Scientific Authors in a Changing World of Scholarly Communication: What Does the Future Hold?

Scholarly communication in science, technology, and medicine has been organized around journal-based scientific publishing for the past 350 years. Scientific publishing has unique business models and includes stakeholders with conflicting interests-publishers, funders, libraries, and scholars who create, curate, and consume the literature. Massive growth and change in scholarly communication, coinciding with digitalization, have amplified stresses inherent in traditional scientific publishing, as evidenced by overwhelmed editors and reviewers, increased retraction rates, emergence of pseudo-journals, strained library budgets, and debates about the metrics of academic recognition for scholarly achievements. Simultaneously, several open access models are gaining traction and online technologies offer opportunities to augment traditional tasks of scientific publishing, develop integrated discovery services, and establish global and equitable scholarly communication through crowdsourcing, software development, big data management, and machine learning. These rapidly evolving developments raise financial, legal, and ethical dilemmas that require solutions, while successful strategies are difficult to predict. Key challenges and trends are reviewed from the authors' perspective about how to engage the scholarly community in this multifaceted process.

The Education Review Board: A Mechanism for Managing Potential Conflicts of Interest in Medical Education

Concerns about the influence of industry support on medical education, research, and patient care have increased in both medical and political circles. Some academic medical centers, questioning whether industry support of medical education could be appropriate and not a conflict of interest, banned such support. In 2009, a Partners HealthCare System commission concluded that interactions with industry remained important to Partners' charitable academic mission and made recommendations to transparently manage such relationships. An Education Review Board (ERB) was created to oversee and manage all industry support of Partners educational activities.Using a case review method, the ERB developed guidelines to implement the commission's recommendations. A multi-funder rule was established that prohibits industry support from only one company for any Partners educational activity. Within that framework, the ERB established guidelines on industry support of educational conferences, clinical fellowships, and trainees' expenses for attending external educational programs; gifts of textbooks and other educational materials; promotional opportunities associated with Partners educational activities; Partners educational activities under contract with an industry entity; and industry-run programs using Partners resources.Although many changes have resulted from the implementation of the ERB guidelines, the number of industry grants for Partners educational activities has remained relatively stable, and funding for these activities declined only moderately during the first three full calendar years (2011-2013) of ERB oversight. The ERB continually educates both the Partners community and industry about the rationale for its guidelines and its openness to their refinement in response to changes in the external environment.

The development, implementation, and assessment of an innovative faculty mentoring leadership program

Effective mentoring is an important component of academic success. Few programs exist to both improve the effectiveness of established mentors and cultivate a multispecialty mentoring community. In 2008, in response to a faculty survey on mentoring, leaders at Brigham and Women's Hospital developed the Faculty Mentoring Leadership Program as a peer learning experience for midcareer and senior faculty physician and scientist mentors to enhance their skills and leadership in mentoring and create a supportive community of mentors. A planning group representing key administrative, educational, clinical, and research mentorship constituencies designed the nine-month course.Participants met monthly for an hour and a half during lunchtime. Two cofacilitators engaged the diverse group of 16 participants in interactive discussions about cases based on the participants' experiences. While the cofacilitators discussed with the participants the dyadic mentor-mentee relationship, they specifically emphasized the value of engaging multiple mentors and establishing mentoring networks. In response to postsession and postcourse (both immediately and after six months) self-assessments, participants reported substantive gains in their mentoring confidence and effectiveness, experienced a renewed sense of enthusiasm for mentoring, and took initial steps to build a diverse network of mentoring relationships.In this article, the authors describe the rationale, design, implementation, assessment, and ongoing impact of this innovative faculty mentoring leadership program. They also share lessons learned for other institutions that are contemplating developing a similar faculty mentoring program.

Poor intentions or poor attention: misrepresentation by applicants to psychiatry residency

OBJECTIVE

This study examines the veracity of self-reported data by applicants to psychiatry residency.

