Is Modern Psychiatry Too Intellectually Restrictive?

The inspiration for this post comes from my reading the history of psychiatry. That was not a particular interest of mine until I began researching threads of knowledge going back into time. Then I started to look at how American psychiatry evolved and the fact that it did not really exist at the same time psychiatry existed in Europe.  This is historically confusing in the US, where certain movements try to connect psychiatry to historical events where there are no connections.  The development of psychiatry in Europe is a complicated and interesting story.  The most striking feature is that those early psychiatrists were trained in neuroanatomy, neuropathology, neurology, and psychiatry.  Freud was a Privadozent in neuropathology.  Adolph Meyer emigrated to the US as a neuropathologist and eventually became the chairman of psychiatry at Johns Hopkins eventually influencing a significant number of American psychiatrists. 

In reading about these early psychiatrists, some authors will refer to them as neurologists even though the person in question identified as a psychiatrist (examples include Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868)).  Others like von Economo (1) were designated psychiatrists and neurologists.  After graduating from medical school in 1901 von Economo spent a year working in an internal medicine clinic and over the next four years worked at various clinics in Europe with Marie, Kraepelin, Alzheimer, and Oppenheim learning psychiatry, neurology, and hypnosis. He returned to the University of Vienna in 1906 and was appointed Professor of Neurology and Psychiatry in 1921. This was an observation from his book Encephalitis Lethargica (2):

"Towards the end of 1916 the wards of the Vienna Psychiatric Clinic contained quite a number of patients with a strange variety of symptoms - cases which had apparently only one feature in common - a difficulty to fit into any known diagnostic scheme.  They had been admitted under the most varied descriptions, such as meningitis, acute disseminated sclerosis, amentia, delirium &c.  The patients all showed a slight influenza-like prodromal condition with trifling pharyngeal symptoms, a slight rise in temperature, soon followed by a variety of nervous symptoms, though generally one sign or another pointed to the midbrain as a source...."

From there von Economo goes on to describe encephalitis lethargica in great detail.  He was subsequently nominated for the Nobel Prize in Medicine four times for this work.  He also worked on neuroanatomy - where he made additional discoveries. His education and career contrasts well with current psychiatric education in the US where it seems that too little content is being spread over too many years - even more if you want to be certified in both neurology and psychiatry. He apparently got what he needed in 4 years while living in 4 different European cities.  Places like the Vienna Psychiatric Clinic also do not exist today - where the only solid criteria for admission is dangerousness and all admissions need to be medically cleared  by somebody (physician or extender) that may be oblivious to neurological and psychiatric presentations of acute illness. 

More to the point – they were probably neuropsychiatrists and that has relevance for the system of board certification in the US.  Prior to board certification most psychiatrists in the US were neuropsychiatrists and practiced neurology and psychiatry. That all changed in 1934 when the American Board of Psychiatry and Neurology (ABPN) – made the rule that all psychiatrists practicing both specialties must pass both board certification exams.

Reading the paper (3) about Bleuler was interesting because it is an easy read that emphasizes several concepts in psychiatry that just repeat if you don’t understand them.  First is the age-old debate about categorical versus dimensional diagnoses.  The author’s conclude that Bleuler supported dimensional diagnoses but it seems they are describing his process as one of detailed formulation rather than dimensions. This was rooted in his method of clinical psychiatry. I suppose a four dimension scale could be envisioned based on Bleuler’s “4 As” (see below) – but my interpretation is that he was looking for detailed medical, family, social, and developmental history.  He is described as a clinician who had close contact with patients rather than an experimentalist – that is the data he was interested in.

Second, the richness of the psychiatric landscape during Bleuler’s time cannot be denied. The psychiatrists were writing and researching across the spectrum of neurology, neuroscience, psychology, and theoretical psychiatry. There was no shortage of ideas about describing clinical phenomena or possible treatments.  Bleuler had contact with many prominent psychiatrists of his time and his opinions about some of their theories was known.

Third,  Bleuler’s approach could be considered pluralistic to use today’s jargon.  He was  clearly engaged in doing the subjective realm and individualized evaluations.  He thought that schizophrenia could be an exaggerated neurosis from psychological conflicts.  He believed that the disease process had a biological basis but he was focused on a psychological treatment.  He also did not see schizophrenia as having a uniformly deteriorating course. His thoughts about the biology of the disorder were undoubtedly affected by the facts that he was not an experimentalist, there were no useful biological treatments and despite many autopsy studies there were no good gross anatomical or histological correlates of schizophrenia.

