Rubin, Eugene H. MD, PhD; Zorumski, Charles F. MD
Dr. Rubin is vice chairman for education and director of psychiatry residency training, and Dr. Zorumski is Samuel B. Guze Professor, and head, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri.
Correspondence and requests for reprints should be addressed to Dr. Rubin, Washington University School of Medicine, Department of Psychiatry, Campus Box 8134, 660 South Euclid, St. Louis, MO 63110-1093; e-mail: 〈firstname.lastname@example.org〉.
This paper is dedicated to the memory of Samuel B. Guze, MD.
The authors acknowledge Dorothy Kinscherf for her helpful suggestions and editorial assistance in the preparation of this manuscript. They also acknowledge support from the National Institutes of Health (EHR and CFZ) and the Bantly Foundation (CFZ).
For an article on a related topic, see page 355.
The field of psychiatry is evolving rapidly. Exciting advances in molecular biology, neurobiology, pharmacology, epidemiology, genetics, neuroimaging, and cognitive neuroscience will influence psychiatric care. As a result, it is imperative that the approaches used in the education of medical students, residents in primary care disciplines, and residents in psychiatry change also. In this paper, we discuss some of the important changes that should occur in psychiatric education if the next generation of practitioners is to be well prepared to care for the patients that seek their help.
HOW UNDERSTANDING OF MENTAL DISORDERS IS ADVANCING
The need to reform psychiatric education seems clear, given advances in our understanding of the basis for mental disorders. There is now ample evidence that most major psychiatric disorders are complexly inherited, representing combinations of multiple genes and gene–environment interactions. Thus, in the future, the diagnosis and treatment of common psychiatric disorders will likely be based increasingly on the molecular mechanisms underlying the disorder, a patient's specific genotype, and environmental triggers. Since broad categories of common disorders will be understood as specific subtypes that require specific therapies, the treatment of schizophrenia and the treatment of depression, as examples, will no longer be based on a monolithic concept of these diseases.
Psychopharmacology has already become quite complex. In the future, mechanism-specific and even patient-specific pharmacologic approaches will require an understanding of advanced molecular and pharmacologic principles. The rapid evolution of the field of pharmacogenetics further suggests that, even in the absence of more mechanism-based treatments, the practice of psychopharmacology will undergo major changes, adding to the complexity of clinical decision making.1 Psychiatrists will be expected to know sophisticated diagnostic procedures and the latest mechanism-based treatments. Diagnostic approaches, for example, may involve a variety of imaging procedures, measurements of substances in the blood or cerebrospinal fluid, biochemical responses to pharmacologic challenges, and the influences of specific genotypes, including single-nucleotide polymorphisms. In addition to new classes of medications, biomedical treatments may involve surgery, implantation of electrical stimulation devices, magnetic treatments, and medications targeting specific brain regions. An example of such approaches that will soon have clinical relevance involves the diagnosis and treatment of dementia of the Alzheimer's type with techniques to image beta amyloid in living people and the ability to inhibit the formation of new beta amyloid with agents such as secretase inhibitors. Colleagues in other medical specialties, other mental health professionals, patients, and their families will expect psychiatrists to be up to date regarding these advances and the latest, most effective treatments.
As scientific advances increase the complexity of diagnosis and broaden therapeutic options, how will practicing psychiatrists utilize formal psychotherapies? Psychiatrists must have superior communication skills in order to diagnose and treat patients with disorders of emotion and thinking. Psychiatrists must be comfortable knowing the indications and risks of effective psychotherapies and should have the background to evaluate data regarding the effectiveness of new psychotherapies. Although a medical background is necessary in order to safely utilize complex somatic treatments and medically-based diagnostic procedures, medical training does not appear to be necessary for mastering various psychotherapies. Many psychiatrists today coordinate treatment plans with non-psychiatrist mental health professionals who specialize in various psychotherapeutic modalities. Such coordinated approaches maximize the use and talents of various members of the mental health team. As the biomedical aspects of psychiatry demand increased time and attention from psychiatrists, it is likely that non-physician mental health professionals will be increasingly utilized to administer time-intensive, formal psychotherapies.
From an examination of demographic trends, it is evident that the current shortage of psychiatrists will substantially increase over the next several decades. To provide adequate psychiatric care to all who need such care, a significant increase in the number of physicians who are knowledgeable about treating patients with psychiatric disorders is required. Even a substantial rise in the number of medical students (U.S. and international medical graduates) who choose psychiatry as their specialty will not meet these needs. Therefore, primary care physicians and non-physician mental health professionals will become increasingly important in the coordinated delivery of mental health care. Primary care physicians should be trained to deliver basic psychiatric care, and psychiatrists must be able to coordinate care effectively with primary care physicians and other mental health professionals.
HOW PSYCHIATRIC EDUCATION SHOULD CHANGE
The current state of psychiatric education reflects a field in transition. Classic therapeutic approaches, including long-term psychoanalytic therapies, are being replaced by treatments with evidence-based support of efficacy, including specific short-term psychotherapies, pharmacotherapies, electroconvulsive therapy, and newer types of treatments, perhaps including transcranial magnetic stimulation. The clinical importance of advances in the molecular neurosciences is just beginning to be appreciated. There are differing opinions about what should be emphasized in psychiatric education. Although this diversity of opinion may be healthy for a field in transition, it is essential that, at a minimum, psychiatric education prepare physicians for the inevitable scientific advances ahead as well as the increasing roles of primary care physicians and non-physician mental health professionals.
