There has been much criticism of the format and process of the certification examination in psychiatry, and some of this is based on lack of information regarding the history of the specialty certification procedures, the Royal College of Physicians and Surgeons and the Board of Examiners. In this first of three reports the history of the Royal College as the certifying organization is traced, and the relevant College structures are briefly described, including the Specialty Committee on Psychiatry which is instrumental in appointing the clinical examiners. The clinical examiners since 1965 are identified.
Quality Assurance Strategies in Psychiatry and Medicine in general have developed rapidly and have been applied widely in the last few years, particularly in the United States. This paper reviews some of those developments both from a methodological and a socio-political point of view. The relevance to the Canadian scene is evaluated, and it is concluded that, although quality assurance is now accepted as an obligation of the health profession, some of the strategies being widely applied in the United States are of questionable value in themselves, and some, particularly cost control techniques, would seem to be irrelevant to the Canadian health field which already has a variety of checks and balances in its universal health insurance system. Though cost control and quality control logically overlap, at times they are allowed to merge and cause conceptual confusion. Finally, as systems are developed in Canada, it is suggested that a means of self-assessment be built in so that the validity and reliability are not in doubt.
From the foregoing it is recommended that: 1. For voluntary patients who are capable of giving informed consent, psychosurgical procedures should be available in much the same way as other surgical procedures: the final decision to proceed with such treatment would be made by the patient and the responsible physician. Psychosurgical procedures should never be undertaken against the wishes of the patient. 2. Psychosurgical procedures should not be confined to patients who have failed to respond to any other kind of treatment, but should also be offered to patients who on the basis of an ill-sustained response to a previous course of treatment, the presence of good pre-morbid personality factors and any other recognized and established observations, show positive indications that they might benefit from psychosurgery. 3. No psychosurgical operation should be undertaken without the completion of a thorough and comprehensive evaluation including medical, psychiatric, neurological, social and psychological investigations which would be performed by an assessment team. The recommendation of the team members should be confined entirely to their own individual disciplines and the final decision with respect to recommending such treatment to the patient should remain the responsibility of the psychiatrist who would decide whether or not to proceed with such a recommendation after carefully considering the assessment of the team. The ultimate decision as to whether or not to proceed with surgery would of necessity be one jointly made by the psychiatrist, the patient and the neurosurgeon. No standard recommendation can be made regarding the length of time that patients might spend undergoing such observations and assessments. It is recommended that these evaluations and operations should be undertaken in such centres as university areas which are uniquely equipped for the evaluation, treatment, rehabilitation and follow-up of such patients. 4. In cases where the ability of the subject to freely give informed consent is questionable, the final decision to recommend treatment should depend upon the deliberations and recommendations of a psychosurgery board. These boards should be established in local centres and the responsibility for their composition and establishment should be undertaken by professional bodies such as Provincial Colleges of Physicians and Surgeons and Provincial Bar Associations acting cooperatively. The psychosurgery board would review patients who were: a) involuntary; b) mentally handicapped for any reason, including mental subnormality; c) serving prisoners or parolees; d) minors. The function of the board would not be to compel or persuade unwilling or reluctant patients to undergo psychosurgical treatment. Its function would be to determine whether or not a psychosurgical procedure would be justified in a given case and to ensure that in such circumstances, appropriate treatment would be available to a patient without any violation of his rights as a citizen. For this reason, it is recommended that, in the constitution of such boards, the professions of psychiatry, law and neurosurgery should be adequately represented. 5. In view of the accumulated literature it is now extremely doubtful whether we can justify calling all psychosurgical procedures “experimental”. However, in order for the refinement and development to continue, it will be desirable for observations and information obtained from psychosurgical procedures and their follow-up to be pooled in the interest of evaluating ongoing progress. 6. It is recommended that the Canadian Psychiatric Association's position on psychosurgery should be subject to periodic review at intervals of not more than three years.
This paper examines the practice of involuntary mental hospitalization through examination of criteria used for committment in a sample of 200 civil commitment certificates. Special reference is made, following previous research, to criteria used to describe the person deemed dangerous to himself or to others. The relevance of the findings of present practices in mental health is discussed. New procedures which facilitate presentation of factual evidence, and which eliminate gratuitous information, are required without delay.
Detailed clinical records were kept on a series of 55 agoraphobic patients who presented to a general hospital psychiatric practice over a 3 year period. A review of the records revealed that 91% of these patients were diagnosed as suffering from a unipolar or bipolar primary affective disorder. The anxiety and phobic symptoms tended to mask the presence of the affective disorder. This observation is consistent with most of the published data on the agoraphobic syndrome. It could also explain the inconsistent effects of treatment of agoraphobia compared with simple phobias. The possible biological and psychological connections between primary affective disorders and the agoraphobic syndrome are discussed.
