Psychiatrist Deans Exchange Ideas with APA on Graduate and Undergraduate Medical Education By Herbert S. Sacks, M.D. APA President

The future of our field is highly dependent upon the unexpected vicissitudes of medical education-both undergraduate and graduate. What is APA's role in education and how do we relate to medical school deans and not just the 14 psychiatrist deans who remain strongly identified with our field? The present health care financing environment has recast clinicians and affected severely the mission and infrastructure of academic health centers. Managed care's impact upon medical education has forced curriculum changes, largely undesirable, and has constrained our research establishment. Diminished access to care and reduced reimbursements have modified well-considered educational goals. Training residents on ambulatory services has become very expensive. The clinical faculty, pressed economically, are teaching less on a voluntary basis, and full-time faculty members are compelled to see more private patients to support their salary base and their departments, leaving less time allocated to teaching and research. The substantial reductions in federal funds for graduate medical education not only have impacted psychiatry but also has caused alarm in pediatrics and internal medicine. These developments, shaping workforce issues, will force a renewed examination of services to vulnerable and special-needs populations and will generate fresh approaches to problems resultant from maldistribution of psychiatrists.

The paradigm shift toward training more primary care physicians and the reduction of IMG graduate medical education slots through HCFA expansion of the New York State Demonstration Project have compelled us to reexamine the old accepted wisdom that had frozen our thinking in the years of plenty. We now have to develop new skills and roles, think about relating more effectively with organized care systems, interact more effectively with the other 23 specialties of medicine, and consider how to train residents in underutilized community outposts.

Committed to supporting clinical and health services research, APA is gratified by the increase in federal funding. In the past 14 years psychiatry enjoyed a startling 470 percent increase in awards from the National Institutes of Health. From number 10 ranked in medical school departments in receiving awards, we have soared to second place. The information explosion and the scientific advances of the past two decades have flowed from such research grants and awards.

In February I convened the Deans' Advisory Conference following upon the annual meeting of the American College of Psychiatrists. The first deans' meeting was led by former APA president Mary Jane England, M.D., two years ago in Tucson. The February meeting was graced by the presence of eight deans, an interim vice chancellor, and a vice president of a major university; APA staff, including our medical director and deputy directors for research and education; psychiatrist executives of standard-setting organizations; a small group of APA officers; a few department chairs; and the chair of our Council on Medical Education and Career Development. For a day and a half the discussion ranged broadly over the issues I headlined above. The meeting was characterized by frank and open discourse (not in the sense of how the U.S. State Department uses these terms). The expertise demonstrated was staggering, and the opportunity afforded by this conclave of psychiatric educators to inform one another about their quests for solutions, creative and often idiosyncratic, only stirred more lively exchanges, illuminating sectors previously little explored.

The topics pursued suggested APA's need to do the following:

• Collaborate with other psychiatric standard-setting and subject-linked organizations more fully. A key joint project is not only to develop a well-articulated vision of what psychiatry is, but, importantly, what it will be in five and 10 years hence.



• Devise the special requirements for psychiatry, identifying changes needed, since this process will define the psychiatrist of the future. The Residency Review Committee should receive suggestions and comments on a speedy basis from APA components, especially those under the umbrella of the Council on Medical Education and Career Development.



• Advocate for the Association of American Medical College's Medical School Objectives Project, which contains many goals consonant with the stated mission of psychiatry. Psychiatrist deans and department chairs should advance these objectives for their respective institutions, enhancing the standing of psychiatry in the overall medical school curriculum.



• Create an APA research institute to increase our credibility in health services research, provide a location for training, and separate the research and advocacy roles of the Association.



• Further develop the Practice Research Network in gathering data on psychiatric practice patterns that are directly helpful to members and provide a scientific database for advocacy.



• Clarify medical student curriculum and develop standard teaching tools, including interactive tapes that teach psychopathology and phenomenology.



• Build a federation with major organizations dedicated to education, such as the American Association of Directors of Psychiatric Residency Training, Association of Directors of Medical Student Education in Psychiatry, American Academy of Child and Adolescent Psychiatry, American Board of Psychiatry and Neurology, American Association of Chairs of Departments of Psychiatry, to develop strategic planning, avoid duplicative efforts, collaborate on important products, share a Web site.



• Expand the Program for Minority Research Training in Psychiatry.



• Be a resource for CME to prepare members for recertification.



• Advocate for true groups in academe (centralized ownership, shared practice patterns across departments), as well as well-integrated groups (academic and nonacademic) utilizing district branches.



• Support a scientific approach to psychotherapy, identifying core skills and researching total treatment packages for specific illnesses.



• Develop new approaches to residency recruitment, especially of U.S. medical graduates. Outreach programs to secondary schools and participation in undergraduate college seminars are important considerations.

In the service of continuing the exciting engagement, with staff assistance I am attempting to edit the proceedings with an executive summary, recommendations for actions, and a set of priorities that could offer guidance to APA. The advice and counsel of the deans will permit APA to influence more effectively emerging public policy in the realm of medical education and its intimate linkage to workforce, access, research, and service issues. The proceedings will stir optimism and hope in our members when they review the brilliant, incisive commentary of our leading psychiatrist deans. The deans have achieved distinction in finding innovative responses to systemic challenges faced by our field as we move into the millennium.