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patients. In addition, at least one mock board examination should be undertaken.

How much time should candidates spend in preparation? Data for Part I are entirely lacking. A
report several decades old found that the average Part II candidate put in approximately 120
hours in preparation. Of course, this time is highly individual: for weak candidates, 120 hours is
not nearly enough, whereas a strong candidate just out of training may require little preparation
at all. Unhappily, it is all too often that the former learn who they are only as a result of taking
the examination itself.

Mock Board Examination

For many years, the mock board examination has been standard preparation for Part II. No
psychiatric candidate, even one who has just graduated from residency, should consider taking
the oral board examination without at least one.

To be effective, the mock examination should be as close to the real thing as possible. Although
the mock candidate would ideally be evaluated by two examiners, time and fiscal restraints often
mandate only one. That lone psychiatrist should

Have served as an official ABPN examiner. That experience will convey the necessary insight
into the rules, process, and spirit of the examination process.

Not be well known to the candidate. Friends or colleagues may exaggerate the merits and
minimize the deficiencies of a candidate's performance.

Be willing to spend the 90 minutes necessary, including the hour-long examination itself
followed by 30 minutes or so for critique. The critique should include a point-by-point
evaluation of the five areas in which candidates are graded, as well as overall score and
comments on every relevant item of content or process raised during the session.

Provide a patient. For obvious reasons, it is critical to the mock board process that this patient be
one with whom the candidate has never had prior contact.

Any interview carefully witnessed by a thoughtful, impartial observer should closely parallel the
sort of problem identified during actual board examinations (discussed earlier). The critique,
which the candidate might want to tape record (with permission of examiners and patient) for
later study, may reveal difficulties in one or more of three possible areas, any of which should set
in motion an immediate plan of action.

Inadequacies of Factual Information

Lack of facts concerning any modality of treatment or any psychiatric diagnosis should stimulate
further review of relevant sections of a standard psychiatric textbook. Although no one expects
candidates to memorize DSM-IV-TR criteria, a thorough understanding of their structure and
basic content is vital. Because Part II candidates have already passed the rigorous Part I
evaluation (Table 53.1-1), problems with content should be minimal. Indeed, if candidates can
demonstrate their ability to provide safe psychiatric care, isolated knowledge deficits should not
be devastating.

After interviewing a young woman with a first-break psychosis, candidate L. admitted to

complete navet regarding the novel antipsychotic agent the patient was taking. If I inherited the
care of this patient, I'd look that drug up in AHFS Drug Information or PDR. And I'd also discuss
it with the drug information pharmacist at our medical center. During the debriefing, the mock
examiner specifically praised this cautious, information-seeking approach to uncharted territory.

Conduct of the Interview

Almost any mock board interview is likely to yield some suggestions for improvement'more eye
contact, fewer interruptions, a different focus or depth when following up on earlier questions.
Other findings may require much more extensive remediation.

I've got to say, I felt really uncomfortable during much of your interview, the examiner told Dr.
M. during the mock board debriefing. The patient had a story he was trying to tell, but you kept
interrupting to ask questions about which medicines he had taken. And some of the important
ideas he did manage to get across'his life didn't seem worth living, for example'you didn't follow
up.

Interpersonal Differences

Although board examiners rarely express negative feelings about the psychiatrists they examine,
the reverse is not uncommon. These feelings extend even to mock examinations, where the stress
of the moment may provoke feelings of distrust or hostility. Under stress, candidates are likely to
react by becoming defensive and rigid. They may argue, clinging so tenaciously to a position that
they cannot acknowledge, much less accept, the fact that an examiner may be trying to suggest
an alternative view of the patient. The fact that a given diagnostic or treatment option may be
perfectly justifiable, even correct, does not excuse any candidate from the need to demonstrate
flexible thinking.

Poor performance on a mock board should prompt an immediate reexamination with a different
examiner. A conflicting opinion could mean that the problem has been solved or that it is
confined to certain types of patient and justifies yet a third mock examination. A second opinion
that confirms the first suggests the need for extensive remediation. Attendance at a board review
course may be indicated. Table 53.2-4 suggests performance guides for the patient examination.

Review Courses
How helpful are the seemingly ubiquitous, definitely expensive review courses offered by
universities and private organizations? Other than personal anecdotes and testimonials,
essentially no data exist for psychiatry. One study in the field of surgery reported that formal
review courses may assist the candidate at high risk of board failure, especially those who have
already experienced one or more failures.

Recently, examiners bemoan evidence that some courses inappropriately counsel candidates to
game the system by asking for repeats of questions, visiting the bathroom on the way to a
discussion of the videotape, and other time-wasting measures. [Such candidates] seem to think
that any time they don't spend talking is time they aren't exposed to criticism. What they don't
realize is that, without adequate time, we can't qualify them for Board certification.

To be maximally helpful, a review course should have faculty with previous experience as board
examiners and should give each student the opportunity to participate in at least one mock board
examination. The course should be undertaken far enough in advance of the actual examination
to allow the opportunity to practice new behaviors.

SUBSPECIALTY BOARD EXAMINATIONS

In addition to the board examinations in general psychiatry, the ABPN offers certificates in six
subspecialties. The oldest of these, dating to 1959, is the child and adolescent psychiatry
examination.

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Child and Adolescent Psychiatry

To sit for this examination, applicants must be board certified in adult psychiatry and have
completed training in a child and adolescent psychiatry program approved by the Accreditation
Council for Graduate Medical Examination (ACGME). The examination is administered once a
year in an all-day session and includes both a written portion and an oral examination that
includes a live patient interview.

The written examination covers core knowledge in the field: child and adolescent development,
consultation, psychopathology, and theory. It lasts approximately 270 minutes and comprises
200 multiple-choice or matching questions. The oral examination has two segments, each
conducted by two examiners. In the preschool and grade-school age segment (75 minutes),
candidates evaluate two cases, one on videotape and the other in a written vignette, and are, in
turn, evaluated on their ability to observe, to describe the child's important behaviors, to
determine what additional information is needed, and to formulate a treatment plan. In the
adolescence segment (60 minutes), the candidate interviews an adolescent psychiatric patient in
the presence of the two examiners. The evaluation is based on the candidate's ability to conduct
the interview, obtain important information, and construct a differential diagnosis and treatment
plan.

Success on the Child Boards

The success rate for the child boards is almost the same as that for Part II'approximately 62
percent over the past 10 years. Some have argued that certification rates in child psychiatry
should be higher. Part of the reason they are not higher could be because this board examination
combines written material with oral examinations in multiple formats.

Other Subspecialty Certificates

By examination, physicians who are board diplomates in general psychiatry can earn certificates
in other subspecialty fields added incrementally since 1991. Each requires 1 additional year of
specialty training after the fourth postgraduate year in an institution approved by the ACGME;
training may usually be completed on a half-time basis. Each is a written, multiple-choice
examination that requires approximately half a day.

Candidates for these certificates, listed in order of date begun, will be tested by computer in the
following areas:

Geriatric psychiatry'biological, developmental, social, and psychological aspects of aging;

diagnostic methods; the interface between general medicine and psychiatry; neuropsychiatric and
neurologic aspects of aging; psychopathology and psychiatric diagnosis; and treatment

Clinical neurophysiology'electroencephalography and electromyography, instrumentation, nerve

conduction studies, and physiology

Addiction psychiatry'biological and behavioral basis of practice, pharmacology of drugs,

pharmacotherapy, psychosocial treatment, and evaluation and consultation

Forensic psychiatry'civil and criminal law; legal regulation of psychiatry;

corrections/correctional health care; legal systems/basic law; children/families; special diagnostic
issues, procedures, and consultations; and risk assessment, medicine, and practice issues

Pain'acute and chronic pain, cancer pain, anesthesia, psychiatry, neurology, physical medicine
and rehabilitation, neurosurgery, pediatrics, ethics, and decision making.

In each of these, the success rate has been far greater than that for Part II and the Child Boards,
with averages ranging from 72 (geriatrics) to 88 percent (forensic).

In 2002, the ABPN approved and sent on to the American Board of Medical Specialties an
application for a new subspecialty board, psychosomatic medicine.
OTHER PSYCHIATRY EXAMINATIONS

The ABPN only assesses graduate psychiatrists, not those in training. It forthrightly claims that it
has no educational mandate and that it is not intended as a way of evaluating training strategies.
Other examinations and formats have been brought forward to do that and provide feedback to
trainees.

