The following description of the activities of the Committee on University and Medical Education was presented to the Executive Council of APsaA at the May Meeting in Montreal by Robert Michels, M.D., who completed his tenure as chairman of that committee in December 1987. The new chairman is Arnold Cooper, M.D.
Established in 1981, under the chairmanship of Robert Wallerstein, the Committee identified three major areas of concern.
The first area of concern is the role of psychoanalysis in the life of the university outside of the medical school. While there was agreement within the Committee that this was an important issue, and some discussion took place about model curricula, readings, and the problems that result when psychoanalysis is taught by nonanalysts, for the most part this issue has been deferred.
The second area of concern was identified as the role of psychoanalysis in the medical school and in departments of psychiatry.
Changes in American psychiatry have shifted the role of psychoanalysis among the leadership of academic psychiatry. There was general agreement that the rate of change was accelerating, and that the role of psychoanalysis in academic leadership was diminishing.
There has been extensive discussion of this issue, and several projects have been initiated.
One such project focused on the fact that the textbooks and teaching materials used by medical students and residents are often inadequate in regard to the teaching of psychoanalysis. Therefore, the Committee commissioned a review of the major psychiatric textbooks from this perspective, which review was completed by Stuart Asch and Eric Marcus, and is in press in the Journal of the American Psychoanalytic Association. The Committee plans to send reprints of the current review as well as periodic revisions to medical students and residency training directors. In this way the Committee hopes to convince textbook publishers of the value of including material about psychoanalysis that adequately meets the standards of our field.
A second project concerned the fact that medical and psychiatric curricula are heavily influenced by nationwide examinations. There are three critical examinations in psychiatry, and the Committee became involved in each of them.
The National Board of Medical Examiners conducts a three-part examination taken by more than three-fourths of the medical students in the United States. The Committee, enlisting the cooperation of the Board, commissioned a comprehensive review of the content of the exam, which was conducted by Alfred Margulies of Boston. The results were distressing. The portion of the exam related to psychoanalytic psychiatry had steadily diminished in recent years, and some of the specific items seemed to reflect a bias. For example, an item that appeared in 1984 required agreement that psychoanalysis was expensive, not based on research, and was prescribed more on the basis of geography and socio-economic status than diagnosis. Forty-nine percent of the students got the correct answer. One hundred percent of the Committee thought there was a problem and took action. Consequent to extensive correspondence with the National Board of Medical Examiners and the leaders of the several committees that construct the exams, psychoanalysts are now invited to participate on the committees (although, regrettably, several have declined).
The second exam confronted by the developing psychiatrist is PRITE, conducted by the American College of Psychiatrists. PRITE was developed by psychoanalyst Paul Fink, a former member of our committee, and is now constructed by a group chaired by another of our members, Russell Gardner. Our committee has been asked to contribute items, and a subcommittee chaired by Hyman Muslin has been appointed to respond. However, for a variety of reasons these items were never contributed by that subcommittee.
The third and last critical exam is that conducted by the American Board of Psychiatry and Neurology. Part I, the written exam, is constructed by a committee that until last year was chaired by John Talbott, a psychoanalyst. Our committee was invited to review the subject outline of the exam and make suggestions. (It is interesting to note that the composition of the ABPN itself is changing. At present only one of the eight psychiatrist directors is a psychoanalyst, whose term expires next year.)
A third project revolves around the fact that about one-fourth of the 127 medical schools in the United States have virtually no psychoanalysts available to participate in their programs, teach their medical students, and influence the careers of their residents. In September of 1985, I wrote to all of the chairmen of departments of psychiatry in the United States inviting them to apply for a Visiting Psychoanalyst Grant from the APsaA. The requirement was that the department not have psychoanalytic teaching available, and that it be interested in exploring the contributions that psychoanalysts can make. Twenty-seven medical schools responded. The Committee has selected eight of these for a pilot effort, and provided each with a Visiting Psychoanalyst and a $1,000 grant to help support the program. The schools and Visiting Psychoanalysts are:
University of Arkansas—Roy Aruffo East Carolina University—
John Rhoads
University of Florida, Gainesville—
Steven Levy
University of Kentucky—
Edward Foulks
Mayo Clinic—Jon Meyer
University of Missouri—Columbia—
Gene Trunnel
University of Texas, San Antonio—
Malkah Notman
West Virginia University—
Jerry Wiener
We have followed the Visiting Psychoanalyst Program closely. Some efforts have been immensely successful, leading to permanent faculty appointments and the evolution of a new program in a school that didn't have one previously. Others have been one-time consultations that did not result in a sustained program. At worst, they were visiting lecturers supported by the American with limited local interest. The program has brought psychoanalysts into contact with five percent of the nation's medical students and residents who had no such opportunity before. The total cost to the American has been donated member time and $8,000.
But as I shift to this third and final area of the Committee's concern, I fear that my tone will shift from enthusiasm to pessimism. An early and continuing interest of the Committee was the attitude of the APsaA, and the psychoanalytic profession in general toward academic psychiatrists, and in particular the attitude toward those who are both psychoanalysts and academic psychiatrists. To this end, we discussed specific issues such as the arrangements for the annual meetings, and the basis for the quantitative requirements for consideration as a training analyst. However, the more general issue was the apparent failure of the American, and of the profession in general, to value and to participate in the life of academic psychiatry and thereby to play a role in influencing that group of future candidates and psychoanalysts who are first trained as physicians and psychiatrists.
The recent broadening of standards for accepting analytic candidates to include non-psychiatrists has made this issue more urgent. However, not even this consideration has stimulated much concern about the role of psychoanalysts in academic psychiatry. The Committee feels that this is an issue central to the future of psychoanalysis, one in which the attitude, in the long run, is far more dangerous to the ties between psychoanalysis and medicine than the training of qualified nonmedical psychoanalysts itself. Many of us came to believe that the indifference and active resistance that seems to characterize the boundary between academic psychiatry and psychoanalysis stems more from psychoanalysis than from academic psychiatry. I believe that ultimately this is the most important of the Committee's three areas of concern, and I fear that to date we have had little impact on it. It requires action within our organization, and a new attitude toward the participation of psychoanalysts in medical and psychiatric education. Such an attitude would make it impossible for one to be regarded highly in psychoanalysis who does not have a role in psychiatric or medical education.
I want to end these remarks by expressing my hope that Arnold Cooper will be able to continue our successful programs, and more importantly, to succeed where we have, to date, failed—that is, in changing ourselves.