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1. 1. A nurse clinician program for the supervision of a large urban diabetic population, based on a 6-week intensive curriculum plus weekly continuing education, has been described. 2. 2. The quality of medical care was compared between the nurse clinician program and the traditional physician house staff system and was found to be equivalent as measured by biochemical parameters, mortality, and morbidity. 3. 3. Advantages of a nurse clinician program include greater continuity of care, more emphasis on preventive medicine (education during clinic visits, telephone calls for non-emergent problems), and decreased multiple clinic visits. An unexpected and very valuable asset of the program was the provision of medical supervision by the individual nurse clinicians in surgical (orthopedic) clinics. Disadvantages include recruitment, training, and adequate remuneration for staff ∗2 .

The migration of foreign medical graduates from less developed Asian countries to the U.S. has been growing in recent years. This case study of Thai medical graduates in Buffalo, New York analyzes factors related to their preference for remaining in the U.S. vs. returning to their home country. The sample appears to be representative of medical graduates from Asia in terms of age, sex, and trainee status. Results indicate those who were interns and residents, nonimmigrants, and nonlicensed, as well as those with a home position to return to had significantly higher probabilities of returning to their home country. Immigrants, posttrainees, and those with a state license and no home position had a high probability of remaining in the U.S. It appears that "pull" factors are more important than "push" factors in determining the residence preference of foreign medical graduates from Asia. Efforts to reverse the growing "brain drain" of physicians from the less developed countries of Asia to the U.S. will be primarily dependent upon U.S. policies regarding immigration and licensure.

The training of teachers is feasible. Platform presence, judgment in the choice and preparation of teaching materials, an optimal and effective teacher-student relationship, and interest in experimentation with new methods of teaching can all be developed in radiology residents of academic caliber to supply more teachers for the next generation. Results of seven years experience in the training of younger teachers are reported.

A quantitative analysis of the activity of pediatricians and nurses reveals striking differences in the degree to which they function appropriately in a university outpatient department. In general, the physicians were concerned with professional patient care and education; the nurses spent more of their time in administrative and nonprofessional tasks than in nursing tasks. Such quantitative data are valuable for the proper planning of programs and allocation of resources within a pediatric ambulatory care organization.

The psychodynamic pattern of acquiring psychotherapy skills can be viewed as one that exhibits regressive periods which tend towards one of two poles, ‘moving towards’, and ‘distancing’. A major block to learning, especially the learning of individual psychotherapy, is the resident's difficulties in the area of self-awareness. Pointing out psychodynamic patterns to him is essential, both to make him cognizant of the existence of the unconscious in the fullest sense and to allow the learning process to progress, possibly in a more adaptive way. Individual psychotherapy supervision is a major vehicle for such learning. Some guidelines for psychotherapy supervision are presented.

L'auteur examine le probleme de la formation de residents en psychiatrie se destinant a la sous-specialite de l'arrieration mentale. La presente communication constitue une partie d'une etude entre...

The psychiatric consultant requires a broad understanding of the context of consultation to supplement his knowledge of psychodynamics. The authors propose viewing the medical ward in the model of a “quasi-open community,” in which a culture is transmitted from one generation of personnel to the next through a ward mythology-which embodies ideals, for example, for the roles of Nurse and Doctor. Requests for psychiatric consultation often result from the partial breakdown in this mythology; the consultant's immediate task is to reconstruct group ideals and facilitate community re-unification in order to promote the recovery of patients. Later on, when the staff has had a chance to distance itself from the threat to its solidarity, the consultant can help the ward community understand both the adaptive and non-adaptive aspects of its own mythology. Case examples illustrate how respecting the quasi-open character of the medical ward and giving credence to its mythology can promote the reconstitution of ward communities in disarray and aid individual patients as well.

THERE is considerable discussion currently on the subject of postgraduate training for a career in Oral Surgery in the United Kingdom. It is of interest therefore to look at the system operating in the United States of America, as it has certain differences from our own. The American postgraduate embarking on a career in Oral Surgery is likely to be somewhat older than his English counterpart as he does not start his dental course until the age of 22, qualifying at about 26. Before commencing a residency he is likely to have undertaken an internship, the equivalent of our house surgeon post, although this is not essential. The fundamental difference between the two systems of training is that whereas the English registrar’s training may comprise up to 8 years working in various hospitals, the American resident usually enrols for a single co-ordinated training programme lasting 3 or 4 years in one centre or group. Such a programme is likely to comprise instruction, clinical practice and research in a planned ratio. There may be considerable differences in course content and emphasis in different States but the principle of a compact planned programme combining both teaching and practice is common to most. Training programmes are provided by Universities with dental and medical schools, certain hospitals, the Armed Forces, United States Public Health Service and the Veterans Administration. The Council on Dental Education of the American Dental Association publishes a list of accredited programmes, which are approved as providing adequate training for the eventual candidate for Oral Surgery Board Examinations, normally taken 5 years after completion of a programme. Centres which consider foreign graduates are indicated in this list. The major centres appear to be able to be highly selective in their choice from the large number of good calibre applicants. It is proposed briefly to describe two programmes which the writers had the privilege of observing over a period of one year. They are those of the University of Washington School of Dentistry in Seattle under the chairmanship of Dr James Hooley and Massachusetts General Hospital under Dr Walter Guralnick. The details given apply to the approximate period 1971-72. These programmes have the advantage, for comparison, of being on opposite sides of the continent. The Seattle course was for 3 years and two new residents were taken on each year. The first year comprised mainly academic work much of it undertaken in the Medical School. The residents attended, with the medical students, an intergrated course in human biology which dealt with each major system in turn

