#{149}1

Academic Psychiatry

Salutes the

1992 AAP/

Mead Johnson Fellows

CHRIS A. CONWAY, M.D.

New England Medical Center

M. CORNELIA CREMENS, M.D.Massachusetts General Hospital

LORI LYNNE DAVIS, M.D.University of Alabama

DOUGLAS ERIC FELTNER, M.D.George Washington University

MADY HORNIG-ROHAN, M.D.University of Vermont

JAMES R. PHELPS, M.D.University of New Mexico

ANNE MARIE STOLINE, M.D.Johns Hopkins Medical Institutions

We look forward to their active participation in theAAP Annual Meeting to be held March 4-7, 1992, at the La

Mansion del Rio Hotel in San Antonio, Texas, their ongoingcommitment to the pursuit of excellence in psychiatric

education, and their future involvement in AAP.

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New Releases FromAmerican Psychiatric Press, Inc.

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� El �HE A Diagnosis and Management) \�#{149} I Written primarily for clinicians, thiscomprehensive volume presents a broadly basedapproach to the diagnosis and management of thedementias. The section on diagnosis closely followsD DSM-III-R criteria in the presentation of clinicalcase examples and a full description of the variousdiagnostic techniques, tools, and rating scales thatare available to the clinician. All aspects of

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Contents: Foreword by Robert N. Butler, MD. Introduction. The diagnosis of dementia.Dementia as a psychodynamic process. The dementia workup. Differential diagnosis.Psychological and behavioral management. Pharmacological management and treatment ofdementia and secondary symptoms. Neuropsychological evaluation of dementia. Dealingwith family caregivers. Legal and ethical aspects of dementia. Mobilizing communityresources. Treatment approaches in Alzheimer’s disease: past, present, and future.Structuring environments for dementia victims. Epilogue. Appendixes. References. Index.

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AcAi�viIcPs�ciiwi 4RYVOLUME 16.NUMBER I .SPRING 1992

REGULAR ARTICLES

1 Medical Students’ Evaluation of Live Psychiatric Interviews

Horacio Fabrega, Jr., M.D., Nadine Robles, Ph.D., Lloyd Benjamin, M.D.,Richard Lllrich, M.S.

10 Recognition of Teaching Excellence Through the Use of Teaching Awards:

A Faculty PerspectiveStephen L. Rued rich, M.D., Carol Cavey, M.D., Kent Katz, Ph.D.,Lynn Grush, M.D.

14 Textbooks and Software Used to Teach Behavioral Science and ClinicalPsychiatry to Medical Students

Lesly Tamarin Mega, M.D., Elizabeth H. Rand, M.D., Karen E. Ritter

24 Outpatient Management Teams: Integrating Educational andAdministrative Tasks

Vivien K. Burt, M.D., Ph.D., Pamela Summit, M.D., Joel Yager, M.D.

29 Components of Supervisors’ Ratings of Therapists’ SkillfulnessSheryl H. Jones, B.S., Ronald F. Krasner, M.D., Kenneth I. Howard, Ph.D.

37 Therapist-Initiated Patient Transfer in the Residency Training SettingHilary Klein, M.D.

NEW IDEA I44 Didactic Modules for Curricular Development in Child and Adolescent Psychiatry

EducationAllan M. Josephson, M.D., Martin J. Drell, M.D.

I52

BOOK FORUM

Evaluation of the Psychiatric Patient: A Primer, by Seymour L. Halleck, M.D.Reviewed by Richard L. Frierson, M.D., Larry R. Faulkner, M.D.

57 Psychiatric Education at the APA Meeting

I EDUCATIONAL ABSTRACTS

Abstracted by Dorthea Juul, Ph.D.

54 A Validity Study of Part ifi of the National Board Examination

54 Validity of NBME Part I and Part II Scores in Prediction of Part III Performance

55 Performance of Various Multiple-Choice Item Types on Medical SpecialtyExaminations: Types A, B, C, K, and X

55 A Comparison of Single Best Answer Multiple-Choice Items (A-type) andComplex Multiple-Choice Items (K-type)

55 Phase-in of the NBME Comprehensive Part I Examination

I DEPARTMENT I

Regular Articles

Medical Students’ Evaluation ofLive Psychiatric Interviews

Horaclo Fabrega, Jr., M.D.

Nadine Robles, Ph.D.

Lloyd Benjamin, M.D.

Richard UIrlch, M.S.

A central concern of psychiatric educators is how medical students learn to evaluate psy-

chopathology and clinically relevant behaviors during a psychiatric clerkship. The pur-

pose of this study is to detennine what characteristics of the students studied correlated

with their accuracy in rating patient psychopathology and also whether the students

show improved accuracy in rating after a 6-week clerkship in a university medical school

department of psychiatry. The study analyzes student ratings of various aspects of psy-

chopathology in live patient-faculty interviews. The accuracy of student ratings com-

pared with faculty ratings constitutes the dependent variable. The role of students’

attitudes toward psychiatry, overall grade performance, and personal background con-

stitute the independent variables; these variables are analyzed in relation to the accuracy

of student ratings. The authors attempt to determine if student ratings improve during

clerkship. The ability to rate clinical phenomenology in psychiatric patients in a live for-

mat is shown to be a measurable trait that improves slightly over time in some areas and

varies in relation to some of the independent variables studied. Results of the study are

compared with previous work in this area. The limitations of the paradigm employed and

the requirements for studying the problem in a more systematic and effective way are out-

lined.

A n important, if not dominating, charac-teristic of psychiatry is its focus on be-

havior. In psychiatry, a person’s behavior isdescribed as deportment, conduct, and de-meanor. A patient’s behavioral characteris-tics, as they pertain to psychopathology, areassessed by use of the conventional cate-gories of the mental status exam. The study

of behavior is not a central focus during thepredlinical years of medical education. Ab-

stract knowledge presented in a didacticformat with practical problem-solving ex-ercises constitutes the primary teachingmethod. During a psychiatric clerkship,medical students are faced with a new task:

learning to objectify and, in some instances,quantify the behavior of patients. For thepsychiatric educator, this raises two impor-tant pedagogical problems: I) how to ratehow well students evaluate patient psycho-pathology and 2) what factors affect the ac-

Dr. Fabrega is Director of Medical Student Educa-

lion, Dr. Robles is Senior Project Coordinator, and Mr.

Ulrich is Biostatistician, Department of Psychiatry, Uni-versity of Pittsburgh School of Medicine. Dr. Benjamin

is currently in private practice in Sacramento, CA. Ad-dress correspondence to Dr. Fabrega, Dept. of Psychia-try, University of Pittsburgh School of Medicine, 3811O’Hara Street, Room E-1123, Pittsburgh, PA 15213.

Copyright © 1992 Academic Psychiatry.

curacy of student ratings.

Much of the research to evaluate clinicalskills determines student improvementthrough student ratings of either videotapedor live interviews with patients. The proto-

type test, developed by Geertsma and Stoller(1), consists of filmed interviews of psychiat-ric patients and involves rating descriptivestatements about behavior and psychopa-thology. By use of the ratings of psychopa-thology by residents, seniors, freshmen, andvolunteers, the authors demonstrate that the

seniors’ ratings most closely approximatethose of practicing psychiatrists. Employing

a similar test, Thurnblad et al. (2) found thatstudents achieve higher clinical assessment

scores at the end of 2 years of preclinicalwork; after that, no further increment wasfound. Langsley and Aycrigg (3) and Mey-erson et al. (4) reported that their filmedinterviews and test discriminated amongdifferent classes of medical students, withupperclassmen registering a superior per-formance to lowerclassmen.

Another strategy involves live patientinterviews. Sturgeon (5) found that studentratings of such interviews significantly cor-related with prior videotaped instruction intheir clerkship but did not correlate withstudent attitudes or written exam grades.Fenton and O’Gorman (6) compared studentperformance on a test using videotaped in-terviews against the students’ live interviewof a patient and found the two methods to besignificantly related. Overall, it seems thatthese attempts to assess clinical skills havebeen successful in differentiating clinicalabilities.

Other studies attempt to relate the de-velopment of clinical competence to otherdomains such as attitudes, grades, board

scores, and faculty evaluation. One area ofinquiry examines how the clerkship affectsmedical student attitudes toward psychia-try. Many studies (7-11) measured attitudesbefore and after exposure to the psychiatricclerkship and found that attitudes changefavorably. In a follow-up study, Wilkinson

et a!. (12) reported that positive attitudes ofthe postclerkship period were maintained 1year later. Both Alexander and Eagles (13)and Wilkinson et a!. (9) noted that womenmedical students consistently hold morepositive attitudes toward psychiatry thantheir male counterparts. In the only study tocompare attitude change with clinical inter-viewing skill, Mumford et al. (14) reportedthat improvement in interviewing skill is notrelated to gains in attitude scores.

The relationship between psychiatric ac-ademic performance and clinical compe-tence is another area of exploration. Forexample, Langsley and Aycrigg (3) foundthat clinical skills are not highly correlatedwith MCAT scores or with psychiatry gradesor with National Board of Medical Examin-ers (NBME) scores. Similarly, Sturgeon (5)reported no relationship between studentability to pass a psychiatric exam and clinicalability. Further, Goldney et al. (15,16) re-ported that medical student ability to delin-eate psychopathology does not significantlycorrelate with written exam scores. Tardiff(17,18) reported that videotape-based examscorrelate minimally with other measures ofstudent performance. Finally, Meyerson (19)

found that using videotapes to assess knowl-edge of psychopathology is moderately re-liable and correlates significantly with thefaculty rating of student clinical perfor-mance. Most studies, with the exception ofMeyerson (19), reported little or no associ-ation between the ability to rate psycho-pathology and traditional assessments offactual knowledge.

With the exception of Mumford (14) andSturgeon (5), most of the reports mentioned

are concerned with assessing the acquisitionof clinical skills in relation to one specificinterest area. In our study, we have includedseveral of the areas covered in previous

studies. From teaching students, we havegained the impression that students withprevious experience in mental health and

pathology have generally shown greater fa-duity in using concepts pertaining to psycho-

pathology. In our study we will also explorethe relationship between student accuracy inclinical ratings and their past experience inpsychology and mental illness.

RATIONALE OF THE STUDY

In this study students rated the behavior ofpatients in a live conference setting while thepatients were interviewed by a faculty mem-ber conducting an intake evaluation. This

procedure was followed because it closelyapproximates the clinical situation in which

students and physicians routinely work. Weconcentrated on specific areas of psychopa-thology and related behaviors rather thanglobal diagnoses. This approach would clar-ify in what areas students needed instruc-tion. One basic aim of the study was toevaluate the influence of student charac-teristics on the accuracy of rating patientbehavior. The following variables werestudied in relation to the accuracy of studentratings: 1) student attitudes toward psychia-try, 2) students’ 2nd-year grade point aver-

age (CPA), 3) students’ scores on the NBME

exam after the clerkship, and 4) students’previous experience in psychology andmental illness. We hypothesized that stu-dents with favorable attitudes, higher gradescores, and more exposure to psychiatrictopics would be more accurate in rating pa-tients. We also made a preliminary effort todetermine whether student ratings becomemore accurate as their clerkships progress.

Consequently, we evaluated accuracy in re-lation to 5) time in the clerkship (Weeks 1-3compared with Weeks 4-6), hypothesizingthat students would be more accurate laterin the clerkship.

METHODS

The study was conducted in a university

medical school department of psychiatryduring one academic year. Four consecutivegroups of 3rd-year students taking their 6-

week clerkship in psychiatry were the sub-

jects of the study. The clerkship is the firstand principal contact that students havewith psychiatric patients and clinical psychi-

atric training. Before this clerkship, duringthe second academic year, students partici-

pate in a 3-week, intensive, didactic psy-chiatry block that emphasizes descriptive

psychiatry and treatment approaches.On the first day of the clerkship, stu-

dents were asked to complete a rating scaledesigned to measure their attitudes towardpsychiatry and to provide background de-tails of their past experience in a psychiatric

environment (14). After the rating scale wascompleted, a senior faculty person (H.F.) in-terviewed a patient “live” in front of thecohort of students for approximately 40 min-utes. The patient being interviewed was notknown to the faculty person or to the stu-dents. The object of the interview was toelicit information about the patient’s medi-cal history, present illness, symptoms, cur-rent mental state, and general personalitytraits. After this intake evaluation, both thestudents and the faculty member rated thepatient using an inventory of 60 items that

addressed various facets of psychopatho-logy and general behavior. The inventoryconsisted of descriptions of behavior. It wascompiled by the faculty person and has pre-viously been used pedagogically in case con-

ference discussions. The inventory has notbeen formally used in previous research.

Students were asked to rate on a 4-pointscale whether each clinical item applied tothe patient. The items have been groupedinto nine analytic clusters describing clinicalpsychopathology, which are listed in Table1 with sample items.

After the rating period, the faculty mem-ber engaged the students in a discussion onthe clinical condition of the patient. No di-red reference to the questionnaire ratingstook place during the discussion. Duringeach of the next 6 weeks of the clerkship, thecohort of students participated in a similarclinical case conference with the same fac-

ulty person and a different patient. Each stu-

dent clerk rated a total six patients. This

procedure was followed with four consecu-tive cohorts of students so that 24 different

patients were rated by the students.Each clerkship averages approximately

15 students; a total 68 students participatedin the study. The principal data of the pres-

ent study are the student ratings on the 60items of the clinical inventory. For each stu-dent, an item deviation score was computed,which consisted of the absolute value of the

student’s deviation from the faculty person’s

score on each item. A cluster deviation scorewas also computed for each student by sum-

ming and then averaging the scores com-prising each cluster. These scores specify

each student’s deviations from the facultyperson. In brief, the principal dependentvariables are the nine cluster deviationscores that were computed for each student

for each of the six patients interviewed dur-ing a clerkship. The independent variables

consisted of 1) student attitudes and values

toward psychiatry as measured by the ques-

tionnaire given before and after the clerk-

ship, 2) student psychiatry GPA during thepreceding academic year, 3) student raw

scores on the NBME exam after the clerk-ship, 4) scores derived from responses aboutprevious interest or experience in psychia-try, and 5) time in the clerkship (early-Weeks 1-3 compared with late-Weeks 4-6interview evaluations). In testing for studentacademic characteristics (i.e., CPA), the av-erage cluster deviation scores were figured

for each of the 68 students across the 6 pa-tients that each student rated. In compari-sons between patients rated early and thoserated late in the clerkship, the average devi-

ation scores were figured for each of the 24patients. Correlation coefficients were usedto evaluate student deviation scores in rela-tion to answers to questions on attitudes,

grade scores, and background variables. Thet-test was used to compare student deviation

scores on patients seen during Weeks 1-3

TABLE 1. Sample of items rated by students

Clusters

Strongly Mildly Mildly Strongly InsufficientAgree Agree Disagree Disagree Information

Sample Items1 2 3 4 0

Physical Appearance

General Behavior

Cognitive Clarity

Speech and Language

Thought Contentand Structure

Perception

Sense of Self and

Surroundings

Affect and Emotion

Functional

Impairment

Movements slowedInappropriate attire

GuardedIntimidating

Alert

Memory difficulties

Slowed speech

Poverty of speech

TangentialShowed delusions

Appeared to be hallucinating

Reports hallucinations

Sense of victimization

Sense of entitlement

Sadness

Anger

Work

Interpersonal relations

with Weeks 4-6 of the clerkship. The relativemagnitude of the cluster deviation scores inthese two subgroups is used as an indicatorof whether there were differences in accu-racy in the two halves of the clerkship.

RESULTS

Student Attitudes in Relation toAccuracy of Ratings of Psychopathology

The questionnaire that examines atti-

tudes toward psychiatry consists of 18 ques-tions on different dimensions of thestudents’ orientation. Because of the diver-sity of this instrument, we did not computean overall score, but instead examined rawanswers to individual questions. The Likertscale responses to these questions were cor-related with the set of 9 deviation scoresyielding 162 correlations. Given this ratherlarge number of correlations, approximately8 can be expected to be statistically signifi-

cant (P < 0.05). Indeed, 9 proved significantin the case of attitudes before the clerkshipand a different 9 on attitudes after the clerk-ship; a number very close to that was ex-pected on the basis of pure chance. All of thecorrelations were between 0.24 and 0.30 ex-cept for one correlation of 0.39.

Student Grade Performancein Relation to Accuracy of

Ratings of Psychopathology

Two measures of the students’ per-formance were used in this part of the study:1) CPA in psychiatry during the precedingacademic year (Year 2 of the curriculum) and2) the NBME exam score obtained at the end

of the 3rd-year clerkship. Student perfor-mance measures were correlated with thenine cluster deviation scores. Students re-ceiving higher scores on the two perfor-mance measures were hypothesized to also

show greater accuracy or lower cluster de-viation scores. The two hypotheses wereconfirmed. The correlation coefficients indi-

cated that students receiving higher grades

during the psychiatry course (grade 1 high-est, grade 4 lowest) of the preceding yearproduced lower faculty deviation scores. Allcorrelations were positive and three were

statistically significant (P < 0.05, one-tailed):physical appearance (r = 0.21, P = 0.087),general behavior (r= 0.31, P = 0.012), andsense of self and surroundings (r = 0.28, P =

0.022). The correlation between the grade

score of the preceding year and the total

deviation score (summed over all clusters)

was also positive and statistically significant(r = 0.42, P = 0.000). Similarly, the correla-

tion coefficient indicated that students withhigher board scores at the end of the clerk-ship produced lower deviation scores. Onecluster, labeled Functional Impairment, wasstatistically significant (r = -0.25, P = 0.042),and six of the remaining eight showed arelated trend ranging from r = -0.06 to r =

-0.18; the exceptions were physical appear-

ance and cognitive clarity. The two proffles

of correlations produced by the two perfor-mance measures (prior year’s grades andboard scores) and the nine cluster deviation

scores were different. There was no indica-tion that grades and board scores tended tocorrelate with the different cluster deviationscores. Hence, we conclude that there is sup-port for the positive association betweenlevel of intellectual performance (grades orboards) and overall accuracy of ratings andno support for a correlation association be-tween performance and ratings on specificaspects of psychopathology.

Student Background Variablesin Relation to Accuracy of

Ratings of Psychopathology

In most instances, student answers toquestions regarding prior personal or fam-ilial experiences with the mentally ill, priorwork in a mental health unit or hospital, thenumber of psychology undergraduatecourses taken, and intentions of specializingin psychiatry did not bear a strong associa-

TABLE 2. Students’ overall ratings of clinical behavior

Cluster-Based Test Early Clerkship Late Clerkship

Significance

on Student’st Value One-Tailed t-Test

Physical appearance 0.7619 ± 0.321 0.7605 ± 0.268 0.01 NS

General behavior 0.7312 ± 0.141 0.7086 ± 0.134 0.40 NS

Cognitive clarity 0.5925 ± 0.215 0.6071 ± 0267 -0.15 NS

Speech and language 0.6155 ± 0.179 0.4360 ± 0.164 2.56 0.009

Thoughtcontentandstructure 0.8183±0.147 0.7397±0.104 1.51 0.073

Perception 0.4877 ± 0.495 0.1697 ± 0.289 1.77 0.046

Sense of self and surroundings 0.8179 ± 0.130 0.7513 ± 0.153 1.15 NS

Affect and mood 0.7695 ± 0.149 0.6375 ± 0.130 2.32 0.015

Functional impairment 0.6620 ± 0.216 0.6660 ± 0.138 -0.05 NS

Total Score 0.7350 ± 0.074 0.6660 ± 0.075 2.25 0.018

Note: Ratings are scores measuring absolute deviation from faculty scores. Values for Early and Late Clerk-

ship are means ± SD. NS = not significant.

tion to cluster deviation scores. In a few in-

stances, a response produced one statisti-cally significant correlation (e.g., havingfriends or relatives in the mental health fieldtended to correlate with a lower clusterdeviation score in the cluster termed Lan-guage) but, because nine correlations wereperformed, this is not a striking finding.Moreover, inspection of the direction of the

correlations across the remaining clusters for

the background variables did not reveal a

pattern or trend that suggests that the vari-

able bears a strong association to ratings of

psychopathology.

Student Clinical Experiencein Relation to Accuracy of

Ratings of Psychopathology: TheQuestion of Student Improvement

The data comparing cluster deviationscores on the nine clusters of psychopathol-

ogy ratings during the first three interviewsvs. the last three interviews are shown inTable 2. Analysis of the relative magnitudeof the results in Table 2 reveals the relativeaccuracy with which students rate differentareas of psychopathology. For example, thecluster Perception is most accurately rated,whereas Thought Content and Structure and

Sense of Self and Surroundings producedthe highest cluster deviation scores. Because

we hypothesized that students would im-prove, a one-tailed significance level was

again used when comparing Early and Lateclerkship ratings. Three of the nine cluster

deviations from faculty scores were signifi-cantly lower during the last 3 weeks of theclerkship (P < 0.05, one-tailed t-test) specif-

ically on the clusters Speech and Language,

Perception and Affect, and Mood. In addi-tion, the total average deviation score was

significantly lower for Weeks 4-6 (P < 0.018,

one-tailed).

DISCUSSION

The results indicate that the baseline atti-tudes toward psychiatry that students holdupon entering the psychiatry clerkship bearno association to how closely they approxi-

mate the faculty person’s ratings. There is

also no evidence that the postclerkship at-titudes toward psychiatry bear an associa-tion to accuracy of ratings. These findings

are consistent with the findings of Sturgeon(5), Mumford et al. (14), and, in part, Larson

et al. (20). Our findings support the idea thatthe ability to rate psychopathology is a cog-nitive capacity that may be uninfluenced by

attitudes and values. These findings also

suggest that students may be able to im-prove their ability to rate psychopathology

regardless of their feelings about psychiatry.In general, the results suggest that educators

should not draw conclusions about stu-dents’ sensitivity or accuracy in judging

psychopathology and behavior from the

students’ attitudes toward psychiatry. Simi-larly, the results imply that educators’ efforts

to change students’ negative attitudes to-ward psychiatry will not necessarily transfer

over to students’ improved accuracy of rat-ing of behavior and psychopathology.

There was a positive association be-tween students’ academic performance inthe previous year and their accuracy of rat-ings of psychopathology. The students’

NBME scores after the clerkship were alsopositively associated with their accuracy in

ratings of psychopathology. These results

differ from those of Langsley and Aycrigg

(3), Sturgeon et a!. (5), and Goidney et al.(15,16). Each of these studies has a different

conception of clinical ability and also differsin the instruction given students. Such fac-tors may account for the differences between

this study and previous studies. It should benoted, however, that the association be-

tween grade performance and accuracy ofclinical ratings was not particularly strong.

