Once the psychiatric resident completes the primary care and neurology rotations, he will start to work on psychiatry inpatient units. Typically, the resident works with an attending psychiatrist and sees 7 or 8 patients daily. Attending psychiatrists must see the patient and play a key role in the patient’s treatment or they cannot bill for their services. This is a change from 20 to 40 years ago, when the resident was the only doctor to see the patient.
Today, the resident and the attending psychiatrist make a joint diagnosis and work with other members of the team, such as a nurse and a social worker, to develop a treatment plan. Frequently, the only role for the resident is for the medication treatment of the patient. The resident may participate in family interventions, but work with the patient’s family is usually left to the social worker. Because of the rapid turnover of inpatients (5 to 7 days on average), psychotherapy is usually not an important part of the treatment. Stabilization with medications and group therapy are the core of the treatment. In the course of his rotation, the resident may see more than 300 patients. Once a patient is discharged, the resident is often unable to follow up with him and does not know the outcome of the treatment unless a patient is readmitted.
At the end of the rotation, the resident can perform diagnostic assessments, work with others to develop a treatment plan, and direct the medication management of a patient. The resident may not, however, be knowledgeable about the extended impact of the medication on the patient.
The resident may then move on to a psychosomatic medicine rotation for 2 months, consulting on patients in medical or surgical units. The resident’s primary responsibility is to make a quick diagnosis and propose a rapid intervention in conjunction with the medical or surgical team and nursing staff. During the supervised consultations, the resident participates in a psychiatric subspecialty, where he may be more of an observer than an active participant. Once again, because of today’s short duration of hospital stays, the resident has limited knowledge of the outcome of his treatment interventions.
On child psychiatry rotations, the resident’s active role in working with children may be limited. The resident functions primarily as an observer. Clinical work is usually heavily supervised and observed. A similar experience may occur on a 2-month rotation in geriatric psychiatry.
In most residencies, outpatient work is a minimum of 12 months in the resident’s third year. The resident is given diverse supervised responsibilities and is required to develop abilities in a number of psychotherapies, including dynamic psychotherapy. Residents generally have between 3 and 5 dynamic psychotherapy cases at a time. If we assume each patient is in treatment an average of 4 months, the resident could have between 12 and 15 patients in psychotherapy during the course of the year. Many of these patients would also be taking medication, and a significant number of other patients would be seen only for medications.
Residents can quickly demonstrate in formats constructed by their teachers that they can perform a number of tasks. However, on their own—outside of their residencies—their skills may be limited. One masters an art by the repetition and learning about oneself and one’s abilities. Unfortunately, in many residency programs, the only activity that the psychiatric resident is able to master in this fashion is in prescribing medication. Experience with a handful of patients in dynamic psychotherapy may not be adequate for the resident to feel that he has mastered psychotherapeutic skills. It is not surprising that on graduation, many residents pursue a career in which their main role is medication management.
Many of today’s residencies reinforce mastering only the art of applying knowledge of the biology of behavior, which informs the use of medications. The unanswered question is, can modern clinical psychiatry survive if training programs provide clinical experiences that may produce expertise in only one of psychiatry’s core disciplines?
Residents must be given adequate time during their training to learn and incorporate the psychological and social elements critical to being a psychiatrist. If psychiatry reduces or abandons its engagement with psychology and social science in understanding and treating mental disorders and focuses predominantly on the biological factors of mental disorders, what will our role as psychiatrists be? Other physicians may assume the responsibility for medicating patients with mental disorders, and others may take on the role of integrating the biological, psychological, and social forces that have an impact on behavior.