P s y c h i a t r i c E d u c a t i o n i n t h e U n i t e d S t a t e s a n d U n i t e d K i n g d o m : S i l n i l a r i t i e s a n d C o n t r a s t s *

B!t ~ ' [ I C I t A E L S H E P I I E R D

T H I R T Y YEARS AGO, in one of his la te essays, H e n r y Siger is t m a d e the f o l l o w i n g obser~,at ion: "'It is i m p o r t a n t to be a w a r e oir the fact tha t the

m e d i c a l idea l has c h a n g e d a g rea t deal in the course of the cen tu r i e s and is evo lv ing cons tan t ly . M e d i c a l educa t i on , the re fo re , can n e v e r r e a c h def ini te

7'7 " " ' forms, b u t is ob l iged to a d a p t i t se l f to e v e r - c h a n g i n g condi t ions . E ( i ) soc ie ty r e q u i r e d of its p h y s i c i a n ce r ta in qua l i t i es , such as k n o w l e d g e , skill, devo t ion to his pa t ien ts , consc ien t iousness . But the pos i t ion of the p h y s i c i a n in soc ie ty a n d the tasks a s s igned to h im c h a n g e d a n d w e r e d e t e r m i n e d p r i m a r i l y by the social and economic s t ruc tu re of a g iven socie ty a n d by the scient i f ie a n d t echn ica l m e a n s a v a i l a b | e to m e d i c i n e at the t ime. If med ica l e d u c a t i o n is to fulfill its p u r p o s e and is to t ra in the p h y s i c i a n not of y e s t e r d a y bu t of tomor row, we m u s t h a v e a c lear p ic tu re of w h a t k i n d of doc to r our p r e s e n t indus t r i a l c iv i l i za t ions requi re . "'~

To most of us this lesson, d r a w n f rom the s t u d y of med ica l h is tory, has n o w b e e n l ea rned . \ V e no longer ques t ion the p r e m i s e t ha t the t r a in ing of doc tors c a n n o t be d ivo rced f rom the func t ion of m e d i c i n e in society. \Ve ac- cep t the n e e d c o n s t a n t l v to rcctef ine~the b o u n d a r i e s of med i ca l e d u c a t i o n in r e l a t ion to social change . In the two m a j o r r e p r e s e n t a t i v e s of the Anglo- A m e r i c a n c o m m u n i t y the p ic tu re , or image , of the p h y s i c i a n differs in severa l i m p o r t a n t respects . In bo th count r ies , howeve r , m e d i c a l educa to r s have be- come i n c r e a s i n g l y a w a r e of the social d i m e n s i o n s of the i r p rofess ion .

No one w h o has fo l l owed the course of med ica l t h i n k i n g in the Anglo- Saxon coun t r i e s over the pas t g e n e r a t i o n can fail to h a v e b e c o m e a w a r e of the i m p a c t of w h a t is ca l l ed "social medic ine" in the U n i t e d K i n g d o m and " c o m p r e h e n s i v e medic ine" in the U n i t e d States . I ts p rogress has been sig- na l i zed b v a p r e o c c u p a t i o n w i t h the e n v i r o n m e n t a l d e t e r m i n a n t s a n d sectuelae of d i sease and its i n v e s t i g a t i o n by e p i d e m i o ] o g i c a l m e t h o d s w h i c h h a v e come to take the i r p l ace a l o n g s i d e the b io log ica l s tud ies w h i c h have already, y i e l d e d so r i ch a harves t . F u r t h e r , the s emina l concep t f o r m u l a t e d by. V i r e h o w and N e u m a n n in the n i n e t e e n t h c e n t u r y , tha t " m e d i c a l sc ience is intr insical ly, a n d e s sen t i a l l y a social s c i ence" has f lowered a h u n d r e d years l a te r as the new d i s c ip l i ne of m e d i c a l soc io logy w h i c h has a l r e a d y r e c r u i t e d severa l h u n d r e d socia l sc ient i s t s in the U n i t e d States. I t is not su rp r i s ing , there fore , t h a t p s y c h i a t r y , a b r a n c h of m e d i c i n e wi th roots so d e e p l y e m b e d d e d in t he social sc iences tha t its r e l a t i o n s h i p to social m e d i c i n e has been c o m p a r e d to " ' . . the ins ide and the ou t s ide of the s ame glove ," s h o u l d h a v e b e g u n at rest to e m e r g e f rom its long pe r iod of h i b e r n a t i o n . T h e r e are, to be sure, o t h e r factors w h i c h a c c o u n t for the n e w in te res t b e i n g t aken in p s y c h i a t r y

*The substance- of this article appeared originally in "'L'Encephale'" (No. 4) and has been tran,olated and reprinted by kind permission of ~he editor.

