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Training psychiatrists for the future

2009; Wiley; Volume: 1; Issue: 3 Linguagem: Inglês

10.1111/j.1758-5872.2009.00038.x

1758-5872

Norman Sartorius,

Child and Adolescent Health

Today's teachers need to train psychiatrists who will be useful to their patients and their profession in a future that is difficult to predict. This problem – enabling people to be useful in the future – was always arduous, but has become even more risky because of the rapidity with which the world is changing. The changes include globalization, often driven by economic as well as by political motives, the “commoditification” of medicine, the decivilization of society, changes to the middle class, population growth (and its demographic changes) and rampant urbanization. Globalization was, at first, seen as an attractive change, promising a free exchange of ideas and wares, free travel from one country to another, sharing of technological advances, increased industrialization, and new market places. All this seemed to be in the offing for everyone. Globalization, however, proceeded differently. Powerful countries inundated the rest of the world with their products, and in many ways, tried to make their value systems accepted by all. Television and other means of communication became, on the whole, a one-way stream. Instead of making it easier to learn about the many cultures of the world, media often produced caricatures rather than realistic portraits of other countries. Soap operas and sensational reporting took up a good part of media's offer. The transmission of traditional cultures was already weakened by changes to households, which no longer maintained multigenerational families, and by the changing position of women who increasingly often sought employment outside of their home. The content of globalized media in this situation became more influential than it would have been had the culture been transmitted and protected in traditional ways, but the rise of vast and widely accessible forms of electronic communication served to distort this process to a “sound bite” mentality. Parts of the new pseudo-global culture were useful replacements of previous beliefs and ways of behavior, but others were not. The changes linked to globalization also had an impact on the quality of life of the vast majority of people. While the probability of starvation in many countries decreased, other reasons for lesser satisfaction with life became prominent, including the loosening of social networks, fragmentation of labor depriving all participants of the sense of having achieved something concrete, increasing complexity of administrative procedures, and uncertainty about the value of yesterday's moral prescriptions. Commoditification of medicine – a neologism that has been promoted by economists and the World Bank – refers to the position that health and health care can and should be handled as any other commodity. This position has been embraced by many, including a number of government officials, even in countries in which the formal policies and statements of the political establishment do not accept this way of seeing health. The advocates of commoditification expect that health care interventions will result in significant (financial) gains or savings and insist that both the immediate and long-term cost/benefit analysis should be given a high, if not the highest position, among criteria for the selection of health interventions. Investment into the care of people with chronic diseases who are not likely to regain working capacity would thus need to be less than the investment into the care of those who will fully recover. Care for the elderly must be provided at a low cost. In this view, the central criterion in the assessment of performance of an institution must be economic gain or at least low expenditure. It is clear that the replacement of the ethical imperative of a civilized society to help its feeble members, reduce pain, save lives, and provide support to those who are suffering from disease takes a severe beating if health care is governed by economic rules rather than by the traditional moral priorities. Ideally, the two requirements should both be satisfied: people should receive the best possible care at the lowest possible price, but it is unfortunate that increasingly often health care provision is based on its cost rather than on its adequacy and acceptability of care. Decivilization is another trend that can be observed in many countries and seems to be gaining strength. The origin of the word decivilization is connected with the notion that the level of civilization of a society can be measured by the amount of care that it offers to its feeble members: the elderly, children, sick or otherwise disabled. In the beginning of the 20th century many countries in the developed world made valiant efforts to provide adequate support to its members in distress and those who were less capable of caring for themselves. As a result, child mortality was reduced and life expectancy of the elderly was extended. A variety of measures that were to help, at least partially, rehabilitation of the disabled were established. In more recent years, the wish to speed up industrial development and to have a rapid return of investments seems to have gained the upper hand in many countries, leading to a weakening of many of the noble initiatives of the previous decades and resulting in a worsening of health and quality of life of the less able. Whether this trend can be stopped or not is an open question: it is parallel to the commoditification of many societal functions in addition to that of health and, therefore, likely to be more difficult to stop. The middle class is changing and it is possible that the changes visible today depict the direction of future trends in this respect. Over the past few decades the middle classes in the developing countries have been growing in numbers and in wealth, now comprising as much as 20% or more of the entire population. Although the percentage is still below that in the developed countries, the absolute numbers are very significant. Thus, for example, in India, the size of the middle class is estimated at more than 200 million people. The middle class has not only grown in numbers, it has also set new levels of expectation in many respects. Its size and demands have led to the development of private health care and to a partial inversion of the brain drain in that the best private institutions in the Third World now hire first-class physicians from their own countries as well as from highly developed countries. The population that has remained poor and sees the type and quality of services offered to the middle class often grows disenchanted with the primary health care services that are offered to it because it feels that it should have access to the same type of services that are offered to their more fortunate compatriots. The poor have always known that the rich have better services, but this was never as visible to them as it is today. In contrast, there are alarming reports about the shrinking of