Educational objectives for a junior psychiatry clerkship : development and rationale.

Explicit instructional objectives have become essential in medical education and have been developed nationally for students in surgery, gynecology, and pediatric clerkships. The authors describe the rationale for and process of developing psychiatry clerkship objectives, first at the Medical College of Pennsylvania (MCP) and then by the Association of Directors of Medical Student Education in Psychiatry. Faculty interviews about the development of psychiatry clerkship objectives at MCP illustrate the objectives' positive educational impact.

Psychiatry clerkship directors: who they are, what they do, and what they think.

We mailed questionnaires to ascertain biographic, academic and attitudinal data about psychiatry clerkship directors in the U.S. The average director is 46 years old, has been in academic medicine for 13 years, and has directed the clerkship for 5.9 years. Most are associate or full professors and hold one or more additional administrative positions, most often director of medical student education in psychiatry. Most view their role as fulfilling and want to direct the clerkship for the rest of their careers. However, most also perceive that their medical school does not provide enough support, that faculty don't teach enough, and that the current economic climate impedes learning. Unless medical student education is supported under managed care, the quality of clerkships and job satisfaction for clerkship directors will decline.

Decline of U.S. medical student career choice of psychiatry and what to do about it.

OBJECTIVE: In 1994, only 3.2% of U.S. medical school graduates chose psychiatry, the lowest proportion since 1929. Success in recruiting such graduates is necessary to maintain adequate numbers of psychiatrists. The authors' goal was to gain an understanding of the determinants of specialty selection to ensure adequate recruitment. METHOD: They reviewed all recruitment-related English-language publications since 1959: 173 papers, 17 reports, and 10 books. RESULTS: They found that recruitment has been cyclical, with success from 1940 to 1969 and from 1985 to 1988, decline from 1970 to 1984 and from 1989 to 1994, and a possible small upswing in 1995. The 1940-1969 success began with 1) public recognition of a dramatic shortage of psychiatrists to serve in the military and treat casualties and 2) the fervor of the community mental health movement, which promised to prevent mental illness; massive resources were provided for psychiatry during this period. The declines were associated with 1) the failure of the community mental health movement to fulfill its promise, 2) psychiatry's becoming more biologically oriented and medically conventional, and 3) the effects of managed care and increased competition for patients. The psychiatry departments that have high recruitment rates are in public-supported schools, particularly in the South, or give considerable priority and resources for medical student psychiatric education. CONCLUSIONS: A study of the psychiatric workforce is needed to ascertain whether there is a surplus or a shortage of psychiatrists. Regardless, to ensure adequate recruitment, medical institutions and departments of psychiatry must commit resources for student education in psychiatry.

DSM-III and DSM-III-R: what are American psychiatrists using and why?

The purpose of this study was to determine whether American psychiatrists have switched from DSM-III to DSM-III-R as their primary diagnostic reference, and to examine what factors predicted the continued use of DSM-III. In 1989, we conducted a mail survey of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) regarding their training in, use of, and opinions about DSM-III and DSM-III-R. Approximately 30% of practitioners continued to use DSM-III as their primary diagnostic reference, although this was less frequently true of researchers and residents. In none of the four groups did a majority believe that DSM-III-R was needed, despite the fact that the majority of each group indicated that it was an improvement over DSM-III. The most commonly perceived reasons for publishing DSM-III-R were that it corrected problems with DSM-III and new research indicated changes were warranted. Compared with DSM-III-R users, DSM-III users more frequently believed that the 7-year interval between the two editions was too short, that DSM-III-R was not needed, and that the revised manual was little better than the original. Thus, 2 years after the publication of DSM-III-R 90% of psychiatrists were using DSM-III-R, at least in part, although a substantial minority continued to use DSM-III as their primary diagnostic manual. Even among DSM-III-R users, many believed that the revised manual was not needed. The perceived need for DSM-III-R was associated with the reasons ascribed to its publication; therefore, acceptance of DSM-IV may be partially a function of how its development is promoted and justified. That nearly one third of a random sample of practicing psychiatrists continued to use DSM-III supports concerns that the publication of DSM manuals every 6 or 7 years will divide the psychiatric community into subgroups using different diagnostic criteria.

Consumers' attitudes toward DSM-III and DSM-III-R: a 1989 survey of psychiatric educators, researchers, practitioners, and senior residents.

To understand how DSM-III and DSM-III-R are used and perceived by educators, researchers, practitioners, and trainees, in the spring of 1989 we surveyed all US psychiatric residency training directors (N = 197), 337 active psychiatrist researchers, a nationwide random sample of 952 practicing psychiatrists, and all PGY-3 and -4 residents. We describe the factors influencing the use of DSM-III and DSM-III-R and the perceptions of strengths and weaknesses of the DSMs from various perspectives (training, research, and practice). A modest increase in the acceptance of the DSM system was noted in comparing the results from the current survey and a similar 1984 survey about DSM-III. The implications of these findings for the development of DSM-IV are discussed.

DSM-IV: a nosology sold before its time?

