Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest

Professional medical associations (PMAs) play an essential role in defining and advancing health care standards. Their conferences, continuing medical education courses, practice guidelines, definitions of ethical norms, and public advocacy positions carry great weight with physicians and the public. Because many PMAs receive extensive funding from pharmaceutical and device companies, it is crucial that their guidelines manage both real and perceived conflict of interests. Any threat to the integrity of PMAs must be thoroughly and effectively resolved. Current PMA policies, however, are not uniform and often lack stringency. To address this situation, the authors first identified and analyzed conflicts of interest that may affect the activities, leadership, and members of PMAs. The authors then went on to formulate guidelines, both short-term and long-term, to prevent the appearance or reality of undue industry influence. The recommendations are rigorous and would require many PMAs to transform their mode of operation and perhaps, to forgo valuable activities. To maintain integrity, sacrifice may be required. Nevertheless, these changes are in the best interest of the PMAs, the profession, their members, and the larger society.

Achieving board certification in psychiatry: a cohort study

OBJECTIVE

The purpose of this study was to track the progress of a cohort of graduates of psychiatry residency training programs in achieving certification by the American Board of Psychiatry and Neurology (ABPN). These data provide a detailed picture of how recent graduates perform on the ABPN's examinations.

METHOD

The subjects for this study were the 739 new candidates who sat for the part I examination in fall 1994. The cohort's performance on the part I and part II examinations was analyzed, as was the relationship between performance on the two examinations.

RESULTS

Approximately 8 years after their first attempt at the part I examination, 85% of the cohort were certified, and 15% were not. The majority passed both the part I and part II examinations on the first attempt. Those who passed part I on the first attempt were more likely than those who failed to pass part II on the first attempt. Of the 627 who were certified at follow-up, 199 (32%) were also certified in one subspecialty, and 29 (5%) were certified in two, for a total of 257 subspecialty certificates.

CONCLUSIONS

The results of this study suggest that most recent graduates of residency training programs who attempt the ABPN process are likely to become board certified, and the majority will do so by passing both components on the first attempt.

Selected characteristics and data of psychiatrists in the United States, 2001-2002

OBJECTIVE

To provide basic data about the physician workforce as a whole and the relative place of psychiatrists in the total workforce. To provide data on characteristics of psychiatrists' work activities in routine psychiatric practice.

METHOD

Data were obtained from the American Medical Association's (AMA) Physician Characteristics and Distribution in the United States, 2002-2003 and the 2002 National Survey of Psychiatric Practice, a nationally representative survey of 2,000 randomly selected psychiatrists in the United States.

RESULTS

Psychiatry is the fourth largest specialty in the United States. Since 1970, psychiatry has grown 86.7%, while child psychiatry has grown 194.6%. However, psychiatrists are distributed unequally across the country, are working fewer hours than in the past, and less of their time is spent in direct patient care activities.

CONCLUSIONS

Psychiatry is a growing and significant part of the U.S. physician workforce. However, if trends that show the psychiatric workforce is aging and working fewer hours continue, it is unclear if its current rate of growth will be able to keep pace with the demand for psychiatric services.

A strategic approach to the psychiatric workforce dilemma

To help build consensus in the field of psychiatry about future psychiatric manpower needs, a 13-step strategic approach to the workforce issue is described. The steps include recognizing the importance of the assumptions that underlie workforce requirements; selecting credible and professional leadership with vision and courage; adopting a strategic plan to clarify workforce assumptions; re-examining the structure and function of established programs; preparing trainees for work in the 21st century; preserving psychiatry's humanistic tradition; enlisting the support of nonacademic psychiatrists; and reinforcing involvement in the fiscal and political aspects of medicine. They also include focusing attention on important policy issues; securing the support of patients, families, and advocates; endorsing a multidisciplinary, biopsychosocial approach to the evaluation and treatment of mental illness; minimizing divisive conflicts within and between national organizations; and developing strategic alliances with other medical disciplines. Implications of the 13-step approach are outlined for psychiatric clinicians, educators, and researchers, as well as for the organizations that serve them.

