Psychiatric education in the emergency room setting.

Abstract

Some background concepts regarding the teaching of clinical psychiatry are briefly reviewed, along with current controversies regarding the content and timing of various aspects of residency training. The main point made in this paper is that the Emergency Room (ER) is a forum of potentially immense value for the teaching of clinical psychiatry but it is a resource which is largely untapped. A technique which remains unexplored involves the use of video tape in the ER. Research which is currently in the planning stage involves the evaluation of therapist variables as to whether patients follow through with recommendations. Research is urgently needed to determine how effective crisis intervention is, as well as how effective different techniques are, for what type of patient and in what type of crisis. While these questions apply just as urgently to all psychotherapy, the crisis situation lends itself more readily to research in that it is more time limited and the effects of intervention as opposed to other life variables are more obvious than in more long-term psychotherapies. The problem of spontaneous improvement is, of course, still very much present. The advantages of ER teaching presented in this paper are the following: I It is an opportunity for participant teaching in a non-dyadic situation. II Supervision is immediate. III Post hoc distortion is eliminated, yet it allows traditional supervision in the post interview discussion. IV The real, as opposed to the contrived situation, should combine service and teaching. V The ER is a natural transition zone from the medical to the psychiatric model. VI Opportunities are provided for rapid resolution of conflict and a sense of mastery. VII Emphasis on the evaluation of ego strength over and above dynamics and genetics is crucial and productive. VIII Crisis demands selective focusing, as well as careful and rapid conceptualization of the tactical intervention - good training for any therapy. IX Real and natural confrontation with social realities is necessary. X A wide range of diagnostic categories is seen. XI ER encounters allow teaching of a flexible psychotherapeutic approach appropriate to different problems. This active empathic approach complements the passive analytic one best learned elsewhere. XII Yet psychoanalytic concepts from psychosexual stages to transference and counter-transference are well demonstrated in the ER. XIII A different psychiatric role model can be provided for medical students, thus enhancing their motivation for psychosocial concepts. Crisis resolution itself should be a cornerstone of medical student teaching. XIV The ER is obviously a place to teach crisis intervention, a well-accepted therapeutic endeavour. XV The involvement of social workers, psychiatrists, psychologists and nurses working together provides an excellent introduction to training in collaborative skills.