Several changes in psychiatric education are needed. Starting early in their medical school training, students should develop an understanding that molecular and cognitive neurosciences, genetics, and epidemiology are critical to understanding mental illnesses. The image of psychiatrists as counselors who happen to be physicians should be replaced by the image of caring physicians who have expertise in clinical neurosciences as well as excellent communication skills. Cultivating this image will require psychiatric educators to become much more involved in the basic science lectures that occur during the earlier years of medical school. Also, increased participation in interdisciplinary conferences involving neurology, pathology, genetics, and radiology would help update the image of psychiatry among students and colleagues. Incorporation of psychiatry into the small-group discussions that form the hallmark of recent curricular changes is of fundamental importance. In the clinical years, systematic integration of psychiatric consultation into required primary care ambulatory rotations would go a long way toward increasing understanding of the influence of psychiatric disorders on primary care medicine. Substantial evidence now exists demonstrating that the prognoses of common medical illnesses, including diabetes and coronary heart disease, are made worse by comorbid depression. Treating comorbid psychiatric illness can improve medical outcomes.2,3 Training in the ambulatory setting should not, however, replace the more intensive exposure derived from psychiatric inpatient experience. Per time invested, inpatient rotations will continue to provide the highest yield in terms of developing diagnostic and therapeutic skills.
For students who become residents in primary care disciplines, psychiatric training should continue during their residencies. Toward this end, we believe that primary care residents should spend a minimum of one month on psychiatric services during their training. Participation in a psychiatric inpatient service, a consultation service, or an emergency psychiatry rotation would allow primary care residents to gain experience in timely diagnosis and treatment of psychiatric patients, as well as in the performance of an effective mental status examination. Ideally, the training experience would also include longitudinal experience in managing patients with psychiatric disorders in an outpatient setting. This might best be accomplished by incorporating psychiatrists or senior psychiatric residents into primary care clinic settings. Joint instructional experiences involving psychiatric and primary care residents should be also encouraged. Seminars reviewing the implications of comorbid psychiatric illness in combination with various medical disorders would be beneficial for both sets of trainees and would help to break down barriers between disciplines. Psychiatry faculty should give grand rounds and participate in case conferences in primary care residency programs, and vice versa.
For students who become psychiatry residents, it is imperative that their residency programs maintain the flexibility needed to adapt to rapid advances in diagnostic procedures and treatments. In the past, the role of pathophysiologic mechanisms in driving clinical decisions was limited, and symptomatic treatments could be readily used without much concern for pathophysiology. This is changing. Psychiatry residents will need a firm foundation in molecular biology, neurobiology, pharmacology, epidemiology, genetics, neuroimaging, and cognitive neurosciences in order to follow these advances throughout their careers and apply them in their practices. Although these topics are introduced in medical school, their in-depth application to illnesses of the brain, cognition, and behavior cannot be accomplished during medical school.
The future of psychiatry depends on research advances, and such advances are dependent upon having an adequate number of psychiatric investigators. This makes it essential to integrate research experience into residency training. Research training instills critical thinking skills that are valuable for every clinician. Furthermore, the present shortage of clinician investigators is so great in psychiatry that the National Institute of Mental Health has commissioned the Institute of Medicine to initiate a study entitled “Incorporating Research into Psychiatric Residency Training” to address these issues specifically.4 It seems clear that increased flexibility in residency program structure and requirements will be needed to accommodate the training of future psychiatric scientists.
We believe that the more rapidly the above changes are implemented, the better prepared physicians will be to help patients with psychiatric disorders. There are many within the field of psychiatry who do not agree with our opinions. Some feel that the psychotherapies should remain the primary emphasis of psychiatry training. We don't dispute the importance of psychotherapies as therapeutic tools, but we do not believe that the primary role of psychiatrists in the future will be the delivery of formal psychotherapies.
To move in the directions described above, it is necessary to have leadership in both medical schools and departments of psychiatry who have this vision of the future of the field. Medical schools and departments will need to recruit or develop faculty with the background and scientific expertise to teach the upcoming developments in clinical neuroscience to medical students, psychiatry residents, primary care residents, and other faculty. Faculty responsible for the formal curriculum should be carefully selected. Course masters should understand the importance of basic and clinical research as well as the importance of evidence-based treatments and the scientific method. Psychiatric educators should take advantage of university-wide expertise by organizing interdisciplinary curricula with other departments, including departments of neurology, neurobiology, radiology, genetics, and psychology. Also, Internet technology provides tremendous opportunities for programs to share resources, including curricula and lectures. Funds to support key faculty in major educational roles are also needed.
Incorporating increased psychiatric education into the curriculum of primary care residencies requires the support of leaders of primary care disciplines. Such support may develop as primary care physicians increasingly find themselves responsible for managing psychiatrically ill patients. Also, as the relevance of such training is made clear during medical school, primary care residents may seek more psychiatric training during their residencies.
In summary, because scientific advances are likely to have dramatic effects on the practice of psychiatry in the near future, psychiatric education in medical schools and residency programs will be increasingly based on molecular and cognitive neurosciences, genetics, and epidemiology. To prepare the next generation of clinicians and scientists, it is imperative that departments of psychiatry develop the expertise to incorporate the coming avalanche of information into psychiatric education. Educational programs must have sufficient flexibility to adapt rapidly to the changing information base that will be required in clinical practice.
The future of psychiatry depends greatly upon its leaders, especially its academic leaders. Their beliefs and commitments will, to a considerable extent, determine the future of the specialty. Leadership requires a vision and a program. These must be derived from a valid grasp of the field and its possibilities that will shape the education and training of medical students (most of whom will not become psychiatrists) and of psychiatric residents.—S. B. Guze, 19925