Societal expectations of American medicine are increasing in intensity and complexity. An appropriate response of teachers of medicine, as a component of the resources of the health care system, is to attempt to define, within their range of competence, responses to those expectations which maximize benefits. One experiment to this point by a faculty of medicine is described.

The author focuses on the problems of the woman resident and draws upon her own experience to illustrate her point that women are not accorded the same consideration as other minorities and that, for women, the residency period may be one of loneliness and misunderstanding. She observes that women have as much to learn from men as men from women and concludes that, if there are enough women staff members to make it possible, each woman and man in a residency program should have some personal supervisory experience with a woman staff supervisor.

L'acquisition de l'habilite therapeutique represente une composante essentielle de l'education psychiatrique. On peut l'enseigner d'un grand nombre de manieres. Nous avons mis en valeur l'importanc...

The Department of Obstetrics and Gynecology at the University of Colorado Medical Center has developed a physicians assistant program in obstetrics and gynecology, modelled after the successful program developed by Dr. Henry Silver in the Department of Pediatrics. A three-year curriculum, consisting of one year of basic science studies, one year of clinical training, and one year of internship has been developed. The first class was admitted in the fall of 1972. The program will have 10 students in each year of training. It is estimated that the total direct cost of the program is $153,486 annually, which gives a cost per student per year of $5,116. The rationale for developing this program and the problems associated with its inception are discussed.

Graduate medical education in the United States has been criticized for fragmentation of responsibility, inadequate funding, variation in quality, inadequate response to physician manpower needs, lack of inservice evaluation, and use of foreign medical graduates. One solution is to establish a graduate-medical-education system that is organized, controlled, and financed on a statewide basis. Such a system could centralize responsibility, adequately finance the educational component of training, respond to the needs of the individual states, and standardize the content and evaluation of the educational programs. A widely representative governing board could determine the nature of the program and work with appropriate state fiscal organizations to handle budgetary needs. Such a system, if implemented, might have certain disadvantages, but would, on balance, greatly mitigate the problems now besetting graduate medical education. (N Engl J Med 291:701–706, 1974)

The problems of foreign residents in psychiatry in Canada are examined under the general headings of communication difficulties, cultural differences, personal and professional problems. It is emphasized that each resident presents his unique combination of problems and possesses positive values of his culture-shift which are potentially contributory to better empathy with patients. About 25 percent to 50 percent of residents in psychiatry in Canada are foreign medical graduates.

How a cry for help, such as a request for admission to a hospital, is answered depends as much on the hospital's political environment as on the patient's presenting problem. The political environment here refers to the hospital complex within which competing interest groups or individuals vie for power or control. A description of the various political power plays that go on as a patient moves toward admission shows the vicissitudes of a system impinging on a patient needing help, and the problems thus presented to the personnel within the system. The situation described is a composite based on the author's training and work experiences in various medical settings.

Summary: The Weed system of problem oriented medical records has been successfully introduced into a general medical unit without the need for computers or specialised stationery. The change requires an increased time commitment by resident and senior staff and the development of a training programme in case record structuring for new staff. The system is acceptable to resident staff who recognise an improvement in their own training and in patient care. A weekly clinical audit has been an integral part of the system. A quality control procedure has been developed and applied to the management of myocardial infarction. This has involved identification of problem areas and formulation of a unit policy. It is felt that this procedure has resulted in an improvement in the quality of total patient care.

Fifteen percent of physicians who began psychiatric residencies at the University of Toronto over a six-year period dropped out. Data were analysed in an effort to determine what factors were related to these resignations. Background data could not differentiate drop-outs from the rest of their cohorts. Drop-outs were rated equal to the non drop-outs by supervisors after one year of training; but after two years of training the remaining were rated to have poorer capabilities for psychiatry. Drop-outs were also more likely to spend their first year in training in a mental hospital. These findings are discussed and recommendations are made for reducing the number of competent residents resigning from training.

The development of a more useful relationship between psychiatry and the law depends upon mutual understanding and solution of common problems. Present training in law for psychiatrists emphasizes acceptance of the status quo. The authors propose a new training approach involving both disciplines that would emphasize interactional problems and practical methods for bringing about change, thus improving the present system.

