How medical schools can maintain quality while adapting to resource constraints.

To gain a better understanding of the effects on medical schools of ongoing transformations in medical practice, science, and public expectations, the Association of American Medical Colleges (AAMC) formed the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) in 1994. Six working groups were appointed to address different issues of importance. This article is a report of the findings and recommendations of the Working Group on Adapting to Resource Constraints. That group was charged to consider how leaders in academic medicine can respond to the challenges of external forces and the anticipated diminishing of resources, and to focus on medical schools and how they can maintain quality while reengineering to effect needed changes. The group members developed their thinking within four categories: size of the academic enterprise; organizational models and their relationships to the clinical enterprise; faculty tenure and compensation; and partnerships with capital-intensive entities. Three recommendations for action, to which the APMOMS unanimously agreed, were made to the AAMC, which has already acted upon them in ways described in the article. The group also developed a series of "ideas for consideration," which represent a range of the members' perspectives. The working group did not seek (and probably could not have obtained) unanimous agreement on many of the issues that these ideas focus upon. The ideas are presented as a series of resolutions designed to stimulate discussion and foster better-informed planning.

Preserving medical schools' academic mission in a competitive marketplace.

To gain a better understanding of the effects on medical schools of transformations in medical practice, science, and public expectations, the AAMC in 1994 formed the Advisory Panel on the Mission and Organization of Medical Schools and appointed six working groups to address relevant issues. This article is a report of the findings of the Working Group on Preserving Medical Schools' Academic Mission in a Competitive Marketplace, which was charged with exploring how medical schools could acquire and/or preserve an adequate patient base for teaching, research, and income generation in a competitive marketplace. The other groups' reports will appear in future issues of Academic Medicine. To understand the diversity of approaches that schools have taken to achieve this goal and to preserve their missions, the group interviewed representatives of nine medical schools, selected to represent a cross section of U.S. medical schools. The interviews took place on four occasions between June 1995 and March 1996. The information and comments shared by participants helped the working group gain insight into the fundamental issues it had been charged to address, including those of new delivery structures, what value schools offer to delivery structures, how education and research can be incorporated and supported financially, possible new pressures on relationships between medical schools and teaching hospitals, changes in faculty physicians' employment relationships and terms, and the role of the medical school in graduate medical education. In collecting and analyzing the data, the working group focused on the distinction between protecting an institution's existing enterprise and preserving an institution's core mission. This article gives a detailed overview of the information and comments each school presented, organized under the appropriate question. The working group's conclusions and commentaries on the findings follow. An appendix presents more detailed summaries of the schools' presentations, organised as case studies. The picture that emerges is complex. The working group concluded that medical schools will take a variety of approaches to define and preserve their missions. Most, but not all, medical schools will be able to secure the patient bases necessary to fulfill their missions even in a competitive marketplace. However, the nature of many of the schools is likely to change, and it is not clear whether the core missions of education and research will continue at their present levels at all schools.

Sexual dimorphism, brain morphology, and schizophrenia.

The study of sexual dimorphism in brain morphology may help delineate subtypes of schizophrenia based, in part, on sex; yield insight into the relationship between brain structure and behavior; and provide a neurodevelopmental context for studying the ontogenesis of schizophrenia. Preliminary findings from an ongoing study of sex differences in brain morphology and neuropsychological performance in schizophrenia suggest that schizophrenic males are characterized by multiple morphological deviations; this may represent an extreme form of normal sexual dimorphism in brain morphology. The role of brain morphology deviation in the ontogenesis of schizophrenia is discussed.

Subtypes of depression in patients with chronic pain.

Recent studies have shown that depression can be assessed in patients who have chronic pain. This study shows that various subtypes of depression can be differentiated in such patients using a standardized diagnostic schema for psychiatric disorders and a self-rating instrument for assessing the level of psychologic distress. In addition, when examining the onset of pain and subtypes of depression, there was no correlation between the onset of major depression and pain, whereas there was a strong positive correlation between the onset of chronic depression and pain. The recognition of the subtypes of depression has clinical implications in the management of the patient with chronic pain and depression.

A research development workshop to stimulate outcome research in consultation-liaison psychiatry.