Nevertheless, our results provide support

for the idea that students’ ability to ac-curately rate psychopathology in patients

varies in relation to student ability to learndescriptive information about psychiatry. In

other words, students who seem to know

more descriptive psychiatry (i.e., get highergrades) seem to be more adept at accuraterating of psychopathology in a live setting.This finding suggests that an emphasis onteaching facts and general knowledge may

contribute to improved accuracy in the rat-ing of behavior and psychopathology. Edu-

cators should thus be heartened that theirefforts to teach psychiatric knowledge maytransfer over into students’ clinical sensitiv-

ities.

There was no indication that the number

of undergraduate psychology courses bears

a relation to student accuracy of ratings. It

should be mentioned that such courses donot necessarily focus on human clinical

behavior. Hence, the possibility that prior

formal undergraduate exposure to psycho-

pathology enhances student ability to assessclinical behavior cannot be excluded.

We attempted to determine if a student’s

ability to accurately assess psychopathologyin an interview setting improved as a func-

tion of participating in the clerkship. Ourresults indicated that in pathology of speech

and language, perception, and emotion/af-fect, there were changes in the deviation

scores in the direction of increased learning.However, a student’s ability to more accu-

rately rate physical appearance, general be-havior, cognitive clarity, and aspects of self

and functional impairment did not signifi-cantly improve. The cluster Thought Struc-

ture and Content was only slightly below thelevel required for significance (P = 0.073,

one-tailed). Some of the clusters not showingimprovement refer to features of social andpsychological behavior that are routinely in-voked in everyday life. This touches on thematter of the differences between rating

social aspects of behavior compared withclassic psychopathology. It is possible that

students’ orientation to such behaviors iswell developed and stabilized before enter-

ing the clerkship in psychiatry, perhaps evenbefore they begin medical school. Hence, the

ability to rate these features routinely in;yoked in everyday life may inhibit learning.

Another possible explanation is that becausethe students are in transition from a lay cul-

ture to a professional one, they may tend tooveridentify with patients and thereby mm-imize or overlook routine aspects of behav-

ior. In general, educators need to be awarethat medical students find it easier to con-

centrate on traditional categories of behaviordenoting psychopathology than they do cat-egories of general social behavior linked topersonality style and functioning.

The cluster Thought Structure andContent is an area in which students needspecialized training to function as betterphysicians, and this area does constitute an

area of new learning. Although group devi-ation scores on this cluster decreased sub-

stantially during the clerkship, the changewas not statistically significant. The stu-

dents’ failure to significantly improve on

those items may be due to their lack of expo-sure to patients exhibiting those pathologi-

cal thought processes. Inspection of the rawdata disclosed that many of the items com-prising this cluster were infrequently en-

countered in the patients evaluated by thefaculty and students. This lack of exposureto these behaviors also may have hamperedtheir ability to accurately recognize them,thus contributing to error variance. This

would account for the relatively large mag-nitude of scores on this cluster. Neverthe-

less, the possibility students may fail to

significantly improve on the cluster Thought

Structure and Content is important and un-derscores that this cluster measures items of

behavior that can be difficult to determine.Although bizarre delusions and derailment

of thought are dramatic and, hence, easier todetermine, these disorders are less common

in our acute patients. On the other hand,

delusions linked to social background (e.g.,religious themes, lower-class beliefs aboutpolice surveillance) and subtle loosening of

thoughts were more common, and these ap-pear to be difficult for the students to recog-nize. Greater experience and knowledge isneeded to learn when and how the beliefspertaining to an area of cultural experience

constitute pathological delusions and when

a seemingly careless or unnecessary elabora-tion of a theme in a conversation constitutesa loose association. Educators should give

special attention not only to explaining themeaning of the term Pathology of ThoughtStructure and Content, but also to how it isrealized in what patients say during the

course of an examination and how this re-lates to sociocultural background.

The live interview format of this studyprovides access to rich and varied material.Each cohort rated six different patients and

each cohort’s patients differed from those ofthe others. However, this format provideslittle in the way of statistical control over therating process and allows for greater error

variance. Similarly, that only one facultyserved as the “gold standard” of psychopa-

thology is problematic, even if this person

served as a principal instructor in the teach-ing of psychopathology. Clearly, standard

taped interviews of intake evaluations alter-

nating with respect to students’ time in train-ing when the rating took place and a greaternumber of expert judges of psychopathol-

ogy is to be preferred so as to better validatestudent ratings. These changes in format and

the continued emphasis on intake inter-views would make a worthwhile researchplan for future studies. In addition, studies

are needed to clarify further what aspects ofpsychopathology prove resistant to learningduring a clerkship and what the effects are

of different types of instructional formats.Finally, more research is needed to specifywhat aspects of general psychiatric knowl-

edge affect the acquisition and refinement ofclinical skills.

References

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11. Maxinen JS: Student attitude changes during “psy-

chiatric medicine” clerkships. Gen Hosp Psychiatry1979; 1:98-103

12. Wilkinson DC, Toone BK,GreerS: Medical students’

attitudes to psychiatry at the end of the clinical

curriculum. Psychol Med 1983b; 13:655-658

13. Alexander DA, Eagles JM: Attitudes of men and

women medical students to psychiatry. Med Educ

1986; 20:449-455

14. Mumford E, Schlesinger H, Cuerdon T, et al: Ratings

of videotaped simulated patient interviews and fourother methods of evaluating a psychiatry clerkship.Am J Psychiatry 1987; 144:316-322

15. Goldney RD, Carr V, Katsikitis M: Assessment of the

delineation of psychopathology by medical stu-

dents. Journal of Psychiatric Education 1983; 7:202-

20716. Goldney RD, McFarlane AC: Assessment in under-

graduate psychiatric education. Med Educ 1986;

20: 117-122

17. Tardiff K, Redfield J, Koran LM: Evaluation of a

videotape technique for measuring dinical psychi-

atric skills of medical students. Med Educ 1978;

53:438-441

18. Tardiff K: A videotape technique for measuring clin-

ical skills: three years of experience. Med Educ 1981;

56:191-197

19. Meyerson AT, Wachtel A, Thornton J: Evaluation of

a psychiatric clerkship by videotape. Am J Psychia-

try 1977; 134:883-886

20. Larson DB. Orleans CS, Houpt JL: Evaluating a clin-

ical psychiatry course using process and outcome

measures. Journal of Medical Education 1980;55:1006-1012

Recognition of Teaching ExcellenceThrough the Use of Teaching Awards

A Faculty Perspective

Stephen L Ruedrich, M.D., Carol Cavey, M.D.

Kent Katz, Ph.D., Lynn Grush, M.D.

Teaching as a faculty activity is often undereinphasized in medical faculty reward sys-

tems for a variety of reasons. One method of recognizing teaching excellence has been

through annual teaching awards offered by many departments and colleges. The authors

surveyed department of psychiatry faculty regarding teaching awards, particularly ques-

tioning whether such awards influence teaching behavior or serve a motivational func-

tion. The results suggest such awards serve an important recognition function, but a

lesser motivational function in academic psychiatry.

“Teaching is its own reward” might wellbe the academic paraphrase of the

ancient homily regarding virtue (1). Manyauthors have highlighted not only the diffi-

culty inherent in defining and quantifyinggood teaching (2), but also the apparent un-

deremphasis, or ignorance, of this faculty

activity in decisions regarding facultypromotion and tenure (3,4). Nonetheless,

advocates of teaching have made recom-mendations for elevating the status of teach-ing in medical schools, either through more

accurate quantification of teaching excel-

lence and specific promotional guidelines

for educational activities (5), or through for-

mal partition of faculties into two distinct

Dr. Ruedrich is Associate Professor, Dr. Cavey isAssistant Professor, and Dr. Katz is Senior Instructor,

Department of Psychiatry, Case Western Reserve Uni-versity School of Medicine, Cleveland, OH; Dr. Crushis a resident in the Department of Psychiatry, Tufts

University College of Medicine, Boston, MA. Address

correspondence to Dr. Ruedrich, Dept. of Psychiatry,MetroHealth Medical Center, 3395 Scranton Road,Cleveland, OH 44109.

Copyright © 1992 Academic Psychiatry.

tracks: researchers and teacher-cliniciangroups (6).

In addition to these methods, other au-

thors have proposed specific and tangible

rewards for teaching efforts. Skeff (7) postu-

lated that faculty are likely to respond toboth intrinsic and extrinsic rewards, and

called for pay raises or other monetary re-

wards as valid feedback for successful teach-

ing. In his review of 12 Canadian medical

schools, McLeod (8) ranked 43 institution-

wide faculty development practices and

compared the prevalence of each practice

with its perceived effectiveness by faculty

development coordinators. Seventy-five

percent of the schools used annual awardsfor teaching excellence, ranking awards as

the fifth most common development prac-tice. This contrasted with its perceived effec-

tiveness, where it ranked 29th of 43 items.

Ruedrich and Reid (9) found similar results

in a teaching award survey within a single

medical school department of psychiatry. In

their results, faculty respondents stated that

they would plan no change in their teaching

based on the initiation of a teaching award

in their department, regardless of their pre-dicted likelihood of receiving such recogni-tion. The authors concluded that the use of

teaching awards appeared to serve a recog-

nition function, but probably not a motiva-

tion function in subsequent teaching.

METHODS

During the academic year 1987-1988, the De-partment of Psychiatry at MetroHealth Med-

ical Center of the Case Western Reserve

University School of Medicine initiated a

teaching award program, in which residentsin psychiatry named a “Teacher of the Year”

from among their supervisors and instruc-tors. The award consisted of an inscribedwall plaque given to the recipient, alongwith an engraved plate adding the recip-ient’s name to a permanent memorial. Theaward continues to given annually. Inacademic year 1988-1989, faculty memberswere surveyed regarding the award. Ques-tions addressed knowledge of the award,opinions regarding teaching awards and

recognition, perceived likelihood of receiv-

ing an award and why, and whether recog-nition would influence subsequent teaching

behavior. The study was essentially a repli-cation of a previous teaching award survey

in a different department of psychiatry ofsimilar size and composition (9). Besides the

obvious benefits of a replication study, it wasalso of interest whether there might be

changes in faculty opinions about teaching

issues surrounding the rapid changes occur-ring in academic medicine. (Copies of thesurvey may be obtained from the senior au-thor.)

RESULTS

professors, 4 were associate professors, and

21 were assistant professors or instructors.Twenty-two (79%) of 28 supported the con-

cept of teaching awards, and only I dis-agreed with the concept.

Of the 28 respondents, 9 (32%) consid-ered themselves likely or very likely to re-

ceive a teaching award in the next 5-7 years,whereas 12 (43%) considered their chances

unlikely, very unlikely, or impossible. Thosewho predicted likelihood generally ascribedthis to intrinsic reasons, such as being good

teachers or role models, whereas those who

considered themselves unlikely to win re-

lated this to extrinsic factors, such as havinglittle contact with students or duties that

prevented them from teaching.Finally, faculty were asked to predict

whether and how the presence of the depart-mental award for teaching excellence would

affect their teaching. A sizable majority (18

[67%] of 27) reported that the award wouldnot change their behavior. Only 6(22%) of 27

thought they would make teaching changes

as a result of the award, and 5 of these 6 didnot think they would receive the awardwithout making such changes.

Separating respondents based on theirmental health discipline provided little ad-

ditional information; the majority of eachgroup supported both an award and the cri-

teria for selection. Respondents in the sepa-rate disciplines disagreed in two major

areas: 1) who should select award recipients,with psychiatrists favoring psychiatricresidents (13 [93%] of 14) and nonpsy-

chiatrists favoring other methods (57%), and2) likelihood of selection, with few psy-chiatrists (3 [21%] of 14), but most non-

psychiatrists (9 [64%] of 14) consideringthemselves unlikely to be selected.

DISCUSSIONResults are reported from 28 full-time fac-

ulty members, including 14 psychiatrists, 9

psychologists, and 5 others (social workers,nonclinical basic scientists, etc.), for a re-

sponse rate of 72%. Of these, 3 were full

Excellence in teaching and its formal recog-nition remain elusive enterpnses in aca-

demic medicine. Not only is teaching ability

difficult to quantify, but it also appears to be

underemphasized in academic decisions re-

garding promotion and tenure. One method

that attempts to constructively address thisissue is the use of specific awards for teach-ing excellence. Many academic departmentsand most medical schools identify teachers

of the year or have some other formal meth-od of providing recognition. In a survey ofmedical school teacher of the year recipients,however, Whitman et al. (10) noted that a

majority (77%) of even those persons recog-

ni.zed for excellent teaching believe that re-wards for teaching are inadequate. In spite

of this, there appears to be widespread belief

among medical faculty that this form of tan-

gible recognition of teaching ability is useful

in promotion and decisions on tenure.In our small sample, nearly 80% of re-

spondents supported teaching awards, al-though 68% of the total sample did not

believe that they would receive an award.These findings are consistent with resultsfrom a previous survey by one of the authors

in which 74% supported awards, but only62% thought they might receive one (9). Itwould seem that the faculty believe thatthere is a benefit to teaching awards evenwhen personal gain is not anticipated.

In the present study, faculty who de-scribed themselves as likely to receive anaward nearly uniformly ascribed their like-

lihood to intrinsic factors, while faculty whodescribed themselves as unlikely award re-cipients attributed this prediction largely to

extrinsic systemic forces. These data essen-

tially replicate a previous study � in whichfaculty members viewed themselves as earn-

ing recognition through their efforts; a lackof such recognition was ascribed to externalfactors.

Although our data seem to support theuse of teaching awards for faculty recogni-

tion, there is little evidence awards provideany motivation for better teaching. The ma-jority of our respondents (67%) said they

would plan no behavioral change because ofan award incentive; this response seemed

unconnected to their perceived likelihood of

winning. A sizable minority (6 [22%] of 27),

however, reported they were likely to in-

crease efforts in teaching, through either

commitment of increased time or attempts toenhance instructional ability, based on the

award. For this subset of faculty, awardsappeared to have at least a limited motiva-tional function. This finding is different fromthat of the previous study, in which almostno respondents planned teaching changes,

regardless of their predicted likelihood of

selection for an award.

CONCLUSION

Teaching and its recognition and reward in

academic medicine remain relatively under-valued compared with research productiv-ity and clinical service. The use of teachingawards by departments (or medical schools)may be one attempt to provide at least a

recognition function for high-quality faculty

teaching. This conclusion seems to be sup-ported by our data, and it probably validatesthe continued use of this relatively inexpen-

sive faculty development practice by educa-tional systems. In addition, our data indicate

that there is a small subset of faculty forwhom the use of teaching awards would

serve as a motivation to improve teachingbehavior. For the majority of faculty, it seems

that other less tangible, and probably more

intrinsic, rewards serve this motivation

function. Subsequent broader studies couldcompare faculty responses across medical

specialties as well as between departments

that offer and do not offer teaching awards.

References

1. Italicus 5: Punica, Book XIII, line 663, Ipsa quidem

virtus sibimet puicherrima merces (Virtue herself is

her own fairest reward), circa AD 75

2. Irby DM: Evaluating instruction in medical educa-

tion. Journal of Medical Education 1983; 58:844-849

3. Rittelmeyer LF: Leadership in an academic depart-

ment of psychiatry. Academic Psychiatry 1990;

14:57-644. Jason H, Westberg J: Teachers and Teaching in U.S.

Medical Schools. Norwalk, CT, Appleton-Century-

Crofts, 1982, pp 121-1 325. Petersdorf RG: The fables and foibles of academe.

Am J Otolaryngol 1985; 6:59-656. Alpert JS, Coles R: Careers in academic medicine:

triple threat or double fake. Arch Intern Med 1988;

148:1906-1907

7. Skeff 1CM: Enhancing teaching effectiveness and vi-

tality in the ambulatory setting. J Gen Intern Med1988; 3(suppl):S26-S33

8. McLeod PJ: Faculty development practices in Cana-

dian medical schools. Can Med Assoc J 1987;

136:709-712

9. Ruedrich SL, Reid WI{ Financial incentives for

teaching: a faculty response. Journal of Medical Ed-

ucation 1985; 60:68

10. Whitman N, Weiss E, Bishop FM: Executive Skills

for Medical Faculty. Salt Lake City, University of

Utah School of Medicine, 1989, pp 100-I 01

Textbooks and Software Used toTeach Behavioral Science and Clinical

Psychiatry to Medical Students

Lesly Tamarin Mega, M.D.

Elizabeth H. Rand, M.D.

Karen E. Ritter

The authors discuss the results of a questionnaire sent to medical schools to assess text-

books and computer software used in teaching behavioral science and clinical psychiatry.Attributes concerning presentation, theoretical viewpoints, and topics covered were rated

by 75 respondents. Certain texts emerged as frequently used. Although the books rated

will become outdated, consumers can use the assessment attributes from the question-

naire to examine forthcoming texts. Authors considering new books or re��isions may

want to know why certain books are popular and to address areas identified as weak in

existing textbooks. The software market needs entrees.

Psy faculty are charged with or-ganizing medical student teaching pro-

grams in behavioral science and clinical

psychiatry. Although some subject matterrequirements are specified by accrediting

agencies, there are no specific or detailedguidelines to help those responsible for de-signing curriculum. Choosing textbooks andother teaching aids is a major component ofcurriculum planning, yet faculty can findlittle help in evaluating texts or computer

software except by inquiring informallyamong their colleagues.

Dr. Mega is Professor and Director of Medical

Student Education in Psychiatry, East Carolina Univer-sity School of Medicine, Greenville, NC. Dr. Rand isAssociate Professor and Discipline Chief, Psychiatry,University of Alabama College of Community Health

Sciences, Tuscaloosa, AL. Ms. Ritteris a medical student

atEastCarolina UniversitySchoolof Medicine. Address

reprint requests to Dr. Mega, Department of PsychiatricMedicine, East Carolina University School of Medicine,Greenville, NC 27858.

Copyright © 1992 Academic Psychiatry.

The present study was born of the au-thors’ need to choose behavioral science and

clinical psychiatry textbooks and interactive

software programs. A review of the litera-hire did not yield specific guidelines that

would permit comparison of psychiatrictextbooks on a broad range of features (1,2).

McLeod recommended that each medicalschool department use a systematic ap-proach to contrast content differencesamong various texts (3). In other specialties,

the Group for Research in Pathology Educa-tion has created a form for their group to usein evaluating pathology books for medical

students (4), and Slone and Martineau haveconducted a random sampling of radiolo-gists and radiology residents, asking them to

recommend reference books and introduc-

tory texts (5).We found reviewing many texts was

helpful but provided no input from experi-enced users, and advice from experienced

users was helpful but resulted in informa-

lion about only a few textbooks. We foundno evaluative information concerning soft-ware. This led us to form a task force in the

Educational Technologies section at the 1989Annual Meeting of the Association for Aca-demic Psychiatry to survey medical schools

regarding the textbooks and computer soft-

ware in use.

METHODS

Medical schools in the United States and

some in Puerto Rico and Canada were sur-veyed in the winter of 1989-1990 regarding

textbooks and software used for teachingbehavioral science and clinical psychiatry.The questionnaire initially was sent to 130psychiatric chairpersons to be distributed tothe people in charge of textbook selection at

each school. After two months a mailing was

sent to 15 additional departments, includingthose in Canada and Puerto Rico, and to

directors of medical student education in

psychiatry at nonresponding schools whowere listed in the 1989 roster of the Asso-

ciation of Directors of Medical Student Edu-

cation in Psychiatry. If the nonrespondingschool was not on this list, a second mailingwas sent to the chairperson.

The authors reviewed a large selectionof representative textbooks and developed

three clusters of attributes to characterize

them: 1) possible theoretical points of view;2) topics likely to be covered in each area ofthe curriculum; and 3) attributes related to

the presentation of material rather than itscontent. A short list of general issues wascreated to characterize instructional soft-ware in use.

Respondents were asked to list up to

twop�� textbooks used to teach behav-ioral science to medical students at their

schools, up to two used to teach clinical psy-chiatry, and up to two software productsused to teach either subject. For each item,

questions were asked about the target stu-dent group (first year, second year, etc.),how long the text or software had been used,

and whether it would be used again nextyear. When the same text was used to cover

both behavioral science and clinical psychi-atry topics, respondents were asked to list

the text in both areas. Each text or softwareproduct was rated on its strength in terms of

each item on the attribute lists, using a 5-point scale from 1=very weak to 5=verystrong, plus N/A for nonapplicable attri-

butes. Space was provided for describing the

main reason the text was selected.A descriptive analysis using frequency

distributions and mean ratings was con-ducted. Because raters were not assignedrandomly and the same texts were not re-viewed by all raters, tests of significance

could not be performed. The distributionsrepresent the respondents’ opinions andpreferences regarding the textbooks andsoftware they used.

RESULTS

We received 75 responses from 145 schoolssurveyed, a 51.7% return rate. Respondents

represented 33 states in all regions of the

United States, as well as Canada and PuertoRico. Not all respondents mentioned a sec-ond text; for those who did, each text was

considered equally. Not all answered forboth behavioral science and clinical psychi-atry. All textbooks cited by respondents and

the frequency of their use in teaching be-havioral science and clinical psychiatry arelisted in Table 1.