246

CO~IPIIEttENS|V.E PSYCltlAq'llY, VOL. (~, N o . 4 ( A U G V S T ) , 1 9 6 5

P S Y C ; I l I A ' I ' I ~ I ( : l i . I ) U C A T I O N I N U. S. A N D U . K . 2 ¢ 1 7

by Bri t ish and A m e r i c a n m e d i c a l educa to r s , and to some of these I shal l refer. Nly p r i n c i p a l theme, howeve r , is p sych ia t r i c e d u c a t i o n as one aspec t o,f med ica l e d u c a t i o n in its social context .

A m e r i c a n a s c e n d a n c y ill the sphe re of med i ca l e d u c a t i o n is a r e l a t ive ly r ecen t p h e n o m e n o n . On w h a t have its a c h i e v e m e n t s d e p e n d e d ? T h e s t a n d a r d four -year cu r r i cu lun l was a d a p t e d f rom the G e r m a n mode l , w i th its emphas i s on tl'le bas ic sc iences u n d e r l y i n g c l in ical p rac t ice . Bu t f rom the b e g i n n i n g the p a t t e r n of ins t ruc t ion has been less r igid , in k e e p i n g wi th the A m e r i c a n style o f h i g h e r educa t ion . D i d a c t i c t e a c h i n g has been m i n i m i z e d : r e sea rch and i nd iv idua l r e a d i n g are e n c o u r a g e d , smal l classes have a l l owed the s e m i n a r to supe r sede the formal l ec tu re or d e m o n s t r a t i o n . T h e s tudent-bod,¢ is con- s e q u e n t l y less a n o n y m o u s a n d its i nd iv idua l m e m b e r s less pass ive t han in m a n y E u r o p e a n coun t r i e s ; t he i r con tac t s w i t h the jun io r f acu l ty are of ten close and the d o c t r i n e of d iv ine professor ia l r ights has been re jec ted . A n y vis i tor w h o has spen t t ime in the b e t t e r A m e r i c a n cen t res mus t have been s t ruck b y the r e l a t ive i n f o r m a l i t y and the f ree i n t e r c h a n g e of op in ions a t all levels. "l;hese a re on ly the r ipples on the sur face of all A m e r i c a n i n s t i t u t i ona l life, i n d i c a t i n g a deep - sea t ed u n d e r c u r r e n t of forces: i n d i v i d u a l asser t iveness , mis t rus t of au tho r i t y , d i s r ega rd for t r ad i t ion , all t e m p e r e d by a w i l l i n g n e s s to e n t e r t a i n f resh ideas and to ex-periment w i th them. "~Vith m e d i c i n e as w i t h o the r fields of k n o w l e d g e , every effort is d i r ec t ed to a n t i c i p a t e the fu tu re .

T h e s t reng th , as wel l as the weaknesses , of A m e r i c a n m e d i c a l e d u c a t i o n res ide in its f lexibil i ty. A cyn ic has r e m a r k e d tha t i t is eas ier to m o v e a c e m e t e r y t han c h a n g e a med ica l c u r r i c u l u m : this is no t t rue in t h e U n i t e d States. ThL~ last f i f teen ),ears have w i tne s sed a l a rge c r o p of "experiments" in med i ca l e d u c a t i o n w h i c h have p l a y e d h a v o c w i t h t he c o n v e n t i o n a l cu r r i cu lum. E c o n o m i c s have of course p l ayed a l a rge pa r t in this t r e n d , T h e h u g e post -

w a r b u i l d i n g p r o g r a m in the U n i t e d States has g iven the na t i on severa l new m e d i c a l schools w h i c h h a v e n a t u r a l l y g iven the l ead for t he se deve lop- ments . E v e n t h e o ldes t a n d mos t conse rva t ive i n s t i t u t i o n s , h o w e v e r , h a v e p a r t i c i p a t e d in the m o v e m e n t t owards a revis ion of t he o ld-s ty le cu r r i cu lum.

