Discussion of Lawrence S. Cubie's Article, Reflections on Training

Dr. Kubie's “Reflections on Training” are written in his usual clear and incisive style. This has its risks for the reader, because the author is so logical and persuasive that one finds oneself agreeing with him too readily.

Kubie says, “The sequence of steps in training for psychiatry should be completely reversed and the content changed. The young doctor should first learn about neurotic illness before he deals with the psychoses.” I am in complete agreement. My own training is testimony to my views. I came at psychiatry from internal medicine by way of analysis and dealing with neurotic patients and believe it helped me understand psychotic patients more readily than I would have had I followed the more conventional route.

I am not wholly persuaded that the psychosis precipitates out of the neurotic process under stress, but this point need not be argued here. I concur with Kubie's belief that a young psychiatrist should begin his training where he can observe some of those early deviations from normal which can lead to neurotic illness. This subsumes the presence on pediatric wards, nurseries and adult medical wards of people capable of instructing young psychiatrists. Of course, there should be such. In my own clinical teaching I constantly find that a medical or surgical ward of a general hospital offers superb material for demonstrating neurotic disturbances.

The suggestion that such a complete reversal of training must come from the top—from the American Psychiatric Association, the American Medical Association, the American Psychoanalytic Association and so forth—seems to me a trifle unrealistic. Revolutions don't start

at the top. They arise out of gradual and cumulative feelings of discontent plus intelligent leadership.

Such a revolution as Kubie pictures, and which I agree is most desirable, should be planted in one or two congenial medical schools after sufficient preparation with ample Foundation support. A graduate from such a revised curriculum migh