of Child Psychiatry into the Basic Residency Program. Edited by Madow L. Malone C. Hilhsdahe, NJ, Town House Press, 1975. pp 14-24
Carbohydrate
The authors observed the effect ofmarijuana on carbohydrate metabolism infed andfasting states in chronic marijuana users. Theyfound no hypoglycemia in 7patients who were given marijuana after fasting for24-72 hours. They alsofoundno significant difference in carbohydrate tolerance and no hypoglycemia during an oral glucose tolerance test in lOpatients who smokedplacebo or marijuana on alternate days. They conclude that marijuana has no effect on carbohydrate metabolism in thefed or the f asted state in well-nourished chronic marijuana users.
BECAUSE
8.
Gen
psychiatric
Emotional
of Marijuana
BY M. ALAN PERMUTF, SHIRLEY Y. HILL,
Arch
7.
J
9.
Emotional
AND
Am
psychiatric residents. Panel discussion at the 125th annual meeting of the American Psychiatric Association, Dallas, Tex, May 1-5, 1972 Pasnau R, Russell A: Psychiatric resident suicide: an analysis of five cases. Am J Psychiatry 132:402-406, 1975
Insti-
by the Naand Mental
For this study 10 nonobese male volunteers ranging in age from 23 to 3 1 who had smoked marijuana at least once a week for one year were admitted to the Clinical Research Center of Washington University Medical School the night before the first ofoun tests was made. These patients fasted overnight. On the morning of day 1 of the study a fasting plasma for glucose and insulim was drawn from each patient, then either I g of marijuana containing 1 .5% L\-9-tetrahydnocannabinol
