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appendix How Can We Teach It? A Proposal for Education of Psychiatrists It is not enough to destroy; one must build. My goal in this book is neither simply to tear down the biopsychosocial (BPS) model nor to have us return to the dogmatisms of the past.As clinicians, we all have a responsibility to move our field forward, even an inch, to show what must be done, or at least guess at it, to replace our ignorance with knowledge rather than skeptical relativism. If the reader agrees with the content of this book, if the BPS model is to be abandoned , and a new model of medical humanism, based on Osler and Jaspers, is to replace it—if, in short, we are to take Verstehen seriously—how is it to be taught? How can we incorporate this approach to psychiatry and medicine into the education of doctors and psychiatrists? Much of what I say here will apply, somewhat altered, to the education of other mental health professionals, like psychologists and social workers, but I will focus on physicians and psychiatrists for now, partly because that is my personal experience and partly because of George Engel’s claim that the BPS model was mainly directed at those groups. the accreditation council for graduate medical education requirements In the United States, the Accreditation Council for Graduate Medical Education (ACGME) sets requirements for certification of residency programs for psychiatrists. (Readers can find the actual text of these requirements online at As relevant to this book, those guidelines identify only the following among psychotherapies : “applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and long-term individual practice, as well as to assuring exposure to family , couples, group and other individual evidence-based psychotherapies.” The didactic curriculum is required to include the following: (a) the major theoretical approaches to understanding the patient-doctor relationship ; (b) the biological, genetic, psychological, sociocultural, economic, ethnic , gender, religious/spiritual, sexual orientation, and family factors that signi ficantly influence physical and psychological development throughout the life cycle . . . the biological, psychological, sociocultural, and iatrogenic factors that affect the prevention, incidence, prevalence and long-term course and treatment of psychiatric disorders and . . . the history of psychiatry and its relationship to the evolution of medicine . . . [and] use of case formulation that includes neuro- biological, phenomenological, psychological, and sociocultural issues involved in the management of cases. The BPS approach is thus used to form a basis for psychiatric training.While the speci fic need for teaching some psychotherapies, in particular psychoanalytic views, is expressed , as is the need for research training, the only reference to any other conceptual aspect of psychiatry is the history of psychiatry. There is no mention of logic or philosophy or understanding the philosophy of science. There is no discussion of relationships between mind and brain, philosophy of mind, epistemology, or ethical theory. Obviously, the major flaw is that conceptual topics are minimized. two questions psychiatry residencies should answer Any program of psychiatric education, if it is conceptually sound, would have to discuss ideas beyond just pharmacology, psychoanalysis, and cognitive behavioral techniques . Some overall structure to explain those and other methods is needed.Adapting suggestions from Phillip Slavney (personal communication, January 2008), I think that a conceptually sound residency program should be so organized such that, on graduation , any psychiatric resident can answer two questions: What is psychiatry all about and what kind of psychiatrist are you? The answer to the first question is provided by method-based psychiatry. The answer to the second question is provided by choosing which methods the resident plans to apply most, and in which populations (e.g., a biological psychiatrist for bipolar disorder, or an existential psychiatrist for depression, or a psychoanalyst for the worried well). If one were to incorporate some of the topic areas I noted as missing above, and if one wanted to specifically address some of the important thinkers and ideas I discuss in this book (in particular, a desire to teach about method-based psychiatry and a nuanced understanding of science and knowledge), a suggested curriculum might be as follows, using the Oxford Textbook of Philosophy and Psychiatry (OTPP) as a core text (Fulford, Thornton, and Graham 2006). outline of a conceptually oriented residency training program Year I: Internship Year Beginning six months into the year, one hour per week should be given to basic conceptual discussions of medicine and psychiatry. Residents will completely read William Osler’s Aequenimitas...


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