METHODS

The authors reviewed the reported publications of all applicants to a psychiatry residency training program over a 2-year span.

RESULTS

Nine percent of applicants reporting publications were found to have misrepresented them. International medical graduates were found to be more likely to have misrepresented their publications than U.S. medical graduates.

CONCLUSION

A small but significant number of applicants to psychiatry residency training misrepresent their publications. Identification of misrepresentation may provide valuable information about the applicant and their future performance in training and practice.

Getting our own house in order: improving psychiatry education to medical students as a prelude to medical school education reform

OBJECTIVE

The authors summarize efforts to revitalize psychiatry teaching to medical students at Harvard Medical School (HMS) in advance of a major overhaul of the medical school curriculum.

METHODS

This preliminary report chronicles key challenges and the organization of the reform effort within the departments of psychiatry affiliated with the medical school.

RESULTS

Based upon a comprehensive internal review of psychiatric education at the medical school, the HMS Psychiatry Executive Committee and psychiatry faculty concluded that psychiatry teaching was underresourced and lacked cohesion and consistent standards and expectations across clinical sites involved in psychiatry teaching. Through a willingness to identify and vigorously address deficiencies in medical student education within a large decentralized program, psychiatry has earned a reputation as an effective reform agent at the medical school.

CONCLUSIONS

Psychiatry education improvements have strengthened our partnership with the medical school as it is undertaking major educational reform of its entire curriculum.

Predictors and outcomes of delirium

OBJECTIVES

To determine factors associated with the occurrence of delirium among patients undergoing surgical repair of abdominal aortic aneurysm (AAA).

METHODS

The sample included all consenting patients who underwent AAA repair during a 12-month period. Before surgery, daily while in hospital, and at 1 and 6 months after surgery, we assessed patients' mood, mental status and functional status. We compared delirious and nondelirious patients for severity of preoperative depressive symptoms, length of hospital stay and mortality. The effects of delirium on postoperative functional status were assessed in conjunction with postoperative depressive symptoms using regression models.

RESULTS

The sample of 35 patients was primarily male and elderly; one-quarter had three or more medical conditions; and eight (23%) developed delirium after surgery. Postoperative delirium was significantly associated with preoperative depressive symptoms, alcohol use and cognitive impairment as well as with longer lengths of stay and poorer functional status at 1 and 6 months after surgery.

CONCLUSION

Identification and treatment of patients with depressive symptoms, alcohol use and cognitive impairment prior to AAA surgery could reduce the incidence of postoperative delirium and the prolonged hospital stays and impaired functional status associated with it. Surgeons should consider using simple screening instruments before surgery to identify patients at risk and referring them for psychiatric evaluation and treatment. They should also consider including psychiatrists early in the care of high-risk patients to improve detection of and early intervention for delirium.

Nonspecific medication side effects and the nocebo phenomenon

Patients taking active medications frequently experience adverse, nonspecific side effects that are not a direct result of the specific pharmacological action of the drug. Although this phenomenon is common, distressing, and costly, it is rarely studied and poorly understood. The nocebo phenomenon, in which placebos produce adverse side effects, offers some insight into nonspecific side effect reporting. We performed a focused review of the literature, which identified several factors that appear to be associated with the nocebo phenomenon and/or reporting of nonspecific side effects while taking active medication: the patient's expectations of adverse effects at the outset of treatment; a process of conditioning in which the patient learns from prior experiences to associate medication-taking with somatic symptoms; certain psychological characteristics such as anxiety, depression, and the tendency to somatize; and situational and contextual factors. Physicians and other health care personnel can attempt to ameliorate nonspecific side effects to active medications by identifying in advance those patients most at risk for developing them and by using a collaborative relationship with the patient to explain and help the patient to understand and tolerate these bothersome but nonharmful symptoms.