T w o of the d o m i n a n t concep t s u n d e r l y i n g these r e fo rms have been of p a r t i c u l a r r e l e v a n c e to p sych ia t ry . T h e first is "integration" of sub jec t -mate r ia l , d e s i g n e d to f ac i l i t a t e l e a rn ing and to save t ime. So fa r t he c u r r i c u l u m has b e e n m o r e successfu l ly "integrated" at the p re -c l in iea l t han at the c l in ica l s tage, p r i n c i p a l l y b e c a u s e the b o u n d a r i e s b e t w e e n the bas ic sc iences are b r e a k i n g d o w n . T e c h n i c a l i nnova t ions , l ike the m u l t i - p u r p o s e l abo ra to ry , h a v e h e l p e d in the t e a c h i n g of i n t e g r a t e d courses, a n d the process has b e e n fur- t he r a i d e d b y the wi l l ingness of i n d i v i d u a l d e p a r t m e n t s to g ive up a u t o n o m o u s b locks of t e a d l i n g - t i m e : t he n u m b e r of hou r s d e v o t e d to a n a t o m y courses in some schools , for example , has b e e n ~'educed by as m u c h as 50 p e r cent . T h e s econd m a j o r t r end has been t he i n t r o d u c t i o n of the behav io ra l , or social sc iences in to med i c ine . Nlost of the p rogres s ive A m e r i c a n schools n o w i n c l u d e more or. less fo rma l courses on these subjec ts in the pre -e l in ica l ) 'ears and at the Un ive r s i t y of K e n t u c k y med ica l school , an a u t o n o m o u s D e p a r t m e n t of B e h a v i o r a l Sc ience has been c rea ted . D u r i n g the c l in ical }'ears, the t each- ing is d i r ec t ed to the p sychosoe i a l c o m p o n e n t s of i l lness, e spec ia l ly to t he

- ~ 4 ~ ~ l ICI 1A E L S ! 11~ P I 1 t (1t l )

minor disabilities and to chronic disease, ,,vhicli are often covered by family- care programs and ' in tegra ted ' medical courses. In addit ion, the m a n y be- havioral scientists now working in American medical schools include within their purview, the s tudy of medic ine and the medical school as a social inst i tut ion and they are becoming closely concerned with the problems of medical educat ion in consequence."

Against this background of new ideas and techniques, the teaching of psych ia t ry in American medical schools has come a long way in the last twenty },ears. But it could not have progressed so far wi thout the impetus p rov ided by the large body of p sychodynamic theol,,, whose content is d rawn largely from the Freud ian view of human deve lopment and from the related concepts under ly ing psychoana ly t ic practice. Controversial in many respects, dynamic psych ia t ry was widely accepted in \Vorld W a r 1I by American mil i tary psychiatr is ts ,.via<) subsequent ly in t roduced it into the medical schools where it has been forged into the principal link relat ing the subject to medic ine and, in part icular , to comprehens ive medicine.

From this ferment of p sychodynamic theory, behavioral science and com- prehens ive medicine, the Commi t t ee on .Medical Educa t ion of the American Psychiat r ic Association was able to p repare at b luepr in t for the teaching of psychia t~ : in medical schools in the 19o0s. The Commi t t ee 1)ased its pro- posals on the fol lowing premise: "Medical pract ice today re(tuires a firm foundat ion in the science and art of interpersonal relations to enable the physic ian to treat pa t ients ra ther than diseases and t() unders tand the social and physical env i ronment that affects the pat ient ' s health. "':~ It r ecommended that the pre-elinical years should include teaching in three related fields. The first of these covers personal i ty growth and dex'eloi)ment, including what was te rmed the "integrative and adapt ive devices of the personal i ty . ' This l~road concept was e labora ted to inchMo: ( a ) the problems of h tmmn development ; ( b ) theories of personal i ty; ( c ) social and cul tural forces bear ing on per- sonal i ty deve lopment and behavior ; ( d ) the" role of l anguage and thinking and ( e ) the role of emotions in physiological function. The second area is the s tudy of psychopa tho logy , covering cteviants from the norms of the previ- ous course. Thirdly , the Commi t t ee r e c o m m e n d e d the teaching of what is

