Trends in American Board of Psychiatry and Neurology specialties and neurologic subspecialties.

OBJECTIVE: To review the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) specialties and neurologic subspecialties and discuss the implications of those trends for subspecialty viability. METHODS: Data on numbers of residency and fellowship programs and graduates and ABPN certification candidates and diplomates were drawn from several sources, including ABPN records, Web sites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of the Journal of the American Medical Association. RESULTS: About four-fifths of neurology graduates pursue fellowship training. While most recent neurology and child neurology graduates attempt to become certified by the ABPN, many clinical neurophysiologists elect not to do so. There appears to have been little interest in establishing fellowships in neurodevelopmental disabilities. The pass rate for fellowship graduates is equivalent to that for the "grandfathers" in clinical neurophysiology. Lower percentages of clinical neurophysiologists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high. CONCLUSION: The initial enthusiastic interest in training and certification in some of the ABPN neurologic subspecialties appears to have slowed, and the long-term viability of those subspecialties will depend upon the answers to a number of complicated social, economic, and political questions in the new health care era.

A collaborative clerkship with a focus on rural community health.

The Deans' Rural Primary Care Clerkship was developed through the collaborative efforts of South Carolina's two medical schools. The clerkship provides students an innovative learning experience in rural community medicine through the unique combination of learning opportunities with community-oriented primary care, continuous quality improvement, interdisciplinary health care teams, and cultural competency. Much of students' learning addresses current directives for population health training. The positive experience students are having in these rural, underserved South Carolina communities will help them better understand the rewards and challenges of rural, community-responsive health care.

Teaching medical students social responsibility: the right thing to do.

As academic medicine has become more focused on the economic pressures of the marketplace, some educators have expressed concern about whether appropriate attention is being given to the character development and moral education of medical students. The authors conclude that medical schools do indeed have a duty to teach their medical students to be socially responsible. They define a socially responsible individual as a person who takes part in activities that contribute to the happiness, health, and prosperity of a community and its members. They suggest that medical students should participate in carefully designed, socially responsible activities in order to (1) practice and have reinforced such qualities as reliability, trustworthiness, dependability, altruism, and compassion; (2) partially reimburse society for the cost of their medical education; (3) increase their exposure to a population-based approach to health care; and (4) help medical schools fulfill their social contract with the public. The authors outline the process for developing a curriculum to teach social responsibility to medical students and list some of the key questions faculty and administrators must address in the processes of development and implementation. They conclude that while faculty responsible for implementing a curriculum in social responsibility must be highly committed and prepared to address numerous difficult questions concerning the curriculum's philosophy, structure, and function, the potential benefits of such a curriculum are well worth the effort.

Ensuring that forensic psychiatry thrives as a medical specialty in the 21st century.

The author contends that forensic psychiatry will thrive as a legitimate medical specialty in the 21st century only if it helps to fulfill the crucial requirement of medical systems in the new health care era. The article presents six basic requirements of future medical systems: effective, efficient, and responsible organizations; quality educational programs of the appropriate type and size; linkage to health care networks; primary care capacity and services; restructured systems for research; and effective leadership. Specific opportunities for forensic psychiatry to help meet these requirements are outlined. The author presents major implications of these opportunities for forensic academicians and practitioners as well as for the American Academy of Psychiatry and the Law.

Ensuring the survival of academic psychiatry in the new health care era.

The authors contend that academic psychiatry will only survive in the future if it helps to fulfill the crucial requirement of academic medicine in the new health care era. They present six basic requirements of academic medicine: 1) effective, efficient, and responsible organizations; 2) quality educational programs of appropriate type and size; 3) linkage to health care networks; 4) primary care capacity and services; 5) restructured systems for research; and 6) effective leadership. Specific strategies for departments of psychiatry to help meet the requirements of academic medicine are outlined. The authors present major implications of these proposed strategies for psychiatric chairs, faculty, and the professional organizations that serve them.

The medical workforce in South Carolina: its current status and a look to the future.

Available data suggest that South Carolina does not have the same degree of problems with its medical workforce as is present in many other areas of the country. While there may be too many specialists and not enough primary care physicians and while maldistribution is also a problem in some areas of the state; it appears that the total number of physicians and the size and focus of the medical education system in South Carolina are about what they should be. Furthermore, the graduate medical education system in South Carolina is currently changing on its own to emphasize more primary care and less specialist training. With careful monitoring, coordination of effort, and specific initiatives to address specialty, maldistribution and curricular issues, the state's medical education programs can take action to build on their current strengths and assure a medical workforce of sufficient size, type, and skill to meet the future needs of the citizens of South Carolina.

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.

Estimating psychiatric manpower requirements based on patients' needs.