PRITE

Nationally standardized examinations for residents who are still in training were adopted by
many specialties during the last third of the 20th century. The Psychiatry Residency In-Training
Examination (PRITE) has been used since 1979. Although it is voluntary, the Residency Review
Committee for psychiatry requires that each program use a formal standardized test as a part of
its evaluation of trainees. By the 1990s, nearly every training program nationwide had adopted it
and it was being administered to more than 5,000 residents each year.

This written examination, developed by representatives of the American College of Psychiatrists,

American Academy of Child and Adolescent Psychiatry, American Association of Directors of
Psychiatric Residency Training, and Association for Academic Psychiatry, as well as two
neurology consultants and two current psychiatry residents, offers trainees the opportunity to
track their progress throughout training and to gauge their own performance against that of
colleagues. To accommodate the schedules of individual training program, the 5-hour PRITE can
be administered on any 2 half-days within a 10-day window during the fall of each year; the
window reduces the likelihood that questions will be circulated by the first examinees to take it.
Since 1996, there has also been a child PRITE, a 150-item test whose purpose and structure are
essentially the same as the general PRITE examination.

Resident input into test item development has been encouraged, causing some feeling that those
who so participate reap a competitive advantage for their efforts. However, in the words of one
participant, I submitted my questions so long before they were scheduled for use that by the time
of the examination, I couldn't remember what I had written!

Training directors sign an agreement that scores will not be used to decide whether a resident
will be dropped from a training program. However, many training directors use the results for
individual counseling and for assessing the effectiveness of their programs. Roughly 10 percent
of the PRITE emphasis is on neurology and the neurosciences; the remainder is on ten principal
psychiatric knowledge areas: adult psychopathology, alcoholism and substance abuse, behavioral
science, child psychiatry, consultation-liaison psychiatry, emergency psychiatry, growth and
development, patient evaluation, psychosocial therapies, and somatic treatment methods.

The goal of the PRITE is truly to educate. Comparative percentile scores are reported for both
the psychiatry and the neurology components of this examination. For the overall test and for
each subsection, training directors and each trainee receive the individual's exact numerical
scores, ranking compared with peers in that program, and nationwide peer-group percentile rank.
Training directors learn the grouped percentile ranks on each subtest for the residents in each
training year, as well as how their residents compared nationally on each question. Residents also
receive copies of the questions and answers, with references for further study.

Some training directors report that extreme scores on the PRITE strongly predict outcome of the
ABPN Part I examination: I've hardly ever seen a resident who scores above the 90th percentile
on the PRITE who has any trouble at all with the boards, one training

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director reported. But I counsel graduating residents who score below 50 percent to take at least
one board review course.

Multiple-Station Examination Format

Similar to the practical examination used for decades in basic science courses, the objective
structured clinical examination (OSCE) uses objective criteria to evaluate trainees' practical
clinical skills. Typically, several stations are set up portraying clinical problems'a videotaped
patient's interview to diagnose, results of laboratory values to interpret, an emergency scenario to
evaluate. Test results are scored according to criteria the faculty determines in advance.
Advantages are that a number of trainees can be evaluated within a short time, evaluations are
objective, the material tested is relevant to actual clinical situations, and the examinations can be
quickly and cheaply administered.

MEASURING THE SUCCESS OF EXAMINATIONS

Does interview control really equate to safe practice of psychiatry? How well do the boards (or
PRITE) test what clinical psychiatrists need to know? An analogous question might be, does
success in the 100-yard dash predict a marathon victory?

Over the years, several criticisms have been leveled at the board's process. For example, after
seven decades, there is still no attempt to link residents' training performance with success on the
boards. Eligibility does not require training directors to certify that graduates possess skill,
knowledge, ethics, or a patient-focused attitude'surviving a 4-year residency suffices. In addition,
although it is a principal sponsor of the ABPN, the American Psychiatric Association does not
require board certification for membership. Without any evidence, some writers have alleged this
is because the organization might lose members, money, and influence.

The question of what such examinations predict has generated more heat than light. Neither of
two important qualities, validity and reliability, has been adequately demonstrated for the
psychiatry boards.
Reliability

In this context, reliability means consistency in a testretest situation. Although some information
about examination reliability is available, much of it was published in the 1970s. ABPN Part I
reliability has been rated high on the basis of having a small standard error of the mean (2 to 4
percent); a narrow interval increases the confidence that the examination results are accurate.
Two aspects of reliability as it relates to the ABPN Part II examination have been addressed:
agreement of the two primary examiners and agreement between the videotape and live patient
examinations.

Examiner Agreement

In 1991, Part II interexaminer consistency was evaluated for 1,422 candidates (2,844 patient
interviews or audiovisual examinations) to judge reliability. In 67 percent, there was perfect
agreement about the candidate's performance: before any discussion, the two examiners each
gave the same Pass, Condition, or Fail grade. For 26 percent of examinations, there were minor
disagreements (a Condition coupled with either a Pass or a Fail); there were major disagreements
(a Fail coupled with a Pass) for only 7 percent. The overall weighted kappa (κ) statistic of .56
was judged to show fair to good agreement beyond chance. When examiners disagreed,
discussion (sometimes involving the senior examiner) usually produced consensus with relative
ease.

A study of examination stability drawn from the same data found that, in the 7 percent in which
there was a major disagreement (Pass and Fail) between examiners, a thorough review of the
candidate's entire performance was usually necessary to reach consensus. Most of these major
disagreements turned on one examiner's concern about something specific the candidate had
done or omitted. Reporting that the examination process was stable across seasons of the year
and different examination sites, these authors found no evidence that factors such as examiner
fatigue or increasing experience influence interexaminer consistency.

In a 1990 assessment of the reliability of evaluative judgment, 94 academic psychiatrists rated a

videotape portraying the first 210 seconds of three interviews. The psychiatrists were asked to
rate the interviews using a data checklist, a global rating scale, and an estimate of time allotted to
various interviewing activities. Only a low level of agreement among raters was found for any of
these methods; this performance did not improve when videotape segments twice as long were
subsequently used.

Finally, in the pilot study that used 18 explicit grading criteria, agreement between raters on both
the audiovisual and live patient examinations yielded a broad range of intraclass correlations
coefficients (from .37 to .77). As of this writing, there had been no further examination of this
opportunity to improve reliability.

Videotape-Patient Agreement
Most examinees agree that the videotape examination is a useful testing device. Several
attributes are relevant to its use. It increases the efficiency of the examination by using only half
the number of patients that would be needed if every candidate interviewed two. Some
candidates may find it easier to discuss a videotape in which the data are already provided than
an actual patient, as data collection depends on the vagaries of the clinical interview. In any
given half-day, all candidates see the same interview tape, which permits a more uniform, hence
more reliable, examination. However, a videotape offers no opportunity to evaluate interaction
with patients, reducing its overall value as a measurement of clinical competence.

In the early 1980s, John Talbott reported the concordance rates between the live patient and
videotape sessions. He defined nonconcordance as a Pass coupled with either a Fail or a
Condition. Concordance was either identical scores on both tests or a Fail coupled with a
Condition. (The latter results in an overall failing grade. Because a Pass coupled with a
Condition usually results in an overall Pass, this definition yields a conservative estimate of
concordance.) Of 2,236 candidates, 52 percent had identical grades and 61 percent were
concordant, an acceptable rate considering that the two formats test somewhat different skills and
carry different weights in the judgment of many examiners. Of the 869 nonconcordant
candidates, 303 (35 percent) were highly discordant (they received a Pass coupled with a Fail). A
candidate with discordant scores was twice as likely to score higher on the videotape session.
Possible explanations for these findings: examiners may grade the videotape examination more
liberally; residency programs may better prepare their graduates to do well in the cognitive
aspects of psychiatry than in the performance skills of patient interviewing, or it may be easier to
discuss a patient for whom the data are already provided.

Talbott summarized the distinctions between the two examination formats by noting that the
patient interview tests whether the candidate can set the patient at ease, establish good
therapeutic contact, maintain interpersonal relatedness, elicit pertinent information, monitor
countertransferential reactions, ask direct and open-ended as well as sympathetic and productive
questions, and shift modes as warranted in the interview. The videotape interview should
concentrate directly on the cognitive aspects of the clinical problems presented (e.g., the mental
status, diagnosis, and therapy).

