A strategic approach to the psychiatric workforce dilemma.

To help build consensus in the field of psychiatry about future psychiatric manpower needs, a 13-step strategic approach to the workforce issue is described. The steps include recognizing the importance of the assumptions that underlie workforce requirements; selecting credible and professional leadership with vision and courage; adopting a strategic plan to clarify workforce assumptions; re-examining the structure and function of established programs; preparing trainees for work in the 21st century; preserving psychiatry's humanistic tradition; enlisting the support of nonacademic psychiatrists; and reinforcing involvement in the fiscal and political aspects of medicine. They also include focusing attention on important policy issues; securing the support of patients, families, and advocates; endorsing a multidisciplinary, biopsychosocial approach to the evaluation and treatment of mental illness; minimizing divisive conflicts within and between national organizations; and developing strategic alliances with other medical disciplines. Implications of the 13-step approach are outlined for psychiatric clinicians, educators, and researchers, as well as for the organizations that serve them.

Hazards of long-term psychotherapy during psychiatric residency.

When he laid the groundwork for modern standards of training psychiatrists, Freud (1937) asked, "Where and how is the poor wretch to acquire the ideal qualifications which he will need in his profession? The answer is, in an analysis of himself" (p. 248). Fromm-Reichmann (1950), an equally important influence on psychiatric education, echoed this sentiment when she professed that "any attempt at intensive psychotherapy is fraught with danger, hence unacceptable, where not preceded by the future psychiatrist's personal analysis" (p. 42). Although most psychiatric residencies do not require personal psychotherapy (Pasnau and Russell 1975), many educators and their trainees still consider psychoanalysis or long-term reconstructive psychotherapy at least a valuable experience and at most a necessary step toward becoming a complete psychiatrist. In our experience, however, psychoanalysis and related psychotherapies can have adverse effects during the turmoil of residency training.

Hospice care.

"Birth and death are the most singular events we experience and therefore the contemplation of death as of birth should be a thing of beauty." The hospice movement emerged out of an awareness that the needs of the dying patient were not being adequately met by the modern medical establishment. It has brought about a positive change in attitudes toward the dying. Hospice has given the patient and family back the responsibility of making decisions regarding life and death. It has called to our awareness difficult moral and ethical issues to which no clear right or wrong answers exist but about which only informed judgments may be made. However, the hospice program has a long way to go. The public needs to be educated about existing financial, social, and medical provisions available to them in preparation for death. The education of medical, nursing, and paramedical professionals must emphasize technical and philosophical principles about death and dying. Teachers must address moral and ethical issues, and physicians must demonstrate kind and compassionate care in the management of their dying patients. Finally, society has the moral obligation to ensure that its dying members have access to care directed specifically to their needs. Hospice does not offer simple solutions to all the problems raised in this article, but it does embody a philosophy of care that acknowledges these issues, and it provides support for those with the courage to address them. Hospice care in the United States is now at a crossroads; whereas such care is appealing and acceptable to the public, this care has yet to find its place as an integral part of the health care system and be accepted as another facet of health delivery.

Attitudes of house officers toward a hospice on a medical service.

A hospice program (HP) was established on the medical service at the Denver Veterans Administration Medical Center (DVAMC) for the care of the terminally ill cancer patients and to integrate such care into house staff training. A two-bed inpatient unit was managed by an intern, a resident, and the attending physician with the aid of a multidisciplinary team. During the program's first year, 29 patients were cared for with an average inpatient stay of 26 days. Twenty-nine out of a possible 33 house officers returned questionnaires evaluating their hospice experience. Twenty-eight respondents felt that the hospice program was appropriate in a teaching hospital. Over half indicated improved awareness of the psychological problems of their patients and families. Two-thirds of the house staff members felt that the HP changed their approach to pain control and made them more comfortable in dealing with terminally ill patients. From this study, it can be concluded that a hospice program can be successfully integrated into an active medical teaching service.

Suicide by burning.

Of 164 patients admitted to a university hospital burn unit, 15 (9%) had attempted suicide, and 5 of the 15 died. The use of a flammable liquid was the most common method of attempted suicide; the most common psychiatric diagnosis was schizophrenia.

Undergraduate education and recruitment into psychiatry.

From 1969 to 1979 senior medical students from the University of Colorado School of Medicine entered psychiatric residencies at an average rate of 3.8%. The university gradually instituted a series of changes in its undergraduate psychiatric education program for medical students, and the senior class of 1980 was the first to be exposed to all of the changes. In 1980-1982 7.7% of the seniors went into psychiatric residencies. The authors describe the curriculum changes and speculate that more attention to the quality of medical students' psychiatric education at the undergraduate level enhances recruitment into psychiatric residencies.