OBJECTIVE: To provide a better understanding of the complexities of estimating psychiatric manpower requirements, the authors describe several approaches to estimation and present a method based on patients' needs. METHODS: A five-step method for psychiatric manpower estimation is used, with estimates of data pertinent to each step, to calculate the total psychiatric manpower requirements for the United States. The method is also used to estimate the hours of psychiatric service per patient per year that might be available under current psychiatric practice and under a managed care scenario. RESULTS: Depending on assumptions about data at each step in the method, the total psychiatric manpower requirements for the U.S. population range from 2,989 to 358,696 full-time-equivalent psychiatrists. The number of available hours of psychiatric service per patient per year is 14.1 hours under current psychiatric practice and 2.8 hours under the managed care scenario. CONCLUSIONS: The key to psychiatric manpower estimation lies in clarifying the assumptions that underlie the specific method used. Even small differences in assumptions mean large differences in estimates. Any credible manpower estimation process must include discussions and negotiations between psychiatrists, other clinicians, administrators, and patients and families to clarify the treatment needs of patients and the roles, responsibilities, and job description of psychiatrists.

A ten-year update of administrative relationships between state hospitals and academic psychiatry departments.

OBJECTIVE: In a follow-up to a survey ten years earlier, the authors investigated current administrative relationships between academic departments of psychiatry and state hospitals. METHODS: A 20-item questionnaire was sent to the chairs of the 110 medical school departments of psychiatry with accredited psychiatric residencies. RESULTS: Eighty-two departments, or 75 percent, responded. Seventy-one percent of the respondents reported that their department had a relationship with a state hospital; 79 percent of these relationships involved the education of psychiatric residents. Most respondents rated the quality of the relationship favorably (4 or 5 on a 5-point scale). Almost all respondents believed that residents can obtain a high-quality education in a state hospital. More than half of the departments responding to a question about the importance of a state hospital rotation rated it of major importance in their residency program. CONCLUSIONS: Many medical school departments of psychiatry remain closely involved with state hospitals and recognize the hospital as an important part of residents' education. Administrators have gained much experience about how to develop and implement mutually beneficial relationships.

Administrative relationships between community mental health centers and academic psychiatry departments: a 12-year update.

OBJECTIVE: The authors investigated the administrative relationships in 1990 between medical school departments of psychiatry and community mental health centers (CMHCs). METHOD: A 20-item questionnaire was sent to the chairpersons of the 110 medical school departments of psychiatry with accredited psychiatric residencies. RESULTS: Sixty-nine percent of the chairpersons responded to the questionnaire. Sixty-eight percent of the responding chairpersons reported that their departments had relationships with CMHCs, and 90% of these relationships involved the education of psychiatric residents. Most responding chairpersons described the quality of their existing CMHC relationships as good to excellent. In the most common type of relationship reported the CMHC was used as a setting for resident education. The vast majority of responding chairpersons stated that quality resident education is possible in a CMHC, and about two-thirds of the responding chairpersons with CMHC relationships involving residency education rated the CMHC rotation as of major importance to their residency programs. CONCLUSIONS: CMHCs continue to be an important and valued component of the educational experience for many psychiatric residents, and many departments of psychiatry have recognized the advantages and benefits of CMHCs for residency training. There are now considerable data on how a relationship between a medical school department and a CMHC should be structured to achieve maximum benefit for both the department and the CMHC.

Problems in the recognition and treatment of patients with dual diagnoses.

BACKGROUND: This study was to find if the dually diagnosed in a teaching psychiatric hospital were being adequately identified and treated. METHOD: The records of 200 adult inpatients were reviewed for psychiatric diagnoses, the presence of a history of substance abuse, and the kinds of treatment rendered those patients. RESULTS: Forty-three percent of the patients admitted were found to have a history of substance abuse, but 31.4% of these had a history of substance abuse in the record without a formal diagnosis. Major depression (26.6%) and schizophrenia (18.7%) were the most frequent diagnoses. Half of the patients received no documented treatment for substance abuse. The most common intervention was education by the nursing staff. CONCLUSIONS: There is a clear need for better recognition and treatment of the dually diagnosed patient.

A method for estimating psychiatrist staffing needs in community mental health programs.

Community mental health programs are facing increasing demands to treat and rehabilitate seriously mentally ill patients even as they encounter shortages and burnout of qualified psychiatrists. The authors propose practical and flexible step-by-step guidelines to help such programs estimate current and future psychiatrist staffing needs. The method involves defining the roles of the psychiatrist, negotiating time allocations to be spent providing direct and indirect services, and determining case loads that are mutually agreeable to staff, administrators, and patients. The method can also be used by psychiatrists to negotiate a manageable working arrangement with a community mental health program.