Textbooks Used toTeach Behavioral Science

There were 61 responding programs; be-

cause 29 programs named two texts, the totalnumber of responses was 90. Respondents

mentioned using 35 different books. Themost popular book chosen for teaching be-havioral science was Understanding Human

Behavior in Health and Illness (UHB) bySimons and Pardes, mentioned by 22 pro-

grams (36%). The others most frequently

TABLE 1. Textbooks used in responding behavioral science and clinical psychiatry programs

Programs Reporting Use

Behavioral Science Clinical Psychiatry

Textbook (N=61) (N=66)

American Psychiatric Association: Diagnostic and Statistical

Manual of Mental Disorders, 3rd rev. ed., 1987;hc $39.95, pb $29.95 (89/90) 0 6

American Psychiatric Association: Quick Reference to theDiagnostic Criteria from DSM-ffl-R, 1987; pb $15.00 1 2

Bernstein L, Bernstein R (eds.): Interviewing: A Guide for Health

Professionals. Appleton & Lange, 1985; pb $21.95 (89/90) 1 0

Bieliauskas L (ed.): The Influence of individual Differences inHealth and illness. Westview, 1982; hc $27.50, pb ed $13.95 (89/90) 1 0

Bowen C, Burnstein A: Psychosocial Basis of Medical Practice:

An Introduction to Human Behavior. Williams & Wilkins, 1974. 1 0

Carr J, Dengerink H (eds.): Behavior Science in the Practice ofMedicine. Elsevier, 1983; $45.00 (89/90) 2 0

Coleman J, Butcher J: Abnormal Psychology and Modern Life,7th ed. Scott, Foresman, 1984 1 0

Faculty, department syllabus 2 1

Fitzgerald H, Walraven M: Human Development, 17th ed.Dunshkin, 1989; pb $9.95 1 0

Flaherty J, Channon R, Davis J: Psychiatry: Diagnosis and

Therapy. Appleton & Lange, 1988; pb $19.95 (89/90) 1 2

Goldman H (ed.): Review of General Psychiatry. Appleton &

Lange, 1984; Lexotone cover $27.50 (89/90); rev. 1988 9 11

Goodwin D, Guze S: Psychiatric Diagnosis, 3rd ed. Oxford UP,

1984. $19.95 (85/86); 4th ed. hc $29.95, pb $16.95 (89/90) 1 3

Gregory I, Smeltzer D: Psychiatry: Essentials of Clinical

Practice, 2nd ed. Little, Brown, 1983; $26.50 (89/90) 1 5

Hackett T, Cassem N: Massachusetts General HospitalHandbook of General Hospital Psychiatry, 2nd ed.Year Book Medical Pubs, 1987; $36.50 (89/90) 0 1

Hyman 5, Arana C: Handbook of Psychiatric Drug Therapy.Little, Brown, 1987; $17.95 (87/88) 1 0

Johnson Wet aL: Basic Psychotherapeutics: A Programmed

Text. Pergamon, 1980; $29.50 (87/88) 1 0

Kaplan H, Sadock B: Clinical Psychiatry, from Synopsis ofPsychiatry. Williams & Wilkins, 1988. 1 4

Kaplan H, Sadock B: Comprehensive Textbook of Psychiatry,2 vols., 5th ed. Williams & Wilkins, 1988; $182.50 (89/90) 1 2

Kaplan H, Sadock B: Modern Synopsis of Comprehensive

Textbook of Psychiatry, 4th ed. Williams & Wilkins, 1984. 3 4

Kaplan H, Sadock B: Synopsis of Psychiatry: Behavioral

Sciences and Clinical Psychiatry, 5th ed. Williams & Wilkins,1987; $35.95 (89/90) 13 15

Krug R, Cam A: Behavioral Sciences. Springer-Verlag,1987; pb $15.95 (89/90) 2 1

Leaverton P: A Review of Biostatistics: A Program forSelf-Instruction, 3rd ed. Little, Brown, 1989. 1 0

Leon R: Psychiatric Interviewing: A Primer. Elsevier, 1981;

$23.50 (89/90) 0

TABLE 1. (continued)

Programs Reporting Use

Behavioral Science Clinical PsychiatryTextbook (N = 61) (N = 66)

Lewis M: Clinical Aspects of Child Development:

An Introductory Synthesis of Developmental Concepts

and Clinical Experience, 3rd ed. Lea & Febiger, 1989. 1 0

McHugh P, Slavney P: The Perspectives of Psychiatry.Belknap Press, 1983; $22.00 (89/90) 1 0

Nemiah I: Foundations of Psychopathology. Aronson, 1973;text $30.00 (89/90) pb $13.95 Oxford UP (89/90) 0 1

Newman B, Newman P: Development Through Life:A Psychosocial Approach, 4th ed. Dorsey, 1987;text $35.50, study guide $10.00 (87/88) 1 0

Nicholi A: The New Harvard Guide to Psychiatry.

Belknap Press, 1988; $45.00 (89/90) 1 3

Reiser D, Rosen D: Medicine as a Human Experience.

University Park, 1984; $18.00 (85/86) 0 1

Reiser D, Schroder A: Patient Interviewing: The HumanDimension. Williams & Wilkins, 1980; pb $18.50 (87/88) 1 1

Sierles F: Behavioral Science for the Boards.Med Master, 1987; pb $12.95 (89/90) 2 0

Simons RC, Pardes H: Understanding Human Behaviorin Health and ifiness, 3rd ed. Williams & Wilkins, 1985;

text $31.50, study guide $16.95 (89/90) 22 2

Stoudemire A (ed.): Clinical Psychiatry for MedicalStudents. Philadelphia, Lippincott, 1990; $32.50. 1 0

Stoudemire A: Human Behavior: An Introduction for Medical

Students. Philadelphia, Uppincott, 1990; $19.95. 1 0

Strayhorn I: Foundations of Clinical Psychiatry. Year BookMedical Pubs., 1982; $40.00 (87/88) 0 1

Sudak H: Clinical Psychiatry. Warren H. Green, 1985;

$55.00 (89/90) 1 0

Talbott Jet al.: American Psychiatric Press Textbook ofPsychiatry. American Psychiatric Press, 1988; $95.00 (89/90) 3 3

Taylor Metal.: General Hospital Psychiatry. Free Press, 1985;$39.95 (89/90) 0 1

Taylor M (ed.): The Neuropsychiatric Mental Status Examination:

A Phenomenologic Program. PMA, 1981; $24.50 0 1

Tomb D: Psychiatry for the House Officer, 2nd ed. Williams &Wilkins, 1984; pb $14.95. 1 9

Waldinger R: Psychiatry for Medical Students. American

Psychiatric Press, 1984; 532.50(89/90) 5 12

Walker J: Essentials of Clinical Psychiatry. Lippincott, 1985;

$27.50 (87/88) 1 0

Wedding L)� Behavior and Medicine. Mosby Yearbook, 1991. 1 0

Weiner Behavioral Science (National Medical Series forIndependent Study). Wiley, 1986; $21.00 (89/90) 2 0

Note: Total in each column exceeds number of respondents because some programs mentioned more thanone book. Prices are from the indicated volume year of Books in Print. hc = hardcover; pb = paperback

TABLE 2. Point of view: comparison of mean ratings of most frequently used textbooks

Behavioral Science Textbooks Clinical Psychiatry Textbooks

UHB SP RGP SP PMS RGP

Point of View (n = 22) (a = 13) (a = 9) (a = 15) (a = 12) (a = 11)

Psychodynamic 4.1 3.1 3.0 3.4 3.4 3.1

Biological 2.7 3.3 3.7 3.8 3.8 3.7

Sociological 3.3 3.1 2.8 3.3 32 2.8

Behavioral 3.0 3.1 2.8 3.2 3.1 3.0

Integrated 3.0 3.2 3.4 3.7 3.9 3.3

Note: I = very weak, 2 = weak, 3 = adequate, 4= strong, 5 = very strong. UHB = Simon and Pardes, Under-

standing Human Behavior; SP = Kaplan and Sadock, Synopsis of Psychiatry; RGP = Goldman, Review of General

Psychiatry PMS = Waldinger, Psychiatry for Medical Students; n = number of respondents using text.

chosen were Synopsis of Psychiatry: Behavioral

Sciences and Clinical Psychiatry (SP) byKaplan and Sadock (n=13, or 21%) and Re-

view of General Psychiatry (RGP) (n=9, or 15%)by Goldman. Seven texts were mentioned by

2 to 5 programs each, and the remaining 25

were used in only I program each.

Overall, the textbooks cited were usedan average of 3.3 years (range, <1�10 years).

UHB’s use averaged 5.0 years, and the othertwo popular texts, SC and RGP, had been in

use 2.1 and 2.7 years, respectively. Manysingle-user texts had been used for 1 year,but nearly all users were anticipating re-adoption the next year. Of current users of

the most popular texts, 64% planned to useUHB the next year, 85% planned to continue

with SP, and 78% planned to continue withRGP.

Table 2 presents the mean ratings of the

five possible points of view for the threemost frequently used texts in behavioralscience teaching. On the average, the total

group of textbooks cited was perceived to bestronger on psychodynamics than on the bi-

ological or sociological perspectives, which

were in turn considered stronger than be-havioral perspectives. Among the three

most frequently cited texts, UHB’s strongestperspective was psychodynamic, SP was

rated more evenly, and RGP was ratedstrongest for its biological perspective.

Comparing coverage of seven specificsubject areas among all 35 texts used in

teaching behavioral science, ethnology wasthe weakest area, with doctor-patient rela-tionship and child development the strong-est. UHB’s strongest ratings were for child

development (4.1) and doctor-patient rela-

tionship (3.9); its lowest were for brain and

behavior (2.1) and mental status exam (2.3).

SP and RGP, by contrast, received theirstrongest ratings where UHB was weakest,mainly in brain and behavior (3.5 and 3.6,respectively) and mental status exam (3.5

and 4.0, respectively). SP and RGP were alsoweak where UI-LB was strong, in doctor-pa-tient relationship (2.8 each) (Table 3). Overallratings for the three most popular texts fellbetween adequate and very strong (Table 5).

When UHB was used as a text, a com-panion text was used by only 45% (n=10) ofthe programs. When SP or RGP was used asa text, a companion text was used by 62%and 67%, respectively. In general, when a

complementary text was used, it was ratedhigher in those areas in which the text listedfirst was weakest.

Textbooks Used to

Teach Clinical Psychiatry

There were 66 responding programs; 23programs mentioned two texts, so there

were 89 responses altogether. Respondentsmentioned using 24 different textbooks. Thethree textbooks mentioned most often wereSynopsis of Psychiatry: Behavioral Sciences and

3.9 2.8 2.8

4.1

3.3

2.9

25

2.3

3.2 2.9

3.0 2.3

3.0 3.1

2.8 3.3

3.5 4.0

3.2 3.3 3.2

3.7 3.7 3.8

4.4 3.9 3.9

4.2 3.6 3.4

3.2 2.5 3.13.3 3.0 2.73.1 2.8 3.1

3.4 3.1 3.2

Clinical Psychiatry (SF) by Kaplan and Sad-ock (n=15, or 23% of responding programs),Psychiatry for Medical Students (PMS) byWaldinger (n=12, or 18%), and Review of Gen-

eral Psychiatry (RGP) by Goldman (n=11, or17%). Psychiatry for the House Officer (PHO)

by Tomb was used by 9 programs, II bookswere mentioned between 2 and 6 times, and

another 9 were mentioned once each. Clini-cal psychiatry books in each school had beenin use a mean of 4-#{189}years. Nearly two-thirds of those using the top three plannedto do so next year, whereas only one-third ofthose using PHO planned to use it again.

Table 2 presents the mean ratings of theperceived points of view of the three mostfrequently used texts in clinical psychiatry.When ratings of all 24 textbooks used wereaveraged, the texts were seen as strongest onbiological perspective and weakest on be-havioral perspective. The three most fre-quently used textbooks were rated as verysimilar to each other and to the group as awhole. SF and PMS were perceived as mar-ginally better integrated than RGP.

The specific subject areas we asked

TABLE 3. Specific subject areas: comparison

of mean ratings of three most fre-quently used behavioral science text-books

Specific SU1{B SP RGP

ubject Area (a = 22) (a = 13) (a =9)

Brain and behavior

Doctor-patient

relationship

Child development!developmental theory

EthnologyEpidemiology and social

psychiatryBasic clinical interviewing

techniques

Mental status exam

2.1 3.5 3.6

Note: I = very weak, 2= weak, 3= adequate,4= strong, 5= very strong. UHB = Simons andPardes, Understanding Human Behavior; SP = Kap-lan and Sadock, Synopsis of Psychiatry; RGP = Gold-man, Review of General Psychiatry-, n = number ofrespondents using text.

about (Table 4) were different in clinical psy-chiatry than in behavioral science. For the 24textbooks, geriatric psychiatry and human

sexuality were seen as not quite adequatelycovered, whereas general psychiatric illness

and its treatment were seen as strongly in-cluded. Again, as with points of view, thetop three books looked quite similar. Theyalso tended to receive strong ratings on theselected attributes (Table 5).

When companion texts were used, theywere often rated strong in those areas wherethe first-listed text was weak. For example,two PMS users also used DSM-ffl-R, whichthey rated high in child psychiatry (4.5), an

area where they saw the PMS text as weak-

est.

Combined Use of a Textbook

Of the 54 programs responding to boththe behavioral science and the clinical psy-

chiatry textbook portions of the question-naire, 38 indicated that they used the same

text for both curricula. Thirteen different

texts were used in this way, most frequently

TABLE 4. Specific subject areas: comparisonof mean ratings of three most fre-quently used clinical psychiatry text-books

Specific S

SP PMS RGPubject Area (a = 15) (a = 12) (a = 11)

Basic clinicalinterviewing

Mental status exam

General psychiatricillnesses

Treatment of psychiatricillnesses

Child psychiatry

Geriatric psychiatryHuman sexuality

Substance abuse

Note: I = very weak, 2= weak, 3= adequate,

4= strong, 5= very strong. SP = Kaplan andSadock, Synopsis of Psychiatry; PMS = Waldinger,Psychiatry for Medical Students; RGP = Goldman,Review of General Psychiatry; n = number of respon-dents using text.

TABLES. Selected attributes: comparison of mean ratings of most frequently used textbooks

Selected Attributes

Behavioral Science Clinical Psychiatry

UHB SP RGP(a = 22) (a = 13) (a = 9)

SP PMS(a = 15) (a = 12)

RGP(a = 11)

4.0 3.2 3.7

3.4 3.5 3.9

3.6 3.1 4.1

3.3 4.0 4.4

35 3.5 3.7

3.1 3.2 3.8

3.1 3.3 3.1

3.7 3.7 4.1

3.5 3.1 3.8

3.2 3.9 3.6

3.9 45 3.7

4.0 4.2 3.9

3.3 3.7 3.7

3.9 3.9 4.0

3.8 3.7 3.5

3.7 3.6 3.7

3.6 4.4 32

3.9 3.8 3.8

3.6 3.4 3.8

3.9 3.3 3.3

3.4 3.9 3.6 3.8 3.8 35

SF (n=14) and RGP (n=8). Other textbooks

assigned for both curricula at more than oneprogram were PMS, UHB, Psychiatry: Essen-

tials of Clinical Practice by Gregory andSmeltzer, and American Psychiatric Press

Textbook of Psychiatry by Talbott.

Reasons for Text Selection

five diagnostic patients to teach psychiatric

principles in the context of conducting aninterview. Those using it offered comments

such as “easy,” “fun,” “will use again,” and“informative.” One school prepared its own

software. Several respondents said that theywished suitable software were available.

DISCUSSION

In answer to the question “What is the

main reason for selection of the text?” themost frequently noted reasons were usabil-ity over four years of medical school educa-tion, conformity to the latest diagnostic andstatistical manuals, and modest cost. Others

emphasized compatibility with their curric-ulum and format of teaching (e.g., lecture,

small group), relevance to National Board

preparation, and student satisfaction.

Software

Eleven of the 75 respondents reportedusing software for teaching. Five programslisted Psycal by Upjohn (6), which simulates

Ease of understanding formedical school level

Clear and concise

Clinical examples used

Defines terms in text or glossary

Chapters built upon each other

Faculty satisfaction

Student satisfaction

Accuracy (free of misprints!theoretical errors)

Emphasizes conceptual learning

Emphasizes detail learning

Helpful in preparing for Boards,

Part I

From these data a picture of each of thepopular texts can be drawn. Understanding

Human Behavior, used by more of our respon-

dents than any other behavioral science text,is clearly seen as having a strong psychody-

namic and a weak biological orientation. InUHB child development and doctor-patientrelationships are perceived to be well cov-ered, whereas brain and behavior, basic clin-ical interviewing, and mental status examare not. Respondents rated this book high inease of understanding and use of clinical

examples. Comments included: “has a de-velopmental perspective”; “is well written

and illustrated with excellent vignettes”;

Note: I = very weak, 2 = weak, 3 = adequate, 4= strong, 5= very strong. UHB = Simons and Pardes, Under-

standing Human Behavior; SP = Kaplan and Sadock, Synopsis of Psychiatry; RGP = Goldman, Review of General

Psychiatry; PMS = Waklinger, Psychiatry for Medical Students; n = number of respondents using text.

“provides material for small-group focus”;

and “is a good introduction to psychiatric

studies.”Synopsis of Psychiatry, used most fre-

quently in clinical psychiatry and secondmost frequently in behavioral science, wasviewed as eclectic in terms of viewpoint.

Users in behavioral science found brain andbehavior and the mental status exam betterrepresented in SF than in UHB, but this wasnot true of child development or the doctor-

patient relationship. They also felt SP waslacking in coverage of basic clinical inter-

viewing. SF was rated high in emphasizing

detail, defining terms, and helping preparefor National Boards. Compared with theother texts, it was not as easy to understand

and used fewer clinical examples. Users ofSF for clinical psychiatry were highly satis-fied with its coverage of general psychiatricillnesses and their treatment. It appealed to

several raters because it could be used for allfour medical school years, making it cost

effective; it was concise and up to date; andit had a study guide.

Review of General Psychiatry, like SP, waspopular in both behavioral science and clin-

ical psychiatry (third most frequently citedfor each) and was selected by some to be

used throughout the four years. It was ratedhighest for its biological viewpoint but was

considered adequate in the psychodynamic.

This book was perceived as similar to SF inits relatively good coverage of brain and be-havior and mental status exam. In contrastto UHB, RGP was considered weakest by

behavioral science users in coverage of thedoctor-patient relationship and child devel-opment. In comparison with the other pop-ular texts for clinical psychiatry, it wasconsidered weaker in treatment of psychi-atric illness and in geriatric psychiatry, butstrong on general psychiatric illness andmental status exam. Users for behavioral sci-ence were pleased with its clinical examplesand its emphasis on conceptual learning. Allusers rated it as clear and concise and likedits definitions of terms. Although percep-

tions of student satisfaction were about the

same for all texts, faculty satisfaction withRGF was notably high among behavioral

science users.Psychiatry for Medical Students was used

second most frequently for dinical psychia-try, but infrequently in behavioral science. Itwas rated highest of any text for its inte-grated point of view. LikeS? and RGP, it was

considered primarily biologically oriented.

Like the other books frequently chosen forclinical psychiatry, PMS was strong on gen-eral psychiatric illness and mental status ex-am. Its weak areas were child psychiatry and

human sexuality. It stood out most for beingclear and concise, easy to understand, andsatisfactory to students.

Although UFIB was used the longestand was the most frequently used text forbehavioral science, only 64% of the respon-dents reported that they would continue touse UHB, compared with SF at 78% and RGPat 85%. The lower planned rate of readoptionof UHB (published 1985) compared with SP(1987) and RPG (1984, revised 1988) maysuggest a concern that UHB is becomingoutdated, even though a more recent publi-cation date does not always mean more up-to-date content.

We noted that the emphasized view-points differed between texts used in clinical

psychiatry and in behavioral science. Al-though the three most popular books used

in behavioral science could be contrasted asto point of view, they were rated, on theaverage, strongest on the psychodynamic

viewpoint. By contrast, the clinical psychia-try texts were rated highest on the biological.

it is unclear whether this reflects the facultyusers’ preferences, the availability of texts onthe market, the nature of the subject matter,or other factors.

Our respondents in behavioral sciencetended to use more than one text plus sup-plementary material, whereas in clinical

psychiatry more often a single text was used.Perhaps the material deemed relevant

and/or the format of the courses were more

variable in behavioral science than in clinical

psychiatry; or perhaps the behavioral sci-ence books are more uneven in quality.

The availability of texts changes rapidly;

some that were included in our study will goout of print and others, such as Talbott et al.’sTextbook of Psychiatry, were too new to beevaluated by our raters. Furthermore, since

the study was completed, at least five newtextbooks have been published: Davis et al.’s

Foundations of Psychiatry; Stoudemire’s twotexts, Human Behavior: An Introduction for

Medical Students and Clinical Psychiatry for

Medical Students; Andreasen and Black’s In-troductory Textbook of Psychiatry; and Kaplanand Sadock’s Pocket Handbook of Clinical Psy-

chiatry.

Even though the specific texts rated inthe study will become dated, we believe cer-tain guidelines can be derived from ourstudy that can be useful to faculty in choos-

ing appropriate texts to meet particularneeds. As recommended by McLeod, a com-

mittee can be formed to make such judg-ments (3).

One can judge textbooks by several at-tributes. The three clusters from the ques-tionnaire and the individual items within the

clusters can serve as a guide for evaluatingany textbook. The point of view of a text canbe considered to determine whether it re-flects that of the course director and faculty.

Coverage of specific topics can be evaluatedso that users will be prepared to supplementwhere the text is weak. Finally, text evalua-tors can weigh selected attributes such as theuse of clinical examples, emphasis on con-ceptual or detail learning, and usefulness inpreparing for Boards. Other, general factorsto consider are the selection of a single text

for use over four years versus different oneseach year, cost, and currentness of the con-tents.

Although we did not ask, one insti-tution’s respondent explained that theirprogram used a faculty syllabus. Probablyothers do likewise to supplement a textbook

or in place of one. If faculty members use

copyrighted materials such as journal arti-cles or textbook chapters in anthology formwithout proper permission, they are expos-ing themselves to lawsuits (7,8). It is possible

that tighter copyright laws may prevail inthe future. With this in mind, choosing one’stext carefully will become even more import-ant.

In looking at the perceived faculty andstudent satisfaction responses, faculty satis-faction was exceptionally high with RGP,whereas student satisfaction was outstand-ing for PMS. It can be argued that one shouldchoose a text that satisfies the faculty if oneexpects them to use it and not to feel com-pelled to contradict it; on the other hand, ifstudents find a text to be user friendly, theywill be more likely to read it. Psychiatry for

the House Officer was the fourth most popular

book assigned for clinical psychiatry. Stu-dent satisfaction seems to have been the in-

fluential factor in this choice.There will always be a place for new

textbooks, but it may behoove authors con-sidering revisions or planning a new book toaddress the areas identified repeatedly as

being weaker. Although faculty satisfactionwith the texts they chose appeared quitegood, certain perceived weaknesses stoodout. In behavioral sciences, every specific

subject area was considered less than ade-

quately covered in one or more of the threemost frequently used texts. In clinical psy-

chiatry, the three most popular texts wereconsidered barely adequate in coveringchild psychiatry and human sexuality.

The respondents conveyed a sense thatthere was little available in the field of com-puter software and expressed a desire formore. Here is an opportunity for innovative

preparation, as well as for more effectivemarketing of existing software that is un-

known to potential users.Some limitations of our data include the

small number of respondents for each of the

many texts reported and lack of informationabout nonresponders. Further, the items we

chose to ask about may not be the most

salient for some readers. These data, there-fore, are only suggestive concerning ourtextbook analysis. The strengths and weak-nesses of these texts can change with newereditions. Lack of randomly assigned review-ers rating the same texts precludes meaning-

ful tests of significance. Regarding software,it is possible that the best available is on

videodisk; we did not ask specifically aboutthis type of technology, although several re-

spondents mentioned the NIMH/NationalLibrary of Medicine’s videodisk AdolescentDepression and Suicide Program (9). Despite

References

these limitations, it is our hope that this data-base may be useful to both those responsible

for choosing textbooks and software andthose intending to create these educationalresources.