%- called " the int roduct ion and pract ice of techni(lueS of in terviewing and the unders t and ing and use of the interpersonal physician-1)atient relat ionship, as a diagnost ic and thet 'apeutic agent.'" Clinical teaching in the third and fourth years was to be based on psychia t r ic in-pat ient experience, ol l t -pat ient work and liaison teaching with o ther depar tments . The methods of teaching in- c luded the ass ignment of s tudents to pat ients and families in l lome-care p rograms or other communi ty settings; the clinical demonstra t ion; the use of r ecorded interviews and fihn material ; par t ic ipat ion in act ive discussion groups and labora tory exper iments des igned to demons t ra te the effects of emotion upon physiological fu notion.

The pa t t e rn of u n d e r g r a d u a t e instrtlction can best be i l lustrated 1)y a sum- mary of the a r rangements obta in ing at one of the older, there conservat ive medical schools where the total nurnber of hollrs devoted to psych ia t ry is

I ' SY( ; I I lA ' I ' I :H(~ I ' ; I ) U ( ; A T I O N I N W. S. A N D U . K, 0 4 9

al~l)roximately two hundred. In tile first year, the medical students at tend a course on hunmn behavior: ill each of thirty vceeks there is a lecture followed by two-hour seminars for fourteen groups of no more than eight students which are conducted |)y preceptors from the psychiatTc depar tment ; there is a c ,ompulsor /examinat ion at the end of the year. In the second year, there are tifteen sessions devoted to general psychopathology and conducted along qmilar lines. In their third ",'ear, the students spend two months in the psy- chiatric vcards and the psychiatric out-patient department . At this time they under take individual psychotherapy with selected patients under the super- vision of preceptors with whom the), meet in small groups of four or five. They" also visit mental hospitals and receive a small number of formal demon- strations and lectures. Also in the third year there is a six weeks" elective period which can 1)e used for the more intensive s tudy of psychiatry if this subject be chosen; research-grants are also available for a limited number of stutlellts. In their fourth y, ear, the students concentrate on the psy, ehiatric problems of general medical practice: they at tend a series of lectures on the subject and its practical side is taught on the medical wards to whicla a psychiatric resident is a t tached for the purpose.

These li1~ks between psychiatry and the other branches of medicine in the final year merit part icular attention. Perhaps the major achievement of American undergradua te instruction in psychiatry has been to ensure that the s tudent will pay regard to the psychological aspects of all forms of illness and will lint neglect what has been called "'the other half of medicine."

American medical students, then, undoubted ly receive a long and svs- tenmtic training in psychiatry. \Vithin the environment of the medical school, however, the springboard to action provided by psychodynamic theory has m'ershadowed its unproven and often d~d)ious assumpti(ms. At tlle graduate stage, the l)ictitre is more complex. ,klost Americall depar tments of psychiatry provide a three-year graduate-program, aiming to equip the woldcl-be special- ist with experience in all t)ranches of clinical psychiatry; in addition, rather more attention is paid to training in "psychosomatic" medicine and less to n(nlrological training than is customary in European eentres. It is during this phase ()f their psychiatr ic education' that the dominant influence on the young physician's professional career can 1)e clearly detected. The American Hand- book of l)sychiatry states bluntly that "At the present time the majority of residents are most: interested in psychodynamic psychia t ry and l)articlllarl) , in psychoanalysis. "'~ The tnl th of this s tatement is beyond dispute. Psycho- analytic training has l)ecome a necessary par t of the American psychiatrist 's ambitions and the Institutes of Psychoanalysis have come to occupy a central positi~m in gradua te training programs. The repercussions on the average student since the war have 1)een considerable, l i e has |)een dr i ven to invest st) much time, money and feeling in his trailHng that his later development is inevitably biased It)wards the model of the psychoanalytic' psychiatrist, a specialized technicia~ in human emotions whose interests and im)fessi()nal ol)jeelives (lifter ra(lieally from those of his llninithtte(l eolleaglles,