With shrinking federal resources, innovative approaches involving both professional organizations and federal program staff are needed to stimulate research in new or undeveloped clinical areas. National Institute of Mental Health staff and members of the American Psychiatric Association's task force on cost-effectiveness in consultation-liaison psychiatry applied a collaborative model, the research development workshop, to stimulate outcome research in consultation-liaison psychiatry, a field with little previous such research. As a result 12 grant proposals have been submitted to NIMH for review in the last three years, and six are now funded. In contrast, in the previous ten fiscal years none of the nearly 700 services research proposals focused on the consultation-liaison area. The model could be applied to other mental health fields in which research should be stimulated.

Products of consultation-liaison psychiatry.

The products of consultation and liaison activities differ considerably and require distinct marketing strategies. Whereas consultation results directly in improved patient care, the products of psychiatric liaison typically consist of less easily measured changes in nonpsychiatric physicians' attitudes and skills. The difficulty of demonstrating the benefits of liaison psychiatry as presently conceived suggest that its future course lies in the active collaboration of liaison psychiatrists in specialized treatment programs.

Models of mental health training for primary care physicians: a validation study.

Since the majority of persons with alcohol, drug abuse, and/or mental disorders (19%) of Americans during any 6-month period are seen exclusively within the general health sector, it is imperative to know the quality and quantity of mental health training for primary care residents. In this study, the five program training model types previously described--Consultation, Liaison, Bridge, Hybrid, Autonomous--are validated by a random sampling technique using a structured instrument to test eight hypotheses developed before data collection to preclude post hoc interpretations. Of 250 programs, 147 responded (60%): 67 Family Practice, 42 Primary Internal Medicine, and 38 Internal Medicine. Since all eight hypotheses were supported by the data, the construct validity of the program model types is significantly substantiated. Multiple discriminant analysis revealed that the relationships between twelve training program characteristics and the five program model types were such that the former could explain 57% of the variance in the latter and correctly classify 89% of the programs.

Recent research developments in consultation-liaison psychiatry.

With the major changes in health care and general hospital practice in the last decade, practice and research in consultation and liaison psychiatry have also changed dramatically. The authors present a selected review of recent advances and implications for five important topics in consultation-liaison research: diagnosis, disease mechanisms, biologic treatments, health services, and psychosocial treatments for medical disorders.

The role of psychiatry in the training of primary care physicians.

The question of psychiatry's role in medicine, and in particular its role in the training of primary care physicians (PCPs), is heightened by the knowledge that 60% of the 15% of patients who have DSM-III diagnosable alcohol, drug abuse, and mental health (ADM) disorders are seen exclusively in the general health sector. In addition, although PCPs have a low recognition rate of ADM disorders and are pessimistic about their outcome even with treatment, they prescribe the majority of tricyclic and anxiolytic medications. Models of mental health training for PC residents in training are examined, with particular emphasis on competencies taught, pedagogic vehicles, disciplines of the mental health teacher, and the relationship to departments of psychiatry. A computerized approach to assist the mental health training of primary care physicians developed at the Mount Sinai School of Medicine and Northwestern is presented. Finally, critical policy issues with regard to psychiatry's future role in training is described.

Depression as a psychopathological disorder in chronic low back pain patients.

An association between chronic pain and depression has been recognised for a long time. However, the exact nature of this association remains unclear. The authors studied 80 consecutive patients with chronic low back pain. Different types of depression were diagnosed using Research Diagnostic Criteria. The relationship between different types of depression and clinical and demographic variables are presented. Beck Depression Inventory and the Montgomery-Asberg Depression Rating Scale were used in an attempt to discriminate between the different types of depression.

Contrasting models for combined medical and psychiatric inpatient treatment.

The authors contrast the clinical, administrative, and reimbursement aspects of two units offering combined medical and psychiatric inpatient treatment, one under medical auspices (the medical/psychiatric model), the other under psychiatric auspices (the psychiatric/medical model). The typical patient on both units suffered from depression with prominent somatic symptoms. The psychiatric/medical model was clinically advantageous because of its greater capacity for containing agitated, psychotic, and suicidal behavior and because of its potentially longer lengths of stay for refractory patients. Furthermore, the psychiatric/medical model offers more predictable payment for psychotherapy under fee-for-service insurance and is less likely to be adversely affected by the current prospective payment system based on diagnosis-related groups.

Health promotion in primary care: a survey of U.S. family practitioners.