Summaries of this material were presentedat recent annual meetings of the Association for

Academic Psychiatry in the Medical Technolo-

gies section (1990) and the Medical Student sec-

tions (1 990 and 1991). The study was funded in

part by small-grant support from the Associa-

tion.

1. Asch SS, Marcus ER: The current status of psycho-analysis in medical student education in the UnitedStates: a preliminary overview. J Am Psychoanal

Assoc 1988; 36:1033-1057

2. Gutnik BE), Haffke EA, Strider FE): Behavioral sci-

ence texts in US. medical schools. Journal of Psychi-atric Education 1982; 6:67-73

3. McLeod PJ: Faculty evaluation of medical textbooks

and optional readings. Journal of Medical Education

1986;61:608-610

4. Friedland ER, Cuppage F, FranciscoJT,etal: A guide

to textbooks for introductory medical school pathol-

ogy courses. Arch Pathol L.ab Med 1990; 114:18-235. Slone RM, Martineau BS: Recommended textbooks

for radiology residents. American Journal of Roent-

genology 1991; 156:863-864

6. Goldman H, Goldman B, Gardner A: Psycal, Version

1.0,2.0. Kalamazoo, Ml, Upjohn Co., 1986,1988

7. Steinbach SE: Have professors forgotten the copy-

right law on photocopies? Chronicle of Higher Edu-

cation, June 22, 1988, 34:A-40

8. Turner JA: Publishers said to plan lawsuit to fight

alleged copyright abuses. Chronicle of Higher Edu-

cation March 15, 1989, 35:A-1,16-179. National Library of Medicine and National Institute

of Mental Health: Adolescent Depression and

Suicide Program (videodisk). s.l., NIMH, 1987.

Available from National Audiovisual Center, 8700

Edgeworth Drive, Capitol Heights, MD 20743-3701

Outpatient Management Teams

Integrating Educational andAdministrative Tasks

VMen K. Burt, M.D., Ph.D.

Pamela Snmmlt, M.D.

Joel Yager, M.D.

To provide a more structured experience in outpatient psychiatric training, the UCLA

Neuropsychiatric Institute’s outpatient department organized outpatient management

teams. Each team is supervised by a pair of faculty psychiatrists. PGY-3 and PGY-4

teams also include a psychologist and a social worker. The teams serve to provide com-

prehensive outpatient psychiatric training, track and review patients seen by the trainees,

and ensure quality of care. In this way, the teams have successfully linked educational,

clinical, and administrative tasks. The authors review the organization and processes of

this out patient program, now in its third year.

e past three decades have seen an in-creased reliance on outpatient treatment

as a primary mode of management for thepsychiatrically ill population, including

those patients with severe illnesses who for-merly were routinely hospitalized for long

periods for intensive treatment (1,2). Be-cause graduating residents are likely to de-vote a significant proportion of their clinicalcareers to treating outpatients, university-based programs should provide residentswith training in a multidisciplinary ap-

From UCLA Neuropsychiatiic Institute. Dr. Burtis Assistant Clinical Professor of Psychiatry, Director of

Adult Outpatient Services, and Associate Residency

Education Director. Dr. Sunmiit is Assistant ClinicalProfessor of Psychiatry; she is also in private practice.Dr. Yager is Professor of Psychiatry and Associate

Chairman for Education; he is also Associate Chief of

Staff/Residency Education at the West Los Angeles VA

Medical Center, Brentwood Division. Address reprintrequests to Dr. Burt, UCLA Neuropsychiatric Institute,

300 UCLA Medical Plaza, Los Angeles, CA 90024.

Copyright © 1992 Academic Psychiatry.

proach to the assessment and managementof psychiatric outpatients. Further, the ef-fectiveness of having nonphysician mental

health practitioners participate in both su-pervision and treatment planning has beenpointed out (3) and may provide psychi-

atrists with useful alternatives in mentalhealth care in a time of reduced public andprivate mental health funding.

At UCLA’s Neuropsychiatric Institute(NPI) and the Brentwood VA Medical Cen-

ter, outpatient training has extended overthe course of the residency, with residentspicking up increasing numbers of outpa-

tients as they move from PGY-2 to PGY-4.

Because of the complexity of the program,trainees often see outpatients during hoursoutside those of their concurrent primary

assignments such as working with inpa-tients or consultation-liaison. In order tointegrate the training, administrative, and

patient-care needs of the large and diver-sified outpatient department, an extensivelyreorganized system involving multidiscipli-

nary teams was devised and implemented inJuly 1988. This article describes the programas it exists in its third year of operation.

STRUCTURE AND FUNCTION OFTHE OUTPATIENT PROGRAM

The Outpatient Management Team (OMT)program at UCLA is responsible for trainingresidents in outpatient evaluation, manage-ment, and therapy. It is expected that abouthalf of the residents’ outpatient caseload willconsist of VA patients from the UCLA-affil-

iated Brentwood VA Psychiatric Hospital inLos Angeles and the other half will be uni-versity-based NPI patients. The residents areencouraged to have a large and diverse case-load composed of men and women withdifferent diagnoses and different ethnicities,and involving treatment of individuals, cou-ples, and families. it is also expected thatresidents’ treatment of outpatients will

include different therapeutic approaches,ranging from all major medication classes tobrief therapy, long-term insight-oriented

psychotherapy, supportive therapies, andcognitive and behavioral therapies. The NPI

outpatients are billed on a sliding-fee scale,with the difference between the cost of theircare and the actual reimbursement made upby a state-funded subsidy program ear-marked for the training of psychiatric resi-

dents in University of California trainingprograms. Financial support for the pro-gram is fixed, and it is the responsibility of

the directors of the various clinical services

to ensure appropriate use of the availablefunds.

All residents from PGY-2 through PGY-

4 are members of OMTs that meet weekly.

The PGY-2 teams, which meet for 90 min-utes, begin in the middle of PGY-2 (first-year

residency), at a point when the residents arepicking up discharged inpatients to be fol-lowed continuously as outpatients. ThePGY-3 and PGY4 residents participate in

their 2-hour weekly teams throughout theirsecond and third residency years. Each team

includes approximately five to six residents,

occasionally a psychology intern, and twopsychiatrists who are designated as the teamleaders: a full-time faculty psychiatrist and acommunity-based volunteer clinical faculty

psychiatrist. These psychiatrists are creden-tialed by the Neuropsychiatric Hospital andthe Brentwood VA Hospital, as stipulated bythe regulations of the Joint Commission onAccreditation of Healthcare Organizations(JCAHO). This is essential in view of the

psychiatrists’ roles as supervisors who for-mally track the well-being of the patients

seen by the team members. The PGY-3 andPGY-4 team faculties also indude a staffsocial worker and a faculty psychologist,

chosen for complementary expertise andcompatible working styles.

Team objectives, which are made clearto faculty and trainees, are the following:1) to provide a coherent and comprehensivetraining program in outpatient psychiatry,2) to longitudinally follow and review the

new and ongoing cases of the trainees, and3) to ensure the good care of all the out-

patients from both university and VAsources.

The psychiatrists are responsible forstructuring team meetings, allocating ap-proximately 45 minutes to the teaching ofoutpatient management topics and the re-mainder to case review. Examples of didac-

tic topics range from distinguishing amongthe DSM-ffl-R personality disorders to man-aging medications in an outpatient setting.

(A detailed topic list and curriculum havebeen developed and will be the subject of aseparate report.) Each leader is responsiblefor assessing the condition of patients seen

by each team member, especially noting theoccurrence of serious clinical incidents, suchas signs of suicidal or violent behavior. Lead-

ers are also aware of each trainee’s generalpsychiatry outpatient caseload and of newadmissions and discharges.

The team psychologist and socialworker provide additional resources for

general outpatient teaching and specific

practical assistance in psychometric testing,

disposition, and other social welfare needs.(The PGY-2 residents have access to theseresources on the inpatient wards to which

they are assigned most of the time during thefirst residency year.)

In addition to attending these teammeetings, each resident also continues to see

two to four individual faculty supervisors

for more in-depth supervision of selectedoutpatients and participates in additional

core curriculum seminars and conferencesdevoted to outpatient psychotherapies and

pharmacological management.The work of the OMTs is monitored

through a series of meetings. Full-time fac-ulty OMT leaders meet monthly with the

director of adult outpatient services to re-view the work of the teams. This reviewaddresses residents’ progress in attaining

educational objectives, outpatient problemsthat may require additional faculty supervi-

sion or consultation, and any practical ad-ministrative problems that impede the workof the teams. During the year, additionalmeetings are occasionally held in which allteam psychiatrists meet with the residencydirectors, chief residents, other residentrepresentatives, and the president of theClinical Faculty Association to review theprogress of the program as a whole and todiscuss emergent problems.

DISCUSSION

The adult outpatient psychiatry program

was reorganized to provide training in themanagement of psychiatric outpatients in astructured format that would simultaneous-ly permit teaching, tracking and supervisingoutpatient caseloads, and administrativequality control of the care provided by train-

ees. The OMT program addresses each ofthese objectives, and after three years of op-eration it has become a fully integrated partof the residency program.

Several authors have addressed theproblems of integrating outpatient activities

into busy, service-demanding training pro-

grams. Paris et al. (4) suggested that out-patient psychiatric training frequently hasbeen a “concurrent rotation,” occurring at thesame time as other rotations and thereforeoften receiving less attention than what ap-pear to be the more pressing needs of other

services. In contrast to inpatient and consul-tation-liaison services, in which attendingpsychiatrists, nurses, and residents review

cases through frequent (often daily) rounds,analogous outpatient reviews are generallylacking. Yet Hales and Borus (5) havepointed out that residents often feel unsure

of their theoretical and service allegiances

and require help in consolidating their iden-tities as practitioners. They must learn to setpriorities, and they need assistance in locat-ing and using available departmental andcommunity resources to fill gaps in their

clinical experience.The interdisciplinary OMTs address

these issues. Thus, the new outpatientprogram has introduced structure into whathad been largely an unstructured program.The teams have provided trainees the op-portunity to work with faculty to manage

their outpatient caseloads, discuss ongoingproblems, and elaborate on some of the is-

sues of outpatient psychiatry in a didacticforum.

One objective for the OMTs was to pro-vide increased exposure to different treat-ment approaches. The teams have devotedconsiderable time to the integration of dif-ferent psychotherapeutic models, such as

combinations of psychotherapies with phar-macotherapy and social therapies. Open dis-

cussions of such approaches are meant to

sharpen the understanding of the strengthsand weaknesses of alternative treatments,ultimately leading to the development ofindividual styles.

Faculty leaders report that the teams en-

able them to gain some familiarity with theresidents’ overall clinical abilities in outpa-

tient work. At the monthly team leaders’meetings, discussions have frequently fo-

cused on problems that some trainees havewith outpatient care, such as difficulty inorganizing and presenting cases, or a ten-

dency to limit their selection of outpatients

or treatment modes (perhaps because oftheir discomfort in electing to treat certain

types of outpatients). These discussionshave sometimes led to one-on-one meetings

between team leaders and particular resi-dents to review problem areas. The residents

have almost always appreciated and re-sponded positively to this feedback. Inmost

cases they have worked carefully on identi-fied problems, and subsequent verbal re-ports by faculty often reflect significantimprovement. The teams appear to offer an

additional vehicle for evaluation, teaching,feedback, and, where necessary, remedia-

tion.The quality-management aspect of the

program functions as follows: over the pastthree years, when an outpatient has seri-

ously decompensated (e.g., via a serioussuicidal gesture, completed suicide, orthreatened or actual violence) it has become

standard procedure for the resident to im-mediately call his or her academic facultyteam leader, who in turn informs the Direc-

tor of Adult Outpatient Services. Plans aremade for the resident to meet with the team

leader to discuss the incident and to reviewthe resident’s case management and follow-

up plans. Support is offered, and the faculty

leader is aware that he or she will counter-sign the chart notes that document the inci-dent. Often the resident, the team facultyleader, the Director of Adult Outpatient Ser-

vices, and the primary individual supervisorall meet together. The team meetings that

follow the incident offer a place where allmembers can discuss the case in a support-ive and empathic atmosphere; the frank and

open discussions that characterize suchmeetings are possible because trainees have

used the team for ongoing discussion oftheir cases so that team members are al-ready familiar with the caseloads of their

peers.

EVALUATION

A number of surveys have been conducted

by the faculty and the UCLA Residents’Council to provide feedback regarding theprogress of the OMTs. It has become appar-ent that the effectiveness of the OMTs for

outpatient psychiatric education and review

of case material is highly dependent on thefaculty’s sensitive appreciation of the train-

ees’ experiences as they openly reveal howthey manage individual cases. The occasion-al reluctance of a resident to present possiblecase management problems to the team ap-pears to be related to how vulnerable someresidents feel in an open forum comprising

peers, interns, and faculty and staff who areregarded as having both seniority and ex-pertise. Little has been written about theexperiences of psychiatry residents in multi-disciplinary teams elsewhere, but in one ar-ticle residents gave multidisciplinary teamsin emergency psychiatry generally good re-

views, although noting occasional reluc-tance to discuss cases with nonmedicalfaculty or trainees (6).

Our surveys have indicated that psy-chologists and social workers can providesignificant resources to the teams. Although

clearly not all outpatients require psycho-logical testing, the availability of psycholo-

gists to provide and review testing when

appropriate is useful. Practical hands-on so-

cial work assistance is sometimes a sig-nificant benefit to the team members, whooften find themselves discussing issues ofdisposition, social welfare, and social aid.Social workers are occasionally able toprovide practical resources in the com-munity for patients and their family mem-

bers, and they sometimes assist moredirectly by acting as cotherapists for groups,

couples, or families. They may also consultin outside sessions with residents who needmore extensive help in disposition for diffi-

cult patients.Continuing difficulties have resulted

from the depletion of mental health com-

References

munity resources, which severely limits thepractical assistance in disposition and othersocial service interventions that social work-ers can offer. Occasionally, the resulting

frustrations have generated strain amongteam members, particularly between social

workers and residents. Although the team

structure provides for the availability ofsocial workers and psychologists with spe-

cial training in their traditional duties, theways in which those duties are actually car-ried out within a team are necessarily limited

by available resources; thus, the teams inev-itably present a “real-life” multidisciplinary

approach to the management of psychiatric

outpatients.

SUMMARY

The OMTs have filled several needs for the

training program and administrative ser-

vices. Ultimately the teams permit account-

ability for outpatient care and residencytraining to be more effectively designated to

the parties responsible, and they allow themany subtleties of practical comprehensiveoutpatient management to be effectively

taught and learned.

1. Borus JF: Deinstitutionalization of the chronically

mentally ifi. N Engi J Med 1981; 305:339-342

2. Braun PB, Kochansky G, Shapiro R, eta!: Overview:

deinstitutionalization of psychiatric patients, a criti-ca! review of outcome studies. AmJ Psychiatry 1981;138:736-749

3. Fauman BJ: Psychiatric residency training in theconsideration of alternatives to hospitalization. Psy-chiatr Clin North Am 1985; 8:609-615

4. Paris J, Kravitz H, Prince R: Report: conference on

key issues in post-graduate psychiatric education in

Canada. Can J Psychiatry 1986; 31:705-707

5. Hales RE, Borus JF: A reexamination of the psychi-

atric resident’s experience in the genera! hospita!.Gen Hosp Psychiatry 1986; 8:432-436

6. Spitz L, B!um HT, Gale MS, eta!: Psychiatric training

for emergency medicine residents ona mu!tidiscipli-

nary team. JACEP 1976; 5:694-697

Copyright © 1992 Academic Psychiatry.

Components of Supervisors’Ratings of Therapists’ SkiHfulness

Sheryl H. Jones, B.S.

Ronald F. Krasner, M.D.

Kenneth I. Howard, Ph.D.

A questionnaire was developed to assess the skillfulness of therapists from the perspective

of the supervisor. This supervisor report yielded two scores: one for psychotherapeutictechniques and one for the educational alliance. These scores had high internal consis-

tency and were relatively independent of one another. Ratings of proficiency in psycho-therapeutic techniques accounted for 54% of the variance in supervisors’ ratings of global

skillfulness; educational alliance contributed an additional 12%. Compared with other su-

pervisors, those who espoused self psychology based more of their appraisal of skillfulness

on the trainee’s use of the supervisory relationship.

e supervision of psychotherapy is aunique learning process that is intended

to integrate the theoretical concepts of psy-

chopathology and treatment with an actualclinical experience. This process involves thestudent therapist and the supervisor in ananalysis of the therapeutic interaction

between therapist and patient. Supervisionbegan in the 1920s and 1930s as an informal

method of teaching psychotherapy. Pioneer-ing attempts to further clarify this method of

teaching were made by Fleming (1), Arlow(2), Searles (3), Ekstein and Wallerstein (4),Grotjahn (5), Tarachow (6), Windholz (7),

and others. More recently there have been anumber of important attempts to under-

stand supervision from the perspective ofprocess (8), developmental models (9,10),

and outcome (11,12). Ultimately, however,there are twop�� goals of supervision:to improve the therapist’s knowledge, be-havior, and attitudes regarding his or herpsychotherapeutic work; and to achieve im-provement in the patients who are treated by

the therapists/trainees (13).

The supervision of psychotherapy hasbecome an integral part of the education ofpsychiatrists and psychologists (14,15). Inthis educational effort, supervisors arecalled upon to monitor the development ofclinical skills and to evaluate the profession-al competence of the therapist in training.The measurement of therapeutic skills, how-

ever, has been quite difficult to achieve (16).To assess the psychiatric resident’s ability todo psychotherapy, Moline and Winer (17)

devised a test of the trainee’s competence to

Ms. Jones is a graduate student and Dr. Krasner is

Director of Medica! Education in the Department ofPsychiatry and Behavioral Sciences, Northwestern Uni-versity Medical School. Dr. Howard is Professor of Psy-cho!ogy and Director of Clinical Training, Department

of Psychology, Northwestern University, Chicago, IL.Address reprint requests to Dr. Krasner, Director ofGraduate Medical Education, Department of Psychiatry

and Behavioral Sciences, Northwestern UniversityMedical Schoo!, 303 East Superior, Room 594, Chicago,IL 60611.

make the “right” interpretation in a particu-lar situation. Later, Winer and Mostert (18)

developed an instrument to measure res-idents’ “dynamic psychotherapy skifis,” but

no results have been reported.

Several excellent reviews of recent re-search on the teaching of therapeutic skills(19,20) seem to agree that the definition andmeasurement of competence in psychother-

apy have progressed little over the years. Yetbecause of supervisors’ unique role in psy-

chiatric education, they are called upon toevaluate the development of residents’ ther-apeutic skills. To further our understandingof these evaluations, it is necessary to have areliable and valid assessment instrument.For this purpose, we have developed a newquestionnaire, the Supervisor’s Report. Inthis article, we present this instrument, its

psychometric properties, and an analysis ofthe components of ratings of therapists’

skillfulness.

METHODS AND PROCEDURES

The Supervisor’s Report (SR) was designedto evaluate the skillfulness of the therapist inconducting psychodynamic psychotherapy.

It was developed as part of a naturalisticstudy of long-term psychodynamic psycho-therapy supported by a five-year researchgrant from the National Institute of MentalHealth (21). The setting for this project is alarge outpatient psychiatric clinic that is part

of Northwestern Memorial Hospital and theDepartment of Psychiatry and Behavioral

Sciences of the Northwestern UniversityMedical School. In the research project,questionnaires are completed throughoutthe course of treatment by patients, thera-

pists, and supervisors. Supervisors of psy-chiatry residents and of clinical psychology

postdoctoral students, interns, and practi-cum students participated in this study.These supervisors were faculty members of

the Northwestern University MedicalSchool Department of Psychiatry and Be-

havioral Sciences.

Supervisors

A background information form was

sent to the 111 supervisors who supervise

individual psychotherapy in the outpatient

psychiatric clinic. However, 10 of these su-pervisors were not currently active in the

program. Of the remaining 101, 90 supervi-sors returned a completed questionnaire, an

89% return rate.The median age of the supervisors was

42. Two-thirds were male and 98% were

Caucasian. Seventy percent were married(19% never married) and two-thirds were

parents, typically with one or two children.Approximately half the supervisors were

Jewish; one-third endorsed no religious affil-iation. The supervisors were highly experi-

enced in clinical work and supervision. The

typical supervisor in this study had super-

vised at least 25 trainees. He or she hadapproximately 15 years of experience as apsychotherapist. All supervisors had seenmore than 20 patients in psychotherapy; 92%had seen more than 40 patients for individ-

ual therapy; 72% had seen more than 40patients in long-term psychotherapy (morethan 6 months). Ninety-three percent of su-

pervisors had been in personal psychother-apy or psychoanalysis themselves; all but Ihad had at least 2 years, and all but Shad had

at least 3 years of personal psychotherapy.Approximately half of the respondents werepsychiatrists and half were psychologists.Fourteen were psychoanalysts or were in

analytic training.To gain an appreciation of the theoreti-

cal orientations of the supervisors in thisstudy, the background information form

contained the following question: “Howwould you describe your own present theo-retical orientation?” Sixteen alternatives

were provided, of which respondents couldcheck as many as applied. No definitions ofthese alternatives were provided. The psy-

chodynamic alternatives included the gen-eral term psychoanalytic as well as terms thatdenote theoretical subsets in psychoanaly-

sis, including object relations, ego psychol-

ogy, and self psychology. As shown in Table1, endorsements fell into three major catego-ries: 1) exclusively psychoanalytic (n=3); 2)psychoanalytic plus some other category orcategories (n=37); and 3) “psychoanalytic”not checked at all (n=7). However, of this lastgroup, 5 endorsed one or more dynamic cat-

egories, but not the category “psycho-

analytic” per se; of those remaining, one

endorsed “eclectic” only and the otherchecked “eclectic” plus two other nondy-

namic categories. Three of the 16 categorieswere not selected by any supervisor.

Perhaps the most strildng observationthat can be made is that all of the supervisors

considered some form of dynamic theory inthe supervision of therapists in this study.

Because an eclectic approach is very likely toinclude some aspects of psychoanalytic the-

ory, even the two supervisors who did notexplicitly endorse a psychodynamic cate-

gory probably used psychodynamic con-

cepts (e.g., resistance, defenses) in theirsupervision. In fact, no supervisor exclu-sively endorsed a recognized nondynamic

orientation (client-centered, cognitive, Ge-stalt) to psychotherapy. Another important

TABLE 1. Current theoretical o rientations ofsupervisors

Theoretical Approach % (a = 47)

Psychoanalytic 85

Object relations 70

Self psychology 62

Ego psychology 43

Interpersona!/Sullivanian 32

Systems/family 23

Biopsychosocial 21

Cognitive 11

Eclectic 11

Existential 13

Client-centered 4

Communication/strategic 2

Other:Disease model 2

observation is that even within the analytic

paradigm, the supervisors saw themselvesas using a variety of dynamic approaches-what might be called an eclectic psychoana-lytic/dynamic approach.