IIi aecollnling f()r tim m'erwhelmi,g, inthwnee t)f l ' retldian theory t )n tlw

O ~ 0 .-~11CI I A E L S I I F ' P l I 1~1~I)

graduate training of Ame.rican psychiatrists, the scientific status of the subject matter has probably been less important than the social setting in which it has developed. It has been suggested that Freudian man flourishes in the

.~ * ) - * , • • Puritan tradition of American morals, the pragmatic and meh(zlstm brand of American philosophy and the economies of American capitalism. The precise contril)ution of such factors to the high reputation enjoyed by the medical psychotherapist among the lay public in America today is difficult to define. "~'Vhat does stand out clearly is the place of psyehotherap), in the

• " S " 1 "" " provision of psychiatric services. The psychotherapist is c.s. (i tlallx a private practi t ioner whose professional orbit is remote from that of his colleague veorking full-time in the mental hospital. These two groups of psychiatrists do not merge, they enjoy ditferent m(asu (s . " "" " r ," of prestige and rewards and they see themselves so differently as to permit the conclusion that "'the state- employed institutional psychiatrist expects and i~niversallv receives less status and prestige from all lay and professional groups than does the private prac- tiee p sydna tns t . -

The ~vo groups also difler in their training. The majority of those who succeed in private practice have been psychoanalyzed and have spent longer in general hospital resMenclts. Still more impnrtant, most of the senior teaehers of medical students are drawn from the private practice gr(,, )up. apart from the comparatively small number of academic staff" members who are wholly engaged in teaching and research. Consetluently the ethos of the pr ivate pract ice group, its prefessional o~ntl,uJk, and the main focus of its activit ies have a power fu l effect on mediv;d stlMents and on the empha- sis and trends of the psychiatric teaching they receive.

There are at last signs of indigeno~ls disconte,~t with this state of affairs. An increasing reeognition of the commlznal implications of psychiatric theory and practice has resldted in a reaction against the narrow, a-s(~cial elements of l)syehodynan|ic teaching. This elmnge of direction finds c'h,ar expression in the 1962 Conference on G.radlmte Psychiatric Education organized by the Ameriealt Psychiatric Association (| alld. still re , re significantly, in tim late President Kennedy's Message to the Congress on :Xlental Illness and Mental Retardation. r Yet at the same time it is clear that for American ps.vdliatry today the cohesive hold of psychodynamics as a eonceptlml system can be h)osened onh,. at the risk of some distint(,gration into a tril)artite division: private, psyehoanalvtieall) '-oriented practice eollld well come to co-{_'xisl with community psychiatry on the one hand and 1)iological psychiatry on the other.

In these eireumstanees, there is perhaps at l)artic~llar il~terest at taching t() the pattern of psychiatric instmnetion in Britain wlliell differs I'rom tllat o f

tim United Slales in several importanl respects. The traditions of B|'ilish medical edueation are longer, more rooted in c'liIHeal apprentieeshi 1) and less

• " e " e , _ (xp r i m ntal than those of the United Slates, In the early 1940"s, major changes were proposed f(n" psychiatric teacl | ing a1~d these plans ft)reshadow(,d some of the meas!sres which were to l)e adol)lC,d 1)>' Am(,ri¢,a1~ eentres, Since tin' second worhl war, however, the major l)r(,occlq)alltn~ t)t' flu, m(,tlieal prt)ft,s- sire) has 1)t,en wilh the c.rpatioz) ~)f lhe Natiolml Ilealll) Servie(,, Tim i~)trotl~m,