OBJECTIVE: The purpose of this study was to determine whether American psychiatrists believe that DSM-IV is being published too soon after DSM-III-R. METHOD: The authors conducted a mail survey of the attitudes of practicing psychiatrists (N = 454), residency program directors (N = 128), residents (N = 1,331), and researchers (N = 196) toward the scheduled publication of DSM-IV in the early 1990s. RESULTS: They found that the majority of all four groups believed that DSM-IV is being published prematurely. In contrast to respondents who believed that the timing of DSM-IV is appropriate, those who indicated that it is being published too soon had more recently completed their residency training and also believed that DSM-III-R was published prematurely. There was no association between the psychiatrists' responses and their theoretical orientation, Board certification status, ownership of the DSM manuals, the length of time they had used DSM-III, and the diagnostic manual (DSM-III or DSM-III-R) they were currently using. CONCLUSIONS: The belief that DSM-IV is being published too soon could contribute to underuse of DSM-IV by substantial numbers of psychiatrists. Thus, to foster compliance with it, APA must preserve in its efforts to demonstrate that the advantages of publishing it in 1993 outweigh the disadvantages of adopting yet another manual.

Diagnosis of affective disorders and schizophrenia in the U.S.: a 1984 survey of psychiatrists and graduating residents.

During a 5-month period in 1983 and 1984, the authors surveyed a random sample of U.S. psychiatrists and all psychiatric residents graduating in 1984, with response rates of 56.1% and 51.9% respectively. They report the diagnostic classifications and subtypes used by the clinicians as well as the clinical features required by the clinicians to diagnose affective disorders and schizophrenia. When diagnosing schizophrenia, the graduating residents differed from their senior colleagues by giving more importance to the course of illness, duration of symptoms, and exclusion of affective disorder. These findings are discussed in light of past surveys and the development of new diagnostic systems.

A controlled experiment with a medical student honor system.

In 1984 the student body at a midwestern medical school created an honor code and student honor council which supplemented the school's proctoring system. In consideration of recommending that the proctoring system be replaced by an honor system, the authors conducted a controlled experiment in which one trimester's behavioral science midterm and final examinations were unproctored and the midterm and final examinations in physiology and neuroscience were proctored. Using anonymous questionnaires, the authors discovered that significantly more students cheated and observed others cheating in behavioral science than in physiology or neuroscience examinations. Of 17 students who observed cheating, only two reported it, and they did so without providing the offenders' names.

Concurrent psychiatric illness in non-Hispanic outpatients diagnosed as having posttraumatic stress disorder.

Twenty-five consecutive admissions to an outpatient group therapy program for combat veterans meeting DSM-III criteria for posttraumatic stress disorder were systematically screened using operational diagnostic criteria for other coexisting psychiatric conditions, past or present. Eighty-four percent had coexisting conditions which, with one exception, were not significantly different in prevalence from those of an inpatient sample of combat veterans previously reported by the authors. The exception was a lower frequency of drug dependence in the outpatients compared with the inpatients. The authors conclude that a high proportion of conditions and symptoms--particularly alcoholism, antisocial personality, drug abuse, depression, and anxiety--can be routinely expected to coexist with posttraumatic stress disorder when it is diagnosed in Vietnam combat veterans.

Consumers' views of DSM-III: attitudes and practices of U.S. psychiatrists and 1984 graduating psychiatric residents.

The authors surveyed U.S. psychiatrists and psychiatric residents graduating in 1984 about their use and views of DSM-III. Although the majority approved of DSM-III generally, 35% of the psychiatrists and 20% of the residents said they would stop using it if it were not required. Residents accepted DSM-III better than did practicing psychiatrists. Many of the respondents doubted the validity of some diagnoses and stated that many of their patients did not satisfy criteria needed for the DSM-III diagnoses in their records. Most respondents did not use all DSM-III axes and did not want new axes. The authors discuss the survey results and their implications for revision of DSM-III.

Posttraumatic stress disorder and concurrent psychiatric illness: a preliminary report.

Twenty-five combat veterans hospitalized for treatment of posttraumatic stress disorder were evaluated for the presence of other disorders. Fourteen patients (56%) met operationally defined criteria for one additional diagnosis, five (20%) for two additional diagnoses, and two (8%) for three additional diagnoses. The coexisting syndromes included alcoholism, drug dependence, antisocial personality disorder, somatization disorder, endogenous depression, and organic mental syndrome. The authors caution that neither the stress disorder nor the coexisting syndrome should be considered the primary condition; clinicians should screen patients with stress disorders for other conditions and treat them when possible.

Indomethacin-induced lithium toxicity.

Indomethacin increases plasma lithium levels. A patient taking lithium for manic-depressive illness became delirious after indomethacin was initiated for arthritis. The probable mechanism of this interaction is the inhibition of prostaglandin synthesis by indomethacin, resulting in renal vasoconstriction and decreased renal excretion of lithium. When indomethacin is administered in addition to lithium, there is a risk of potentially fatal lithium toxicity.