Therapists in Training

All therapists participating in the psy-

chotherapy research program completed abackground information form. The thera-pists who were evaluated by the supervisorsin our study were part of this larger group.More than 90% were between 25 and 37

years of age; approximately half were male

and approximately half were married. Most

had had considerable additional experience.

For example, 74% percent had already seenat least 20 patients in psychotherapy.Ninety-one percent of the therapists in train-ing either had undergone or were currentlyin personal psychotherapy.

Patients

Based on information gathered on pa-tients in this clinic, 68% were female and 82%were between the ages of 21 and 40. The vast

majority were not currently married, andover two-thirds were employed full time.Over 80% of the patients had attended col-

lege; of these, about a third had attended

graduate school. Nearly half of the patientshad received some previous therapy. The

patient sample can be characterized asyoung, highly educated, and mildly to mod-erately disturbed.

Instrument and Procedure

The SR is a three-page questionnaire de-signed to be completed by the supervisor ona specific supervisee/therapist regarding

one of his or her cases at a particular point inthe treatment. The questionnaire lists 25therapeutic behaviors that are commonly

advocated for therapists in psychodynamic

psychotherapy. Without taking into account

the level of training of the therapist, thesupervisor is asked to rate how well the su-

pervisee is able to perform these. A 4-pointresponse scale ranging from “very poorly”

to “very well” is provided. The supervisors

are also asked to provide a global assessment

of the therapist’s skillfulness compared withhis or her peers and compared with an ex-

pert. The questionnaire was adapted from an

evaluation form that was already used in theassessment of psychiatry residents.

All supervisors who completed the

background information form (n=90) weremailed the SR and asked to complete it ontheir most recent supervisory session. Forty-

seven supervisors (52%) returned completedSR questionnaires; of the remaining 43, 19

supervisors indicated that they were notpresently supervising individual psycho-

therapy cases, 5 questionnaires were re-turned with incomplete information, and 19current supervisors did not return a ques-tionnaire. The total return rate was 79%. Acomparison of the background characteris-tics of those who responded (n=47) andthose who did not (n=24; 19 who did notreturn the SR plus 5 who returned it incom-plete) revealed no trends or significant dif-

ferences.

RESULTS

Performance ofTherapy-Related Behaviors

The first question we examined waswhat the therapists in training were or werenot doing well as judged by the supervisors.Table 2 provides the descriptive data on 23rated behaviors. (Two of the 25 rated behav-iors were not included in the analysis be-cause of missing data.)

What was done well. The highest ratings

were in the area of educational affiance;almost all trainees were able to cooperatesuccessfully with their supervisors. Virtu-

ally none were doing less than “well” atseeing the supervisor as a helping person,

listening to supervisor comments, being able

to ask for help, and showing a capacity to

work with the supervisor on difficulties inthe learning alliance. All also were able to

present clinical material well, and most actu-ally did “very well” in this regard. The train-ees also were rated highly on behaviorsinvolving their own affect: recognizing theirown reactions to patients and empathizingwith the patients’ feeling states. Finally, es-

tablishing and maintaining a treatment alli-ance and listening uncritically to the patientwere done “very well” by more than 50% ofthe trainees.

What was done poorly. Trainees wererated as having the most difficulty with dif-ferentiating the affiance from other uses the

patient makes of the therapist, withstandingthe patient’s affects, perceiving unconsciousmeanings, facilitating the patient’s use of thetherapist, understanding and appropriatelyusing interpretations, and recognizing andhandling defenses and resistances. These areall areas that are often emphasized in super-vision.

In examining the 23 therapy-related be-haviors, it became clear that there was anatural division of these behaviors. On con-ceptual grounds, we identified two compo-nents-psychotherapeutic techniques and

educational alliance. A score was derived foreach component. The score for psychothera-peutic techniques was based on the sum ofthe 19 items that describe behaviors and abil-ities therapists employ in therapy. The alphafor this score was 0.92, indicating a highdegree of internal consistency. The educa-tional affiance score was obtained from itemsdescribing the supervisee’s abffity to estab-lish a good educational affiance by seeing thesupervisor as a helping person, by listeningto the supervisor’s comments, by being able

to ask for help, and by showing a capacity towork with the supervisor on difficulties inthe learning alliance. The internal consis-tency for this score was also high (alpha =

0.90). The correlation between the two scores

was 0.61.

Establish and maintain the treatment alliance 4.3 54.3

Listen uncritically to the patient 8.5 51.1

Differentiate the alliance from other uses the patient makes of the therapist 25.0 15.0

Recognize when the alliance has been disturbed 11.4 40.9

Empathize with the patient’s feeling states 10.6 55.3

Withstand the patient’s affects 24.4 20.0

Perceive unconscious meanings 25.5 19.1

Recognize and understand the transference 15.2 30.4

Facilitate the patient’s use of the therapist 25.0 31.8

Understand and appropriately use various interventions:Questions 11.6 44.2

Clarifications 17.4 21.7Interpretations 21.7 15.2

Recognize and handle defenses and resistances 23.9 8.7

Evaluate responses to interventions 14.9 29.8

Recognize his or her own emotional reactions to patients 2.1 59.6

Assess change 6.7 28.9

Conceptualize in dynamic and interpersonal terms 12.8 34.0

Establish a good educational alliance:See supervisor as a helping person 0.0 70.2

Listen to supervisor’s comments 0.0 74.5Be able to ask for help 4.3 74.5

Present the clinical material 0.0 57.4

Show a capacity to work with supervisor on difficulties in the learning alliance 6.7 64.4

Note: Because of missing data, n’s for percentages ranged from 40 to 47.

Skillfulness

The second section of the SR focuses onglobal assessments of the therapist’s per-formance. In this section, supervisors were

asked to rate the therapist’s skillfulness com-

pared with that of his or her peers and of anexpert. The correlation between the two

comparisons was high (r=0.87). To enhance

the reliabffity of the skillfulness index, thesetwo items were summed, yielding an alpha

of 0.91.The correlation between the psychother-

apeutic techniques score and the skillfulness

index was 0.73 (P<0.00I). The correlationswith the skillfulness index of 10 of the 23

items reached the P<0.001 level of signi-

ficance (see Table 3). The correlation be-

tween the educational alliance score and theskillfulness index was 0.36 (P<0.05). Interest-ingly, when further correlations were com-

puted to determine the relationship betweenthe skillfulness rating and other factors, such

as the difficulty of the patient, how well thepatient was getting along emotionally and

psychologically, and how the therapy wasprogressing, none of these were found to be

significantly correlated with the super-visor’s rating of the therapist’s skillfulness.

A stepwise multiple regression revealed

that 54% of the variance in skillfulness couldbe accounted for by the psychotherapeutic

TABLE 2. Ratings of therapists: distribution of responses

%

Very Poorly/ Very

Therapeutic Behavior Poorly Well

Recommen d and implement the psychotherapeutic treatment plan 8.5 42.6

0.48

0.20

0.50

0.620.710.66

0.47

0.56

0.24

0.14

0.38

0.35’

0.390.32’

0.34’

0.32’

techniques score alone, with an additional12% accounted for by the educational affi-ance score.

Validity of the Supervisor Report

Having demonstrated the reliability ofthe two scores from the SR, it is next impor-

tant to demonstrate validity. We have some

TABLE 3. Correlations of therapeutic behaviorswith global skillfulness rating(N = 47)

Behavior Correlation

Recommend and implement thepsychotherapeutic treatment plan 0.65

Establish and maintain the treatment

alliance 0.55”

Listen uncritically to the patient 0.45’

Differentiate the affiance from other uses

the patient makes of the therapist 0.41

Recognize when the affiance has been

disturbed 0.35

Empathize with the patient’s feeling states

Withstand the patient’s affects

Perceive unconscious meanings

Recognize and understand thetransference 0.40

Facilitate the patient’s use of the therapist 0.58”

Understand and appropriately use

various interventions:Questions

Clarifications

Interpretations

Recognize and handle defenses andresistances

Evaluate responses to interventions

Recognize his or her own emotional

reactions to patients

Assess change

Conceptualize in dynamic andinterpersonal terms

Establish a good educational alliance:

See supervisor as a helping person

Listen to supervisor’s comments

Be able to ask for help

Present the clinical material

Show a capacity to work with supervisor

on difficulties in the learning alliance

Note: ‘P <0.05, P <0.01, “‘P < 0.001

indication of validity in the significant rela-

tionship of each score to a global assessment

of skillfulness. Another indicator would bethe ability to show that the two scores make

different contributions to a global assess-ment of skillfulness across different theoret-

ical orientations.To explore this matter, a secondary an-

alysis was performed using those whoendorsed self psychology as one of theirpresent theoretical influences (n=29) com-pared with those who did not endorse selfpsychology (n=18). A stepwise multiple re-gression was performed for each of these

two groups. The psychotherapeutic tech-niques score and the educational alliance

score were the independent variables; theskillfulness index was the dependent vari-able (Table 4). For the non-self psychologygroup, the psychotherapeutic techniques

score accounted for 79% of the variance(PczO.001), whereas educational affiance ac-counted for an insignificant amount (1%) of

the variance. For the self psychology group,psychotherapeutic techniques comprised52% of the variance (P<0.001), and educa-tional alliance contributed 30% of the vari-

ance (P<0.01). Thus, we have additional

evidence supporting the validity of the SR.

DISCUSSION

For as long as supervision has been used toteach therapists how to conduct psychother-apy, there has been a wide variety of opin-ions regarding which factors contributemost to therapist skillfulness and how bestto teach them. Supervision is a unique teach-ing tool which, like psychotherapy itself, has

both cognitive and affective components.Differences in emphasizing these two com-ponents have tended to correspond to points

along a continuum. Representing the cogni-tive end, Tarachow (6) stated: “The basic rule

is that the teaching of the resident should beinstruction in terms of the problems andneeds of the patient, as expressed in the spe-

cific clinical phenomena of the patient. The

TABLE 4. Contributions of scores for techniqueacross theoretical orientations

vs. educational alliance to variance in skillfulness rating

Theoretical

Orientation N

R2

Psychotherapeutic

Techniques

Educational

Alliance

Total sample

Non-self psychology groupSelf psychology group

47

1829

0.54”

0.79”

0.52”

0.12

0.01

0.30’�

Note: “P < 0.01, �“P <0.001

supervisor is an instructor and not a psy-chotherapist” (p. 303). On the affective end,Fleming (22) held that “the supervisorteaches the basic skills of communicatingwith a patient by teaching the student howto communicate adequately with the super-visor himself. The degree to which the stu-

dent accomplishes this learning goal will

reflect the level of his skill in communicatingwith his patient” (p. 417). Further, Searles (3)asserted that even the supervisor’s privatefantasies and his personal feelings about thesupervisee are useful in the teaching of psy-

chotherapy.In this study, we asked an experienced

group of supervisors to make judgmentsabout how well they thought their super-visees were conducting psychotherapy. Theinstrument we designed to gather this infor-mation delineated a number of behaviorsand attitudes thought to comprise therapistskillfulness. Using the continuum describedabove, these components were divided intotwo major groupings: elements thought to

comprise specific psychotherapeutic tech-niques and elements thought to reflect the

educational affiance between supervisor andsupervisee. The instrument proved to bevalid and internally consistent, both in terms

of the identification of what was done wellversus poorly by the therapist-trainees, andin terms of correlations of those scores withratings of global skillfulness.

With regard to the performance of su-pervisees, some of the behaviors that weredone well, such as relating well to patients

and supervisors, may be a reflection of theinterpersonal skills required for admissionto clinical training programs. On the otherhand, the behaviors that were done rela-tively poorly, such as the perception of un-conscious meanings and the recognition andhandling of defenses and resistances, refer to

skills that are training goals requiring activeteaching efforts.

In our sample there was a much highercorrelation between global skillfulness rat-ings and the psychotherapeutic techniquesscore than between skillfulness ratings andthe educational alliance score. A secondaryanalysis of a group of our supervisors, thosewho endorsed a self psychology orientationon the supervisor’s background information

questionnaire, revealed a striking change inthis trend. In this latter group the correlationbetween skillfulness and the psychothera-peutic techniques score was lower, and the

correlation between skillfulness and the ed-ucational alliance score was much higher,indicating this group placed some emphasis

on the affective end of the continuum. On theother hand, the quality of the educational

alliance played no role in the ratings oftrainee skillfulness for supervisors who didnot endorse a self psychology orientation,indicating this group had a cognitive em-phasis.

On what grounds do supervisors of psy-chotherapy judge their supervisees to be

skillful? Because supervision is undoubted-ly the cornerstone of psychiatric education,

and especially psychotherapy education,

this question is crucial to our assessment ofthe trainees’ progress and whether our pro-grams are accomplishing their educationalgoals. Therapist skillfulness is clearly not the

product of a dry, affectless, didactic interac-

tion between supervisor and student. Nor,however, is it only the product of the su-

pervisee’s ability to get along with his or hersupervisor. The instrument that we have in-troduced here is a first step in accuratelymeasuring these components of supervisor

ratings of supervisees.In future work we would like to deter-

mine whether our instrument remains valid

across clinical sites. Also, having access to

the large naturalistic study by NIMH of theoutcomes of long-term psychotherapy willpermit us to study a number of related ques-

Ref erences

tions, including the relationship between thesupervisors’ ratings of skillfulness and ac-

tual patient outcomes and the tracking ofskillfulness ratings for trainees over time as

they progress through their educational pro-

grams. We hope that then we will have someobjective data as to whether our residentsbecome more skillful over time and whetherthis can be demonstrated in terms of howwell their patients do.

The authors acknowledge the contribution of

the members of the Northwestern/Chicago Psy-

chotherapy Research Group. A version of this

article was presented at the 21st Annual Meeting

of the Society for Psychotherapy Research, June

28, 1990. This work was supported by NIMH

Grant ROl MH42901.

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18:135-146

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sion. Psychiatry 1955; 18:9-156. Tarachow S: An Introduction to Psychotherapy.

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232

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and psychotherapy. Bull MenningerClin 1976; 403-1(13

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tion and Supervision 1987; 26:260-269

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apeutic skill, in Handbook of Psychotherapy and

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Therapist-InitiatedPatient Transfer in the

Residency Training Setting

Hilary Klein, M,D,

Therapist-initiated transfers of dynamic psychotherapy patients, precipitated by theneed for residents to have a broad exposure to varied services, are common pheno-

mena in residency training settings. Both the transferring therapist and the patient

may experience these transfers as distressing. The inexperienced therapist may initiate

inappropriate transfers, incomplete terminations, or social behavior toward the patient.

A case example is presented and discussed in light of the relevant literature. Recom-

mendations for prophylactic measures include education, strong supervisory support

to explore countertransference issues, and the use of a case conference at points of

transfer.

erapist-iitiated terminations are com-mon phenomena in residency training

settings (1-5). Each resident must rotatethrough varied services, and this may

precipitate the transfer of psychotherapypatients from one resident to another. Al-

though some psychotherapy cases can befollowed longitudinally regardless of rota-

tional changes for the resident, realistic timeconstraints may make this continuity of caredifficult or impossible to provide for anentire caseload. For the insight-oriented

psychotherapy patient, these transfers,sometimes multiple, may be particularly dis-tressing. Keith (2) coined the term “transfer

syndrome” to describe both the resident’sand the patient’s symptoms resulting from

the administratively dictated loss of a thera-pist in a clinic setting. When the terminationprocess is incomplete, the result maybe thatthe current therapist knowingly or un-

knowingly competes with the patient’s ide-alized representations of the previous

therapists.

THERAPISTS’ RESPONSES

TO TRANSFER

Termination of long-term psychotherapy

has been a neglected area of residency train-ing programs (1). The inexperienced thera-pist, when rotating to a new service, may

need to initiate premature terminations thathave little to do with the patient’s therapeu-

tic needs. In a survey of psychiatric residentsat the University of Toronto, a change in thetrainee’s rotation was the most common rea-

son for the termination of cases (1). Althoughthis experience can offer the resident theopportunity for growth as a therapist, it mayalso present problems to the inexperienced

Dr. Klein ia a resident, Department of Psychiatry

and Behavioral Sciences, The University of Texas Med-

ical Branch at Galveston. Address reprint requests to Dr.

Klein, Department of Psychiatry and Behavioral Sci-

ences D-29, The University of Texas Medical Branch at

Galveston, Galveston, TX 77550.

Copyright © 1992 Academic Psychiatry.

resident. In addition, the therapist who isuncomfortable with loss may unwittingly

sabotage an otherwise adequate treatment

by unconsciously encouraging an inade-

quate or incomplete termination (6). Resi-dent therapists may manifest symptoms of atransfer syndrome (2). For example, under-

estimating his or her importance to the pa-tient permits the novice therapist to avoidfeelings of loss and may result in allowing

insufficient treatment time for the explora-tion of termination issues. The self -denigra-tion of the inexperienced therapist can leadthe neophyte to minimize the importance of

the therapeutic relationship. Lacking per-

spective about the therapeutic process, thetransferring resident may underrate or over-rate any gains the patient has made, thus

protecting the therapist against “fantasiednarcissistic wounds at the hands of the in-

coming therapist” (2, p. 188).Therapist-initiated terminations carry

increased risk of destructive countertrans-

ference phenomena. The therapist who feelsguilt or narcissistic despair about the termi-

nation may act out such countertransference

feelings (5) in the form of inappropriate orincomplete terminations and transfers or inthe form of social behavior (3). Social behav-ior may include actively seeking or passively

accepting overtures of friendship from a for-mer patient. Wallace (6) feels that a normalfriendship between a therapist and a formerpatient is an impossibility. The prior thera-peutic relationship has been based on thenecessary asymmetry in self-disclosure andvulnerability. Indeed, former patients maycontinue to consider their prior therapistsinvincible, thereby effectively precluding a

balanced friendship. Furthermore, the ther-

apist who allows these attempts at friend-ship ethically precludes any therapeuticrelationship in the future should the patientneed or want to return to treatment.

The choice of which patients to continue

treating and which to terminate or transfermay be made on the basis of countertransfer-

ence issues (1), particularly in the residency

training setting, where time constraintsmake it necessary for inexperienced thera-pists to initiate terminations and transfers.Adequate supervision is necessary to exam-

ine these aspects of therapist-initiated termi-

nations and transfers.

CHOICE OF REFERRAL

The transfer of patients from one resident to

another may evoke feelings of insecurity and

shame at having a peer see one’s work. Thesefeelings may be intensified when the trans-ferring resident has unrecognized counter-transference issues regarding the patient. Atthis institution, transferred patients can bereassigned to a resident chosen by either the

outpatient clinic administrator or the trans-ferring resident. Wood and Wood (7) haveidentified two factors that may motivate aresident’s choice of a new therapist for a

patient. The first is the desire to choose aperson with whom the transferring resident

can identify: “An aspect of this action is thatone chooses someone who may be seen as an

extension of oneself and, in that sense, pre-

serves the fantasy of maintaining some in-vestment in or control over that patient’s

treatment” (7, p. 86). The second factor is thenarcissistic desire to enhance one’s sense ofself. In the training setting, the transferringresident may choose to refer the patient to atherapist who will acknowledge and admirethe resident’s therapeutic work or conimis-erate about the difficulty of working with aparticular patient. Within this context, thetransferring resident may seek to maintain

the illusion of having made a decision basedon the patient’s particular needs rather thanon the resident’s desire for affirmation orempathy from the new therapist.

PATIENTS’ RESPONSES TO TRANSFER

Transfer of a psychotherapy patient is notonly a loss but often may be experienced bythe patient as a rejection (6). Anger, usuallyrepressed toward the transferring therapist

and displaced onto the new therapist, is the

most common patient response to transfer(3). The new therapist may be verbally

abused, may be compared unfavorably with

the previous therapist, and may hear com-plaints about a particular aspect of the ther-apeutic management. The patient may fail to

take medications or attend sessions. Thesedefenses provide the increasingly cautious

patient with protection against another ex-pected loss (3). Sequential transfers of psy-

chotherapy patients may feel like repeated

narcissistic blows to patients who may al-

ready be ego-compromised.In an effort to balance the educational

needs of residents with the treatment needs

of patients, the training institution may re-spond more vigorously to the more easily

heard voices of residency training commit-

tees. The danger inherent in this response is

that the ethical issue of a patient’s right toappropriate treatment may be poorly ad-

dressed. Many patients who seek treatment

at an academic institution have become in-

ured to the endless changes in care providers

dictated by the educational needs of residentphysicians. Those patients who experiencethese changes as capricious or degrading,

however, may have little recourse but to at-tempt to find treatment elsewhere, an optionrarely available to the indigent patient. Ifunrecognized, the patient’s frustration maybe misinterpreted and mishandled, thereby

evoking countertransference phenomena,

particularly within the psychotherapy set-ting.

Continued contact with the previoustherapist after the transfer denies the patientthe experience of the loss and the anger itevokes, in addition to allowing an enactmentof the patient’s “conscious-unconscious fan-tasy that your mutual involvement will notend with termination, but that you will atlast reward him for all his effort with a realrelationship” (6, p. 321). For some patients,grief may be expressed by attempting to per-suade either the transferring therapist or thenew therapist that continued therapy is no

longer needed (2). A patient-initiated termi-

nation allows the patient to avoid an explo-ration of the painful affect engendered by theloss of the therapeutic relationship, and pro-

tects against future rejections (3).The following case example illustrates

some of the pitfalls that may confound thetreatment of the psychotherapy patient whohas experienced multiple transfers. This casewill be followed by a discussion of prophy-

lactic measures that have specific applica-

tion to the residency training setting.

Case Report

Ms. A., a 29-year-old recovering alcoholic, washospitalized in 1987 when she suffered a sei-zure that caused her to fall off a bar stool. Dur-ing her 20-day stay on the acute psychiatric unitshe was seen for daily therapy by therapist #1,the ward resident. Upon discharge, Ms. A. be-

gan outpatient psychotherapy with therapist#2, an outpatient resident. Ms. A. and therapist#2 agreed at the outset that their work wouldbe limited to 3 months because therapist #2

would then be rotating to another service. Forthis reason, therapy sessions were intentionallysupportive in nature.