The process of evaluating the professional competence of trainees in the mental health field is accompanied by complexities that are more extensive than in other professional fields. The authors draw on personal experiences with mental health trainees to delineate some of the rational and irrational components of the evaluation process. They describe dilemmas and conflicts for both the evaluator and the trainee and make a number of recommendations aimed at clarifying individual and institutional roles and responsibilities and minimizing personal and institutional distress.

The authors designed a study to test the relative efficacy of minimal individual contact versus group therapy, given an equal amount of therapist time allocated to each treatment. One hundred forty-four aftercare patients were randomly assigned to either group or individual therapy conducted by 12 incoming first-year residents. Results at the end of one year showed no significant differences in outcome measures for either group. However, the therapists greatly preferred the group method, and the group patients seemed more enthusiastic. Greater utilization of group treatment in aftercare clinics is recommended.

Summary When training backgrounds, ratings, and clinical practices among Navy psychiatrists were considered, a definite profile between rated competence and performance emerged. Doctors rated as highly competent were generally older and had more experience since training than did doctors with low-rated competence. High ratings were associated also with the ability of doctors to manage patients with relatively few drugs and few physical restraints. With respect to differences in management or major diagnostic groups, it appeared that ratings reflected agreement between clinical practices and administrative policies. Generally, it is assumed that fewer clinical hours and decisions should affect the character and behavior disorder group as compared with other diagnostic categories. High competence ratings were characteristic of doctors who followed this dictum. Although posthospital outcomes were not significantly related to ratings in the small samples of this study, a trend in this direction was evident. R...

This study examined the effect of a residency training program on the services delivered to patients on two psychiatric wards of a general hospital. Data obtained before and after the introduction of the program indicated that screening procedures and the relationship between ward and intake services improved, uninteresting cases were not "dumped." and treatment was focused on the more seriously ill patients.

The APA Task Force on Women was created to study the special issues and problems of women, especially in relation to the practice of psychiatry, and the special concerns of women psychiatrists. In this paper, the author details the specific areas the task force is examining, summarizes the findings of some of the few reports in the literature, and outlines the projects the task force has undertaken.

The study of psychiatric manpower needs is both important and difficult. Some previously available data on the numbers of psychiatrists in each province of Canada are examined in conjunction with one new item relating to the number of residents in each Canadian university department of psychiatry. Unfortunately, no clear-cut conclusions can be drawn, ‘but some suggestions are made for further studies. Probably more questions are raised than answered, but this reflects the state of our current knowledge or lack of it. The data show that there are currently (fall 1973) 1,614 psychiatrists in Canada compared with 1,478 in 1971; 944 in 1966 and 549 in 1961. There was thus a net increase of 929 (169.2 percent) psychiatrists in Canada between 1961 and 1971. Even allowing for the increase in the size of population, the ratio of 1 psychiatrist: 33,200 of population in 1961 decreased (improved) to 1 psychiatrist: 14,600 of population in 1971, which represents a 56.0 percent change. There were 549 residents in Canadian university departments of psychiatry in the fall of 1973. This level if maintained, would double the number of practising psychiatrists in Canada in 14 years. However, this also assumes that all residents complete their training and continue practising in Canada, that none of the existing Canadian psychiatrists retire or leave the country, and no immigrant psychiatrists arrive in Canada. These assumptions are unlikely, but accurate data are not available to correct them. McGill and the University of Toronto departments of psychiatry are dominant and they are currently (fall 1973) training 45.3 percent of all Canadian psychiatry residents (McGill 20.5 percent and Toronto 24.8 percent). Unfortunately a number of university departments did not or were unable to supply information on the number of psychiatry residents in training in past years, which makes a comprehensive study impossible.

Learning the art of psychotherapy can be an anxiety-provoking endeavour. These anxieties are engendered by the loss of the medical model, with attendant feelings of anger, doubt and alienation, and by the development of a psychodynamic model which facilitates the rising into consciousness of the resident's own warded-off wishes. Transient overidentification with the patient, inability to handle silences and counter-transference feelings of anger, lust or envy are other phenomena which stimulate anxiety in the neophyte therapist. The conflictual dual role of the supervisor, as seen by the resident, is one other source of anxiety. It is necessary for the resident to deal with and, hopefully, work through these stresses so that he may learn and practise psychotherapy in a non-constricted, non-distorted manner.

One proposed method for delivery of primary health care to underserved areas is the establishment of family health centers connected administratively to hospitals. This paper describes the development of a family health center by a community hospital to serve a town which had previously been unable to attract a physician. FOR DECADES, SOME HEALTH AUTHORITIES have advocated that hospitals play a more vigorous role in the delivery of ambulatory health care. They maintain that the present hospital, as an integrated entity, has the means to organize and coordinate a health care delivery system and to establish quality controls and, in addition, serve an educational function.2