Limits of Reliability

The great strength of the ABPN examination continues to be its weakness: the subjectivity of
Part II. Considerable effort has been expended to make it fair and, within the

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limits of the genre, standardized. Yet, from time to time, stories surface that suggest the fragility
of its impartiality. These stories do not come solely from erstwhile candidates.
The day before each oral examination, all new examiners and those who have not examined
recently are required to attend a half-day course, one purpose of which is to ensure uniform
scoring. In one exercise, the novice examiners were divided into groups to view and discuss a
videotape of a candidate interviewing a difficult, manic-appearing patient. One group
unanimously agreed to pass the candidate. An examiner from that group was later somewhat
startled when a friend who had viewed the same video with a different group said, We all agreed
that the candidate should fail.

Of course, no one can expect all examiners to agree about candidates who appear marginal.
However, the anecdote suggests how much the power of group thinking can influence even
board diplomates who are trying their best to render objective, independent judgments about
their fellow psychiatrists. Indeed, for all the efforts to achieve reliability, the weight of published
evidence has, so far, demonstrated only modest reliability.

Validity

Validity is defined as the ability of an examination to yield an accurate measure of a

psychiatrist's clinical adequacy. Several types of validity are relevant to these examinations.

Content Validity

Does the examination evaluate material that experts consider vital to the assessment of
psychiatric capability? The countless hours devoted to writing questions for national
examinations would seem to defend a positive answer to this question. In a 1982 survey of 482
psychiatric clinicians and academicians, 92 to 99 percent agreed which ten skills were most
important for a clinical psychiatrist. In descending order, these were conducting a comprehensive
interview, evaluating the need for hospitalization, demonstrating reliability, conscientiousness
and integrity, accurate diagnosis, formulating and implementing a treatment plan, assessing
potential for suicide and violence, providing supportive psychotherapy, medication use,
compassion for patient and family, and recognition of countertransference problems. Although
this is exactly the sort of information sought in Part II of the boards, the concept of content
validity carries with it the taint of circular reasoning.

Construct Validity

A test with construct validity actually measures what it claims to measure. For example, if an
examination measures competence in a medical specialty, then test performance should correlate
positively with amount of training. This was indeed the finding in a study conducted in 1982 by
the American Board of Emergency Medicine. Similar findings are reported yearly for the PRITE.
The fact that first-time examinees are far more likely than repeaters to pass either part of the
ABPN can be taken to indicate that examination's construct validity.

Criterion Validity
In criterion validity, a new test is validated against an established measure of supposed great
accuracy. When the established measure is made at a future time, as in a follow-up study, it is
called predictive validity.

A 1975 study of 200 candidates evaluated the predictive validity of Part I. Of candidates who
passed Part I on the first try, 88 percent ultimately became board certified, compared with
ultimate success in only 12 percent of those who failed their first attempt at Part I. Only
approximately one-half of all psychiatry candidates passed both parts of the Boards on the first
try, eliciting this comment from the authors: This may mean that the examinations are deficient,
that candidates are insufficiently prepared, or that the examinations, despite an admitted need for
further improvement, do serve to maintain essential professional standards by not permitting
overly easy access to specialty status.

Comparison of the test scores of 701 physicians who had taken both the 1992 PRITE and the
1994 ABPN Part I examination revealed a Pearson correlation of .67 between the psychiatry
portions of the two examinations. Although the authors considered this correlation moderate, one
wonders why it was not higher. After all, the two examinations used similar methods to test
supposedly similar aspects of cognitive learning. Nonetheless, such openness mandates a yearly
rewriting of the examination itself, which retains only enough questions from the prior year to
allow comparison with examinations given in previous years. Development and administration
costs of the examination are borne by the training programs, which pay a flat fee of $116 per
resident tested each year. Residents invest only their time.

Other Correlations

A 1985 study found a low correlation between performance on Part I and the ratings of training
directors, and another study failed to show any correlation between psychiatry in-training
evaluations and other measures of candidate performance, such as multiple-choice questions and
oral examinations. Extremely limited data validate board diplomates' ability to render care that is
better than that given by nondiplomates. The only such mental health study yet reported
compared outcome of psychotherapy delivered by residents to nine patients with the following
evaluations: didactic examination, global ratings by trainers, supervisors' ratings based on
therapists' recollections of sessions, self-ratings, and independent evaluators' ratings of
videotaped sessions. Patient outcome only correlated with the supervisors' ratings, which (as the
authors acknowledged) could have been influenced by knowledge of that outcome. This halo
effect was subsequently diminished when, after viewing videotapes of their trainees' actual
therapy sessions, supervisors revised their overall evaluations downward. It appeared that
trainees' personality characteristics and ability to discuss theoretical material could enhance
supervisor's opinions of them.

A few nonmental health studies support the validity of board certification: (1) Lower mortality
rates for Medicare populations were found in hospitals that had the highest proportion of board-
certified physicians; (2) board-certified surgeons had lower morbidity and mortality rates than
surgeons who were not board certified; (3) board-certified emergency specialists performed
better in an examination in their specialty; (4) board-certified internists received higher peer
ratings than their colleagues without board status, which may be nothing more than halo effect;
and (5) death and failure-to-rescue rates were less for midcareer board-certified anesthesiologists
than for comparable noncertified practitioners. However, the authors note that this finding could
be consequent to the type of hospital at which the two groups practice.

Ethics and morals are hard enough to define, let alone measure. However, one study evaluated
the possible effect of board certification for physicians disciplined by the Medical Board of the
State of California. Board certification was significantly less common (P <.001) among
physicians against whom any disciplinary measure had been taken than among a comparison
group of physicians who had not been disciplined (53 vs. 73 percent). However, a subsequent
study found no such difference between disciplined and nondisciplined psychiatrists (board
certification was reported for 43 percent vs. 46 percent, respectively). Another study found that
board certification did not predict medical board discipline for sex-related offenses.

The ability of ABPN certification in general psychiatry to signify quality mental health delivery
is often regarded almost as a tenet of faith. With much to recommend it in terms of logic, it
remains largely unproven. One review of the evaluation of trainees' problem-solving skills
concluded that observation of a single patientprovider encounter was unlikely to predict
accurately how that

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trainee would perform in a different clinical situation. Currently, few data would suggest a more
optimistic conclusion about the ability of any examination now used by psychiatric training
programs. As a corollary to evidenced-based medicine, American psychiatry'indeed, all
American medical specialties'should adopt as a task of utmost importance the search for
correlations between board certification and clinical ability or patient outcome.

MAINTENANCE OF CERTIFICATION

Since 1994 (1995 for child and adolescent psychiatry), the ABPN certificate issued in general
psychiatry and subspecialty examinations has been good for 10 years. Ideally, recertification for
any profession as complicated and high risk as the care of psychiatric patients requires the
evaluation of many qualities. These span a range from highly objective to the most subjective,
including knowledge, judgment, skills, and attitudes. Of course, only the first of these can be
readily assessed by written examination. That is why the concept of an ongoing maintenance of
certification has evolved in psychiatry, as well as in the other specialties of medicine. Ultimately,
this process will involve not only a periodic examination but other methods that will help to
guarantee continuing education and improvement in clinicians. Since 1999, the ACGME has
listed a variety of competencies that should inform the practice of clinicians in every medical
specialty (Table 53.2-5).

Table 53.2-5 Accreditation Council for Graduate Medical Examination (ACGME) Competencies

--------------------------------------------------------------------------------

1. Patient care

a. Caring and respectful behaviors

b. Interviewing

c. Informed decision making

d. Develop and carry out patient management plans

e. Counsel and educate patients and families

f. Performance of procedures

i. Routine physical examination

ii. Medical procedures

g. Preventive health services

h. Work within a team

2. Medical knowledge

a. Investigatory and analytic thinking

b. Knowledge and application of basic sciences

3. Practice-based learning and improvement

a. Analyze own practice for needed improvements

b. Use of evidence from scientific studies

c. Application of research and statistical methods

d. Use of information technology

 e. Facilitate learning of others

4. Interpersonal and communication skills

a. Creation of therapeutic relationship with patients

b. Listening skills

5. Professionalism

a. Respect and altruism

b. Ethically sound practice

c. Sensitive to cultural, age, gender, disability issues

6. Systems-based practice

a. Understand interaction of individual practice with the larger system

b. Knowledge of practice and delivery systems

c. Practice cost-effective care

d. Advocate for patients within the health care system

--------------------------------------------------------------------------------

Whereas psychiatry recertification examinations were originally planned as an open-book

examination to be taken at home, in recent years, the ABPN has moved to something less
informal (and more expensive). Recognizing the value to the public of its certificates as marks of
competence and quality and the fact that, unless taken on-site, the board cannot swear that the
clinician actually took the examination. That is why candidates for any psychiatry or
subspecialty recertification must now travel to Chicago, where the ABPN has established an
examination center for computerized testing. The board claims that this examination is easier and
less stressful to take than the pencil-and-paper variety; examinees can flag questions and come
back to them later, and mistakes such as putting answers in the wrong place or marking two
answers for one question simply cannot be made.
As with Parts I and II, the recertification examination it is not a referenced test; theoretically, all
can pass. Indeed, a very high percentage of test takers should pass, inasmuch as this process is
only a reaffirmation of competence already demonstrated. This has been the experience of the
first few candidates to recertify. For example, pass rates for clinical neurophysiology and
geriatric psychiatry have averaged 97 percent. Furthermore, there is no limit on the number of
times a candidate for recertification can retake this examination. If there has been a lapse of
certification, even of months or years, only the recertification test is needed to reestablish the
credential'there is no need to retake the original examination. Although examinees have no
access to resource materials, according to ABPN, test content is core and essential information
that requires no such materials.