In 3 months Ms. A. was transferred to resi-dent therapist #3, who was beginning her out-patient rotation. The patient and this therapistwere able to form a strong therapeutic affiance

that facilitated weekly insight-oriented psycho-therapy sessions. Therapist #3 continued to seethis patient in therapy for a total of 18 months.The patient was transferred to therapist #4when therapist #3 finished her residency train-ing. Therapist #3 prepared Ms. A. for termina-

tion by exploring this issue in many of the finalsessions. She introduced the patient to therapist#4 in one of these sessions. In addition, thera-pist #3 provided Ms. A. with her home address.

During Ms. A.’s initial session with thera-pist #4, she exhibited poorly concealed rage to-

ward this new therapist for being “not like my

other therapists.” The patient rejected any inter-pretation of her anger as a displacement fromtherapist #3. After this session Ms. A. visited

the office of therapist #1 and found therapists

#1 and #2 in conversation. She expressed to

them her anger toward therapist #4 and her

feeling that therapist #4 did not like her. Shewas encouraged to discuss these feelings in her

sessions with therapist #4. Both therapist #1

and therapist #2 informed therapist #4 about

this impromptu visit several days after it oc-

curred.For the next 3 months Ms. A. continued to

express her anger toward therapist #4 in week-ly insight-oriented psychotherapy sessions. At

various times she complained that therapist #4was cold, did not like her, did not care abouther, and was not like her other therapists. Shetold therapist #4 that the therapist was not do-

ing her job when she refused to accede to the

patient’s demands that the therapist determine

the agenda for therapy sessions. Ms. A. fre-

quently said, “You’re supposed to tell me whatto talk about like my other therapists did.”

Just minutes prior to the patient’s 14th and

final session, therapist #4 received a telephonecall from therapist #1 informing her that Ms. A.

had written to therapist #1 at home asking her

to call the patient to discuss urgent matters.

When therapist #1 called Ms. A., the patient

told her that she wanted to terminate therapy

because therapist #4 did not care about her. Thepatient was encouraged to discuss this in her

next session with therapist #4. Therapist #1 also

revealed in the phone conversation with thera-pist #4 that Ms. A. had been visiting her in heroffice frequently after therapy sessions withtherapist #4, that Ms. A. had bought and deliv-

ered a baby gift for therapist #1 in response toreceiving a mailed birth announcement fromthe therapist, and that Ms. A. had been regu-larly exchanging letters with therapist #3.

In the final session, Ms. A. announced that

she had arranged for private therapy with acounselor who specialized in the treatment of

adults who had experienced incest in child-

hood. Immediately after this session, Ms. A.

saw therapist #2 in an office waiting area. Sheproceeded to tell her that she had just termi-

nated therapy with therapist #4. Therapist #2did not invite lengthy discussion with the pa-tient and later informed therapist #4 about theinterchange.

The same week, Ms. A. wrote to therapist

#1, again requesting a phone call. As a result of

feedback from therapist #4’s supervisor, thera-

pist #1 called Ms. A. to say that she now sawtheir ongoing relationship as having interfered

with Ms. A.’s ability to form a therapeutic affi-ance with therapist #4. She suggested to Ms. A.

that she discuss therapeutic issues with her new

therapist. Ms. A. seemed angry but did not ex-press this overtly.

Therapist #3 later revealed to therapist #4

that she had received a letter from Ms. A. in-

forming her about the termination. In this letter

the patient described having felt sadness whenshe left the final session with therapist #4, ex-pressed concern about hurting therapist #4’sfeelings, and reiterated that she had experi-enced therapist #4 as cold. Therapist #3 re-

sponded with a lengthy letter to Ms. A. that

acknowledged that their bimonthly letter ex-changes had interfered with Ms. A.’s ability toengage in a true therapeutic relationship withtherapist #4. Therapist #3 requested a written

response from Ms. A.

The case of Ms. A. illustrates some of the

pitfalls of multiple transfers of a psychother-

apy patient. The terminations with thera-

pists #1 and #3 were incomplete. Therapist

#1 maintained an ongoing social relation-

ship with the patient by allowing the patientto visit informally and by allowing her to

participate in the celebration of the ther-

apist’s new motherhood. Bimonthly ex-

changes of letters between Ms. A. and

therapist #3 functioned as a therapy equiva-lent. The therapist’s warning that the letters

would not be personal implied instead a

professional purpose. Continuing access to

both therapist #1 and #3 (and to a lesser

extent therapist #2) provided Ms. A. with anoutlet for affect that more appropriately

could have been explored in sessions with

therapist #4.Ms. A.’s two years of psychotherapy

took place within a complex social milieu inwhich all of her therapists, past and present,

had both personal and professional rela-

tionships. In the residency training setting,

discomfort with self-disclosure may make

communication among resident colleagues

difficult. When personal relationships are

also involved, residents may be even lesswilling to discuss one another’s counter-transference issues for fear of damaging the

personal relationship or losing esteem. Inaddition, Ms. A.’s intense yearning for a sta-ble and trustworthy maternal relationship,along with her pleasant demeanor, made herpersonal overtures toward her therapistsdifficult to resist. The proximity of the offices

of the therapists allowed Ms. A. to makeinformal visits to her previous therapists

when she came for her sessions with thera-pist #4. Although in this setting occasional

serendipitous contact with a former patientmay be unavoidable, these contacts may in-

trude into the ongoing psychotherapy. Thepersonal relationships among the four ther-

apists were fertile ground for a reluctance to

counsel and query one another about these

events as they unfolded.

For this patient, multiple incomplete ter-

minations and transfers had particular sig-

nificance. Ms. A. experienced emotional,

sexual, and physical abuse and multiple

losses and rejections in her chaotic child-

hood. This had impaired her ability to form

and maintain trusting attachments. Her cur-

rent relationship with her mother was an

anxious attachment, conditional on Ms. A.’s

denial of negative affect. Should Ms. A. ex-press to her mother the enormity of her rage,

she would risk reabandonment. She enacted

this dilemma with her four female thera-

pists. Feeling abandoned because of her

multiple transfers, she was unable to express

her resultant anger at her first three thera-

pists for fear of losing her continued attach-

ments to them. One might speculate that in

her treatment with the fourth therapist the

patient split good mother (therapists #1, 2,

and 3) from bad mother (therapist #4) andwas then able to express toward the bad,

withholding, “cold” mother her rage at be-

ing repeatedly abandoned. As a result, she

could maintain the idealized and longed-for

fantasy of a warm and nurturing mother, an

intensely seductive experience for this pa-

tient.

Finally, one cannot ignore the possibility

that Ms. A. and therapist #4 may simply

have been a poor therapeutic match. Per-

haps, as Ms. A. suggested, this therapist wascold and withholding and the patient was

attempting to express her experience of ther-apist #4 first to the therapist herself and thento the previous therapists, whom shetrusted. If so, when the patient met withresistance on all fronts she may have felt that

she had no option but to terminate treat-ment.

DISCUSSION

Transfers, intrinsic to this and other trainingsettings, may have iatrogenic and deleteri-

ous effects. The ability to maintain and build

on therapeutic gains will be influenced by

how these terminations are handled. Dif-

ficulties arising from therapist-initiated ter-

minations are inevitable, but they can be

mitigated by adopting prophylactic mea-

sures.

The residency training setting is an ideal

place to educate neophyte therapists about

the problems inherent in the transfer of psy-

chotherapy patients. The curriculum shouldreflect the importance of termination issues.

This can be effectively accomplished by of-

fering all residents an ongoing seminar on

termination, with discussion both of didactic

material and of cases illustrating critical in-

cidents that may occur in termination and

transfer. The parallel issues for the PGY-4

resident who is facing “termination” from

the residency training program and “trans-fer” to the professional world would add anextra dimension to such a seminar.

When the training program promotes aclimate of openness about one’s work alongwith a system for review and critique, this

education will be particularly effective. Anessential but often neglected need in psycho-

therapy training programs is presentation

by faculty of their own psychotherapy cases.

This models behavior that encourages train-ees to more comfortably present their case

material for review. Although individual

psychotherapy supervision is essential,

group supervision with both faculty and res-

idents sharing the presentation, review, andcritique functions creates an atmosphere inwhich self-disclosure among colleagues re-

places the solitariness of the therapeutic en-

deavor.

The apportioning of the curriculum pieis generally a valid indicator of a training

program’s priorities. All residents should be

encouraged to carry several long-termpsychotherapy patients (1 year or longer)throughout their training regardless of

changes in their rotations. When a training

program is strongly committed to providingsolid psychotherapy training, the curricu-lum will be structured to permit cases to be

followed longitudinally until their con-clusion, whether natural or premature. Thismay necessitate preserving a block of time,

perhaps half a day per week, for outpatient

psychotherapy regardless of the resident’s

primary clinical assignment.There will still remain a large group of

patients who cannot be assigned to a singleresident-therapist. Of these, patients whohave serious problems with trust and object

constancy may need to be assigned topermanent staff. For other patients, en-couraging institutional rather than thera-pist-directed transference may prevent or

ameliorate the difficulties for a chronic, seri-ally transferred patient.

This institutional transference can be ac-complished by increasing access to psychiat-ric services. Our institution, for example, has

a walk-in clinic for psychiatric emergencies

that occur during normal hours. Much as afamily physician schedules frequent ap-pointments with a somatizing patient in

order to provide attention without exactingthe price of a complaint, a psychiatric social

worker can be available to these chronic pa-tients when their need is more than psy-chotherapy can provide but is less thanemergent. Offering group, marital, or family

therapy when warranted broadens the avail-able services for a particular patient whilediffusing the intensity of any one particulartherapeutic relationship. When those pro-

viding the services become less important

than the services themselves, the way is

opened for an institutional transference.Finally, for those patients who must be

transferred, a short but mandatory psycho-

therapy moratorium between the old andthe new therapy provides a time for the pa-

tient to punctuate and process the ending ofan important relationship (D. Davis, person-

al communication). This can be supportedby using the moratorium period to enter atransition group in which group process fo-

cuses on issues of termination, feelings of

abandonment, and misgivings about begin-ning a new therapeutic relationship. Contactwith the prior therapist, although enticing

on the transference-countertransferencelevel, should be explicitly discouraged by

the transferring therapist in order to ease the

formation of an affiance with the new thera-

pist.

Careful supervision during terminationand transfer is essential. The supervision

process should include the use of processnotes, audiotapes, and videotapes, particu-

larly as termination approaches. From themoment the therapist broaches to the patient

the need for termination and transfer, asupervisor’s surveillance for countertrans-ference phenomena must be intensified. In

the face of the trainee’s desire to quickly tie

up all emotional loose ends, it is the super-visor’s steadfast vigilance that can enhance

both the trainee’s professional growth andthe patient’s therapeutic gains. Adequate

time in the terminating therapy is required

for the exploration of the patient’s responseto the imminent loss. The transferring resi-

dent should introduce the patient to the new

therapist in order to freely endorse the trans-fer and encourage the patient to initiate anew therapeutic alliance.

The new therapist should make any timeconstraints for the treatment explicit at theoutset of the therapy. The therapist may alsoneed to demonstrate honest concern for thenewly transferred patient by making more

time available, if needed, in order to allow

the patient to examine the intense feelings

surrounding the separation and loss. Thismay necessitate the scheduling of additional

sessions.A review of the case presented suggests

that a case conference with previous andcurrent therapists and supervisors should

become a routine procedure at any and allpoints of termination and transfer. The case

of Ms. A. highlights some of the errors thatwell-intentioned but neophyte therapistscan unwittingly make. There, a case confer-

ence would have been a suitable format for

collective problem solving as well as an

arena for resident support. More generally,a resident group, perhaps led by a psycho-dynamically oriented therapist who is not

directly involved in the education of train-ees, can be a forum wherein discussion ofpersonal discomforts and concerns is en-

couraged. Such a group might have pro-vided the appropriate environment forsorting out personal from professional rela-

References

tionship issues for the four therapists in-volved in the treatment of Ms. A. Individualresidents who demonstrate significant diffi-

culties with transference and countertrans-ference issues that cannot be adequately

addressed within the training programshould be referred for personal psychother-

apy.Although most patients and most thera-

pists struggle with intense feelings at points

of termination or transfer, the opportunityexists for both personal and professionalgrowth. For some patients, a change in ther-

apists and therapeutic styles may be ex-perienced as refreshing and stimulating.Because the problems that arise in the trans-fernng of psychotherapy patients are partic-

ularly common within the residency setting,attention to this aspect of the therapeuticprocess is crucial both to the training of res-idents as psychotherapists and to successfultherapeutic intervention for the patient.

1. DeBosset F, Styrsky E: Termination in individualpsychotherapy: a survey of residents’ experience.

Can J Psychiatry, 1986; 31:636-6412. Keith C: Multiple transfers of psychotherapy pa-

tients. Arch Gen Psychiatry 1966; 14:185-1893. O’Reilly R: The transfer syndrome. Can J Psychiatry

1987; 32:674-6784. SmithS: Interrupted treatment and forced termina-

tions. International Journal of Psychoanalytic Psy-

chotherapy 1982; 9:337-352

5. Weddington WW, Cavenar JO: Termination initi-ated by the therapist: a countertransference storm.AmJ Psychiatry, 1979; 136:1302-1305

6. Wallace, ER: Dynamic Psychiatry in Theory andPractice. Philadelphia, Lea and Febiger, 1983

7. Wood EC, Wood CD: Referral issues in psycho-

therapy and psychoanalysis. AmJ Psychother 1990;

44:85-94

New Idea

Didactic Modules for CurricularDevelopment in Child and

Adolescent Psychiatry Education

Allan M. Josephson, M.D.

Martin J. Drell, M.D.

A group of child and adolescent psychiatry educators in the Association for Academic

Psychiatry have developed didactic aids, termed modules,for curricular development in

child psychiatry training programs. These modules consist of sets of references designed

to communicate the essence of a subject area. The design is flexible, allowing the modules

to be used by programs with varying amounts of time available for teaching the desig-

nated subject. The project has been endorsed by the major organizations representing

education in child psychiatry. Eight modules are available for distribution, and a mecha-

nism is in place for creating others. The authors believe this concept will be equally usefulin adult psychiatry programs.

A knowledge explosion is occurring in

child and adolescent psychiatry. New

journals (1), the expansion of existing jour-nals (2), and a push for research in the field

(3) are evidence that knowledge is accumu-

lating at a faster pace. It is increasingly diffi-

cult for clinicians and researchers to keep

abreast of their own areas of expertise. These

recent developments have intensified the

challenge child and adolescent psychiatristshave always faced in attempting to integrate

findings from the neurosciences, child de-velopment, and pediatrics into clinical prac-tice of child and adolescent psychiatry (4).

Dr. Josephson is Associate Professor, Departmentof Psychiatry and Health Behavior, and Chief, Sectionof Child, Adolescent and Family Psychiatry, MedicalCollege of Georgia, Augusta. Dr. Drell is Head, Division

of Infant, Child, and Adolescent Psychiatry, Depart-ment of Psychiatry, Louisiana State University Schoolof Medicine, New Orleans, LA. Address reprint re-quests to Dr. Josephson, Department of Psychiatry andHealth Behavior, Medical College of Georgia, Augusta,GA 30912-3800.

Copyright © 1992 Academic Psychiatry.

These concerns are not unique to child

psychiatrists. General psychiatry (5) and

medicine (6) have also struggled with the

issue of how to integrate sources of profes-

sional information efficiently and effectivelyin an era of information explosion. Hanson

and colleagues (7) recently conducted a re-

gional survey of general psychiatrists’ prac-

tices in tracking current literature. They

found little had changed in the methods

practicing psychiatrists used in the 15 years

that had elapsed since a similar previous

survey (8). This is disquieting in view of the

extent of the current literature. There are noavailable data on how training directors cull

literature and decide what material is rele-

vant for their curricula.

THE NEED FOR DIDACTIC AIDS

Consider further the quandary of thebusy training director who attempts to cover

comprehensively the breadth of current lit-

erature in our field. Most sections and divi-

sions of child and adolescent psychiatry do

not have experts in each area that is neces-

sary for a thorough education in child andadolescent psychiatry. Furthermore, exist-ing bibliographies (9) are usually too exten-

sive to be of immediate practical value incurriculum development. Such bibliogra-

phies are not typically ranked with respect

to educational value; nor are they sequenced

in a developmental order, from basic to com-

plex, to parallel trainees’ needs for more

information as they grow professionally. Fi-nally, a factor in decisions about which liter-

ature trainees should read is that the amount

of didactic time available for each topic var-ies from program to program.

These observations arose out of our in-teraction with child and adolescent psychia-try educators in the Association of AcademicPsychiatry (AAP) during the last several

years. Concurrently, a national survey oftraining directors conducted by the Childand Adolescent Psychiatry Caucus of the

American Association of Directors ofPsychiatric Residency Training (AADPRT)

confirmed our perspective (10). Not surpris-ingly, this survey revealed that 45% of pro-

grams indicated a desire for didactic aids for

use in their programs, especially in newer

areas of knowledge.

The Module Solution

The development of the module projectby the AAP was a response to this subjective

and objective assessment of the need for di-dactic aids in child and adolescent psychia-try education. The goal of the project was toprovide a mechanism to address the grow-ing literature in our field by offering a se-quential approach to the literature that hadheuristic value. As conceptualized by one ofthe authors (M.J.D.), a module is a preparedset of references designed to communicate

the essence of a subject area. Modules arepragmatic aids, the prime value of which isto cover newer areas of knowledge or updateolder ones. Modules identify essential arti-

des and organize them sequentially, from

basic to advanced, to facilitate learning.Those compiling modules need not be theexpert or final authorities in an area, but they

should be working in the area and be conver-

sant with the relevant literature.Each module is designed to be flexible in

its applicability, allowing it to be of equal

value to programs with limited or extensivedidactic time available for a subject. In prac-tical usage, such a sequentially organizedmodule could end after any session or be

used in its entirety. The design of the mod-

ules does not imply any explicit curricular

recommendation as to, for example, qualifi-

cations of instructors or placement of the

topic within a larger curricular sequence.Modules are a resource, not a directive or

requirement, for a training curriculum.

Module Structure

The term module has several lay usages.For the purposes of our project, each mod-

ule:

1. Defines an area of instruction.

2. Offers a list of recommended readings

to be covered in weekly 1-hour didac-tic units.

3. Limits readings for any session to lessthan 50 pages.

4. Sequences the readings into units from

basic (e.g., review article) to more ad-

vanced. The following question is used

as a guide in module preparation:What articles (or audiovisual aids)would you use if you had only 1 hour

of available didactic time? The ques-tion is repeated for each hour of avail-

able time to a maximum of 8 hours.5. Offers a brief rationale for why the

reading is being recommended.

Modules can take one of two forms.They can be redesigned each time a courselength changes (as in the Infant Psychiatry

module presented in Appendix A). This

method has the advantage of being precisely

tailored to the length of the course offered.In this case, the author redesigns the entiremodule with each additional time period.For example, there is a clear difference in theinfant module between week 2 in a 2-week

course and week 2 in a 3-week course. Alter-natively, the module can be designed in one

immutable sequence (as in the module Inte-

grating Individual and Family Therapy pre-

sented in Appendix B) in which eachadditional unit builds upon the previous

units. This latter approach involves writing

just one module and allowing the user to

terminate at any sequence in the module.

In the latter part of 1988, a mailing was

sent by the AAP to all training directors inchild and adolescent psychiatry, informing

them about the project and soliciting mod-ules.

To date, eight modules have been gener-ated:

1. Infant Psychiatry, by M.J. Drell, M.D.2. Integrating Individual and Family

Therapy, by A.M. Josephson, M.D.3. Genetics for the Child Psychiatry Resi-

dent, by R.K. Abramson, Ph.D., andH. Wright, M.D., M.B.A.

4. Family Therapy, by L. Claman, M.D.5. Consultation-Liaison Child Psychiatry,

by P. Holden, M.D.6. Adolescent Inpatient Psychiatry, by

M. Slomowitz, M.D.7. Developmental Neurobiology, by A.S.

Unis, M.D.8. Developmental Disabilities, by J. For-

ster, M.D.

During the development of these mod-ules, AADPRT, the Committee on Trainingof the American Academy of Child and Ad-olescent Psychiatry (AACAP), and the Soci-ety of Professors of Child and Adolescent

Psychiatry (SPCP) joined in the project. Acall for modules has been sent by each ofthese organizations to its membership. Themodule project is now one nidus around

which collaborative efforts of these organi-

zations have coalesced. As an example ofthis collaboration, modules are now avail-able for distribution on request from theAADPRT Executive Office (c/oThe Instituteof Living, 400 Washington Street, Hartford,CT 06106). Excerpts from the modules wehave designed are presented in AppendicesA and B to serve as examples of the modularconcept and to stimulate others to design

and submit modules.

DISCUSSION

Pragmatic Concerns

Modules represent a distinct departurefrom mere lists of articles or highlighted keyreadings, and even from annotated bibli-ographies. The modules’ sequencing of thereadings, provision of a rationale for eacharticle’s inclusion, and suggestion of options

to aid in understanding the literature (e.g.,recommending audiovisual aids) makethem user friendly and particularly in tune

with the needs of busy training directors.

The module concept has severalstrengths: timeliness, applicability, and flex-ibility. Didactic modules such as these are

likely to be important aids that help the busytraining director or psychiatric educatorkeep abreast of knowledge in child and ad-olescent psychiatry so that he or she candesign effective educational experiences fortrainees. Training programs vary tremen-

dously, especially in aspects such as size ofresidency class, expertise and number of fac-ulty, and didactic time available. The flexiblemodules we have presented can be used by

programs of disparate sizes and orienta-tions. Their utility seems limited only by

their availability and the level of enthusiasmdemonstrated by the teachers who use them.

Modules of any length appear likely to

be useful. Even a 2-week module may beuseful in certain topic areas, especially if thetopic has not been in the curriculum before.

A module longer than 8 weeks may also be

useful in content areas that require more

emphasis. Further, the choice of weekly di-

dactic units of 1 hour is arbitrary. A modulecould be useful if the educator decided to

combine weeks I and 2 into a 2-hour session.This would require more available time forreading, such as during an elective rotation.

Conceptual Aspects

To further clarify the module concept, itis useful to see modules as analogous tomedical consultations. Consultation re-quests typically arise out of a need for assis-

tance from a source with more knowledgeand expertise than oneself. In medicine, theconsultee is not bound to accept each of theconsultant’s recommendations, but rather

accepts them only insofar as they are consis-

tent with appropriate care of the patient. Theconsultee is typically aware of other factorsthat may render a recommendation ineffec-tive. A consultee also can use several dif-

ferent consultants for similar types ofproblems.

