Tuesday, July 30, 2013

Is Psychiatry Residency Training Backwards?

For decades, the process of turning a medical school graduate into a psychiatrist has remained essentially the same: A post-graduate year 1 (PGY 1) internship that includes rotations in medicine and neurology in addition to psychiatry, followed by 3 additional years of residency training focused on psychiatry. Even though psychiatry residency programs are famously diverse, they almost always follow the pattern of mostly inpatient psychiatry for PGY 1-2 and mostly outpatient psychiatry for PGY 3-4. Child psychiatry exposure typically occurs for only a few months during PGY 2 or 3.

Earlier this year, 1Boring Old Man had an excellent series of posts that included a look back at his experience as a residency training program director in the 1970's, when he pulled his residents from a large state hospital because the experience was no longer educational. Yet most psychiatry programs across the country still have their psychiatry residents staffing inpatient units during their first two years of training, even as the length of stay at acute inpatient psychiatry units continues to decline. What does this do? I think it puts an emphasis on "medication-first" thinking, because changing some meds around (usually by adding more rather than taking any away) is really all one can do for a patient who is just going to be in the hospital for a few days.

Additionally, I believe that being exposed to the most severe mental illnesses during PGY 1-2 primes young clinicians to over-pathologize when they end up interacting with less ill patient interactions later on. Ordinary sadness or grieving may be called depression. "Hearing voices" (which is how many people describe their intrusive thoughts or internal monologues) starts to sound like schizophrenia. Mood swings or anger outbursts often get diagnosed as bipolar disorder. Of course, there are certainly other forces driving the pathologizing of normal behavior, but I do think the way training is structured facilitates this type of thinking.

Lastly, the focus on treating adult individual psychopathology deprives trainees of developing a crucial developmental and social perspective. Family therapy is something that is usually taught briefly, if at all, during the PGY 3 or 4 years. During my years of general psychiatry residency, I had the vague sense that a patient's interactions with family or her experiences growing up may have influenced her symptoms over the course of her life, but the attitude of my attendings seemed to be: since those things can't really be changed, why focus on them? It wasn't until my two years of child psychiatry training that I finally started to understand the roles that early childhood adversity and interactions amongst family members play in an individual's patterns of behavior.

I think that psychiatry residency programs would be improved immensely by earlier clinical exposure to assessing children (both "normally-developing" and ones with behavioral problems) and their families, as a counterpoint to the biomedical neurotransmitter-based framework that residents are most familiar with. This not an original idea. Other psychiatrists have suggested the same thing, including Dr. Carl Feinstein, head of child and adolescent psychiatry at Stanford (which is somewhat ironic given Stanford psychiatry's overall biological orientation). Daniel Carlat's book Unhinged proposes some more fundamental changes in the process of training psychiatrists.

Sadly, as psychiatry becomes increasingly driven by managed care, it looks like residency training will continue to languish as psychiatry departments come under pressure to increase patient volumes so they can operate in the black.