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Under the varied pressures of decreasing recruitment of American medical school graduates into psychiatry, the thrust of health care policymakers to decrease the production of specialist physicians, and financial cutbacks for training by hospitals, universities, and governments at all levels, many psychiatric training programs are considering downsizing or have already implemented plans to do so. The authors describe the motivations, early experiences, anticipated concerns, and thoughts regarding downsizing obtained from interviews or questionnaires provided by 17 programs in 1993. On the basis of the authors' experiences, some recommendations are offered for the many programs likely to deal with this issue in the future.

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Much of the literature on resident moonlighting has been editorial in nature. Very little information on psychiatric residents' moonlighting practices and attitudes exists. The authors developed an instrument that was mailed to survey the chief residents of all 203 Accreditation Council for Graduate Medical Education-approved psychiatry residencies, with 137 (67.5%) programs responding. According to the responses, the percentage of residents moonlighting increased with each successive year of training, with an average of 31 hours per resident per month. The two major reasons given for moonlighting were payment of living expenses (58%) and repayment of student loans (24%). No supervision was provided to 22% of the moonlighting residents. Only 10% of the programs proscribed moonlighting by their residents. To better assess the positive and negative effects of moonlighting, it is time to truly monitor and guide the moonlighting experience for both residents and their programs.

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The author describes his two years of experience as a physician reviewer for two managed care companies. With case examples, he illustrates how the training process and his early activities as a reviewer increased his awareness of the need for accountability in psychiatric practice. He describes several issues that he had to clarify before he felt comfortable in the reviewer's role. Among them were the need for psychiatrists to practice more crisis intervention; the difference between intensive treatment and 24-hour inpatient care; the need to find alternative solutions to situations in which patients are hospitalized for social or logistical reasons; the need for careful discharge planning; and the need to recognize and deal with the adversarial relationships that develop with colleagues whose cases are reviewed. The author offers a typology of the interactions that occur between physician reviewers and attending psychiatrists. He concludes that reviewing may have both salutary and detrimental effects on psychiatric practice.

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Self-directed learning has been identified as an essential element of professional development. In this approach, students receive in advance a complete set of objectives and didactic knowledge (cognitive) learning materials, are provided opportunities to develop skills with actual or simulated clinical experiences, and adapt a broad and flexible array of educational media to their individual learning styles. In the development of a self-directed psychopa-thology course for second-year medical students, the authors incorporated four modifications to the traditional lecture and small group (faculty-directed) approach: 1) independent (self-directed) learning with no prescribed study times or sequence to the material, 2) use of student and facult y-directed interviews of patients, 3) greater freedom for selecting teaching methods in small groups, and 4) elimination of formal lectures. The authors describe the educational results with such an approach.

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"Balance" has become the watchword of psychiatry programs. It seems that almost all residency training programs claim to be balanced. But what do we mean by this term? This article summarizes the author's evolving thinking about what makes for a balanced program and suggests that diversity may be a better term. The author advocates that balance is not as simple as teaching both psychodynamics and biological psychiatry. Instead, it entails a considered, intellectual approach that involves long-term vs. other psychotherapies, neuro-science vs. psychopharmacology, theoretical pharmacology vs. practical pharmacology, social psychiatry vs. treating minority patients, representing all viewpoints in psychiatry vs. integrating them.

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In this pilot study, the authors examined faculty responses to a proposed new evaluation form for residents. Because past research on priorities for psychiatric residency curricula have depended on direct surveys, previous findings may represent auricular ideals instead of what faculty actually evaluate. The goal of the study was to draw inferences about priorities in psychiatric education by studying what components (knowledge, skills, and attitudes) of a psychiatry residency that faculty are willing to spend their time evaluating. The responses were grouped by agreement about whether the item 1) could be evaluated on their site, 2) could be evaluated during psychotherapy supervision, 3) should be combined with other items, and 4) should be eliminated. The results showed much agreement about which items to include and little agreement about which ones to exclude. Fundamental psychiatric skills and attitudes were rated as most important, and there was widespread interest in a diversity of knowledge, skills, and attitudes that psychiatric residents should possess. The authors found this method, which could be easily applied to other programs, useful in setting auricular priorities.

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PURPOSE: To examine the relationship between preclinical medical school course examinations and critical-thinking skills by correlating examination results with the Watson-Glaser Critical Thinking Appraisal (WGCTA), an 80-item critical-thinking inventory. METHOD: The 196 students in the class of 1993 at the University of Texas Southwestern Medical Center at Dallas Southwestern Medical School were given the WGCTA during the second half of their freshman year. A composite WGCTA score and five subtest scores were calculated for each student. The course examinations were 25 tests, each with a majority of multiple-choice items, from courses given during the first two years of the school curriculum. The students' undergraduate grade-point average (GPAs), medical school GPAs, and Medical College Admission Test (MCAT) scores were also included in the analysis. Pearson product-moment correlations were calculated between the students' WGCTA scores and their examination scores, MCAT scores, and GPAs. RESULTS: Sixteen of the examinations--in the behavioral sciences, psychiatry, ethics, pathology, introduction to clinical medicine, genetics, endocrinology, and cell biology--had significant positive correlations with the WGCTA, as did MCAT scores and first-year GPAs. Correlations were more robust with the WGCTA subscales for interpretation (18 examinations), evaluation of arguments (15), and deduction (13), and less robust with the subscales for inference (7) and recognition of assumptions (3). CONCLUSIONS: The results suggest that objective multiple-choice examinations can at least partially reflect critical-thinking skills.