the middle class in industrialized countries, which seems to lead to other consequences, including the erosion of the moral prescriptions created by the middle class and of their enforcement. The loss of purchasing power affects self-confidence and the educational inflation – the continuous increase of minimal requirements for employment – increases the cost of education and the numbers of those who cannot afford to pay for their children's or their own extended period of education. The epidemic of burn-out among those employed (and those searching for jobs) and the growing rates of crime are also, in part, due to the reduction of the size and strength of the middle class that acted as the basic fabric of societies in most of the developed countries in the past century or more. The changes of the demographic structure of many societies as well as urbanization have profound effects on the organization of health care and on everyday life of communities. Earlier preoccupation with the growth of the numbers of the elderly has been, to an extent, stilled by the recognition that the biological limit of old age in many countries moved upward so that the numbers of elderly people (defined by their vulnerability and greater likelihood to require help from others rather than by their chronological age) remains constant. Other problems that were earlier given less attention are taking the stage now. They include the negative population growth in many countries, growing rate of divorces and continuous decrease of the length of marriages, decreasing family size and its reduced capacity to provide care for the disabled as well as growing reluctance to create families (and to invest in their duration and solidity). The prediction of the needs to which the psychiatrists of the future will have to respond is made even more difficult by the trends of change of medicine observable since a few decades ago. These include changes of medical ethics, goals of medical interventions, and relationships between doctors and their patients. Thus, for example, the patient's right to die is being increasingly often considered as an option that stands in opposition to the duty to live, which has been one of the cornerstones of medical practice. The reliance on laboratory and diagnostic apparatus combined with the emphasis on reduction of cost of care has led to care that is experienced as dehumanized and unsatisfactory, although it is incomparably more efficient than it was in the past. The recognition of the patient's assessment of their quality of life as a determinant factor in medical decisions introduced new hesitations and dilemmas, for example, concerning the treatment of severe pain by medications that lead to addiction and concerning the rejection of treatment that might be life-saving at the cost of severe physical deformation. The relationship between doctors and their patients has also undergone major changes and will undoubtedly change even further. Patients who have learned a great deal about their illness by consulting literature and the Internet often challenge their physician's decisions and suggestions, and the traditional paternalism of doctors is no longer an acceptable option for their behavior. In some countries the fear of litigation leads to arrangements of practice that make a discussion of sensitive topics impossible. The emphasis on the patient's right to make decisions about their health and their treatment clash with some cultures' customs of a full participation of families in all decisions about the patient's treatment. As the practice of medicine becomes more similar to industrial production, medicine as a vocation and partly magical practice changes to medicine as a profession often with an unnecessary transparency of treatment interventions. Burn-out syndromes previously occurring almost exclusively in departments providing care to terminally ill patients are now seen more and more frequently in other settings. Burn-out is not present only in health care personnel, it is more and more often visible in patients who survive for a long time with exhausting chronic illnesses and severe disabilities. The changes to doctor/patient relationships are to an extent complicated by the obsolescence of current strategies of health care organization. The application of the strategy of community care grows more and more difficult in urban settings where economic constraints cause cutbacks in community care and where community cohesion is weakened. The small, nuclear families increasing in numbers are less and less able to provide long-term care, both because it is difficult to reconcile the wish (and need) to work outside the home when caring for a chronically ill person at home and because the financial resources of smaller families are often modest. Governments the world over are reluctant to provide sufficient resources to families caring for patients at home and continue to expect that families will remain the main source of care for the increasing numbers of elderly and disabled persons in the community. The reliance on primary care practitioners as gatekeepers for the health system that proved useful in some countries a few decades ago is being imposed in other countries, despite considerable changes in societies and medicine. Concepts such as specialized primary health care hide the failure of introducing the general practitioner as a gatekeeper; however, a growing number of general practitioners concentrate on a field of work or a group of diseases, thus becoming specialists in the guise of general practitioners. To discuss the training of psychiatrists for the future it is necessary to define three things: first, which problems are the central responsibility of psychiatry; second, what methods psychiatry can and should use in dealing with these problems; and third, how much time is necessary to learn how to recognize problems that should be treated by psychiatrists and to treat them. Unfortunately, there is no clarity about these three definitions. Faced with the fact that there are as yet no laboratory methods to confirm the diagnosis of a mental disorder, psychiatrists have created operational definitions of mental disorders. This was a major step forward, but problems remain. The most obvious of these is the existence of “sub-threshold” disorders; that is, disorders that do not meet the criteria of a mental disorder contained in currently used classifications of mental disorders. People with such disorders contact health services and ask for help. Psychiatrists and other health workers can provide them with some help but when doing so, they are operating in an ill-defined space which those in charge of reimbursement decisions conclude could contain almost any human problem. Other problems that emerge as a consequence of the consensual nature of definitions of mental disorders include the difficulty of directing research to a well defined group of disorders. At present, the operational definitions of mental disorders rely on cluster symptoms and in some classifications, for example, that of the American Psychiatric Association, also on the presence of disability and