The patterns and themes noted in this paper run throughout the history of psychiatry.  Since psychiatry became the default profession for treating severe mental illnesses, there have been hypotheses about the nature of the illnesses, how to medically evaluate them, and how to treat them. As illustrated on this blog, there are often critics outside of the field who seem to ask these questions as if no psychiatrist has ever thought about them in the past.

In many ways the intellectual landscape of turn of the century psychiatry was richer than it is today. We currently have a refined product in terms of classification, but many of the questions relevant of psychopathology and neuroscience remain open. The basic problem of biological complexity is not easily answered and it is only recently being approached.  Biological and psychotherapy options appear to have been maxed out by heterogeneity problem.  From a historical perspective, what is most alarming to me is that there has not been a synthesis of these questions and approaches to bring current psychiatrists and trainees up to speed.  Much of the time seems to be spent on the same research techniques and critiquing endless clinical trials.

At a global level, the intellectual landscape of the field seems constricted.  The board certification process has certainly been part of that as well as the general goals of standardization.  There has been an enormous effort on standardizing nomenclature at the cost of de-emphasizing psychopathology. Clinical practice has been standardized largely based on settings and administrative codes. Documentation has been standardized by the same codes and electronic health records.  Much of the documentation is essentially worthless in describing patient progress or the unique features of the individual and is essentially there to satisfy business administrators.  The training of new psychiatrists is standardized in some areas - but there are very few specifics in terms of what trainees need to see in order to be good psychiatrists.  For example, there is an apparent assumption that if you spend a month or two in a neurology clinic - you will have adequate exposure to accurately assess neurological problems presenting as psychiatric problems and make the correct triage or treatment decisions.   

 I don’t think expanding the intellectual landscape for residency programs would take much.  It will take a bit of integration.  The sanctioning bodies of medical education have made the task harder than it should be by not specifying all of the important educational topics and letting the programs each sort it out on their own.  That means residents will see certain concepts inconsistently if at all, presentations and seminars will depend on the availability, interest, and quality of the teaching staff, and even then, topics are likely to be followed too rigidly.

The first question is what exactly should that landscape be?  Residency requirements by the ACGME are surprisingly vague.  They are focused primarily on clinical experiences based on clinical populations and settings, availability of supervision, and overriding goals of excellence, motivation, and interest on the part of the teaching faculty. There are some broad technical markers of specific experiences by psychiatric subspeciality or skill (eg. psychotherapy, managing drug interactions, etc).  I know that the residency directors meet frequently and it would not surprise me to find out that there are more detailed approaches shared among them – but if that occurs, I do not know where to access it.

My suggested approach at integration would be teaching the historical controversies and concepts that are still relevant all at once.  There are several integrative papers in the literature already.  There are also still some big concepts that need formulation and discussion like the biological diversity and heterogeneity issues that run throughout all of medicine. A potential academic model for this approach already exists and I suggest it is in the Voet, Voet, and Pratt - Fundamentals of Biochemistry - 6th edition.  One of the issues that frequently arises during discussions of this nature is how much philosophy needs to be included. My reading of the literature suggests that if anything there has been an excess of philosophy being applied to psychiatry.  At times psychiatry is made to seem like psychiatrists themselves have never considered the obvious questions. Teaching residents about psychiatry and the way that psychiatrists have attempted to formulate and solve problems seems like as good a place to start as any to me.

It can start with the names in this paper.    

Pattern matching also needs to be reemphasized. The reason a psychiatrist can diagnose bipolar disorder is that they have seen many cases and many variations - not because they have read the DSM.  The same is true for all of the mimics of bipolar disorder including neurological conditions. I am concerned about the level of exposure that residents have to acute neurological problems, especially now that many inpatient neurology services have been replaced by hospitalists with neurology consultants. There is a long list of acute neurological presentations that every psychiatrist must see and diagnose in training and distance from our neurology colleagues makes that more difficult. 

 

George Dawson, MD, DFAPA

 

References:

1:  Kaya Y, Uysal H, Akkoyunlu G, Sarikcioglu L. Constantin von Economo (1876-1931) and his legacy to neuroscience. Childs Nerv Syst. 2016 Feb;32(2):217-20. doi: 10.1007/s00381-015-2647-0. Epub 2015 Feb 24. PMID: 25707481.