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Educators often find it difficult to identify variables that accurately assess the knowledge that residents have gained due to their training. Recently in professional education circles, attention has shifted from process to outcome variables, with more emphasis being placed on student gains rather than on program resources. A methodology used extensively to assess undergraduate education is the value-added approach. This methodology is often demonstrated by a change in scores from two administrations of a test instrument that measures students' specific knowledge or aptitudes. Residency training programs that offer standardized examinations to their residents are in a good position to utilize this evaluation technique. This article will demonstrate how the value-added technique can be used to demonstrate cognitive growth in psychiatric residents by using the Psychiatry Resident In-Training Examination.

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OBJECTIVE: The authors sought to determine whether 20 years of cultural change have altered the clinical lore and earlier findings that Mexican-Americans are more resistant to psychotherapy than other ethnic groups and less likely to be referred for it. METHOD: All charts of patients seen on a university hospital psychotherapy service since its inception in 1979 were reviewed in three separate studies. The charts of all cases closed as of 1984, the charts of all active patients during 1985, and the charts of all patients screened for therapy in 1986 were included. Ethnic background, age, sex, education, income, treatment modality recommended, duration of therapy, and outcome (interrupted versus completed therapy) were recorded for each patient. RESULTS: There were minor significant differences between the Mexican-American patients and the Anglo-American patients in age and education. No other significant differences were found. CONCLUSIONS: Because of cultural change, altered psychiatric perspectives, and/or the effects of socioeconomic status as a confounding variable in previous studies, the accepted clinical lore and earlier findings about psychotherapy with Mexican-Americans may no longer apply.

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OBJECTIVE: The aim of this study was to explore the behavior of psychotherapy supervisors by using the Psychotherapy Supervision Inventory. METHOD: The authors used the Psychotherapy Supervision Inventory to rate 53 videotaped supervision sessions of 34 different supervisors. They also used the variable of the rater's perception of the excellence of the supervisor as a teacher. The data were subjected to a cluster analysis and a K-means analysis. Discriminant function analyses were applied to the comparison of the behavior of 19 supervisors with two different residents and the behavior of all 34 supervisors with residents in three different years of training. The relationship between rater-perceived excellence and Psychotherapy Supervision Inventory scores was analyzed by using stepwise multiple regression. RESULTS: There was a high level of agreement among the four raters' judgments of supervisors' excellence. Empathy accounted for 72% of the variance in rater-perceived excellence and focus on the therapist accounted for an additional 5%. When empathy was dropped from the equation, experiential orientation accounted for 60% of the variance in ratings of excellence, clarification and interpretation accounted for an additional 16%, and depth accounted for another 3%. CONCLUSIONS: In the context of established relationships, supervisors have stable behavior patterns. Rater-perceived excellence is related to the supervisor's focusing on the resident's immediate experiences and making many synthesizing comments in depth. The Psychotherapy Supervision Inventory can be used to orient supervisors to supervision and provide feedback about their behavior.

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Psychiatric practice involves complex thinking patterns. In addition to commanding a huge number of facts, the student must learn to manipulate factual knowledge to solve diagnostic problems, develop treatment plans, and critically evaluate those plans. This study demonstrates an empirical method for evaluating the level of cognitive processes tested in multiple choice examinations. Use of Bloom's taxonomy in evaluating test items demonstrated the majority of test items on a psychiatry clerkship examination and a resident in-training examination fell into the most basic cognitive level, that of simple recall. The utility of Bloom's taxonomy is discussed along with implications for medical education.

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Ninety-six patients requesting psychotherapy were studied prospectively at the time of screening interview by four senior psychiatrists using a variation on Luborsky's Helping Alliance questionnaire and the Osgood Semantic Differential. Significant differences were found at the time of screening between early dropouts and continuers, among screeners' rate of early dropouts, and among patients' perceptions of screeners. The screener with a high early dropout rate was seen as being more passive and less potent, and offering less new understanding than other screeners. Patients who dropped out early experienced a less strong helping alliance, felt they gained less new understanding, liked the clinician less well, felt less well liked and less respected, and saw the interviewer as more passive and psychotherapy as less potent than did continuers.

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There is uncertainty about the future role of psychodynamic psychotherapy in psychiatric practice and education. The Association for Academic Psychiatry and the American Association of Directors of Psychiatry Residency Training formed a joint task force to review the issue. It developed a rationale for continued training in expressive psychotherapy and a model curriculum for such training that is both effective and realistic in terms of the diverse demands and structures of modern residencies. A minimum curriculum was also designed for resource-poor programs.

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