All reexaminations require 4 or 5 hours to complete. Subspecialty certification requires passing

both the psychiatry and subspecialty test; however, child psychiatrists need only take the child
and adolescent examination. Cost is currently $1,825 for each recertification examination. Dates
are listed on the recertification portion of the ABPN Web site (www.abpn.com). An outline of
content for each examination is also posted on this Web site. The board recommends that
reexaminees use the same resources used in writing the questions: peer-reviewed journals,
current texts and monographs, review articles, practice guidelines, accredited continuing medical
education programs.

The traditional oral and written examinations are only two of the possible evaluation methods.
Many others have been proposed, and some have actually been put into practice by various
medical specialty boards. The following list presents brief descriptions of several of these and
indicates the ACGME competency areas (Table 53.2-5) for which each is best suited.

360-degree evaluation. These instruments are completed by people in a clinician's sphere of

influence. They include superiors, peers, and subordinates, as well as patients and their families.
Usually, rating scales are used to assess how often behaviors are performed; the results are fed
back to the clinician in summary form. (1h, 3d, 3e, 5b, 5c, 6d)

Chart-stimulated recall oral examination. An experienced clinician, using previously submitted

charts and established interview protocols, probes reasoning behind the workup, diagnoses,
interpretation of findings, and treatment plans. Each case takes 5 to 10 minutes; a typical
examination lasts 2 hours. (1c, 1d, 2a, 3b)

Checklist evaluation. Used successfully for testing and self-evaluation, a yes/no or

complete/partial/absent checklist can be created for specific behaviors that make up a task.
Criteria must be set to indicate levels of performance. (1b, 1fii, 6c)

Objective structured clinical examination. Discussed previously. (1b, 1e, 1fi, 1g, 4a, 4b, 5a, 5c)

Patient surveys. Satisfaction with various aspects of medical care can be assessed by simply
asking patients; many aspects of physician behaviors can be evaluated by this means. Usually,
responses are solicited as a choice of adjectives (poor, fair, good, excellent) or by subscribing to
a statement: The doctor devoted full attention to me and my problems nearly always, sometimes,
hardly ever. (1a, 1e, 4a, 4b, 5a, 6d)

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Portfolios. A clinician can assemble material that might include summaries of research
supporting a treatment plan, a log of procedures performed, a quality improvement plan, how
ethical dilemmas faced were handled, patient outcome tracking, and counseling transcripts.
Summary statements can include applications of what has been learned and a plan for meeting
additional learning needs. (3a, 3b, 3c, 3d)

Record review. Printed or electronic documents can be mined for information, abstracted
according to a protocol, such as drugs prescribed, patient outcomes, procedures performed, and
tests ordered. This information is compared to accepted standards of patient care. A handful of
records may be all that is needed to assess quality of care. (1g, 3b).

Standardized oral examinations. A trained examiner poses questions concerning management

based on case scenarios of clinical issues the examinee should be able to handle. Reasons for
requesting clinical information, interpretations of findings, and treatment plans can be assessed
in just a few minutes. In a 90- to 150-minute examination, a variety of clinical scenarios can be
evaluated. (2a, 2b, 3b)

Standardized patients. A number of well people are trained to simulate a variety of medical
conditions in a standardized way. During the interview, a physician observer uses a checklist
(criteria drawn up in advance) to evaluate how the examinee performs a history, orders tests,
makes a diagnosis, develops a treatment plan, or provides therapy. (1a, 1e, 1fi, 4a, 4b)

Written or computer-based multiple choice questions. Previously described. (2b, 3b, 6b)

It should be noted that, whereas most of these resources have been evaluated for validity, most
still afford considerable opportunity for investigation of validity. Of course, none of these
methods by itself can evaluate the totality of a physician's competence, hence the value of
multiple measures. Even if many methods of testing are used, they can present only an imperfect
representation of the true qualities any candidate possesses. Because training programs,
professional organizations, and examining boards deal with the same relatively small group of
individuals, efforts at close collaboration among a wide variety of testing, educational, and other
professional organizations should increasingly be undertaken to meld multiple evaluations of
trainees' competence, including residency directors' evaluations, in-residence training
examination scores, and written and oral performance on the boards.
SUGGESTED CROSS-REFERENCES

Section 53.1 contains information about the history and current operations of the American
Board of Psychiatry and Neurology. The standard psychiatric history and mental status
examination are covered in Sections 7.1 and 7.3. A general discussion of reliability and validity
can be found in Section 5.2.

REFERENCES

*Bienenfeld D, Kylkylo W, Lehrer D: Closing the loop: assessing the effectiveness of

psychiatric competency measures. Acad Psychiatry. 2003;27:131.

Borus JF, Yager J: Ongoing evaluation in psychiatry: the first step toward quality. Am J
Psychiatry. 1986;143:1415.

Case SM, Swanson DB. Constructing Written Test Questions for the Basic and Clinical
Sciences. Philadelphia: National Board of Medical Examiners; 1996.

Chevron ED, Rounsaville BJ: Evaluating the clinical skills of psychotherapists. Arch Gen
Psychiatry. 1983;40:1129.

Giordano FL, Briones DF: Assessing residents' competence in psychotherapy. Acad Psychiatry.
2003;27:145.

Hein JG. International medical graduates and communication. In: Husain SA, Muoz RA, Balon
R. International Medical Graduates in Psychiatry in the United States. Washington, DC:
American Psychiatric Press; 1997.

Hodges B, Regehr G, Hanson M, McNaughton N: Validation of an objective structured clinical

examination in psychiatry. Acad Med. 1998;73:910.

*Johnston KC: Responding to the ACGME's competency requirements: an innovative instrument

from the University of Virginia's neurology residency. Acad Med. 2003;78:1217.

Juul D, Martin MJ, Scheiber SC: The examination for added qualifications in geriatric
psychiatry. Am J Geriatr Psychiatry. 1996;4:24.

Juul D, Scully JH Jr, Scheiber SC: Achieving board certification in psychiatry: a cohort study.
Am J Psychiatry. 2003;160(3):563.

Juul D, Tucker GJ. The part I psychiatry examination: facts about the written examination. In:
Shore JH, Scheiber SC. Certification, Recertification and Lifetime Learning in Psychiatry.
Washington, DC: American Psychiatric Press; 1994.
Langsley DG. Certification in psychiatry and neurology: past, present, and future. In: Shore JH,
Scheiber SC. Certification, Recertification and Lifetime Learning in Psychiatry. Washington,
DC: American Psychiatric Press; 1994.

Loschen EL: Using the Objective Structured clinical examination in a psychiatry residency.
Acad Psychiatry. 1993;17:95.

*Manring J, Beitman BD, Dewan MJ: Evaluating competence in psychotherapy. Acad

Psychiatry. 2003;27:136.

McDermott JF, Streltzer J, Lum KY, Nordquist CR, Danko G: Pilot study of explicit grading
criteria in the American Board of Psychiatry and Neurology Part II examination. Am J
Psychiatry. 1996;153:1097.

McDermott JF, Tanguay PE, Scheiber SC, Juul D, Shore JH, Tucker GJ, McCurdy, L, Terr LC:
Reliability of the part II board certification examination in psychiatry: interexaminer consistency.
Am J Psychiatry. 1991;148:1672.

McDermott JF, Tanguay PE, Scheiber SC, Juul D, Shore JH, Tucker GJ, McCurdy, L, Terr LC:
Reliability of the part II board certification examination in psychiatry: examination stability. Am
J Psychiatry. 1993;150:1077.

McGuire CH. Medical problem-solving: a critique of the literature. Research in Medical

Education: 1984 Proceedings of the 23rd Annual Conference, 1984; Washington, DC.