Somatic symptom reporting in women and men

Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

Somatic symptom reporting in women and men

Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

Psychiatric symptoms and medical utilization in primary care patients

In two studies, the authors evaluated the impact of psychiatric disorders on medical care utilization in a primary care setting. In the first study, 526 consecutive patients in a teaching hospital primary care practice completed the 18-item RAND Mental Health Inventory to identify clinically significant depression and/or anxiety and a questionnaire about the use of psychiatric treatment and psychoactive medications. The medical utilization of those patients defined as depressed and/ or anxious was compared with those defined as not depressed and/or anxious. Patients identified as depressed and/or anxious reported significantly increased medical utilization, but this was not confirmed by the hospital's computerized record system. In the second study, the authors analyzed medical care utilization for the years before and after the first outpatient psychiatry appointment of a sample of 91 patients referred from the same primary care practice to the hospital's outpatient psychiatry clinic over a 1-year period. In both studies there was not a statistically significant difference in medical utilization among those patients receiving psychiatric treatment. The findings demonstrate the difficulties in examining cost offset in a primary care population and raise questions about it as a realistic outcome measure of the effect of psychiatric treatment.

Functional somatic syndromes

The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one's condition is likely to worsen; the "sick role," including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.

Somatization and medicalization in the era of managed care

Somatization, the reporting of somatic symptoms that have no pathophysiological explanation, appears to be increasing as sociocultural currents reduce the public's tolerance of mild symptoms and benign infirmities and lower the threshold for seeking medical attention for such complaints. These trends coincide with a progressive medicalization of physical distress in which uncomfortable bodily states and isolated symptoms are reclassified as diseases for which medical treatment is sought. Somatization and medicalization are likely to become more problematic in the era of managed care. Under capitation, providers will have greater incentives to reduce utilization, and somatizing patients may feel forced to express their "disease" in more urgent and exaggerated terms in order to gain access to the physician. In addition, prepaid subscribers will suffer little financial disincentive to seek medical attention for relatively minor complaints; therefore, they are likely to increase the demand for physician consultation. This situation suggests an urgent need to improve the management of somatizing patients. Innovative consultative, behavioral, and educational interventions are now available. In addition, medical professionals should greet the process of medicalization with considerable caution and educate the public more about the normative presence of symptoms and bodily distress in healthy people. Additional research is needed into somatization and its relationship to the demand for medical care. In an era of managed care, increased attention should be devoted to understanding and controlling the demand for care, a large portion of which is symptom driven.

Long-term outcome of state hospital patients discharged into structured community residential settings

OBJECTIVE

This longitudinal study examined various dimensions of the lives of patients with chronic mental illness immediately before and again several years after their discharge from a state hospital into well-staffed structured community residential settings.

METHODS

Fifty-three patients with chronic mental illness and long histories of hospitalization were evaluated shortly before their state hospital discharge using a comprehensive structured assessment of nine dimensions of functioning and symptomatology. A follow-up assessment was undertaken a mean of 7.5 years after discharge into four structured group home settings.

RESULTS

At follow-up, 57 percent of the patients continued to live in structured community residential settings, 28 percent had moved on to independent living, and 16 percent had returned to an institutional setting. Fifty-five percent needed hospital readmission, but the total sample spent only 11 percent of the time after discharge in the hospital. At follow-up, patients showed significant improvements in cognitive and social functioning, and 94 percent expressed a preference for life in the community.

CONCLUSIONS

Many patients discharged to structured community residential settings seem to prefer them to the state hospital, are able to graduate to independent settings, and show improvement in important dimensions of functioning after several years in the community. Other dimensions seem resistant to change despite the structure and support afforded by residential settings.

Economics and psychiatric education: the irresistible force meets the moveable object

Recent changes in health care delivery and financing threaten the traditional funding base for psychiatric education. These changes are disrupting the often-tenuous "critical balances" in psychiatry residency, weighting them toward greater provision of services and less training, education, autonomy of practice, and time for personal needs. Three strategies for adapting creatively to the new fiscal and organizational realities in health care are described: decreasing the number of residents and residency-training programs, rethinking the content of residency so that it provides training for the practice realities of the twenty-first century, and marketing the quality and cost-effectiveness of academic psychiatry systems better in a managed care environment.

