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This discussion by a very thoughtful and progressive person in the training field comes from a great length and breadth of experience. Dr. Kubie's well known suggestion of the development of a doctorate in psychological medicine has stimulated much discussion in the training area.
His complaint that the young psychiatrist is exposed first to the psychotic patient will fall on many receptive ears and I, too, feel that this is reversing the process which should be followed. His suggestion that the young psychiatrist should first be exposed to early human psychological development by the observation of children, especially in the pediatric wards and in the nurseries, is a good one. This process has, I believe, been fairly thoroughly investigated by such schools as Western Reserve and actually is the kind of experience which many medical students have even before they graduate from medical school.
In the specialized psychiatric training area we have found that it is useful to start some of our first-year residents on child psychiatry, at least to the extent that they have a chance to observe behavior of children and participate in the family inter-reactions which characterize therapy with this age group.
My support for Dr. Kubie's views is based on a somewhat different concern: starting the young psychiatrist in the hospital with psychotic patients and leaving the outpatient work to the latter part of the residency sets up a sort of hierarchy. By implication, the least trained person is qualified to handle the sickest patient, whereas outpatient psychotherapy, presumably largely with neurotics, is a kind of exclusive activity which can be handled only by the most experienced resident. This attitude is further underlined by some practicing psychiatrists who tend to transfer their patients if intercurrent developments require hospitalization.
The situation would be adequately handled if residents in psychiatry started with outpatients or inpatients, depending on the schedulin