Morrison J, Morrison T: Psychiatrists disciplined by a state medical board. Am J Psychiatry.

2001;158:474.

*Morrison J, Muoz RA. Boarding Time. 3rd ed. Washington, DC: American Psychiatric Press;
2003.

Morrison J, Wickersham P: Physicians disciplined by a state medical board. JAMA.

1998;279:1889.

Ramsey P, Carline J, Inui T: Predictive validity of certification by the American Board of

Internal Medicine. Ann Intern Med. 1989;110:719.

*Sargent J, Sexson S, Cuffe S, Drell M, Dugan T, Ferren P, Kim WJ, Stubbe D, Zima B, Brown
T: Assessment of competency in child and adolescent psychiatry training. Acad Psychiatry.
2004;28:18.

Shapiro T, Juul D, Scheiber SC: Exploration of failure on the subspecialty examination for child
and adolescent psychiatry. Am J Psychiatry. 1996;153:693.
Shore JH, Scheiber SC, eds. Certification, Recertification and Lifetime Learning in Psychiatry.
Washington, DC: American Psychiatric Press; 1994.

Sierles F, Daghestani A, Weiner CL, deVito R, Fichtner CG, Garfield DAS: Psychometric
properties of ABPN-style oral examinations administered jointly by two psychiatry residency
programs. Acad Psychiatry. 2001;25:214.

Silber JH, Kennedy SK, Even-Shoshan O, Chen W, Mosher RE, Showan AM, Longnecker DE:
Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002;96:1044.

Smeltzer DJ, Jones BA: Reliability and validity of the psychiatry resident in-training
examination. Acad Psychiatry. 1990;14:115.

Tanguay PE, McDermott JF, Philips I: A study of the board certification examination in child
and adolescent psychiatry. J Am Acad Child Adolesc Psychiatry. 1990;29:821.

Templeton B, Allen MM: Interrater reliability in evaluating trainee interviewing skills. Acad.
Psychiatry. 1990;14:188.

Wade TP, Kaminski DL: Comparative evaluation of educational methods in surgical resident
education. Arch Surgery. 1995;130:83.

Webb LC, Juul D, Reynolds CF III, Ruiz B, Ruiz P, Scheiber SC, Scully J: How well does the
psychiatry residency in-training examination predict performance on the American Board of
Psychiatry and Neurology Part I Examination? Am J Psychiatry. 1996;153:831.

Yager J, Bienenfeld D: How competent are we to assess psychotherapeutic competence in

psychiatric residents? Acad Psychiatry. 2003;27:174.

53.3 An Anthropological View of Psychiatry

Tanya Marie Luhrmann Ph.D.

Part of "53 - Psychiatric Education"

Psychiatry probably changed more profoundly in the second half of the 20th century than any
other field of medicine. As in other fields, the explosion of new technologies made possible a
research and treatment agenda unthinkable in the 1960s. However, in psychiatry, even the basic
presumptions about the cause and treatment of mental illness have turned upside down. In the
1960s, many psychiatrists regarded psychopharmacology with scorn. Now, psychopharmacology

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dominates the field, and the marketing zeal of pharmaceutical companies is a central fact of any
psychiatrist's life. Once, good psychotherapy was synonymous with psychoanalysis, and, with
rare exceptions, psychiatrists were the only people accepted into psychoanalytic training. Now,
psychoanalysis is under threat on many fronts, and other psychotherapies, often developed and
carried out by psychologists and social workers, are often assumed by the public to be cheaper
and more effective. Yet, many psychiatrists still regard psychoanalytically oriented therapy as an
important psychiatric skill. These changes have left young psychiatrists-in-training with a
complex array of tasks to master.

The author of this section is an anthropologist who, over the course of more than 4 years of
fieldwork in the early 1990s (resulting in the book Of Two Minds, published in 2000), spent 3
years in a local hospital, attending lectures, spending time with residents, and participating in
medical meetings. The author also spent 4 months at an elite private psychiatric hospital, 3
months in a community service hospital, and stretches of a week or two each in places that
represented a kind of ideal type of the extremes'a psychoanalytic hospital, a scientific research
unit, a state hospital, and a nonacademic community hospital's psychiatric unit. The author also
traveled around the country speaking with hospital administrators, psychiatry residency program
directors, and young psychiatrists. She watched hundreds of lectures to residents through 3 years
of training; attended more than 100 rounds or team meetings; shadowed residents during the day
and during on-call evenings; spent substantial periods of time on psychodynamic, eclectic, and
biomedical units; interviewed most residents in one program annually for 3 years; and
interviewed many others elsewhere. This section reports on these ethnographic findings.

Almost all psychiatrists seem to agree on two basic premises'that mental illness results from a
complex interaction of biomedical and psychosocial factors and that it is best treated by a
combination of biomedical and psychosocial interventions. Yet, despite a clear intellectual and
pragmatic focus on complexity, contemporary psychiatry tends to be presented through two
approaches rooted in the history of the field, so different that they could be called different
cultures.

HISTORICAL ASPECTS OF PSYCHIATRIC TRAINING

One of these approaches draws its inspiration from psychoanalysis, which dominated psychiatry
in the decades after World War II and still remains the dominant paradigm for psychotherapy in
a psychiatric setting. It dominated because, at the time, psychoanalysis introduced a theory of
mind that, in its complexity and explanatory power, was clearly superior to its predecessors and
clearly better equipped to handle mental distress. It also changed the image of the severely
psychiatrically impaired. Patients were no longer imagined as deeply abnormal, as they had been
(more or less) in the 19th century, when psychiatry was a custodial enterprise. They became
victims of an ordinary struggle that wounded some (those who became patients) more than
others. Psychoanalysis alone was not responsible for this shift in attention from the alien to the
everyday (it was under way before psychoanalysis had much impact on American psychiatry),
but, as that shift occurred, psychoanalysis became a powerful theory that justified psychiatrists'
treatment of ordinary people, and psychoanalysis was hailed as psychiatry's powerful new
method.

World War II established the value of psychoanalysis both within psychiatry and within the
public awareness of psychiatric problems. More than a million applicants were rejected for
military duty because of psychiatric or neurological disorder; more than a million patients with
neuropsychiatric casualties were admitted to military hospitals between January 1942 and
December 1945. At the front, the symptoms of shell-shocked soldiers'incapacitating anxiety,
recurrent nightmares, intrusive thoughts about one's victims'seemed to demand an account of
something like an unconscious. Psychoanalysis could not only give an explanation for the
symptoms, but also offered something like a cure. In 1946, the National Mental Health Act
vastly increased the money available for training and research in psychiatry, created the National
Institute of Mental Health, and built a network of 69 new hospitals for the Veterans
Administration, mostly to deal with psychiatric casualties. Most, by then, had a psychoanalytic
focus.

For many reasons'among them, the failure of psychoanalysis to help many severely ill patients,
the ambiguity of psychoanalytic diagnosis and the problems this created both for serious research
and for an emerging insurance industry, and the emergence of the anti-psychiatry movement'an
alternative paradigm began to acquire a noticeable disciplinary presence in the 1970s. These
psychiatrists saw themselves as scientists, and, to them, that word set them apart from
psychoanalysis, to which many of them were openly hostile and which few of them regarded as
scientific. They were committed to what they called strict standards of evidence and were
determined to create a psychiatry that looked more like the rest of medicine, in which patients
were understood to have diseases and in which doctors identified the diseases and then targeted
them by treating the body, just as medicine identified and treated cardiac illness, thyroiditis, and
diabetes. This emerging school of scientific or remedicalized psychiatry owed its allegiance not
to Sigmund Freud, but to Emil Kraepelin (a German psychiatrist born the same year as Freud)
who had created an important taxonomy of psychiatric illness by studying symptom clusters and
final outcomes and by collecting family histories to trace hereditary traits. The new psychiatric
scientists argued, in effect, that psychiatry had made a wrong turn in following Freud instead of
Kraepelin. They tended to believe that, if a disorder could be distinctly identified with specific
criteria, a common clinical course, and perhaps a family history, it probably had an underlying
organic cause and was a disease like any other. The third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III), published in 1980, exemplified the shift from the
psychodynamic approach (at least with respect to diagnosis) to the Kraepelinian one.