Teaching and learning psychiatry

This article reviews the teaching-learning process in psychiatry. It describes eight attributes of a successful teacher, suggests ways that psychiatrists may improve their teaching skills, and delineates four stages (exposure, incorporation, integration, and mastery) of the learning process that have implications for how and what we teach. Methods to evaluate teaching rigorously so that it can be academically rewarded are described. At a time when the place of the psychiatric teacher in the academic medical center is precarious and often discouraging, the author discusses sources of support from students, fellow faculty, and national colleagues that can help sustain teaching in, and teachers of, psychiatry.

Teaching psychiatric residents to teach

Teaching other residents and medical students is one of the primary activities of psychiatric residents, yet most receive minimal or no formal training or supervision on how to teach. This report describes a Teaching Day Workshop, designed and implemented by residents at the Massachusetts General Hospital with the support of their faculty and an educational consultant, as one model to introduce the concepts and techniques of teaching to psychiatric residents. The participating residents were unanimous in their positive appraisal of the workshop, and they recommended that additional seminars on teaching be integrated into the residency's core curriculum. Ways that the Teaching Day Workshop can be adapted for use by other residency training programs are discussed. The authors believe that teaching residents to be better teachers can have an impact on recruitment of medical students into psychiatry and psychiatric residents into careers in academic psychiatry.

A survival guide for psychiatric residency training directors

This paper catalogues the inevitable problems that beset training directors and describes coping strategies designed to improve the likelihood of the training director's survival and the quality of his or her life. The difficulties of the job include picking residents, struggling to assure that the faculty provides decent teaching programs, contending with repetitive bureaucratic details, being overloaded by numerous tasks, and warily watching as residents who somehow squeaked through the program are sent off on their own. Offsetting the hassles are the exciting jobs of picking residents, guiding the faculty in setting up teaching programs, keeping a complicated program running, mastering numerous challenges, and watching with satisfaction as new, competent psychiatrists graduate.

Child psychiatry fellowship training: a crisis in recruitment and manpower

Eighty-three percent (104 of 126) of the accredited child psychiatry fellowships in the United States responded to a survey of current manpower and training problems facing child psychiatry. Thirty-five percent of the respondents were having trouble filling their classes with highly qualified fellows, and 45% were having difficulty recruiting faculty child psychiatrists. Other significant problems included developing faculty interest in research, providing didactic seminars in new areas such as developmental neurobiology and infant psychiatry, and funding fellow and faculty positions and research. The authors examine this crisis in manpower, recruitment, and training and suggest solutions on local and national levels.

Looking back, moving ahead

This issue marks an important transition for Academic Psychiatry. As we assume editorship, we wish to acknowledge our debt and gratitude to the vision, persistence, and hard work of the journal's founding editor-in-chief, Dr. Zebulon Taintor.

Developing minimal national standards for clinical experience in psychiatric training

There are no minimum standards for the clinical training of psychiatrists with regard to the type and number of patients evaluated or treated. Interest in establishing such standards derives from a need for greater accountability, a high fail rate on the clinical portion of the American Board of Psychiatry and Neurology examinations, and an increasing demand for precise documentation of competence in specific areas by hospital privileging committees. Although considerable disagreement exists as to what the overall requirements should be, some minimum requirements can be agreed on. The authors discuss concerns about minimal standards and make suggestions for further development of standards.

