by Walter Weintraub, MD
[Fall 1997; Vol.24 No. 3]
Since I’ve been involved with psychiatric residency training for more than 40 years, Gerry Klee thought I might have something useful to say on the matter. My topic is a then-and-now look at inpatient residency training.
Let me state my bias from the outset. Whatever progress has been made in the treatment of seriously ill psychiatric patients, the impact on residents’ training has been mostly negative. And the decline in the quality of that training can be attributed primarily to the radical shortening of patients’ hospital stays.
The most obvious consequence of short hospital stays is a tremendous increase in patient turnover. When I was inpatient chief at the University of Maryland in the 1960s, eight first-year residents treated about 150 patients a year. Now, eight residents treat about 2,000 patients.
Institutional survival dictates that beds must be filled. All hospitals in the area are competing for treatable, paying patients. As a result, patients formerly considered inappropriate for psychiatric inpatient treatment—primarily alcoholics and drug abusers—are being admitted in large numbers. Some experience with these patients is useful for beginning residents, but too many can be demoralizing.
Short stays have made it almost impossible to teach milieu therapy. Learning about a psychiatric ward as a small community requires at least a few long-term patients. Modern milieu therapy has been reduced to introductions and brief discussions of patients’ complaints.
Moving patients rapidly in and out of the hospital means treatment often begins before a diagnosis has been made. Psychotic patients frequently are given neuroleptic medication on admission. If symptoms improve quickly, patients are assumed to be responding to the medication, even though non-drug factors probably are at work.
Those of us who began our careers before antipsychotic medication was introduced can recall that seriously disturbed patients frequently went into remission within a few days of admission. We assumed that a structured hospital environment and escape from psychosocial stressors were responsible for the improvement. Today, rapid improvement is attributed to the medication, a claim that even the pharmaceutical companies don’t make. The result? Prolonged and unnecessary neuroleptic use.
When inpatient psychiatry was practiced more leisurely, selected patients were followed after discharge by the same residents who treated them in the hospital. Today, shorter inpatient rotations and trainees’ more frequent assignment to other institutions works against resident-patient bonding, making continuity of care almost impossible, and dulling the intensity of residents’ curiosity about diagnosis and treatment.
Brief stays also mean the diagnostic process often cannot be completed within the few days allowed for hospital care. Why not finish it after discharge? Because more admissions mean more discharges, and less outpatient care is available to former inpatients. The additional diagnostic work needed after brief hospitalization often is not completed. What was done quickly in the hospital is assumed by the outpatient resident to have been done correctly. Reassessment of the diagnosis and treatment plan may not occur.
My colleagues working on inpatient units tell me about 70 to 80 percent of psychotic patients admitted to their services have been recently exposed to street drugs. The street drug epidemic has changed the presentation of patients admitted to psychiatric hospitals. A beginning resident recently complained that her psychotic patients did not resemble those she read about in her textbooks. She said patients in her northern European, drug-free culture were much closer to the “classic” schizophrenics and bipolar patients assigned to her in the United States. Many patients given the diagnosis of schizophrenia, she said, had only the positive symptoms. Most were not withdrawn, and few had disturbances of associations or other Bleulerian stigmata.
Distinguishing genuine schizophrenic or bipolar patients from drug abusers can be difficult and time-consuming. Patients are not always truthful about their drug habit, and third-party information may be required. Such data often are not obtainable during a brief hospitalization. Are certain patients being misdiagnosed and sentenced to a lifetime of unnecessary antipsychotic medication?
Several years ago, I scolded a resident because his workups were inadequate. “How can you make an accurate diagnosis without a complete history?” I asked. No shrinking violet, the resident wondered whether the history or diagnosis really mattered. He noted that almost all patients were served a four-drug cocktail no matter what the history or diagnosis: a neuroleptic for psychotic symptoms, an antidepressant for depressive symptoms, a benzodiazepine for anxiety, and a “mood stabilizer” for mercurial feelings.
In the early days of pharmacotherapy, we were taught to treat the diagnosed illness with a single medication and to assume that all associated symptoms would disappear. Thus, treating a depressed schizophrenic with a neuroleptic would take care of both the depression and the thought disorder. Experience has taught us that things are more complicated, that one drug does not necessarily do away with all symptoms. I believe, however, that we have gone too far in trying to manage symptoms with multidrug cocktails. Some self-discipline in prescribing is in order.
When I was a resident, my admission notes, discharge summaries, and workups were carefully reviewed by my attending in my presence—a most valuable educational experience. Today, rapid patient turnover means residents’ workups are shorter and third-party data are sparse, and we no longer agree about which historical data should be included. And, concern about legal issues has influenced what should and shouldn’t be included, making the record of questionable accuracy in certain cases.
For training purposes, it was formerly considered useful to prolong the hospitalization of some “classic” patients for further study and treatment. In return, the hospital fee might be reduced or eliminated. Today, managed care has eliminated the teaching case: the term itself is unfamiliar to today’s residents. We’re told all patients are teaching cases, which often means no patients are.
In addition to psychotherapy and pharmacotherapy, an inpatient treatment plan formerly included such auxiliary treatments as occupational therapy, art therapy, dance therapy, music therapy, work therapy, etc. Residents could discuss their patients with clinicians who approached diagnosis and treatment from different viewpoints. Such enriching experiences are rare today. Even the practice of inpatient group and family therapy is becoming increasingly difficult when patient stays do not exceed several days.
Has anything good happened? Of course. Patients have benefited greatly from the new drugs, and residents are more skillful than their predecessors in prescribing them. Residents are treating a greater variety of patients and with an impressive economy of time. Inappropriate treatments, such as intensive psychotherapy with regressed schizophrenic patients, have disappeared. Treatments now are evaluated according to proven effectiveness rather than ideological correctness. Psychoanalysis and intensive psychotherapy formerly were considered the treatments of choice for upper- and middle-class patients, and pharmacotherapy and ECT were denigrated as “blue collar” treatments. With the development of elegant models to explain drug actions, pharmacotherapy has become more acceptable to patients of all social classes.
Dr. Weintraub is a clinical professor of psychiatry at the University of Maryland Psychiatric Institute, where he has been for 40 years. He was director of the Psychiatric Residency Program from 1970 to 1990 and was the major architect of The Maryland Plan.