A national sample of family practice physicians reported on the treatments and referrals they provide for each of three behavioral health risks--cigarette smoking, obesity, and insufficient exercise--and on obstacles to effective office-based health promotion. Most respondents reported regular health education and advice, but infrequent systematic treatment or referral for the substantial proportions of their patients who smoke cigarettes (40%), are obese (40%), or get too little exercise (70%). Results confirm past impressions that primary-care physicians (a) are somewhat reluctant to treat such problems, (b) overutilize relatively ineffective risk education strategies, and (c) underutilize potentially more effective behavioral or psychological treatments, either in their practices or via referral to outside programs and specialists. Physicians' pessimism about their patients' abilities to change health lifestyles, a lack of confidence in their own and outside treatments, and perceived patient rejection of referral for lifestyle change treatment, appear the major contributors to this underutilization along with the known financial and organizational obstacles to office-based health promotion and a lack of time and training for these activities. Suggestions for improving primary-care training and supports for health-promotion services are offered.

Models of mental health training for primary care physicians.

Of the 15% of the population with DSM III diagnosable disorders, 54% are seen exclusively by their primary care physician or by other health professionals. To understand how primary care physicians are prepared for this task the authors attempted to develop a taxonomy of mental health training programs for primary care physicians by: review of the literature, interviews with program sponsors, review of NIMH training grants, and site visits to teaching programs. From this process six program types were defined: consultation, liaison, bridge, hybrid, autonomous, and postgraduate specialization. The characteristics and emphasis of these model types are described as well as program needs for future training. Competence in psychosomatic medicine, psychophysiologic reactions, and the interactions of biologic, psychologic, and social factors in health and disease can be imparted to primary care physicians by such mental health training program designs.

How primary care physicians treat psychiatric disorders: a national survey of family practitioners.

A survey of 350 family practice physicians nationwide showed that 22.6% of their patients had significant psychiatric disorders. Physicians reported treating most psychiatric problems themselves, usually through a combination of psychotropic drugs, advice, and reassurance. The results suggest that anxiolytics are more conservatively used and referrals for mental health care more often made than past studies indicate. Physicians cited patient resistance and time limitations as the most important barriers to primary care mental health treatment, followed by limited third-party payment for mental health services, poor coordination between the primary care and mental health care sectors, and insufficient training to treat psychiatric disorders.

Differentiation of depression from chronic pain with the dexamethasone suppression test and DSM-III.

The concept of chronic pain has become enmeshed with depression. In an attempt to unravel this complex relationship, the authors studied a uniform group of 42 patients with chronic pain, i.e., patients who had chronic low back pain with defined organic pathology, in relation to the dexamethasone suppression test (DST). The results were analyzed in relation to the presence or absence of major depression and cortisol suppression. Forty-one percent of the patients with major depression had abnormal cortisol responses to dexamethasone administration; all patients without major depression had normal responses. These results suggest that chronic pain patients differ from patients with major depression and a positive DST.

Propranolol and depression: a reevaluation based on a pilot clinical trial.

A wide range of neuropsychiatric side effects are attributed to propranolol including visual hallucinations, somnulence, memory impairment, decrease in response time, dizziness, confusional states, insomnia, nightmares, fatigue, sedation and depression. Benson et al., in a summary review of several clinical studies of 5,846 patients being treated with a variety of beta adrenergic blocking agents, listed depression as a rare side effect of propranolol that was usually reported only after long term treatment at high doses. Despite the widely circulated attribution that depression is a side effect of propranolol, there is a paucity of evidence to directly link this drug with clinically significant mood disturbance. For example, the most widely quoted reference attributing propranolol as a depressogenic agent was a "letter to the editor" which was a retrospective, uncontrolled, unblinded study that did not use a standardized depression rating scale. Most of the evidence linking propranolol to depressive symptoms have derived from scattered case reports in which the onset of depressive symptoms were attributed to this agent. Given the well known cyclic onset and remissions of affective disorders, and the prevalence of depression in the general medical population as a whole, the role of propranolol in these cases is debatable.

The clinical concept of chronic pain.

In this article, the authors present a rationale for considering pain to be a major health problem in the United States, based on epidemiologic data. They then define the nature of pain disorders in terms of their acute and chronic forms. By extending the definition of pain into a psychogenic/organic dichotomy, the authors introduce the concept of personality variables and psychodynamic considerations that have been attributed to patients with chronic pain. Finally, the overlap and evidence for depression as a coexisting variable with chronic pain is considered. Throughout the article, the authors are arguing implicitly for a multimodal approach to therapy.