2:  von Economo C.  Encephalitis Lethargica.  Oxford University Press, London. 1929. page B.

3:  Heckers S. Bleuler and the neurobiology of schizophrenia. Schizophr Bull. 2011 Nov;37(6):1131-5. doi: 10.1093/schbul/sbr108. Epub 2011 Aug 26. PMID: 21873614; PMCID: PMC3196934.

Open Access <-you can read this paper

Supplementary:

I just accessed and read the following paper this morning several days after the above post.  It is an open access paper that can be read and downloaded.  It basically makes the same argument that my post makes - an integrated approach to psychiatry and neurology (and neuroscience) is preferable.  It is written from the neurology perspective and that may be why the suggested remedies fall short.  Integration between the specialties is really not possible as long as one (psychiatry) is disproportionally rationed and is under an administrative burden that divorces it from clinical reality. 

Perez DL, Keshavan MS, Scharf JM, Boes AD, Price BH. Bridging the Great Divide: What Can Neurology Learn From Psychiatry? J Neuropsychiatry Clin Neurosci. 2018 Fall;30(4):271-278. doi: 10.1176/appi.neuropsych.17100200. Epub 2018 Jun 25. PMID: 29939105; PMCID: PMC6309772.

Breakfast With My Old Mentor

I have some other posts ready to go, but I wanted to end the year on a positive note.  I could not think of anything more positive than my old mentor being back in town and suggesting that we meet for breakfast.  I would not be where I am today without mentors.  Mentors who told me what to do and silent mentors who I could just identity with.  Both types have been invaluable to a guy who did not have a clear idea of what he wanted to do in life.  When it comes to people who carefully plan their life and people who are on kind of a random walk - I was firmly in the latter camp until some time after college.

The only reason I went to college was to play football.  I got a scholarship.  It did not take long to discover that was a bad idea.  That discovery was facilitated by a gangrenous appendix.  During the hospital stay, one of my professors came in to visit.  He basically told me to snap out of  it, drop the idea of coaching and a physical education minor, and do something more rigorous academically.  He literally told me that I was wasting my time.  He was very animated about it.  When he left I wondered why an unpopular professor with a reputation for eccentricity would visit a freshman who he had only known for about a month and tell me that my life trajectory was wrong.  And why would I immediately see that he was right?

It was not long before I had met chemistry and biology professors that I could identify with.  I also had very positive experiences with the English and Philosophy professors.  That led to increasing motivation and academic rigor.  Medical school was not much different.  It was natural to gravitate to neuroanatomists, biochemists, neurosurgeons, neurologists, internists, endocrinologists, nephrologists, cardiologists, and infectious  disease specialists.  Learning medicine and psychiatry in medical school and residency was an exciting immersive educational experience.  Not all of the professors were stimulating or inspiring.  I did not consider those fields for a second.  After the computer match of several specialties psychiatry was the next step.

I met my mentor  in my PGY2 year in 1984.  He had just left private practice to do research.  There was never any doubt that he was extremely knowledgeable in psychiatry.  At the time there was an active debate between the so-called biological psychiatrists and the psychiatrists who were more psychotherapy oriented.  The biological psychiatrists were basically phenomenologists in search of biological paradigms at the time.  Some of the more prominent paradigms at the time were psychopharmacology, genetics, primate research and neuroendocrinology.  In many cases, residents were split by identification with some faculty or alienation from others.  My mentor was comfortable in all areas.  We could discuss biological theories and then how to introduce and conduct psychodynamic psychotherapy.  He explained how he did it and it made things possible.  He highlighted our discussions with with examples from his own experience.  He asked me questions about what it was really like to be a psychiatrist: "Suppose you are at a cocktail party and a person approaches you.  That person appears to be acting out.  Do you react to them like psychiatrist or not? Do you think that you can put being a psychiatrist on hold?"  Questions that most PGY2s have not had time to contemplate when doing night call on psychiatric units full of transplant patients - many with difficult to control diabetes.  All of this was worked in between seeing patients and doing the usual patients presentation in the clinic and the hospital.

I moved on to a different program  for the last two years.  The same biological psychiatry versus psychotherapists going on in the new program where interestingly there were biological researchers with strong interests in both psychodynamic and behavioral therapy.  It was the only program where I have ever seen pharmacotherapy contingent on whether or not the behavior therapy was attempted or successful.  Even more psychiatrists with the same orientation as my original mentor.