Hazards of long-term psychotherapy during psychiatric residency

When he laid the groundwork for modern standards of training psychiatrists, Freud (1937) asked, "Where and how is the poor wretch to acquire the ideal qualifications which he will need in his profession? The answer is, in an analysis of himself" (p. 248). Fromm-Reichmann (1950), an equally important influence on psychiatric education, echoed this sentiment when she professed that "any attempt at intensive psychotherapy is fraught with danger, hence unacceptable, where not preceded by the future psychiatrist's personal analysis" (p. 42). Although most psychiatric residencies do not require personal psychotherapy (Pasnau and Russell 1975), many educators and their trainees still consider psychoanalysis or long-term reconstructive psychotherapy at least a valuable experience and at most a necessary step toward becoming a complete psychiatrist. In our experience, however, psychoanalysis and related psychotherapies can have adverse effects during the turmoil of residency training.

Hospice care

"Birth and death are the most singular events we experience and therefore the contemplation of death as of birth should be a thing of beauty." The hospice movement emerged out of an awareness that the needs of the dying patient were not being adequately met by the modern medical establishment. It has brought about a positive change in attitudes toward the dying. Hospice has given the patient and family back the responsibility of making decisions regarding life and death. It has called to our awareness difficult moral and ethical issues to which no clear right or wrong answers exist but about which only informed judgments may be made. However, the hospice program has a long way to go. The public needs to be educated about existing financial, social, and medical provisions available to them in preparation for death. The education of medical, nursing, and paramedical professionals must emphasize technical and philosophical principles about death and dying. Teachers must address moral and ethical issues, and physicians must demonstrate kind and compassionate care in the management of their dying patients. Finally, society has the moral obligation to ensure that its dying members have access to care directed specifically to their needs. Hospice does not offer simple solutions to all the problems raised in this article, but it does embody a philosophy of care that acknowledges these issues, and it provides support for those with the courage to address them. Hospice care in the United States is now at a crossroads; whereas such care is appealing and acceptable to the public, this care has yet to find its place as an integral part of the health care system and be accepted as another facet of health delivery.

Attitudes of house officers toward a hospice on a medical service

A hospice program (HP) was established on the medical service at the Denver Veterans Administration Medical Center (DVAMC) for the care of the terminally ill cancer patients and to integrate such care into house staff training. A two-bed inpatient unit was managed by an intern, a resident, and the attending physician with the aid of a multidisciplinary team. During the program's first year, 29 patients were cared for with an average inpatient stay of 26 days. Twenty-nine out of a possible 33 house officers returned questionnaires evaluating their hospice experience. Twenty-eight respondents felt that the hospice program was appropriate in a teaching hospital. Over half indicated improved awareness of the psychological problems of their patients and families. Two-thirds of the house staff members felt that the HP changed their approach to pain control and made them more comfortable in dealing with terminally ill patients. From this study, it can be concluded that a hospice program can be successfully integrated into an active medical teaching service.

Suicide by burning

Of 164 patients admitted to a university hospital burn unit, 15 (9%) had attempted suicide, and 5 of the 15 died. The use of a flammable liquid was the most common method of attempted suicide; the most common psychiatric diagnosis was schizophrenia.

Undergraduate education and recruitment into psychiatry

From 1969 to 1979 senior medical students from the University of Colorado School of Medicine entered psychiatric residencies at an average rate of 3.8%. The university gradually instituted a series of changes in its undergraduate psychiatric education program for medical students, and the senior class of 1980 was the first to be exposed to all of the changes. In 1980-1982 7.7% of the seniors went into psychiatric residencies. The authors describe the curriculum changes and speculate that more attention to the quality of medical students' psychiatric education at the undergraduate level enhances recruitment into psychiatric residencies.