P S Y C , ' I I I A T I t i ( ; I ! ; i ) U ( ; A T I O N I N l r . S. A N D tJ . 1,2. 2 5 1

lion of Ihis remarkable social experiment llas ah'eady changed radically, the conditions of medical practice ill the United Kingdom and no branch of medi- cine has been affected more profo~Jndly than psychiatry. The reasons have 1)"ten summed up as follows: %Vith the advent of the. National Health Service in 1948 it was no longer possil)le to avoid recognition of what has always 1)een known, that the problems of mental slckne, s constit-uted a major issue of public healtl~ in the country. It was not only that large n u m l ) e r s of patients suffering fr(;m serious menial illnesses required treatment and care in hos- pital, not only that a proportion of the popldation from birth or very early life were mentally defective and had to be cared for and educated by special methods in mental deficiency hospitals, hut also that a much larger proportion of the population suffered from single or recurrent episodes of minor psycho- logical illnesses vehich disrupted family life and caused a high sickness rate i~, industry. For them, there was little or inadeqtmte provision for psychiatric llelp or treatment. £loreover, 1))' 19'48 it had 1)ecolne accepted that many of tile social prol)lems with which our society is aftlicted, drunkenness, ('lrug addiction, illegitimacy, prostitution, hoinosexuality, and juvenile delinquency, t o m e n t i o n a few, invoh'ed isslies which to a greater or less degq-ee fall wit]lin the l)rovince of psychiatry . . . By this lime . . tllere was widespread ad- herence to the idea not only among psychiatrists but also among specialists in other 1)ralmhes of mectieitm, that psychological factors were the major factors ilJ cm~sation, in many physical disorders which formerly were wholly the province of organic medicine.""

The perspective 1)fought to British psychiatry by tlm National I lealth Service has slime been mdarged 10' the .Xlental l leal th Act of 195,9 which outlines the structure alJtl fiJnction of the c()mmiinity-st,rviees to complement the institutional care ()f tlu r me~ltally sick. ln(h.e(l, tim term "social i)sychiatr,v" Ires come I() designate a distinctly British contrilmticm, nnmeh as 'psycho- dynamic psychiatry" has characterized Amerit,an tl~inking. Slleh tamiliar achievem~,z~ts of tim British mental il(~spitals as the so-called "open-door" system, the "tht'ral)elztie e~mlnmnity" alJd lhe rmphasis (m rehabilitation are ~lt~x,,, being (h;velol)ed in close eolJjlt~mtiol~ wi th a prrJgrmn ~)t" extra-mm-al facili- lies whic]~ ilmhltle day-lmspitals, eommlmity-hostels and domiciliary services. lleslllts are already visiiJh,: the. number of ocClll)ied hospital l)eds is falling

#

and it ]ms even proved f(,asil)le to ch)se some instihstions. At the same time, it }ias l)eeonle lmssil~h. ' to come to grips witl~ the ln~ge v~htme of mental ill- health which is ~ormallv treated, or n~ore often negleeted, by the general practitiom,r, the i~ter~fist "and the ~mtn'ologist.

"rh~,:;e clm~g~,s have 1)em~ aeeompani~.d 1~)' and (h,l)m~de~t on new measures in psychiatric traini~g. In 1944 an Inte,'-i)el)artmm~tal Committee pointed o~fl that "'properly l)la~lned and (.aref, dly c.ond,~eted medical eduction is the (.ssel~tiai t'o~n)dalion of a e~nnl)relu,nsive health service."" I~, the ease of psy- ehiatr)' it was fell that tim demands of Ihe ~nent:~l health servic~'s were likely lo 1>,.' so h~'avy t lmt IIH, trai~)ing of Sl)ecialist l)sycl)ialrists and lmrt ieular ly of teachers ~t' psycldatry slu~shl I~, l/,i'¢m~ pri~witv, i~ c~t~s~'~i~m~ce, the post- grad~mle phase of j),,.;yc}fiatric ~,d~wali~.~ Ires rec~,iv~,d ~mwl~ attmfli~m and the

- 9 ~ .~ l l C I trA E;I_, S H I : ] I 'HEI I I)

model of training has been most highly developed at the Institute of Psy- chiatry of the University of London. Here the trainee-specialist, usually an older and more ex-perienced physician than his American counterpart, receives intensive instruction for three to five years; he takes graded elinieal responsi- bility for a wide variety of patients and attends tutorial seminars throughout his period of tutelage. The formal objective of the training is the University Diploma of Psychological Medicine, an examination normally taken after at least three ),ears" specified instruction and held in two parts; the first covers the biology, of the nervous system, psychology, soeiology and genetics, the second embraces clinical psychiatry and clinical neurology. The candidate is also required to under take a piece of original work under supervision and tor this purpose he is able to call on the resources of the six university de- partments within the Insti tute .......... those of psychiatry, biochemistry, experi- mental neurology, psyehology, nextropathology and neuromldoerinolog.v.