By the early 1980s, psychiatry in many hospitals had become a sprawling confrontation between
what were then thought of as two camps: either psychiatric illness was like a disease, reliable
diagnosis was important, and psychopharmacology was the major and crucial intervention or
psychiatric illness was not disease-like, diagnosis was not important, and psychopharmacology
was a crutch. In some hospitals, there was a quiet war that left behind wreckage of bitterness and
folklore about the days when the biological psychiatrists (as this group came to be called) and the
psychoanalysts sat at different tables during lunch and when case conferences could be cruel,
covert duels. The public battles, in the journals and the media, were fierce. One long-running
case, Osheroff v. Chestnut Lodge, was settled in favor of a patient who had sued his
psychoanalytically oriented psychiatrists for their failure to medicate, and it established new
guidelines for the standard of care.

CURRENT TRENDS IN TRAINING

Today, research psychiatry is a branch of neuroscience. Many of the leading researchers attend
and present at the annual Society for Neuroscience conference. Many work in laboratories,
where they use chemicals and Petri dishes. Some do experiments with rats. Some scan the

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brain to determine relative blood flow under various conditions. Others run large-scale statistical
studies of pharmacological response. These scientists are quite unlike psychoanalysts. Yet, the
new psychiatric science did not itself pose a threat to psychodynamic psychiatry, because, for all
the foolishness of psychoanalysis in the era of its great arrogance, psychodynamic psychotherapy
made a significant difference in the lives of patients, and most psychiatrists knew it. Despite the
ideological conflicts, by the mid-1980s, many hospitals had settled down to what many
perceived as a two-toned psychiatry. Residency programs spoke (as they continue to speak) of a
need for an integrated psychiatry. Yet, in residency programs in the mid- and late 1980s, there
were (roughly speaking) two kinds of psychiatric orientations'biomedical and psychodynamic.
This opposition oversimplifies the complexity of psychiatric practice but still captures an
important part of the experience. One of the consequences of ideological tension was to create a
more dichotomous sensibility than might have been the case otherwise.

DUALISM IN TRAINING

Despite talk of integration, there is a great deal of practical dualism in the current training of new
psychiatrists. The often-stated ideal is to combine a biomedical and a psychodynamic
approach'or, more broadly, a bodily and a psychosocial approach'when dealing with any patient.
However, practically speaking, the basic demands of inpatient care in most hospitals are
biomedical; demand on psychotherapy skills tends to be restricted to working with
psychotherapy outpatients or in settings specifically identified as psychotherapeutic. As a result,
it becomes easy for two different sets of assumptions and practices to be established.

As residents engage in psychiatric training, they confront an array of tasks that they must master
to be recognized as competent. These basic tasks can be readily identified as associated with the
biomedical or psychosocial orientation. For example, the residencies typically offer residents two
(or more) lectures a week. Typically, one of these addresses more biomedical topics, like
diagnosis or psychopharmacology, and another addresses topics in psychotherapy. Sometimes,
there are inpatient units in which residents are expected to treat patients with psychotherapy.
They are rare, but, when they exist, they tend to be easily identified as unlike other kinds of
units. They are called psychodynamic units, or process-oriented units, and they often focus on
personality disorders. Residents tend to be clearly aware that the work on such units demands a
different kind of expertise. Far more often, residents are expected to use psychotherapy with
certain kinds of outpatients. Those outpatients are called psychotherapy patients; they make
appointments on a different kind of schedule (once or twice a week compared to once a month)
for a different amount of time (approximately 1 hour compared to 15 minutes or so), and the
resident is supervised by a different kind of expert, a psychotherapy supervisor. Finally, there are
roughly two dominant categories of acknowledged experts'psychoanalysts and psychiatric
scientists'each usually thought to be the best one can be in his or her domain. Psychoanalysis is
no longer the only form of psychotherapy taught in psychiatry, but because it was, until recently,
the elite, senior psychotherapy-oriented psychiatrists still usually are psychoanalysts.

Impact of Dualism on Empathy

What is the possible impact of this practical dualism on the doctorpatient relationship? These
different tasks'biomedical and psychodynamic'teach young doctors to empathize with their
patients in different ways. Both are empathic, but they are not empathic in the same way.
Empathy is a process, not an emotion. It is a process in which the empathizer imagines what it is
to be someone else, the person being empathized with. And empathy is imperfect. The density of
one person's experience exceeds what an observer can grasp, and so, in empathy, as in life, there
are many truths, and each one springs from a specific conjunction of the empathizer and the
empathized with. One can be more empathic or less, but the way one is empathic'with what in a
person's life one empathizes with and how'has a great deal to do with who one is and how one
conceives of one's task at that moment. Empathy has components that an observer can see when
a student is taught to perform an empathic task'how to perceive the person being empathized
with, how to relate to him or her, how to behave appropriately with him or her, and who to aspire
to be with him or her. These are present in the way one person hears and responds to another'the
person one sees as the person one hopes he or she is, with feelings and behaviors one has been
encouraged to adopt.

No person is simple. Psychiatrists are taught to listen to people in particular ways'they listen for
signals most nonpsychiatrists cannot hear and look for patterns most nonpsychiatrists cannot see.
Their two primary tasks, however'diagnosis and psychopharmacology on the one hand and
psychodynamic psychotherapy on the other'teach them to listen and look in ways that are
different from each other. They must learn to perceive the patient so as to do their task, and what
they learn is often inherent to the tasks themselves, not to the style or personality of the doctor.
They must learn to anticipate the patient in the settings of their different tasks, and they must
learn what counts as appropriate behavior on the units dominated by either biomedical or
psychodynamic concerns. Again, these differences are part of the tasks, not the result of the
doctor's personality, although, certainly, different tasks may appeal to different kinds of people.
They must learn who is admired in these different domains so that one can ask, when a young
doctor has seen a patient, not only what he or she saw in the patient, but who he or she should
aspire to be in response. All this is part of the way young psychiatrists learn to be doctors with
patients.

FOUR QUESTIONS

One can look at the impact of this dualism more carefully by asking four questions. First, how do
different tasks teach young psychiatrists who the patient is'or, more pragmatically, what's wrong
with this patient and what should a psychiatrist pay attention to in the encounter with this
patient? Second, how do different tasks prime the young psychiatrist to react emotionally to the
patient? Third, how do different tasks teach the young psychiatrist to behave around the patient?
Fourth, if the young psychiatrist wants to be the best he or she can be, who does he or she want
to be with the patient? These questions will organize the presentation of the material.

What Is Wrong with the Patient?

In the Hospital

In the hospital, a young psychiatrist's basic task'the task that he or she cannot fail at and remain
in the program'is to admit patients to an inpatient service. This is fundamentally a biomedical
task. To admit the patient, the doctor interviews the patient and dictates a number of paragraphs,
which are the medical and legal justification for the patient's presence in the hospital and which
provide the evidence and argument for the identification of the illness according to the current
manual of psychiatric nosology, the DSM-IV-TR, which models serious psychiatric illnesses as
like other medical illness. There is enormous public pressure on the young resident to be
competent at this task. The admissions note is the single most consistently read document about
the person as a patient throughout the hospitalization and beyond; it should be a clean, typed
summary that explains why the patient came into the

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hospital and what the doctor thought about that patient at that time. The note is read by peers on
call, by senior doctors, by nurses, vocational counselors'by anyone who has contact with the
patient and has need to see the patient's medical chart. Moreover, the young psychiatrist who has
written the admissions note often must verbally present the patient'in morning rounds and team
meetings'to a group of peers and seniors who evaluate the accuracy of the diagnosis and may, in
fact, publicly reinterview the patient.
LEARNING PROCESS

Residents use a common learning strategy to master the knowledge necessary to admit and
diagnose patients. Initially, they memorize lists of diagnostic criteria, sometimes with mnemonic
aids. They attend lectures on the differences between depression and psychotic depression, or
between organic delusional disorder and schizophrenia, in which the person teaching the class
may write the criteria out on the board and explain them. During the first months of doing
admissions, new residents will pick up the small DSM handbook while talking to a patient and
turn to a specific diagnosis to make sure they have asked about all the criteria. Often, the lore
passed on to new residents about the admissions process circles around the symptoms and the
criteria. As one chief resident advised, Try to memorize the topic you always forget; I always
used to forget about obsessive symptoms. The daily structure of hospital life creates a learning
environment that is highly effective in persuading residents to memorize these complex
categories by criteria, because the failure to be good enough becomes a public humiliation.

