Is Today's 21st Century Burnout 19th Century's Neurasthenia?

This essay addresses the relevance of the concept of "burnout" to concerns about the mental and physical health of today's physicians and those training to join the medical profession. Comparisons are made with the diagnosis of neurasthenia in the 19th century. Social contributors to and the influence of stress on the phenomena in each instance are presented.

Medically Unexplained Symptoms: Barriers to Effective Treatment When Nothing Is the Matter.

Patients with symptoms that elude medical explanation are a perennial challenge to practicing physicians of all disciplines. Articles appear virtually monthly advising physicians how to care for them. Efforts at postgraduate education have attempted to ameliorate the situation but have shown limited or disappointing results at best. Physicians continue either to avoid these patients or to resort to a "seat-of-the-pants" approach to management. Literature on patients with medically unexplained symptoms, along with extensive experience consulting with primary care physicians, suggests that it is not primarily lack of physician skills but rather a series of barriers to adequate care that may account for suboptimal management. Barriers to implementation of effective care reside in the nature of medical education, the doctor-patient relationship, heterogeneity of symptoms and labels, changes in the health care system, and other variables. These impediments are considered here, with suggested potential remedies, in the conviction that the proper care of patients with medically unexplained symptoms can, among other things, bring satisfaction to both the patient and the physician, and help to reduce ineffective health resource utilization.

Developmental life of the medical student: curriculum considerations.

Few medical educators would dispute that the emotional development and well being of the medical student is of critical importance in the pathway to physicianhood. It has been suggested that failure to address this aspect of medical education may account for various health problems and levels of impairment during medical school and beyond. Some authors have suggested that the personal development and "professionalization" of the student occurs through modeling, the medical school "culture," and the "hidden curriculum." In recognition of the randomness, incompleteness, or inadequacy of this approach, a number of attempts have been made to address this important but difficult dimension of medical education. However, programs designed to foster self-reflection and appreciation of affect in the physician-patient relationship are often limited as electives or unsupported by faculty and staff and therefore fall short of their objective. The author proposes that a pedagogical framework based on an analogy of life cycle theory (a la Erikson or others) offers a schema within which to consider efforts being made in medical curricula to promote self-awareness, appreciation of affect in oneself and one's patients, and a context in which to minimize the risk of illness and impairment.

Psychiatry and the general hospital in an age of uncertainty.

General hospitals have had an illustrious role in the evolution of psychiatry. They have provided a rich soil for the growth of inpatient psychiatric units, consultation-liaison psychiatry, psychosomatic medicine, med-psych units, outpatient psychiatric clinics, emergency services and a whole spectrum of resources for the communities in which they dwell. In some respects, whether attached to universities or not, they have functioned as small colleges for the education and training of scores of health professionals. In the setting of the general hospital, psychiatry has had opportunities to become remedicalized and integrated into the mainstream of medicine. However, recent trends in health care run the risk of jeopardizing these accomplishments. Managed care has had a profound impact on the way psychiatry is practiced, taught, and reimbursed. Concerns about cost-containment have raised questions about whether the general hospital will remain the best and most economical setting for psychiatric services. If the primacy of the patient is lost, psychiatry's role in the general hospital will be uncertain. The need to safeguard psychiatry's achievements must be a worldwide endeavor.