Primary health care providers' recognition and diagnosis of mental disorders in their patients

Primary care physicians and nurse practitioners are the initial casefinders of mental health problems and major providers of mental health treatment in the United States. However, past studies suggest that such primary care providers often neither recognize nor correctly diagnose their patients' mental disorders. This study compared an HMO's primary providers' direct assessments of the current emotional disorders of patients just seen for an outpatient medical visit with those of mental health professionals assessing the same patients with the Structured Clinical Interview for DSM III R (SCID). Using the SCID-derived diagnosis as the standard, the primary providers failed to recognize almost two-thirds of their patients with a current mental disorder. Although confident in their assessments, the primary providers were also able to correctly identify very few of the specific mental disorders most prevalent in primary medical care practice; they identified only one of the seven depressions, three of the 18 anxiety disorders, and none of the four alcohol or drug abuse disorders. Reasons for these diagnostic discrepancies, comparisons with past studies, and training to improve primary providers' diagnosis of mental disorders in their patients are discussed.

[Identifying mental health service needs of persons with schizophrenia]

The present study aimed to identify the needs and describe the use of twenty mental health services in a population of chronic schizophrenic patients living in two regions in Quebec (Estrie and Centre-Sud). An attempt was also made to determine the principal reasons for which some services were not being used when they were identified as clinically required. The population considered was composed of the patients (N = 88) who had been discharged from the psychiatric care units of five general hospitals over a period of five months in 1982, and for whom the attending psychiatrist could confirm with certainty a diagnosis of chronic schizophrenia in accordance with the criteria of DSM-III. Medical files of these patients were reviewed, and the patients and psychiatrists themselves were interviewed separately regarding the patients' needs and use of twenty mental health services over the period from the seventh to the twelfth month after discharge from hospital. Results of the study show that services which were most often identified as clinically required were: 1) taking of neuroleptics, 2) organization of leisure activities, 3) case management, and 4) individual supportive therapy. At the same time, results indicate a poor fit between needs and use for most of rehabilitation and psychosocial services. The main reasons for non-use of services which were identified as clinically required are also presented. The implications of these results for the organization of mental health services for persons suffering from chronic schizophrenia are discussed, especially the importance of case management services.

Are we training too many psychiatrists?

In contrast to the past decade's concerns about an undersupply of psychiatric manpower, the authors point out that the profession may soon be facing the prospect of an oversupply of psychiatrists. Given the present rate of producing psychiatrists, shifts in demands for psychiatric services, changing payment and access patterns regarding specialty medical care, increasing numbers of nonpsychiatrist mental health professionals, and a probable surfeit of primary care physicians, underemployment of psychiatrists may become commonplace. Future psychiatrists will likely be used more as consultants, and the profession will need fewer, but better trained, graduates. The authors present alternative proposals to deal with service needs related to such reductions.

Performance of screening and diagnostic tests. Application of receiver operating characteristic analysis

Evaluation of psychiatric screening and diagnostic tests has benefited from the application of sensitivity, specificity, the kappa-statistic, and predictive values. These measures derive their meaning from a single criterion threshold. Receiver operating characteristic (ROC) analysis extends assessment of test performance by providing information about all possible pairs of achievable sensitivity and specificity values. The ROC analysis offers a comprehensive means for comparing different tests or different scoring procedures for one test. As a demonstration we used the ROC analysis to evaluate three types of scoring rules for one psychiatric test, the Health Opinion Survey. The demonstration indicated that ROC analysis can profitably take a place among the standard methods for test evaluation in psychiatric research. In addition, ROC analysis can assist clinicians in selecting appropriate test procedures for particular patient populations.

The influence of newspaper reports on outbreaks of mass hysteria

A previous study suggested that newspaper reports contributed to the generation and propagation of a recent epidemic of "mysterious gas poisoning" among Arab schoolgirls. To further explore the role of the press in mass hysteria, the authors reviewed newspaper reports related to two separate outbreaks of hysteria among schoolchildren. Despite extensive coverage of both epidemics, only one questionably related new outbreak and no relapses of illness in the original settings occurred following these reports. The variable influence the media may have on mass hysteria and the multitude of other factors that can affect such outbreaks are discussed.