We ordered breakfast and settled in.  It was the first time we would be talking for an hour in 32 years.  I had talked with him briefly outside of a lecture that he was getting ready for at an APA meeting.  He brought me up to speed on what he was doing.  He got in on the ground floor of psychiatric research in a particular specialty and it was apparent that he knew most of the field cold.  He e-mailed me several papers later.  We discussed a few medical problems and the morbidity of the aging process.  We discussed some issues that come up teaching residents and I remembered some of the things he told me about my personality and style that were dead on.  We talked about my concern over the FDA contraindication for bupropion in active or resolved eating disorders and what needed to be done about that.  We discussed the historical development of the DSM and its limitations.  He told me something I had never heard there - organized psychology tried to come up with an alternative to the DSM-III and failed.  I informed him about the Psychodynamic Diagnostic Manual (PDM) and my experience discussing it with some East Coast clinicians.  We made a few jokes - technically we were peers, but he was always easy to relate to.  As the hour wound down we settled on a few truths that we had come to over the years about psychiatry and I thought I would include them here as a positive jumping off point for the new year:

1.  It is all about the biology -

I have always reflected on my teachers of clinical psychiatry and concluded that I was very fortunate to be taught by the best from two very different programs.  That all started with my mentor.  About two thirds of the way into our conversation he made this statement and I found myself in complete agreement.  When I was in medical school psychiatry was in a very primitive state and a lot of that was due to the nature versus nurture argument.  The psychiatric assessment and mental status exam has not changed since that time.  There are generally 200 - 300 data points gathered in a standard assessment and the goal is to come up with a formulation of the problem and a separate list of diagnoses.  If you are a resident of course they need to be DSM diagnoses.  The  problem then as now is that the explanatory power of the formulation is not necessarily robust.  At the end of that presentation somebody in the crowd could always say: "So is it nature or is it nurture?"  On either end of that spectrum the formulation could encompass - "Who cares if it is nature or nurture - I just prescribe medication for specific diagnoses." to  "I only do psychotherapy - this is repressed narcissistic rage.  I prescribe a little amitriptyline if needed for sleep."  Hardly robust explanatory paradigms and the old Popperian baggage that psychoanalytic theories were not falsifiable.

The biggest missed opportunity during residency was not capitalizing on the neuroscience of the day.  The academic centers where I was studying were firmly into primatology, neuroendocrinology, and psychopharmacology.  Nobody seemed to pick up on Kandel's early work for about a decade.  There was much debate about what biological psychiatry was and the definition I was picking up on at the time was treatment with medications.  There was a focus on neurotransmitters and neural transmission.  But my entire residency occurred before the advent of selective serotonin reuptake inhibitors (SSRIs) and atypical antipsychotics (AAPs).  The most effective medication for the indication was lithium and that is still probably the case.  Over the intervening decades neuroscience has taken off.  We now have an early appreciation of the complexity of the brain and nervous system with advances  every year.  We are very close to the point where we are able to investigate putative neuroscience based mechanisms for stress, psychological trauma, environmentally determined epigenetic changes that cause important changes in behavior, common psychiatric syndromes, genetically determined changes in drug metabolism, and primary genetic transmission of mental disorders.  There has been an explosion of information about the molecular biology of addiction and dementias.  It seems that many people have discovered in the last 10 years what Kandel was writing about in 1979 - psychotherapy changes biology.  How else would it work?  All of this information is immediately relevant for psychiatrists.  

2.  The last thing that we need is another research proven psychotherapy -

I found that I had psychotherapy training in residency that was second to none.  As a resident that occurred primarily as one hour of direct supervision for every hour that I was in session with a patient and that was about 450 hours per year for three years.  The psychotherapy supervisors were diverse in terms of their orientation.  I picked up additional training on inpatient services from psychoanalysts and others.  It seemed obvious to me that you have to say something useful to people when you see them and that typically flowed from one form of therapy or the other.  In psychiatry due to the severity of the problem and the general lack of medical care - flexibility was necessary.  I can recall making a diagnosis of probable partial complex seizures in a patient I thought that short term psychodynamic crisis oriented therapy might be useful.