PROTOTYPES

At some point in the first year, the resident moves from memorizing criteria to recognizing
prototypes. A prototype is a cluster of characteristics that constitutes a good example of a class.
When one thinks with prototypes, one asks whether the item in question resembles the best
example of that class, not whether it meets specified rules or criteria of that category. Is an
ostrich a bird or a grazing animal? Prototype users ask themselves whether the ostrich is more
like a sparrow or more like a cow, relying both on what they can see and also on an array of
background theory and assumptions. An impressive battery of work in cognitive science argues
that for most of everyday categories'particularly basic-level categories like table and chair and
dog'people reason by prototype. When one looks at a piece of furniture to decide whether it is a
table or a chair, one does not list the rules of membership in the table and chair categories in the
mind. That takes time. It also often does not work, as many category members do not have all the
apparent criteria of the class. (A bird that cannot fly, like the penguin, is still a bird.) Instead, the
evidence suggests, one calls to mind the best examples of each category and decides which one
the questionable object most resembles. People do not ask themselves whether this chair meets
the criteria for chair-ship. They look at it, and they know it is a chair.

The great advantage of prototype use is that it is fast and efficient. One recognizes, rather than
remembers, a list of membership rules. The cost is that the boundaries between categories
become starker. Cognitive scientists use the phrase prototype effects to describe this
phenomenon. People process information about prototypes more quickly than information about
nonprototypes, but they also tend to clump information around prototypes, so they are more
likely to overinterpret similarity to a prototype. Very new residents, asked whether a patient
meets DSM criteria for schizophrenia or bipolar disorder, will pick up the DSM and read the
criteria for each. They may find that the patient meets some for both and that the difference
between the two categories is not that straightforward, at least in this case. One year later, when
residents have developed prototypes for the illnesses, they will probably not reach for the
diagnostic handbook and will probably not feel that the difference between the categories is
inherently uncertain. They are more likely to believe that there are clear differences between
illness categories and are more likely to pick up data in a case presentation that corresponds to
the prototype and ignore information that does not. As this happens, it becomes difficult for new
psychiatrists to remember that initial skepticism about the diagnostic criteria. The patient's illness
seems less like a sorting problem'is it like this or like that'and more like a simple identification
task. The diagnoses begin to feel like real, distinct objects in the body.

The cumulative effect of the learning process is to imply that for each diagnosis there is an
underlying disease, a stuff that the diagnosis names, and that the stuff trumps the diagnosis. That
is, through the process of memorizing the criteria and learning to prototype the categories,
psychiatrists learn to talk and act as if the disorders are there in the world, that they are instantly
recognizable, and that the printed diagnostic criteria may only partially describe the real
disorders. Young psychiatrists behave as if these categories are natural kinds. A natural kind is
something real in the world, like a zebra or a horse (but not a table). One knows that there is a
natural difference between a zebra and a horse, even if an albino zebra has no stripes and a
troublesome philosopher has painted black stripes on a white horse. The difference between
zebras and horses is genuine. It is not a matter of social convention, it was not invented, and
whatever makes the difference is intrinsically, even causally, related to the difference between
categories. Gold is not the same as fool's gold, even though both are golden, because it is made
from a different chemical compound. Nonexperts know that experts know the difference between
the two and that there is a real underlying difference, even though they do not know what it is.

There is an important caveat here. The training experience that tends to encourage young
psychiatrists cognitively to treat diagnoses like different underlying diseases is relevant only to
some diagnoses'the Axis I disorders, which tend to be understood as the most serious disorders
and as the disorders that justify hospital admission. The Axis II disorders tend not to be used in
admissions notes as the justification for admission to hospital-level care. Psychiatric researchers
do have heated debates about whether these clusters are fundamentally distinct. Certainly some
of the personality disorders can be as deadly as the Axis I disorder, in that people with
personality disorders can be at significant risk for suicide. However, because (for the most part)
only Axis I disorders are used to justify hospital admission, only Axis I diagnoses are learned
with bird-watching acuity as distinct and clear-cut objects. Because the character disorders are
supposed to imply long-standing and constant problems, most hospitals (or at least their insurers)
insist on limiting psychiatric hospital admissions to patients who can be described as having an
Axis I category in an acute phase. Hospital admissions are meant to be limited to those who are a
danger to self or others or incapable of self-care. In the admissions note, those states are usually
attributed to an Axis I disorder, the patient is treated for the Axis I disorder, and the personality
disorder becomes something that makes the person more or less difficult to treat (they are
dramatic, irritable, entitled, and so forth) but is not the cause of his or her illness. Whether or not
these Axis I disorders (or, for that matter, the Axis II disorders) turn out to have underlying
diseases, Axis I diagnoses are already powerfully socialized as if they have them and as if the
Axis II diagnoses do not.

CATEGORY CRITIQUE

By the end of their residency, young psychiatrists often develop a sophisticated critique of these
diagnostic categories. This is because there is a major contradiction in the learning process that
challenges the naturalness of these distinctions. Psychiatric medications treat symptoms, not
diseases. They touch

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the way people act, not the underlying mechanisms. When they focus on medications, psychiatric
residents sometimes behave as if the symptoms are the things in the world and the diagnostic
categories are the inventions of committees and reified by insurance companies. Thinking in
terms of medication can leave the psychiatrist skeptical and hesitant about diagnosis itself
because, ultimately, the medication is more important than the diagnosis, because prescribing
medication is what the doctor actually does.

Thus, while the process of diagnosis helps to convince young psychiatrists that they are dealing
with organic disease, they can then turn around and question the diagnostic categories because,
in a sense, they no longer need them. At this point, challenging the categories does not challenge
the existence of organic disease. By the end of their residency, young psychiatrists will say that
individuals just don't fit the categories and will not infrequently describe themselves as focusing
on the symptoms rather than on the categories. They will talk of being phenomenologically
minded. They will talk about the lore of psychiatry, by which they mean rule-of-thumb
generalizations that ring true to their own experience and that they will teach to their students but
that rarely appear in the official teaching texts of the profession.

TWO-TIER LEVEL OF EXPERTISE

One of the results of this complexity is that an observer can see a two-tier level of expertise on
biomedical topics among psychiatrists. There is what one may call basic competence. After a
year, a young psychiatrist can usually diagnose very rapidly; usually, he or she knows a fair
amount about some medications associated with the major disorders. The adequate young
psychiatrist can sound knowledgeable, prescribe adequate doses, and expect to see behavioral
change if he or she is familiar with one antipsychotic, one or two antidepressants, one mood
stabilizer, and, perhaps, one or two antianxiety agents for good measure. At this level of
expertise, the psychiatrist sometimes behaves as if the underlying stuff is the disease and, other
times, as if the stuff is symptoms picked out by medication. In team meetings and case
conferences, psychiatrists talk about schizophrenia, psychotic depression, and so forth. When
they worry about what to do for patients, they talk about anxiety, psychosis, and despair.

Ten years later (in any field, it seems to take approximately 10 years to acquire deep expertise)
some psychiatrists seem to reach what one may call a level of connoisseurship in diagnosis and
psychopharmacology. At this level, the discrete distinctions between the categories break down,
and the contradiction between the thing-like diseases that the diagnoses pick out and the thing-
like symptoms that the medications treat tends to be replaced by more tentative subcategories
generated by knowledge of the brain, knowledge of psychopharmacological process, and sheer
clinical experience of illness behavior. In addition, at other levels of high expertise (in
cardiology, oncology, or, for that matter, stamp-collecting), consensus breaks down. Different
senior psychiatric experts have widely diverging ideas about what they are treating and how to
treat it. One expert sees mood disorders when another sees personality disorders. One expert sees
dissociative disorder when another sees histrionics. More generally, connoisseurship in the
biomedical domain involves complicated knowledge of biological pathways. An adequate
resident can recognize depression and know which drugs to prescribe and at what dose without
knowing anything about what happens to the brain during depression nor anything about how the
drugs might work. That ignorance makes depression seem particularly like a thing, because it
makes the depressiondisease relationship seem simple. The more sophisticated the psychiatrist,
the more depression appears to be the behavioral end point of an array of neural pathways
continually shaped by genes, physical environment, life events, psychodynamic habits,
temperament, family, and so forth.

In Psychotherapy

Learning about psychotherapy creates different demands and establishes quite different
competencies. There is much less public performance. For the most part, no one sees the resident
with the patient, unless the resident videotapes a session, and, even then, the only person who
sees the performance is the psychotherapy supervisor, and supervision also usually takes place in
private. In most cases, the psychotherapy supervisor never sees the patient in person. In many
cases, the supervisor never sees a video of the session or listens to a tape recording of it. Instead,
the resident and supervisor meet at a prearranged time, the resident tells the supervisor what went
on in the session, and the supervisor advises the resident on what to do next.