This analogy is helpful in addressing

two issues that have been raised concerningthe use of modules. First is the concern thatmodules will be used as “cookbooks,” sup-planting a training director’s individual

decisions about curricular experiences or ob-viating the training director’s responsibilityfor quality control. The modules are notmeant to be merely cookbooks; they aremeant to be a resource in curricular de-velopment. We must add, however, that

cookbooks can be very helpful for those un-familiar with certain types of food prepa-ration. Similarly, training directors needassistance in the many areas unfamiliar to

their faculty that need to be covered in child

psychiatry residencies. In such areas, the useof modules allows the training director toconsult flexibly with others who are moreconversant with the subject matter. The di-rector is free to reject the consultation, usepart of the consultation, or seek several con-sultations. Like a medical consultation, a

module is not a mandate, but a suggestion ofoptions.

A second issue that the consulting anal-ogy ifiuminates is that of how decisions weremade to accept modules. Authors were

given the freedom to develop the modules intheir own way. All modules that were writ-ten according to the specified format were

accepted. There was, and is, no prohibitionon developing two modules in the same

topic area. In that sense, modules are not incompetition, and arbitrary determinationsare not made about which is the best mod-ule. Just as the consultee chooses which con-sultant will be most helpful to his or herneeds, the training director can choose be-tween two modules in the same topic area.

The goal in developing the modules was notto make a priori assumptions about which

modules would be useful. Rather, wewanted training directors to have access toany module generated and let them deter-mine its usefulness in their program.

CURRENT STATUS AND

FUTURE DIRECTIONS

The response to the module concept hasbeen substantial. Each author has dissemi-

nated his or her module within the variouspsychiatric teaching organizations. In an ef-

fort to increase the availability of currentmodules, the AAP, AADPRT, AACAP, and

SPCP have all described the modules in their

newsletters and identified the AADPRT Ex-ecutive Office as a central distribution point.

Requests for modules are increasing. Themost widely used module to date is InfantPsychiatry, which has been distributed tomost child psychiatry programs.

The utility of this concept is not limitedto child and adolescent psychiatry. We viewthe challenge of the rapid accumulation ofknowledge in general psychiatry as similar

to that in child and adolescent psychiatry

and believe general psychiatry trainingdirectors and their residents have similar

needs for such didactic aids. The concept of

modules also has potential to meet the needs

of practitioners for effective continuing psy-

chiatric education. They are designed so asto be excellent self-study tools. Practitionerswould be free to “consult” a module, using

the entire module or only sections of panic-ular interest.

One of the goals of this article is to in-crease the profession’s level of awareness of

the modules. There appears to be a need forsuch resources, and a vehicle for regular

publication of modules would further in-crease accessibility. It is anticipated that themodules will grow in utility as the knowl-

edge base in child and adolescent psychiatry

continues to expand rapidly. We hope thecurrent modules are only a beginning.

It should be noted that the effectiveness

of the modules is, as yet, formally untested.

Questions that need to be answered once

modules are used on a more widespreadbasis include the following: Does the use of

References

modules objectively improve the knowledge

base of residents? Does the use of modules

increase didactic course ratings by resi-dents? How many programs utilize modules

in their entirety? How many programs useparts of the modules?

Other modules are being planned in, for

example, adolescent substance abuse andcross-cultural child psychiatry, and we en-

courage other submissions. The main pre-requisite is an avid interest in an area,

familiarity with the literature, and the en-

ergy to organize a learning experience se-

quentially. Once familiarity in a field is

established, the time commitment requiredto develop a module is, in our experience,not particularly onerous. Inquiries and sub-

missions should be directed to child and

adolescent psychiatry training representa-tives of AADPRT, AAP, AACAP, and SPCP.Our joint collaboration in this effort enriches

us all.

1. Popper CW, Frazier SH (eds): Journal of Child andAdolescent Psychopharmacology, vol 1. New York,

Mary Ann Liebert, 1990

2. Schowalter JE: Presidential address: catchers in therye. J Am Acad Child Adolesc Psychiatry 1990;

29:10-16

3. Shapiro T: Child and adolescent psychiatry researchand academic promise. Academic Psychiatry 1989;13:219-226

4. Thomas A, Chess S: The Dynamics of PsychologicalDevelopment. New York, Brunner/Mazel, 1980

5. Rockwell DA: Keeping up: reported journal read-

ings of psychiatrists. J Med Educ 1974; 49:705-7076. Haynes RB, McKibbon KA, Fitzgerald D, et al: How

to keep up with the medical literature, I: why try to

keep up and how to get started. Ann Intern Med

1986; 105:149-1537. Hanson AL, Chisholin MS. McGuire M, et al: Track-

ing the clinical literature: what is out there? Aca-demic Psychiatry 1991; 15:33-39

8. Rockwell DA: Keeping up: reported journal read-ings of psychiatrists. Journal of Medical Education1974; 49:705-707

9. Berlin I, Leventhal B (eds): Bibliography for Trainingin Child and Adolescent Mental Health. Albuquer-

que, University of New Mexico Press, 1991

10. Beresin, EV, Borus JF: Child psychiatry fellowship

trainin . a crisis in recruitment and manpower. AmJ Psychiatry 1989; 146:759-763

APPENDIX A. Module Area of Instruction Infant Psychiatry

Martial. Drell, M.D.

Introduction: This module deals with the field of infant psychiatry, bringing together a series of articles con-cerning psychiatric work with infants and toddlers (age 0-3 years) and their caretakers. This document is notexhaustive and represents only one way of arranging and thinking about this area. In fact, there are points atwhich alternative strategies and alternative readings are suggested. This module assumes that issues of de-velopment concerning infant psychiatry have not been covered in other seminars. Although dynamically ori-ented, it attempts to present the thinking of those influenced by other orientations.

I. If 1 week is allotted to teach this subject, the following readings are suggested:

Readings:

1. Thomas A: Current trends to developmental theory. Am J Orthopsychiatry 1981; 51:580-609.

2. Call J: Psychiatric syndromes of infancy, in Basic Handbook of Child Psychiatry, vol 5. Editor in chiefJ. Noshpitz. New York, Basic Books, 1987, pp. 242-262.

3. Shapiro T: A psychiatrist for infants, in Infant Psychiatry. Edited byE. Rexford, S. Sander, T. Shapiro.New Haven, Yale University Press, 1976, pp. 3-6.

Rationale: The organization of these readings is guided by the idea that the basic areas of reading in infantpsychiatry should include:

1. Principles of infant psychological development

2. History of infant psychiatry

3. Principles and practices of assessment and diagnosis

4. Principles and practices of treatment

5. Clinical syndromes and special clinical groups

6. Research

Thomas effectively introduces current trends in thinking concerning development, the best starting point tobegin any discussion of infant psychiatry. Call introduces the concept of development as it pertains to infant

psychiatry. He describes healthy responses as well as developmental deviations and other disturbances in in-

fancy. This paper gives the trainee an overview of clinical work with infants. Shapiro’s paper could open a

discussion on what child psychiatrists might do to help infants and their families. The discussion is often

helped by the insertion of a clinical case (e.g., a mother of a 12-month-old calls to say that her child is havinga feeding problem; what would you do?). Key points requiring emphasis are:

1. The importance of a developmental, biopsychosocial perspective.

2. The importance of a transactional viewpoint.

3. The importance of what the infant contributes to the transaction. This can be emphasized by showing

a film. The Amazing Newborn (Ross Laboratories) or Benjamin: The First Six Months of Life (PublicBroadcasting Corporation) show remarkable areas of competence observed in infants. A trip to a

daycare center would accentuate the readings, allowing trainees to observe infants, their differences,and their interactions with caretakers.

II. If 2 weeks are allotted to teach this subject, the following readings are suggested:

First Week, Readings: Same as in I.

Second Week, Readings:

1. Minde K, Minde R: Psychiatric intervention in infancy: a review. JAm Acad Child Adolesc Psychia-try 1981; 20:217-238.

2. Fraiberg S, Shapiro V, Cherniss D: Treatment modalities, in Frontiers in Infant Psychiatry. Edited byCall J, Galenson E, Tyson R. New York, Basic Books, 1983, pp. 56-73.

3. A case study of your choice from one of the following case books:

a. Greenspan S (ed): Infants in Multirisk Famili . Case Studies in Preventive Interventions.Clinical Infant Reports, no.3. New York, International Universities Press, 1987.

b. Provence S (ed): Infants and Parents: Clinical Case Reports. New York, IUP, 1983.

c. Fraiberg S (ed): Clinical Studies in Infant Mental Health: The First Year of Life. New York,

Basic Books, 1980.

Rationale: The rationale for the second week of readings is to try to answer the questions posed in the first

week concerning interventions. The case reports provide clinical material elucidating unique aspects of clini-cal work with infants.

APPENDIX A. (Continued)

Alternative reading is Mary Blehar’s monograph entitled ‘Development of Mental Health in Infancy”

(NIMH Monographs 3, DHHS Pub!. No. (ADM) 80-862,1982). Ideally, this should be divided into two sec-

tions, pp. 1-43 and pp. 44-82. This monograph nicely covers the area, especially accentuating research find-ings. The monograph’s 22-page bibliography is also quite useful for literature before 1982.

IlL If 3 weeks are allotted to teach this subject, the following readings are suggested:

First Week, Readings: Same as in I.

Second Week, Readings:

1. Minde K, Minde R Psychiatric assessment of infants and their families, in Infant Psychiatry: An In-

troductory Textbook Beverly Hills, CA, Sage, 1986, pp. 53-68.

2. Minde K, Minde R Infant testing, in Infant Psychiatry: An Introductory Textbook, pp. 69-85.

3. Gaensbauer R, Harmon R: Clinical assessment in infancy utilizing structured playroom situations. JAmer Acad Child Psychiatry 1981; 20:264-286.

Third Week, Readings: Same as second-week readings in II.

Rationale: With 3 hours available for instruction, a week of readings on assessment is added. Thus, develop-

ment, assessment, diagnosis, and treatment are covered. The artides on assessment provide an overview of

this area and can be nicely augmented by a videotape of an infant assessment.

Note: This excerpt describes 3 of the 8 units in this module.

APPENDIX B. Module Area of Instruction: Integrating Individual and Family TherapyAllan M. Josephson, M.D.

Introduction: The following module structures an 8-week series of readings that allows the trainee to be-come familiar with concepts, both theoretical and practical, that can be used in integrating individual and

family psychotherapy. This module draws on literature sources from adult psychiatry, family systems per-

spectives, and child and adolescent psychiatry. This broad-based review of literature, while focused on theproblems confronting the child and adolescent psychiatrist, necessarily draws from the expertise of others

who work with adults and, relatedly, families.

The module is divided into four sections. The first, covering weeks I-N, deals with conceptual issues

from the vantage points of child and adolescent psychiatry, adult psychiatry, and family systems theory. The

second, given in weeks V and VI, emphasizes the individual theoretical perspectives of object relations and

self psychology. Both of these theories have interactional components in that the formation of mind and self

occurs in the context of social interaction. The third section, discussed in week VII, includes special problems

related to integrating family work in treatment of children and adolescents. The fourth section, summarizedin week VIII, emphasizes a growing body of developmental research literature demonstrating that the self oc-

curs or develops in the context of interaction. Although not specifically related to family therapy or individ-

ual therapy, this literature can be used as empirical support for what is increasingly common

psychotherapeutic practice.

I. Overview from the Perspective of Child Psychiatry

Readings:

1. Malone C: Child Psychiatry and Family Therapy: An Overview. Journal of the American Academy

of Child Psychiatry 1979; 18:4-21.

2. Steinhauer PD, Tisdall TW: The integrated use of individual and family psychotherapy. Can J Psy-chiatry 1984; 29:89-97.

Rationale: Both of these articles, written from the perspective of child and adolescent psychiatrists, focus onthe historical timeliness of this topic. They refer to barriers that have prevented integrating these dynamic

therapies. Malone’s article discusses conceptual and clinical contributions to child psychiatry from family

therapy and to family therapy from child psychiatry. Steinhauer and Tisdall offer practical suggestions re-

lated to integrating these two therapies using ego disturbances as a bridge.

II. Overview front the Perspective of Adult Psychiatry

Readings:

1. Holmes J: Family therapy and individual therapy: comparisons and contrasts. Br J Psychiatry 1985;

147:668-676.

APPENDIX B. (Continued)

2. Sugarman S: Individual and family therapy: an overview of the interface, in The Interface of Individ-ual and Family Therapy. Edited by Sugarman S. Rockville, MD, Aspen Publishers, 1984, pp. 1-16.

3. Beitman BD, Goldfried MR. Norcross JC: The movement toward integrating the psychotherapies: anoverview. AmJ Psychiatry 1989; 146:138-147.

Rationale: These three articles provide conceptual and practical directions on integration from the perspec-tive of adult psychiatry. Holmes compares and contrasts psychoanalytic and family therapies. He describesnew frames of reference in family therapy (the system) and in psychoanalytic therapy (the unconscious). Thisarticle is important for historical as well as contemporary purposes in that elements of family therapy aroseout of psychoanalytic constructs and treatments. Sugarman’s review is eclectic. He attempts to develop aspectrum of treatments ranging from purist approaches that use only individual and family treatment, tomore integrative approaches that attempt to bring together individual and family work at both a conceptualand a practical level. Beitman and colleagues describe differences between integration and eclecticism in psy-chotherapeutic practice. They describe historical forces leading to the integration movement, the movement’sthemes, and major issues of contention within the movement.

III. Overview from the Perspective of Family Systems Theory

Readings:

1. Nichols M: Finding the family and losing the self, in The Self and the System: Expanding the Limitsof Family Therapy. New York, Brunner/Mazel, 1987, pp. 1-37.

2. Nichols M: The problem of change, in The Self and the System: Expanding the Limits of Family Ther-apy, pp. 39-64.

Rationale: In these two chapters from a challenging recent book, Nichols, a leader in the field of family ther-apy, describes how the development of family therapy and its systems concept lost sight of the psychologyof the individual. He offers critiques of two corollary trends in family therapy: techniquism and a flight intooverly abstract thinking. He cogently describes how these trends obscure the reality of the individual per-sons, both adults and children, who make up families. These readings serve to balance the dramatic claims offamily therapists about sudden and decisive change. Nichols counters that decisive and lasting change takesplace only when individual family members change the way they think and act.

IV. Integrating Individual and Family Therapies: A Developmental Perspective

Readings:

1. Wachtel EF, Wachtel PL: The contextual unconscious, in Family Dynamics in Individual Psychother-apy. New York, Guilford Press, 1986, pp. 1-42.

2. Wachtel EF, Wachtel PL: Meeting the cast of characters: rationale and dinical relevance, in Family

Dynamics in Individual Psychotherapy, pp. 177-211.

3. Wachtel EF, Wachtel PL: Meeting the cast of characters: guidelines for technique, in Family Dynam-ics in Individual Psychotherapy, pp.212-239.

Rationale: In these readings, the Wachtels provide a historical overview useful for integration. They empha-size development as a common bridge between individual theories of psychotherapy and family systems the-ories. They describe a cumulative model of development in which experiences are not seen as crucial becausethey are “stamped into the psyche in an indelible way but because they influence the kinds of later experi-ences the person will have.” The Wachtels discuss multiple processes of change and how these occur from anindividual and an interactional point of view. Pragmatic ways of bringing family members into individualtherapies are described, and illustrations of some of the problems that arise are offered.

V. An Object Relations Peispective on Integration

Readings:

1. Scharif DE, Scharif JS: The integration of individual, family, and couple therapy, in Object RelationsFamily Therapy. North Vale, NJ, Jason Aronson, 1987, pp. 255-281.

2. Slipp S: Object relations in family therapy, in The Technique and Practice of Object Relations FamilyTherapy, North Vale, NJ, Jason Aronson, 1987, pp.3-24.

Rationale: Object relations theory is hospitable to the interactional perspective. It is thus not surprising that

this individual psychology is currently being viewed from the perspective of the family as the context for in-trapsychic development. The Scharffs describe how individual and family therapies are mutually catalyzing.

A fundamental tenet of the object relations approach to family therapy is that the treatment of the family andthe treatment of the individual are theoretically and therapeutically consistent with each other. Slipp’s chap-ter provides an overview of similar views.

Note: This excerpt describes 5 (weeks I-V) of the 8 sessions in this module.

Book Forum

William Sledge, M.D.

Acting Book Forum Editor

Evaluation of the Psychiatric

Patient: A Primer

By Seymour L. Halleck, M.D.

Plenum Medical Book Company,

New York, 1991, 210 pages

ISBN 0-306-43749-X, $35.00

Reviewed by Richard L. Frierson, M.D.,

and Larry R. Faulkner, M.D.

I n performing psychiatric evaluations,

psychiatrists focus on arriving at accurate

diagnoses of mental disorders and syn-

dromes. Since the introduction of DSM-Ill

(and the subsequent release of DSM-III-R),

psychiatric evaluation has become systema-tized and aims at eliciting symptoms that

meet criteria for a DSM-III diagnosis. This

descriptive approach to psychiatric nosol-ogy has been encouraged by third-partyreimbursement, utilization review, and cur-

rent legal and economic climates. Emphasishas shifted, however, to arriving at an accu-rate diagnosis in a timely and cost-efficient

manner. Unfortunately, we frequently findourselves making a diagnosis without gain-ing a true understanding of our patient’sproblems or experience. We are at a losswhen we cannot place our complex patient

in a circumscribed diagnostic category.In Evaluation of the Psychiatric Patient: A

Primer, Dr. Halleck presents an evaluationprocess geared to obtaining a clearer under-

standing of our patient’s personal world, aswell as formulating a diagnostic impression.

Dr. Halleck encourages a focus on all aspects

of a patient’s experience, from the biologicalto the psychological and spiritual. This book

is written for all those faced with the task ofperforming psychiatric evaluations and isparticularly useful for medical students andpsychiatric residents who are beginning tolearn interviewing skills. Containing chap-

ters on obtaining patient information, taking

a history, evaluating personality traits,structuring the mental status examination,and using additional procedures and diag-

nostic tests (laboratory, imaging, and psy-chological testing), the volume is well

organized. A final chapter is dedicated todetermining mental capacities and other is-

sues pertinent to forensic psychiatric evalu-

ation.Dr. Halleck covers the common obsta-

cles that are encountered in the evaluationprocess. Patient attitudes about the inter-view and their effect on communication arediscussed. He offers techniques that can be

used to alter the interview style in order tomaximize information gathering. The im-

portance of the doctor-patient interactionand its influence on information gathering ispresented. Special attention is given toempathic understanding and how patientsoften communicate more freely when theyfeel that they are understood. This explora-tion of the process of evaluation is oftenneglected in other books on this subject. This

book serves as an excellent introduction tothe verbal and nonverbal subtleties of theinterview process.

While discussing the process of inter-viewing, Dr. Halleck does not ignore theimportance of the interview content. We areoften limited in time when conducting eval-uations; Dr. Halleck suggests a hierarchy of

questioning that helps maximize the use of

time. Throughout the book, examples of in-

terview questions are given. For example,

the section on personality assessment con-tains sample questions that explore and un-cover recurring patterns in the patient’sinteractions with others. Although Dr.Halleck cautions against making judgments

about a patient’s personality traits based ona single interview, this section offers usefultechniques that facilitate a beginning explo-

ration of personality.

The chapter on mental status examina-

tion is comprehensive, with each aspect dis-cussed in terms of differential diagnosis. Dr.

Halleck offers a vocabulary of descriptives

to record affect, mood, and motor behavior.A special discussion of the evaluation of thesuicidal or dangerous patient is presented,

differentiating those patients who havethreatened or attempted suicide from thosewho have threatened or attempted harm to

others. Although brief, the chapter on diag-

nostic tests reviews the organic causes ofpsychiatric disturbances and the proceduresmost useful in uncovering them.

Although this book is a thorough reviewof psychiatric evaluation, it is flawed by the

lack of a chapter on documenting the resultsand communicating them to others. In cur-rent psychiatric practice, we are called on to

relay the results of our examinations to otherpsychiatrists, nonpsychiatric physicians,and mental health professionals who mayhave little or no medical training. A good

evaluation is useless if it is poorly written.Also, there are special requirements in writ-

ten forensic evaluations, and a discussion of

these would have made an excellent addi-tion to the forensic chapter.

In summary, Evaluation of the Psychiatric

Patient: A Primer will stimulate the readers to

reconsider how they perform a psychiatric

evaluation. Our methods seldom change un-less we question them. After reading Dr.Halleck’s book, we wonder if our current

approach prevents us from gaining a clearercomprehension of our patients’ lives, if so,Dr. Halleck may be right-we find ourselves

defining the disorder but often miss describ-

ing the person.

Dr. Frzerron ts chief resident, William S.

Hall Psychiatric Institute, Columbia, SC.

Dr. Faulkner is professor and chairman,

Department of Neuropsychiatry and

Behavioral Science, Univet�ity of South

Carolina School of Medicine, and director,

William S. Hall Psychiatric Institute.

Dr. Sledge served as section editor for this

issue in place of Dr. Halleck, the regular

editor of Book Forum.

Educational Abstracts

DorthcaJuul, Ph.D.

Abstract Editor

Veloski JJ, Hojat M, Gonnella JS:

A validity study of Part III of theNational Board Examination.

Evaluation and the HealthProfessions 1990; 13:227-240

Jefferson Medical College (JMC) has com-piled an extensive data base on its students,

including information on postgraduate andundergraduate performance. Veloski andhis colleagues examined the relationshipsamong a number of performance variablesin order to assess the validity of Part ifi of the

National Board of Medical Examiners(NBME) exam.

The subjects were 1,866 graduates ofJMC between 1970 and 1984, representing

60% of all graduates during that time. Thevariables were freshman and sophomoregrade point averages (GPAs); composite rat-ing and written test score from six junior

clerkships; total scores on Parts I, II, and Illof the NBME exam; ratings of four aspects ofclinical competence at the end of the firstyear of residency; and area of postgraduatespecialization.

Correlations between all variables arereported, and all are significantly differentfrom zero (P <0.01). The correlations be-tween Parts I and II and Parts I and III were0.77 and 0.58, respectively, and 0.70 betweenParts II and ifi. The correlations between

junior clerkship rating and Parts I, II, and IIIwere 0.26,0.28, and 0.24, respectively.

The areas of postgraduate competencewere knowledge, data-gathering skills, clin-

ical judgment, and professional attitude. The

correlations of the first three ratings with theNBME test scores ranged from 0.16 to 0.26.The correlations with professional attitudewere somewhat lower; they ranged from0.09 to 0.13. The correlations between junior

clerkship rating and the postgraduate rat-ings ranged from 0.26 to 0.33.