distress. Symptoms vary with time and culture; disability depends on the setting in which the person lives and distress is a highly personal variable. These considerations are gaining acceptance and it is hoped that the revisions of the major classifications of mental disorders will take these matters into account. Defining methods of diagnosis and treatment of mental disorders is also a problem. The need to rely on recognizing symptoms on the basis of patients' accounts has been made slightly more objective by the construction of a variety of psychiatric semi-standardized and standardized methods of examination. While much objectivity is gained by the use of such methods, their application tends to hide the presence of unusual symptoms or phenomena that are not covered by the questionnaires and assessment schedules. These are sometimes disregarded, sometimes lumped into a category of “other” and sometimes presumed to be variations of symptoms included in the standardized instruments and coded there. Methods of treatment in psychiatry have, in recent times, gained some respectability, mainly by the discovery and application of medications. Most of these medications, however, are not disorder-specific, but deal with symptoms that usually appear in a number of mental disorders. Other methods of treatment of psychiatry are also by and large unspecific and a number of them are not clearly defined or operationalized. The fact that the definition of problems with which psychiatry should deal is not very clear and that many methods of psychiatry are not operationally defined makes if difficult to agree on the minimal duration of training that would be sufficient to become a specialist in psychiatry. That this is so is best illustrated by the vast variations in the duration of psychiatric training, which range from a few months to as long as 6 years or more. In this situation it might be best to define the training pragmatically, for today and for the future. This would mean that a first step to the definition of training should reflect what psychiatrists are expected to do, in addition to recognizing mental disorders and prescribing treatment for them. In a developing country, and sometimes in developed countries, the tasks of psychiatrists usually include those shown on Table 1. Postgraduate training in psychiatry in a vast majority of countries includes education about clinical work and little else. In some countries a few hours a week are given to a variety of subjects, ranging from neuroanatomy to the history of development of psychoanalysis. Psychiatrists in training are spending most of their time in clinical duties, often with little or no direct supervision. Many developed countries have introduced specific and sufficient supervision requirements, but even there, the application of these rules is not universally strict. Training and practical experience in the performance of the other tasks listed in Table 1 are usually absent. Even in clinical work, learning how to manage mental disorders in the presence of physical illness is given insufficient time and collaborative teaching involving psychiatrists and specialists in other disciplines is still an exception. In addition to the training that should aim to provide knowledge about the performance of the tasks listed above, it would be important to ensure that future psychiatrists are given the skills to carry them out and that they acquire attitudes that will make their behavior and daily work more useful and more effective. Among the skills that should be learned, communication skills are of particular importance because they will help in the performance of all the tasks of psychiatrists and can be invaluable in responding to their civic duties. While the emerging approach of competency based education attempts to address issues such as this, no country has as yet successfully implemented such an approach. Making extraordinary predictions about the distant future is a safe and easy task because it is unlikely that the prophets will be there when their predictions are verified. Predictions about the immediate future, however, are more difficult because those that have been wrong come back to haunt us much sooner than we thought possible. By extending trends visible today several predictions can be made with a fair amount of confidence. One of them is that the currently recognizable trend of dehumanization of medicine will become stronger, to the detriment of the quality of life of health personnel and a reduction of medicine's usefulness to patients. Trends such as the increased reliance on apparatus and standardized procedures that make medical interventions more efficient, as well as the reduction of the time doctors can spend with their patients, will undoubtedly continue over the next decade or so. Psychiatry and the behavioral sciences have the knowledge that could counteract the process of dehumanization and the challenge that should face future psychiatrists will be to make this knowledge available and used. The art and science of practicing psychiatry is based on human relations and it is the knowledge and skills about making these relations, about listening to patients and families and understanding their needs, that psychiatry could promote. Another trend that is observable today and likely to become more prominent in the future is that many of the people who will ask for help will suffer from more than one illness. This trend will be supported by the aging of the population and the better chances of survival when suffering from a chronic illness. The comorbidity of mental and physical illnesses is likely to become a rule rather than an exception and it will be of great importance to prepare psychiatrists facing this challenge by inculcating attitudes and providing skills and knowledge to deal with it. Psychiatrists need to be made more clearly aware that they are basically physicians and that their duties do not stop at the treatment of mental illness but extend themselves, at least, to the recognition of physical illness, if not to their treatment. The notion of replacing psychiatric services by comprehensive services that can handle the needs of people suffering from several diseases should lead to changes in the undergraduate and postgraduate training, and in the organization of service systems. How best to do this should be one of the operational research topics for the immediate future. The world will continue to change and new trends of its development will become observable. These should be followed and serve as the determinants of the postgraduate training of psychiatrists and of the organization of their services. Today's teachers of psychiatry must understand that their plans for the instruction of new graduates must reflect the current state of medicine and society's development and that they must remain sufficiently flexible to follow trends and help future psychiatrists to face and overcome challenges as they emerge. This paper was presented at the TOP (Teachers of Psychiatry) Conference in Singapore, 23 February 2009. You can view it on YouTube at: http://www.youtube.com/watch?v=7Ttm-aKACpo