If basic competence in diagnosis and psychopharmacology is like becoming a master bird-

watcher, the skill of psychotherapy is more like learning to be a storyteller. There are
identification tasks in psychotherapy, but they are more numerous and they focus on narrower
events. Academic psychologists have argued that expertise depends, in large part, on the amount
and organization of knowledge around the area of expertise'what they call the domain: chess,
ballet, the Aztecs, psychiatry, whatever the expert is an expert in. Many argue that the highest
level of expertise is, indeed (as the therapists argue), reached after 10 years in the domain. The
experts' memories seem to depend on their capacity for perceiving meaningful patterns
(cognitive scientists would call them schemas), and the immense storage in their domain of
expertise seems to enable them to plan strategically in that domain and anticipate potential
sequences of moves in the future.

EMOTIONMOTIVATIONBEHAVIOR BUNDLES

What the psychotherapist remembers is a lexicon of narrative patterns that he or she uses to
understand what is going on with the patient, moment to moment, in a particular session and over
a long analysis. These patterns are best described as emotionmotivationbehavior bundles' that is,
an emotion (like anger) that interacts with a motivation (she is a nice person and does not see
herself as hating her patient) that causes some piece of behavior (she was furious at her patient
but did not allow herself to recognize the anger, and, during the session, for some reason, she
was unable to hear her patient). Young psychiatrists tell stories by chunking details around such
patterns, which can then be combined in many different ways, or which may emerge in new
forms in new patients. (The word chunk is used by cognitive scientists to evoke the way people
remember details by pulling them into a central concept, like iron filings to a magnet.)
Identifying these bundles is complicated by the inherent oddity of separating out the expert's own
emotional response from the relationship the expert is trying to interpret. That is why it takes so
long to become a psychotherapist and why it is easier to be a competent diagnostician (but not
easier to be a psychopharmacological connoisseur). In psychotherapy, there are many more
patterns than there are common diagnoses related to each other in more complicated ways. In
some important sense, a person is not a competent psychotherapist until he or she becomes a
connoisseur-level expert. There is no public and clear-cut threshold of adequacy, no basic
competence, as there is in diagnosis and psychopharmacology.

Psychologically minded people create emotionmotivationbehavior models all the time.

Psychiatric residents (and others in training) have two additional sources of help in building
these models. The first is psychodynamic theory, which provides a great abundance of partially
abstract models to interpret human behavior. The residents learn this theory from teachers, from
peers, and, occasionally, from books. The theoretical model will suggest that, if someone
exhibits a certain set of behaviors, then the behavioral pattern is this and the motivating

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emotions are that. The models offered in various texts do not all complement each other.
Sometimes, they flatly contradict each other. In general, psychiatric residents (or psychiatric
clinicians) are not worried by the contradictions and, in general, do not see their task as one of
arbitrating them. For psychiatrists, these models are tools they can use to help them understand
their patients. They are like spades and garden shears (useful or not useful), not like equations
(true or false).
The second source of models is a privileged access not only to a greater-than-average range of
human experience (including serious depression and psychosis, which laypeople rarely see and
recognize), but also to feelings and stories usually kept private. By the time they graduate,
psychiatric residents not only will have seen hundreds of severely disturbed patients, they also
will have heard hundreds of detailed accounts of fantasies, actions, desires, frustrations, and so
forth, the likes of which most people encounter only in novels and in a handful of living people.
These are not abstract models. They are stories of how this patient spoke about commonplaces
for 3 months in therapy and suddenly began to cry, or how that patient abruptly quit therapy and
called back 4 months later, or how the son of an entrepreneur was crippled by his father's great
success and, yet, had to take care of him as the father sank into senility. These are like chess
games the young psychiatrist plays again and again, seeing a life unfold, looking for the ways
different strategies play out in different settings. They help a psychiatrist to say to him- or
herself, Ah, that is the way you reacted to your brother's death, but it is not the way all people
would react. It is a unique reaction, and it tells me something about you, because I have seen
similar reactions to different problems, and I have seen people react differently to similar
problems.

SENSING EMOTIONS

This learning process probably helps most young psychiatrists to sense the emotions of other
people more accurately. At least, the discourse helps the residents to make fine distinctions
between emotions and their roles in different settings. Whether the learning process actually
teaches residents to sense emotions more keenly is less clear. However, at least some academic
psychologists conclude that it does. Indeed, the good, psychodynamically oriented residents
seem to become more intuitive over time. They seem to be able to meet a person for a short time
and to summarize that person's experience in a manner that seems accurate. Some residents will
become identified as wizards who are able to interview a patient and dazzle a crowd with their
skill in understanding, who give people in their office a sense that they have deeply understood
them. Even so, the understanding is undoubtedly shaped in an idiosyncratic way: Out of the
many possible valid interpretations of one patient's behavior, the therapist settles on one, and,
because no person has a single interpretation of his or her own life, the patient's sense of being
understood arises in what is, essentially, a negotiation between the patient's perspective and the
therapist's. It must also be said that there are some psychiatrists who learn little. There are
residents who are clumsy in the psychodynamic china shop at the beginning of their residency
and who remain so at the end.

In any event, the important general point is that the basic learning experience in the biomedical
domain invites new psychiatrists to think that the most important question about a patient is what
class or category he or she belongs in, whereas the basic psychotherapy training invites them to
think about the patient's uniqueness.

How Is the Doctor Primed Emotionally to Relate to the Patient?

In the Hospital

Hospital training in psychiatry continues the demand for emotional detachment that becomes so
powerful a lesson in medical school and internship. The basic activities, for instance, feel much
of a piece: admitting patients, prescribing medications, daily rounds, filling in forms. The
lectures on psychopharmacology recapitulate the style of knowledge presented in medical school
lectures. Residents memorize lists of medications with their side effects and learn something
about their mechanisms in the same way that they memorized body parts and mechanisms as
students. The hospital setting in psychiatry recapitulates the medical setting of internship'hospital
corridors, bustling emergency departments, wards, rounds, and team meetings. The doctor's role
is understood as it was in internship'the doctor is supposed to make a diagnosis that is more or
less reasonable, for which, at any rate, he or she will not be criticized in rounds, and prescribe a
medication for that condition that is also reasonable. As in internship, the patient becomes, in
some sense, the enemy. In many hospitals, interns and residents spend more than 100 hours a
week in the hospital. The call schedule is often more tolerable in psychiatry than it is in medicine
and often becomes more tolerable as the resident becomes more senior. Nevertheless, residents
are often tired and overworked. The people who are the direct cause of the work are the patients.

DIFFICULT PATIENTS

Psychiatry, in some ways, exacerbates the problems that breed hostility against patients. The
author was particularly struck by this in a hospital system in a city with relatively poor facilities
for the homeless. The main burden of overnight call in this hospital was that many of the
chronically ill homeless patients'most of whom were also drug and alcohol abusers'would try to
talk their way into the hospital for a free bed for the night. They would present themselves in the
emergency department at odd hours in the evening (the bus ran all night) and claim that their
voices (their hallucinations) were acting up and that they felt suicidal and would kill themselves
unless they were admitted to the hospital. These patients were often big men (often 200 lb) and
often unkempt and unwashed. The security guards were supposed to search them for weapons,
but they were usually too busy. The resident, often a slight 27-year-old woman, took such a
psychiatric patient into an interview room down the length of a corridor, away from the public
openness of the emergency department waiting area. In principle, she could ask a security guard
to stand outside the door, but the security guards were hard to find and often uncooperative. So,
the resident would be confronted with a large, possibly dangerous man, who she knew was
probably desperate for a clean bed for the night. If she admitted him based on his claims of
suicidality and he slept off his alcoholic stupor and was cheerful in the morning, the resident
risked being publicly chastised by the team director of whichever team the patient was assigned
to. If she did not admit him, she risked the possibility that the man would swear or even lunge at
her in anger. She also faced the risk that he might actually be suicidal. No matter how warm-
hearted or compassionate the resident, these conditions invite a creeping cynicism. They invite
the doctor to see patients as a source of harm to his or her well-being.
In Psychotherapy

In psychotherapy training, by contrast, new psychiatrists learn that doctors can hurt patients.
Psychotherapy teachers talk about psychotherapy's demands for intimacy, for tolerating the
needs of other people, and for responding to their emotional needs as they are, without the
interference of the therapist's own anxieties and troubles. They talk about the personal
intrusiveness of psychotherapy, that learning to practice psychotherapy means that the young
therapists must learn to tolerate knowledge about their own selves, which may be embarrassing
and shameful. They point out the way the patient perceives the therapist and how the therapist
perceives the patient, and they make it clear that both parties will distort the relationship but that
it is the therapist's responsibility not to act on the distortion. They talk about the need