Over the years, psychotherapy research led to more manuals for standardized approaches.  I remember getting an early copy of Linehan's Dialectical Behavior Therapy mailed directly to me from the inventor herself.  I accumulated a library of psychotherapy texts on supportive, psychodynamic, behavioral, cognitive behavioral, and the more recent modifications.  But the problem with psychotherapy was never a lack of useful models.  There was fairly good evidence that psychotherapy may not be all that specific.  Therapists from different schools could both get good results.  There was a general lack of adequate research of psychodynamic/psychoanalytic therapy.  There were also some clinical trials that may have left the wrong impression.  I recall an early partially negative trial of psychotherapy in schizophrenia that seemed counter to older anecdotal literature.  More recent cognitive behavioral therapy of schizophrenia and other severe mental illnesses seems to correct the idea that psychotherapy is not useful.

In our discussion of psychotherapy we both agreed that there is really no research based psychotherapy available largely due to managed care environments.  I thought the average number of sessions for most managed care patients was 3.  He had just read an article suggesting it was 1.  Either way the practical limitations for psychiatrists in these settings is that they are scheduled for brief medication focused visits and long intervals.  A person with a severe mental illness who is not in a crisis situation may be seen every 3 months for 15 - 20 minutes.  But even in that rationed and sparse setting, I worked with a psychiatrist who established incredible relationships with people.  I had people asking me for years after he left, if I knew what had become of him.   

We both agreed that it was futile to keep doing psychotherapy research on heterogeneous populations and inventing different psychotherapies when the results are generally the same (and probably limited by varying subject characteristics) and research proven psychotherapy cannot be provided due to managed care rationing.  The therapeutic alliance and useful discussions with patients need continued application.  Nothing useful tends to happen unless the patient believes they are clearly understood and that is communicated by the psychiatrist.


3.  Residents have to care about the DSM - we don't -

Through all of the fake news about the release of the DSM-5,  I maintained that all of the hype was hardly necessary for a very imperfect classification system that is slightly important to psychiatrists - but nobody else.  We agreed it was useful for residents to learn but really not that important for practicing psychiatrists.  The basis of that agreement and the need for the residents to learn it is that we know all of the deficiencies and the few strong points better than anybody else.  It caused me to recall the electronic medical record that I use.  Each major diagnostic category has about 240 listed diagnoses or nearly the total in the DSM-5.  There are so many that I can have difficulty finding the correct one.  Like most psychiatrists, I am using about 1/4 of the diagnoses and recognize the limitations not only of those diagnoses - but limitations of the idea that simple verbal descriptions can parse the most complicated organ into a large number of useful diagnoses.

All in all it was a good breakfast.  I was happy to see my mentor and he was happy to see me.  Along the way I think I evolved into a competent clinical psychiatrist with a very similar skill set (except the extensive research).  I know that the other residents in my class did the same.

I feel privileged and elevated by acquiring those skills directly from my mentors and colleagues along the way.  It transformed my early random walk into academics into a focused professional life.

And I am very grateful for that.      


Happy New Year!

George Dawson, MD, DFAPA




Attribution

Eggs Benedict picture at the top is By balise42 (http://www.flickr.com/photos/ipalatin/5261997126/) [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons at https://upload.wikimedia.org/wikipedia/commons/2/2b/Eggs_benedict.jpg

Suggested Changes to Psychiatric Residency Programs

I received an e-mail two weeks ago that asked for my suggestions on immediately reforming residency programs for psychiatry.  I had the experience of completing my residency in two different university based programs.  My residency occurred at the height of the controversy between the self described biological psychiatrists and the psychotherapists and psychoanalysts.  Although I have never seen it written about there was open animosity between the groups at times.  A biological psychiatrist back in the day might make a statement like: "I don't do talk therapy".  A psychotherapy oriented psychiatrist might refer to the biological types as "Dial twisters" referring to an approach that suggested excessive biological reductionism.  Apparently neither group had read Kandel's seminal article in the New England Journal of Medicine four years earlier and how plasticity can be affected by talking, medications, and of course other experiences.

Several years ago, I attended an anniversary of the University of Wisconsin Department of Psychiatry, the program I eventually completed my residency at.  Thomas Insel, MD was one of the invited speakers.   He outlined a revolutionary approach to educating psychiatry residents that involved a joint 2 year neuroscience internship with residents from neurology and neurosurgery.  He did not provide any details.  When I sent him a follow up e-mail two years later, he said it would probably not happen on his watch.  I can easily build on that theme.  I think that a two year program focused on basic and clinical neuroscience remains a good approach.  The current approach to getting the relevant information is haphazard at best.  It depends on lectures in neuroscience being interspersed with clinical rotations of varying quality and to a large extent it depends on the faculty.  How many faculty are there and how many of them are expected to produce managed care style billings or "productivity" rather than high quality teaching.