Dur ing his period of training the graduate is exposed to a wide variety of vievqmints, ranging from the neurochemieal to tim psychoanalytical, all of which are relevant in different degrees to the them T and practice of eliniea] psychiatry. "Such diversity," according to Professor Sir Aubrev Lewis, "is in keeping with the policy of the Institute and its associated hospitals ( the Maudsley and Bethlem) whereby responsible proponents of diverse views state them fairly" and without heat, as in other branches of university teaching, and the pupils are free to listen, weigh, accept, reject or modify and assimi- late. "'u~ It is therefore not surprising that no school of thought has achieved dominance in the United Kingdom and in clinical practice most clinicians strive to pay appropriate regard to the biological, sociological and psychologi- cal factors which enter into all psx'chiatric illness. In this way they are helped by their conditions of work. LAke most physicians in Britain, tim majority hold salaried posts in the National l teal th Service or the universities and the full-time private practice of psychiatry is neither common nor part icularly remunerative.

The infiltration of formal psychiatric teaching into the underg'raduate medi- cal schools has been a more gradual process than in the United States. F'or this there have been several reasons, among them the competing claims of other disciplines in the transitional phase of post-war medicine, the shortage of trained teachers and the traditional tendency of British clinical mediciim to incorporate the psychosocial aspects of disease. But the speed of advance in tim early years yeas retarded, above all, by the eatltious empirical approach of British psychiatrists to their subject and its role in the medical curriculum. The lloyal College of Physicians put the mat ter clearly in 1943 with its state- ment that "'Psychiatry is a specialty, or not a specialty, in much the same way fundamenta l ly as surgery and medicine are; and, just as in medicine or surgery, the practi t ioner is less likely to under take t reatment which is beyond his colnl)etence or to neglect mc'asurc's which are well within it if he has a solid, well-planned, limited b,,t coherent cotJrse of clinical and s,,'stc,matie teaching. This teaelling I n i i s t be limiled, l>oc.'iuse psychiatry h.'ls n o t yet the

PSYCIIIA' IqqlC; E D U C A T I O N 1N U. S. A N D U . K . 2 5 ~

weal th of secured knowledge that would war r an t an ambi t ious course com- pa rab l e in length of detai l wi th those of somat ic medic ine ; it must be solid, because the s tudent is too raw to be able to profit by d e b a t a b l e speculat ions about h u m a n nature; it must b e well-plannc~l and coherent, to make wha t is taught a pa r t of the whole teaching the med ica l s tudent receives re levant to

• " " 1 1 the g e n e r a l p r a c t i c e of med i c ine . T h e ou t l ook h e r e is l e s s exube ran t , the c la ims less ex tens ive t i tan t hose w h i c h

rest on p s y c h o d y n a m i c theme,, 1)ut t hey h a v e la id the f o u n d a t i o n s of w h a t is p r o v i n g to be a g r o w i n g a n d a c c e p t a b l e sys tem. Befo re the w a r the re was on ly one u n d e r g r a d u a t e c h a i r of p s y c h i a t r y ; n o w t h e y are to be f o u n d in mos t ml ivers i t i e s a n d m e m b e r s of t he d e p a r t m e n t s w o r k v e r y c lose ly w i t h the i r co l l eagues in gene ra l m e d i c i n e , n e u r o l o g y a n d social m e d i c i n e . A n d the task of t he p s y c h i a t r i c e d u c a t o r is f a c i l i t a t e d by the n e w d i g n i t y of his sub jec t and 1)y the in t e re s t t aken in it by m a n y sen io r g e n e r a l p r ac t i t i one r s , p a e d i a - t r ic ians a n d p u b l i c h e a l t h phys i c i ans w h o h a v e e m p h a s i z e d tha t p s y c h i a t r i c skills are neces sa ry for the p r a c t i c e of c o m m u n i t y - m e d i c i n e .

