Going to sea: psychiatric education in an era of accountability : Shein Lecture, American Association of Directors of Psychiatric Residency Training, March, 2014.

Abstract

Thank you. It is a great honor to be speaking with you today. I look forward to a dialogue regarding one of the most important tasks we as academic physicians have—educating the next generation. Without healthy academic departments with a balanced attention to clinical, research, and educational excellence, we fail in both our mission and obligation. We fail not only in the present but also in the future. Our departments are the places where we create the future, and in no area is this more critical than in the care, feeding, and rearing of our young. Our residents and fellows are our professional progeny; they have a high call on our time, attention, and mentorship. The question for us is whether in an era of accountability— notice that I did not say accountable care—we are able to fulfill that mission and indeed whether we understand the tasks associated with this role as we should. I would like to dedicate this talk to a mentor of mine— Avery Weisman. Avery was one of my PGY III supervisors at the Massachusetts General Hospital (MGH). In addition to founding the consultation service—now named for him—in the early 1950s and being a guide to the legendary chairman of my training, Tom Hackett, Avery was a training analyst at the Boston Psychoanalytic, a leading figure in existential psychiatry and, it turns out, one of the major influences on Aaron Beck—the founder of cognitive-behavior therapy (CBT)— during his residency in Boston. I remember Avery telling me that you do not have to tell patients everything that you know. That advice is useful in many circumstances. Avery is living in Arizona and will turn 100 this December. So this is in part a thank you for your presence in the life of a young psychiatry resident. The subtitle of my talk, psychiatric education in an era of accountability, is really about a far broader trend than the accountable care act—it is about the balance and tension between measurement—what we measure, how we measure, and what we do not or cannot do because of where our limited attention is focused. There are also other ways of knowing and judging the completion of key tasks in the development of young physicians. Please do not misunderstand; I am by no means opposed to measurement or evidence or making sure we graduate psychiatry residents and fellows who are as capable as they can be. It is more a question of really thinking together about the tasks of training and how we assess not only their presence or absence in our trainees but also what methodologies and approaches will achieve which of those ends. Einstein is often quoted as saying that not everything that counts can be counted and not everything that can be counted counts. From the looks of how often he is cited, there must be something in that idea with which many of us resonate. Except unfortunately there is no evidence that he ever said it, as much as we may wish that he did. Something in that non-quote speaks to a sense that we have overemphasized accuracy, proof, and measurement. I want to explore the current period we are in—most broadly at least for psychiatry beginning with the long arc of academic psychiatry in the twentieth and twenty-first centuries. We are and have been in an extended period of expanding the populations under the care of psychiatrists and our interaction with general medicine, academic medical centers, and Presented at the 43rd Annual Meeting of the American Association of Directors of Psychiatric Residency Training, Tucson, Arizona, March 12–15, 2014.