A reexamination of the psychiatric resident's experience in the general hospital

The authors discuss three phases of psychiatric residency training: the beginning psychiatry training syndrome, the professional and psychologic changes associated with the second year, and the senior resident year, characterized by transition to practice issues. Since most residency training experiences occur in general hospital settings, it is imperative that general hospital psychiatrists be aware of the professional and emotional changes that residents experience as they move from inpatient to outpatient settings and assume more administrative responsibilities in departments of psychiatry. The authors recommend preventive steps that residency training directors in general hospitals might take to reduce residents' adverse emotional responses to stresses associated with each training period in the general hospital.

Ongoing evaluation in psychiatry: the first step toward quality

Concern about quality control in psychiatric training has been heightened by the lack of standardized assessment within residencies to ensure that graduates reach a level of competence commensurate with the ability to practice independently and the high failure rate on the American Board of Psychiatry and Neurology examination. An APA task force explored the paucity of evaluation of both training programs and residents and made 10 recommendations for improving the quality of residency training. The authors describe the evaluative components of these recommendations and the political steps taken to gain professional consensus for their requirement in all training programs.

The 'offset effect' of mental health treatment on ambulatory medical care utilization and charges. Month-by-month and grouped-month analyses of a five-year study

The five-year ambulatory medical care experience of 400 patients with mental disorders was studied to test the "offset" hypothesis that patients receiving timely mental health specialist treatment have lower subsequent utilization of, and charges for, care than patients not receiving such specialist treatment. Specialist treatment was associated with significant offset savings in utilization and charges for the non-psychiatric medical care of treated patients with either severe or less severe mental disorders. However, the visits and charges for such specialist treatment boosted the overall (nonpsychiatric plus mental health specialist) care utilization and charges of the specialist-treated patients above those of patients treated solely by their nonpsychiatric physicians; this overall increase was especially pronounced for patients with severe mental disorders. The findings suggest the need for randomized prospective offset studies comparing utilization, cost, and clinical outcomes.

Consumer evaluation of a community mental health service, II: Perceptions of clinical care

Using patient self-report and therapist questionnaires, the authors investigated the perceptions of patients at a community mental health service about several aspects of their clinical care: what they expected from treatment, what they found helpful about treatment, how they thought treatment could be improved, their therapist preferences, and their perceptions of their treatment outcome. The patients' desire for advice and the perceived helpfulness of the advice given in therapy, the patients' limited preference for a therapist of their own ethnicity, and other findings are discussed, as is the usefulness of such consumer evaluations in mental health care delivery.

Strangers bearing gifts: a retrospective look at the early years of community mental health center consultation

Many early community mental health center (CMHC) consultations floundered when consultants attempted to apply Gerald Caplan 's community consultation theory, which the author describes as based on a private consultation paradigm, to the very different realities of government-mandated public paradigm consultation by CMHCs to public agencies. CMHC consultants were often perceived by consultees as "strangers bearing gifts" due to the lack of clarity concerning the rationale, contracts, roles, responsibilities, evaluation, and consultant- consultee exchanges of their public paradigm consultations. The otherwise disastrous recent losses of financial support for CMHCs are beneficially forcing them to shift their community consultation practices toward the private paradigm.

Marital and family therapy for troubled physicians and their families. A bridge over troubled waters

Because individual therapy for troubled physicians has been notoriously difficult and often ineffective, we report our experience using a treatment--marital therapy--newly applied to such problems in the medical community. The sample involved 13 male physicians and their spouses with emotional difficulties in themselves and/or their relationships. After marital treatment, there was substantial improvement in more than 92% (12/13) of the physicians, their spouses, and/or their marital relationships.

Teaching residents the administrative aspects of psychiatric practice

As the trend toward the organization and bureaucratization of professional practice increases, psychiatrists will require a better understanding of the administrative aspects of their practice. However, a survey of the American Association of Directors of Psychiatric Residency Training indicated that less than one-third of residency programs currently require core training in this area. The author presents a curricular blueprint that specifies learning objectives and a series of graduated training experiences over the course of residency in which essential teaching about the administrative aspects of psychiatric practice can be provided.