T h e b r i e f a c c o u n t can of course do no m o r e t h a n ske tch t he ou t l ines of Br i t i sh a n d A m e r i c a n p s y c h i a t r i c e d u c a t i o n . C l e a r l y m u c h has b e e n a c h i e v e d a n d naucla m o r e r e m a i n s to be done . D e s p i t e w i d e d i f fe rences in t he i r objec- tives a n d u n d e r l y i n g a s s u m p t i o n s e d u c a t o r s in b o t h coun t r i e s can a l r e a d y c l a im to h a v e r a i s ed the s ta tus of p s y c h i a t r y as a b r a n c h of m e d i c i n e and as an a c a d e m i c d i sc ip l ine and to h a v e b roug t l t i t b a c k in to the m e d i c a l school . Pe rhaps mos t i m p o r t a n t , ) ,oung doc to r s a re b e c o m i n g i n c r e a s i n g l y a t t r a c t e d to work w h i c h ho lds ou t the p r o m i s e of b r o a d c l in ica l ex 'per ience a n d in- t e l l ec tua l s t imu la t ion . As an i n c r ea s ing n u m l ) e r o f t a l en t ed m e n and w o m e n take np the c h a l l e n g e of the m a n y p s y c h i a t r i c p r o b l e m s w h i c h d e m a n d sc ient i f ic i nves t i ga t i on t h e y wil l i n e v i t a b l y r e d i s c o v e r the t ru th of F lexner ' s d i c t u m tha t " ' . . . r e sea rch can no m o r e be d i v o r c e d f rom m e d i c a l e d u c a t i o n than can m e d i c a l e d u c a t i o n be d i v o r c e d f rom research . "a~-

R E F E R E N C E S

]. Sigt'rist, II. E.: Remarks on social medi- t.inc in medical education, h~: llenry I~. Sigcrist on the Sociology of ,Medi- cine. Roehmer, Xl. I. (ed.). New York, M. I). Puhlications Inc., 1960.

2. Shep|lerd, 3I.: "'Tile Teaching of Psy- chiatry in the United States." An A. S. NI. E. llc'porl of the Travelling l%l- lows. 1,ondon, Pitman Medical Pub- lishing Co. Ltd., 1964.

3. American Psychiatric Association Com- mittee on Medical F~dueation: An out- lira, for a cuJrrieulum for teachin~ psychiatry in mcdic;d schools. J. Med. F]dlac. ,31:11.5, 1q56.

't. (,ildt'a, I']. I".: Teachhl~ p~ychi;dry to residents. In: American l l;mdbook ot

Psychiatry. N e w York, Basic Books Inc., 1959, Ch. 98.

5. Pasamaniek, B.. and Rettig. S.: Status and work satisfaction of psychiatrists. Arch. Neurol. & Psvchiat. 81:399. 1959.

~3. A. P. A.: Training the psychiatrist to meet changing needs. Report of the Conference on (,raduate Psychiatric Education, VCashington, I963.

7. Kennedy, J. 1".: Message from the Pres- ident of the United States relative to ment~d illness and mental retarda- tion, 88th ColJgrt'ss, 1st Session, Ilo~lse of Represt.ntatives, Document No. 58. Febrtmrv 5th, 1903.

8. llill. 13.: The role of psychiatry in reed-

.54 ~ f l C I I A E L S}IEI~I~I L~lqD

.icine. Journal of the Royal Institute of Public ttealth and Hygiene, p. 232, Oct . 1959.

9. ~linistry of Health: Report of the In- ter-Departmental Committee on Med- ical Schools. t-I. M. S. O., 2944.

J0. Lewis, A.: Letter from Britain. Amer. J. Psychiat. 110:401, 1953.

11. Royal College of Physicians: Interim Reports of l'sychological Medicine Committee on Undergr:l(hmte and Postgraduate ].~ducation in Psychi~ltry, 1943 and 1944,

12. Flexner, A.: Xledical Education. New York, MacMillm~, 1925.

Michael Shepherd, D.M., M.B.C.P., D.P.M., Reader i~, Psychiatry, Institute of Psychiatry, The U12iversity of Londos~,

London, Enghmd.