A comprehensive and integrated approach that will teach state of the art neuroscience and provide the relevant training in neurology and medicine is possible.  There are many obvious areas for improvement.  Residents often spend their time on clinical rotations of minimal relevance for psychiatrists.  I can recall learning ICU medicine and needing to familiarize myself with various tasks (Swan-Ganz catheters, central lines, ventilator settings, dopamine drips, balloon pumps) that I would never use again.  I needed to be seeing hundreds of people with heart disease, arrhythmias, hypertension, diabetes, other endocrine disorders and neurological disorders.  I saw many of those people when they were hospitalized, but seeing these folks in ambulatory care settings designed to enhance the learning experience for a psychiatrist would provide a better experience.   The process should probably start earlier in the fourth year of medical school.  Prospective psychiatrists should be focused on electives in neurology, medicine, and neurosurgery rather than psychiatry.

The teaching of psychiatry needs to address the practical concerns about diagnosis and treatment but also philosophical concerns.  Residents need to be familiar with the antipsychiatry philosophy and the existing literature that refutes it.  Residents need to know about the issue of the validity and reliability of psychiatric diagnoses and how that is established.  There is actually a rich history of how that came about but it could easily be summarized in one seminar.  One of the features that I was interested in when I was interviewing for residency positions was whether or not the program supplied a reading list.  There were surprisingly few that did.  This subject area would be a good example of required reading that is necessary to bring any prospective resident up to speed.

A good model to illustrate the difference between a neuroscience based approach as opposed to a symptoms based approach is American Society of Addiction Medicine (ASAM) definition of addiction on their web site.  Unlike the DSM collection of symptoms designed to pick a group of statistical outliers,  the ASAM definition correlates known addictive behaviors with brain substrates or systems.  Both of the standard texts in the field by Lowinson and Ruiz and the ASAM text by Ries, Feillin, Miller, and Saitz are chock full of neuroscience as it applies to addiction.  When I teach those lectures, I generally am talking about how medications work in addiction at that level but also how psychological and social factors work at the level of neurobiology.  I have not seen the DSM5 at this time, but I do think that it is time to move past defining every possible substance of abuse and associated syndrome and incorporating neuroscience.  Especially when the neuroscience in this case has been around for 50 years.   Residency programs need to teach that level of detail.

Psychiatrists need to maintain superior communication skills relative to other physicians and that means getting a good basic experience in interviewing and psychotherapy techniques.  At the same time - the psychiatrist of the future needs to be able to order and interpret tests including ECGs and MRI scans.  That wide skill base taxes every faculty except the very largest academic departments.  In the Internet age, there is really no reason that every residency program should not have access to the same standardized PowerPoints, lectures, and didactic material.  The ASCP Model Psychopharmacology Program is an excellent example of what is possible.  I would go a step beyond that and say that there should be a culture within organized psychiatry so that every psychiatrist should have access to the same material.  Establishing a culture where everyone (trainees and practicing psychiatrists alike) is up to speed and competent across the broad array of topics that psychiatrists need to be familiar with is a proven approach that is rarely used in medical education.

Psychiatry also needs to be focused on old school quality.  Not the kind of quality that depends on a customer satisfaction survey.  The issues of diagnostic assessment and appropriate prescribing at at the top of the list.  How do we make sure that every person consulting with a psychiatrist gets a high quality evaluation and treatment plan and not a plan dictated by a managed care company?  The University of Wisconsin has a paradigm for networking with all physicians in their collaborative Memory Clinics program.  I see no reason why that could not be extended to different diagnostic groups across the state.  The focus would be on quality assessment and to prevent outliers in terms of treatment.  It could be open to any psychiatrist who wanted to join and it could have additional benefits of providing university resources like online access to the medical library to clinicians in the field.

An interested, excited, and technically competent psychiatrist is the ultimate goal of residency and it should continue throughout the career of a psychiatrist.  That can only happen with a focus on professionalism at all levels.  My definition of professionalism does not include managing costs so that  a managed care organization can make more money.  Psychiatrists need to forget about being cost effective and get back to defining and providing the best possible care.   

George Dawson, MD. DFAPA