To assess the validity of Part Ill, the sub-jects were divided into three groups on thebasis of their average rating on postgraduate

clinical competence, and their performance

on Part III was compared. The top group hadhigher scores than the middle and bottomgroups, and the middle group did betterthan the bottom group. Subjects who wereoffered further residency training at thesame site scored better on Part III than did

those who were not, as did those who hadtrained in broad areas (internal medicine,family practice, flexible or transitional year)

compared with those who specializedearlier. The authors conclude that thesefindings provide support for the criterion-related and construct validity of Part III.

There have been few longitudinal stud-ies of medical students that include post-

graduate data. This study demonstrates lowbut significant correlations between un-

dergraduate and postgraduate clinical per-formance and scores on Parts I, H, and Ill.Test scores correlate higher with each other

than with undergraduate and postgraduate

ratings.

Swanson DB, Case SM, NungesterRJ: Validity of NBME Part I and Part

II scores in prediction of Part IIIperformance. Academic Medicine

1991; 66:S7-S9

Researchers at the NBME recently reportedon the relationships among performance onParts I, H, and ifi of the NBME exam. The

subjects were 12,213 physicians who grad-

uated from a Liaison Committee on MedicalEducation-accredited medical school in1987 and took Part ifi of the exam in March

and/or May 1988. If an examinee requiredmultiple attempts to pass the exam, the finalscore was used. In addition to total scores,subtest scores on Parts land II were includedin the study.

The observed correlations were 0.75 be-tween Parts land 11,0.64 between Parts land

ifi, and 0.78 between Parts 11 and III and aresimilar to those reported by Veloski et al. Ofparticular interest to psychiatric educators isthe correlation of 0.54 between the Part I

Behavioral Science score and the Part 11 Psy-chiatry score. The Part 11 Psychiatry scorewas correlated 0.75 with Part 11 total score

and 0.51 with Part ifi total score.A factor analysis was done to explore the

relationships among scores, and three fac-tors emerged. One was labeled biomedicalsciences and consisted of five Part I scores:Anatomy, Biochemistry, Microbiology,Pharmacology, and Physiology. The secondwas labeled psychosocial science, and it in-

cluded Part I Behavioral Science and Part IIPsychiatry and Preventive Medicine/PublicHealth. The remaining scores (Part I Pathol-ogy; Part H Medicine, Obstetrics/Gynecol-ogy, Pediatrics, and Surgery; and Part IIItotal score) clustered together and loadedsubstantially on both factors.

Regression analyses were done to deter-mine how well performance on Parts I andII predicted performance on Part Ill. Part I

scores alone predicted 40% of the variance inPart III score, Part H alone predicted 60%,and Parts I and 11 together predicted 61%.There was no improvement in predictionwhen subtest scores were used instead oftotal scores.

The authors conclude, “To the extent

that Part ifi measures important aspects of

clinical performance, Parts I and 11 can aid

residency programs in selection of trainees”(p. S9). However, the small correlations be-tween residency performance and scores onNBME examinations found by Veloski et al.

suggest that program directors will have toconsider additional factors in selecting their

trainees.

Case SM, Downing SM: Performanceof various multiple-choice item types

on medical specialty examinations:types A, B, C, K, and X, in Research inMedical Education: Proceedings ofthe Twenty-Eighth Annual

Conference. Washington, DC:Association of American Medical

Colleges, 1989, pp 167-172

Dawson-Saunders B, Nungester RJ,Downing SM: A comparison of singlebest answer multiple-choice items(A-type) and complex multiple-choiceitems (K-type), in Research inMedical Education: Proceedings ofthe Twenty-Eighth AnnualConference. Washington, DC:Association of American MedicalColleges, 1989, pp 161-166

Swanson DB, Case SM, Kelley PR,Lawley JL, Nungester RJ, Powell RD,Volle RL: Phase-in of the NBMEComprehensive Part I Examination.

Academic Medicine 1991; 66:443-444

The transition to one pathway to licensurein the United States began with the admin-istration of NBME Comprehensive Part ItoU.S. medical students in June1991 and Com-prehensive Part II in September. In 1992,

Comprehensive Part I becomes Step 1, andComprehensive Part II becomes Step 2. Step3, a hybrid of Federation Licensing Examina-tion (FLEX) Comprehensive Part II andNBME Part HI, will first be administered in

June 1994. The three steps will constitute theonly pathway to licensure for both American

and foreign medical school graduates.Schools that did not require their students totake or pass the NBME examinations maynow decide to do so because there will be no

other option for licensure as there was withthe FLEX examination.

Swanson et al. outline the differences

between the old and new Part I examina-tions, including redesign of the test blue-print, conversion from norm-referenced tocontent-based standards, and alterations inscore report format. In addition, there havebeen item format changes, and the studies by

Case and Downing and Dawson-Saunderset al. provide the basis for these changes.Specifically, multiple true/false items (K-type) and A/B/Both/Neither items (C-type)have been deleted. One-best answer (A-type) and matching items (B-type) have beenretained, and extended matching items (R-type) have been added (similar to regularmatching items but include many more op-tions).

Case and Downing analyzed the per-formance of various item types on eightspecialty certification, in-training, or special

competency examinations that contained onthe average 325 items administered to 400examinees. The total number of items was2,641, and the total number of examineeswas about 10,000.

They found that K-type items wereflagged more often than other item formatsin the review stage because of poor psy-

chometric characteristics and more of them,percentage-wise, were deleted from finalscoring. Positive A-type items and B-typeitems were flagged less often than other itemtypes.

Dawson-Saunders et al. did a similar

study using three Part I examinations, andthey also found that the K-type items weredeleted more often than A-type items. TheK-type items were more difficult than A-

type and less efficient because they tooklonger to answer and more were needed toreach the same level of reliability. In addi-

tion, the K-type did not appear to measurehigher cognitive processes than the A-typeitems, a possible justification for their reten-

tion.The results of these studies have led the

NBME to discontinue C- and K-type items.Medical school faculty members who in-cluded these items on their own tests toprepare their students for the NBME ex-aminations can also discontinue their use,and focusing on A- and B-type items shouldenhance the measurement characteristics oftheir examinations.

AcADE1vIIcPSYGHIAWY

Editor ____

JONATHAN F. BORUS, M.D.American Association of

Boston, Mass. Directors of Psychiatric

Deputy Editor Residency TrainingPresident

WILLIAM H. SLEDGE, M.D. SIDNEY H. WEISSMAN, M.D.

New Haven, Conn. Chicago, ifi.

President-ElectBook Forum Editor

RONALD 0. RIEDER, M.D.

SEYMOUR L. HALLECK, M.D. New York, N.Y.

Chapel Hifi, N.C. SecretaryALLAN TASMAN, M.D.

Abstracts Editor Louisville, Ky.

DOROTHEA JUUL, P1-iD. TreasurerCARLYLE H. CHAN, M.D.

Deerfield, ifi. Milwaukee, WIs.

Executive SecretaryEditorial Board Members CYNTHIA D. CONRAD, M.D., Pt-iD.

Hartford, Conn.ARNOLD M. COOPER, M.D. STEFAN STEIN, M.D.

New York, N.Y. New York, N.Y.Association for

MINA K. DULCAN, M.D. ALAN STOUDEMIRE, M.D. Academic PsychiatryAtlanta, Ga. Atlanta, Ga.

PresidentROBERT E. HALES, M.D. GORDON STRAUSS, M.D.

ROBERT E. HALES, M.D.San Francisco, Calif. Los Angeles, � San Francisco, Calif.

JERALD KAY, M.D. ZEBULON TAINTOR, M.D. President-Elect

Dayton, Ohio New York, N.Y. FREDERICK C. GUGGENHEIM, M.D.

JAMES LOMAX II, M.D. GARY J. TUCKER, M.D. Little Rock, Ark

Houston, Tex. Seattle, Wash.

CAROLYN B. ROBINOWITZ, M.D. SHERWYN M. WOODS, M.D. BERNARD L. FRANKEL, M.D.

Washington, D.C. Los Angeles, Calif. Washington, D.C.

STEPHEN C. SCHEIBER, M.D. JOEL YAGER, M.D. Treasurer

Chicago, Ill. Los Angeles, Calif. ALLAN TASMAN, M.D.

Louisville, Ky.

Corresponding Member Organizations Executive SecretaryDON R. upsrrr, M.D.

American Association of Chairmen of Departments of Psychiatry Cambridge, Mass.

Association for the Study of Medical Education (United Kingdom)

Association of Directors of Medical Student Education in Psychiatry

Association of University Professors of Psychiatry (United Kingdom)

Coordinators of Psychiatric Education (Canada)

Coordinators of Undez�raduate Psychiatric Education (Canada)

Society of Professors of Child Psychiatry

Academic Psychi atry (formerly the Journal of Psychiatric Education)

publishes material describing educational efforts for and by psychiatrists

as well as articles addressing other issues relevant to the academicmissions of departments of psychiatry. The journal provides a forum

for work which furthers knowledge in psychiatric education andstimulates improvements in academic psychiatry.

Journal PolicyAdvisory Committee

AcAJi�11cPSYCHIATRY

CAROL C. NADELSON, M.D.

Editor-in-Chief

JONATHAN F. BORUS, M.D.

EditorAcademic Psychiatry

SHERVERT H. FRAZIER, M.D.

JERALD KAY, M.D.Editor

The Journal of Psychotherapy

Practice and Research

SHELDON I. MILLER, M.D.

EditorThe American Journal on Addictions

ROBERTO. PASNAU, M.D.

THOMAS N. WISE, M.D.

Editor-in-ChiefPsychosomatics

STUART C. YUDOFSKY, M.D.Editor

The Journal of Neuropsychiatry

and Clinical Neurosciences

Board of Directors

MELVIN SABSHIN, M.D.

President and

Chairman of the Board

EUSSA P. BENEDEK, M.D.

HARVEY BLUESTONE, M.D.

DOYLE I. CARSON, M.D.

LAWRENCE HARTMANN, M.D.

ROBERTO. PASNAU, M.D.

JOFIN A. TALBOTF, M.D.

Ex Officio

CAROL C. NADELSON, M.D.Editor-in-Chief

RONALD E. McMILLENGeneral Manager

SHERVERT H. FRAZIER, M.D.

Founder Consultant

American Psychiatric Press, Inc.Journals Division

JOHN McDUFFIEManaging Editor

MARTIN LYNDSROXANNE RHODES

Assistant Editors

SOL ELENA MORALES

Editorial Assistant

CLAIRE REINBURG

Editorial Director

JANE HOOVER DAVENPORT

Electronic Pre-Press Director

PAMELA BIESINGER

Electronic Pre-Press Manager

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Academic Psychiatry is abstracted or indexed in Psychological Abstnicts, ErcerptaMedics. Chicago Psychoanalytic Literature, Social Sciences Citation Index, Current Con-tents/Social and Baltavioral Sciences, Automatic Subject Citation Indez, Abstracts ResearchPastoral Cars, Current Opinion in Psychiatry, and Infonnation Updatea.

Psychiatric Education at the APA Meeting

May 2-7, 1992, Washington, D.C.

From the preliminary program for the APA An-

nual Meeting, here is an advance look at sessions

that focus on academic psychiatry issues.

MONDAY, MAY 4

9:OO-1th30 a.m.

1W9.American Board of Psychiatry and Neurol-

ogy Update: 1992 with Emphasis on Recer-

tification. Joint sessions with the AmericanBoard of Psychiatry and Neurology. Ste-

phen C. Scheiber, M.D.

1W13. Medical School Abuse and After:

Psychiatry’s Mandate. Catherine A. Mar-

tin, M.D.

1W14. Women in American Psychiatry: Recruit-

ment and Roles. Joint session with the

American Association of Directors of Psy-

chiatry Residency Training. Sidney H.Weissman, M.D.

1W15. The Use of Live Drama to Teach Psycho-

therapy. Lesley R. Dickson, M.D.

11:00 a.m.-12:30 p.m.

(1)613. Women in Leadership. Elissa P. Benedek,

M.D.

[1)6)4. Psychiatry Enters the Brave New World of

Health Economics. Joseph T. English, M.D.

[1)6)5. Publish or Perish. Hugh L. Freeman, D.M.1W21. Residency Training and Managed Care.

Barry Blackwell, M.D.

1W27. Psychiatric Education in a Prison Mental

Hospital. Donald H. Williams, M.D.

1W35. Cross-Cultural Psychiatry Education: An

Integrated Approach. Rochelle L. Klinger,

M.D.

2:00-3:30 p.m.

ED617. Child Psychiatry and Psychopharmacol-

ogy (for residents only). Magda Campbell,

M.D.

si6. Which Academic Programs Will Survive

and Thrive in the 1990s? Joint Session with

the Association for Academic Psychiatry.

A. The Gender Gap in Academic Psychia-try. Ellen Leibenluft, M.D.

B. NIMH Funding and Departmental

Health. Darrell G. Kirch, M.D.C. New Approaches to Academic Promo-

tion. David Spiegel, M.D.D. Managed Care and Psychiatric Educa-

tion. James E. Sabin, M.D.E. The Dean’s Perspective. Layton

McCurdy, M.D.S20. Humane Values: Ethnic and Gender Cur-

riculum Issues. APA Assembly Committeeof Representatives of Minority/Under-

represented Groups.

A. Integrating Gay and Lesbian Issues ina Curriculum. Robert P. Cabaj, M.D.

B. Teaching the New Psychology ofWomen and Men. Leah J. Dickstein,M.D.

C. American-Indian Patients: They Don’tWear Feathers. David C. Foos, M.D.

D. Ethnic Focus Units: TransculturalTraining Sites. Francis G. Lu, M.D.

E. Somatic Symptoms in Hispanics: Train-ing Issues. Ian A. Canino, M.D.

F. Inpatient Treatment of the BlackPatient. Michelle 0. Clark, M.D.

2:00-5:00 p.m.S21. Emergency Psychiatry: New Research Di-

rections. Joint Session with the American

Association for Emergency Psychiatrists.

D. Residency Training in Emergency Psy-chiatry: 1990. James R. Hillard, M.D.

S24. New Perspectives on Supportive Psycho-therapy.

D. The Role of Theory in Teaching Sup-portive Therapy. Henry Pinsker, M.D.

2:30-5:00 p.m.

Videotape Session: New Video Technolo-

gies in Education.

Interactive Video as an Adjunct to Psy-

chiatric Education: Demonstration and

Discussion of a Pilot Project. JonathanPolan, M.D.; Technical Advisor JeffreyPorter.

Computer Consultant for Drug-Resistant Psychoses. David N. Osser,M.D.

TUESDAY, MAY 5

9:00-1030 a.m.

L13. Approaching Medicine’s Humanness Sci-entifically: An Evolutionary Imperative.

George L. Engel, M.D. (Adolf Meyer Lec-ture).

CW18. Choosing a Residency That’s Right forYou: Taking the Vital Signs. APA Commit-tee on Medical Student Education. Carol

A. Bernstein, M.D.

1W41. Writing for the Public. John M. Oldham,M.D.

1W43. Should Academic Departments SponsorManaged Care? James R. Hillard, M.D.

IW47. The Life Cyde of the Chief Resident: Issuesin Supervision. Alan Z.A. Manevitz, M.D.

1W48. Residency Training in Community MentalHealth Centers. Mark E. Servis, M.D.

11:00 a.m.-12:30 p.m.

(DGJ12. Women in Psychiatry: Cracking the Glass

Ceiling. Carolyn B. Robinowitz, M.D.

[PS155. Psychiatric Training for Oncologists. Ste-phen P. Hersh, M.D.

CW2I. Community Psychiatry Issues in Train-ing. APA Committee of Residents and Fel-

lows. Alexandra S. Heber, M.D.

CW24. Recruitment and Promotion of Women inPsychiatry. APA Committee on Women.

Gail Erlick Robinson, M.D.

1W56. Supervisors/Supervisees: What Do We

Really Expect? Malkah T. Notman, M.D.1W60. IMGs’ Problems, Adjustments and Cop-

ing. Richard Balon, M.D.2:00-3:30 p.m.

(1)6113. Careers in Academic and Public Psychia-

try. Herbert Pardes, M.D.2:00-5:00 p.m.

S51. Developing Women as Psychiatric Re-

searchers.

A. Women Physicians: New Institutional

Responses. Leah J. Dickstein, M.D.B. Gender Issues in the Growth of

Women Researchers. Catherine A.Martin, M.D.

C. Ambitious Women: Asset or Liability?Irma J. Bland, M.D.

D. Research Career Female Resident’sPerspective. Kaye L. McGinty, M.D.

E. Mentoring: A New Perspective. EllenLeibenluft, M.D.

S53. Arts in Medicine: A Beginning in Louis-ville.E. Teaching Empathy Through Role Play-

ing. Adam Blatner, M.D.F. The Arts for Medical Students. Leak J.

Dickstein, M.D.

WEDNESDAY, MAY 6

9:00-10:30 a.m.

L19. Carol C. Nadelson, M.D. (Seymour D.

Vestermark Lecture).

CW3O. Psychiatric Subspecialty Recognition and

Accreditation. APA Council on Medical

Education and Career Development andAPA Workgroup on Certification and Ac-creditation. Jerald Kay, M.D.

CW36. Early Career Concerns. APA Committee

of Young Psychiatrists. H. Paul Putmanifi, M.D.

1100 a.in.-12:30 p.m.

CW37. Recertification in Psychiatry. APA WorkGroup on Recertification. Gordon D.Strauss, M.D.

1W74. Women and Leadership: Why theChasm? Sponsored by the Association ofWomen Psychiatrists. Leak J. Dickstein,

M.D.1W76. Training for Prevention of Therapist/Pa-

tient Sexual Exploitation. Steven Samuel,Ph.D.

1W82. The Neuropsychiatry Clinic in ResidencyTraining. Deborah L. Warden, M.D.

2:00-5:00 p.m.

$69. Emerging Issues in Social Psychiatry: To-ward the Year 2000. Joint Session with theAmerican Association for Social Psychia-

try.

C. Our Unrecognized Roles in Medical

Education. Leonard E. Lawrence,M.D.

S79. Geriatric Psychiatry: A Model for Sub-

specialization. Joint Session with the

American Association for Geriatric Psychi-atiy.

A. Fellowship Recruitment: Crisis or Op-portunity? Gary W. Small, M.D.

B. Geriatric Psychiatry Meets ResidencyEducation. Joel Yager, M.D.

C. Interface with Consultation-LiaisonPsychiatry. David G. Folks, M.D.

D. Canadian Perspectives on Training.Joel Sadavoy, M.D.

E. ABP&N Examination and RelatedTopics. Stephen C. Scheiber, M.D.

$81. Physicians and HIV Disease.A. HIV Disease and Medical Students.

Leak J. Dickstein, M.D.B. HIV Disease and the Resident Physi-

cian. Michael F. Myers, M.D.

THURSDAY, MAY 7

9:00-10:30 a.m.

cW50. Successful Research Mentoring. APACommittee on Research Training. Tana A.Grady, M.D., Ellen Leibenluft, M.D.

CW51. How to Organize a District Branch Resi-dents Group. APA New York County Dis-trict Branch Residents Committee. Paula

G. Panzer, M.D., Marc Cantillon, M.D.CW53. The Impact of a Fellowship in Public Psy-

chiatry. APA Mead Johnson FellowshipSelection Committee. Stuart L. Keill, M.D.

1w84. The Concept of Hope in Psychiatric Edu-

cation. Robert C. Jespersen, M.D.1W98. Issues in the Development of Pregnancy

Leave Policies. Anna 0. Fels, M.D.11:00 a.m.-12:30 p.m.

CWS7. Skeletons in Our Closet: Suicide, Drugs

and Psychotherapy. APA/Burroughs

Wellcome Fellows. Amy R Koreen, M.D.

IW111. Helping Medical Educators: The

Psychiatrist’s Duty. Cheryl S. Al-Mateen,M.D.

2.�00-500 p.m.

S120. Psychotherapy in Public Sector Psychiatry.

E. Is Public Inpatient Therapy TrainingPossible? Anna M. Spielvogel, M.D.

CW = Component Workshop; EDGI = Discus-sion Group; 1W = Issue Workshop; L = Lecture;

[PS] = Paper Session; S = Symposium.

Submit the original

typescript and

three copies to:

Jonathan F. Borus, M.D.Editor

Academic Psychiatry

American PsychiatricPress, Inc.

1400 K Street, N.W.Washington, DC 20005

Information for Contributors

e American Association

of Directors of Psychiatric

Residency Training and theAssociation for AcademicPsychiatry have joined to-gether to sponsor Academic

Psychiatry, a peer-reviewedquarterly journal published

by American PsychiatricPress, Inc. Formerly the Jour-

nal of Psychiatric Education,Academic Psychiatry is dedi-

cated to the publication ofwork concerning educational

efforts by and for psychia-trists, and articles addressingteaching, research, adminis-trative, clinical, organiza-

tional, and economic issuesrelevant to the academic mis-

sions of departments of psy-chiatiy. The Editors invitehigh-quality submissions thatfurther knowledge in psychi-atric education and stimulate

improvements in academicpsychiatry.

Peer Review: All submissions are reviewed by at least twoexperts to determine the originality, validity, and importanceto the field of their content and conclusions. Reviewers of amanuscript will be blind to the authors’ identity, and authorswifi be sent reviewer comments that are judged to be useful tothem. Academic Psychiatry has initiated a rapid review proce-dure, and authors can expect to receive notification of theEditor’s decision regarding their submission within threemonths of receipt of the submission by the journal office. Tofoster rapid publication, any required revisions are expected tobe accomplished by the authors within an additional two-month period.

Manuscript Specifications: Manuscripts must be preparedaccording to the manuscript specifications of The AmericanJournal of Psychiatry. All manuscripts wifi be edited for clar-ity, conciseness, and conformity to journal style.

Original Articles: Original reports of empirical research orcritical analyses of important topics in psychiatric education oracademic psychiatry may be submitted in one of the followingformats. Special Articles are overview articles that bring to-gether important information on a topic of general interest toacademic psychiatrists. Authors who wish to write a SpecialArticle are advised to check with the Editor to ensure that asimilar work has not already been submitted or invited. SpecialArticles may not exceed 6,250 words (25 double-spaced pages),including tables, figures, an abstract of no more than 100 words,and no more than 100 references. Regular Articles may notexceed 3,750 words (15 double-spaced pages), including refer-

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New Ideas: This section includes descriptions of innovativeprograms, curriculums, teaching strategies, techniques, andtechnologies worthy of broad dissemination to the field. Gen-erally, the programs being described should have been irn-plemented, and some form of evaluation should be reported.Submissions for the New Ideas section are limited to 3,750words (15 double-spaced pages).

Commentary: Submissions for the Commentary sectionshould be tightly reasoned opinion pieces not exceeding 3,750words (15 double-spaced pages) that address an importantissue in psychiatric education or academic psychiatry.

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