This article is the first of a two part review of the psychoanalytic theory of depression. In this first part of the review the work of the major contributors to the psychoanalytic theory of depression is discussed. The writings of Abraham, Freud, Rado, Klein, Jacobson, Benedek, Bibring, Spitz, Sandler and Bowlby, among other, are presented and critically reviewed by the author. The work of these authors has been selected for this review because they have made the most seminal contributions to the development of the psychoanalytic theory of depression. Necessarily those authors whose contributions have been largely clinical have not been included, the major focus of this review being theoretical. In reviewing the writings of the major contributions the major themes in the theory of depression can be discussed. These themes will form the subject of the next paper in this review.
Although there has been much criticism of specialty certification examinations there is general agreement that they are an important safeguard of competence in medical specialties where the consumer cannot judge this. The Canadian Royal College has made strenuous attempts to improve certification techniques but these have not been heretofore widely reported. This paper reports on the rationale for the replacement of the essay examination by multiple choice questionnaires, the problems associated with MCQ, and the efforts made to improve the fairness, validity and reliability of the clinical (oral) examination. These efforts have been in the areas of selection of examiners, training for examiners, standardization of marking and the conduct of the examination. A description is given of the conduct of the examination and what the examiners look for in the candidate's performance. The development and increasing importance of the In-Training Evaluation are discussed. The publication of A Resident's Guide to Psychiatric Education with multinational participation advances the possibility of future reciprocity in psychiatric examinations conducted in several English speaking countries.
This report is based on a survey of all those postgraduates in psychiatry who graduated from the training program at the University of Toronto between the years 1966–1976. We were interested in obtaining the views of our colleagues about the Certification Examination in Psychiatry, because it was our impression that there has been a great deal of dissatisfaction with the examination procedure over the years. A total of 238 questionnaires were sent out and 140 replies were received. Our analysis indicated that 90% of those responding had been successful in the certification examination, but 85.3% were dissatisfied with the examination process. It is significant that 85.3% of our sample felt that some form of certification procedure was necessary. The certification procedure is designed to determine whether an adequately trained physician is “safe and competent” to practise as a specialist in psychiatry. The examination's ability to assess areas of psychiatric practice (somatic and social therapies, interview and diagnostic technique, research and teaching skills) were also evaluated. The Royal College has made changes in the examination procedure over the last few years, for example the changeover to complete multiple choice questions was well received by our sample. Other suggested changes are examined in terms of our colleagues’ enthusiasm for their in-corporation into the examination procedure.
The purpose of the study was to assess the feasibility of using demographic and social competence information to predict length of stay in a psychiatric hospital. The results indicated that social competence variables were much better predictors of length of stay than demographic variables. Moreover, no combination of demographic and social competence variables led to more accurate predictors than social competence information alone.
The authors review the literature on Munchausen's syndrome and speculate about possible underlying psychological mechanisms. The proposed DSM III classification of factitious illnesses suggests a continuum from hysteria on one end of the spectrum to malingering on the other. Two case studies are presented which represent variants of this syndrome. Both patients were given a sodium amytal interview, a procedure not previously reported in the Munchausen's literature. The procedure was helpful in eliciting a more accurate history and a clearer sense of the underlying dynamics. Some suggestions for further research are made.
No analysis of Canadian certification examinations in psychiatry has previously been published although analyses of the American Board of Psychiatry and Neurology and the British Membership examinations are available. Because candidates, directors of residency training, mental health planners and consumers are all interested in who passes and who fails the certification examinations, available examination data for English speaking candidates are analyzed. Successful candidates are more likely to be younger; to have attended medical schools in English speaking countries (in North America, the British Isles, or the "old Dominions"); to have placed in the upper two-thirds of their medical school class; to have entered psychiatric training soon after graduating from medical school and then to have completed their training without interruption. Some limitations of the examinations and the problem of candidates who fail are briefly discussed.
There has been much criticism of the format and process of the certification examination in psychiatry, and some of this is based on lack of information regarding the history of the specialty certification procedures, the Royal College of Physicians and Surgeons and the Board of Examiners. In this first of three reports the history of the Royal College as the certifying organization is traced, and the relevant College structures are briefly described, including the Specialty Committee on Psychiatry which is instrumental in appointing the clinical examiners. The clinical examiners since 1965 are identified.
Medical students' views of the subjects: Psychiatry, Neurology and Surgery were studied before and after a nine week course which included Psychiatry and Neurology. Surgery was not being taught and was regarded as a control subject. Visual analogue measures of each subject as a career possibility, its importance and its interest were obtained in addition to a ranking for career choice of eight specialties. In addition, students' attitudes to psychiatrists, neurologists and surgeons (as control) were studied using semantic differential scores. The scores on the subjects showed changes favourable to Psychiatry after teaching which were not paralleled in Neurology or Surgery. The semantic differential scores clearly discriminated the three specialists; there were small changes after teaching but the broad differences in attitude to the specialists remained. Some evidence is presented that the more favourable changes towards Psychiatry were related to the quality and intensity of teaching.
Monosymptomatic hypochondriacal psychoses are akin to paranoia. Although presenting with a variety of delusional complaints in individual cases, the condition appears to represent a relatively dis crete diagnostic entity. It is less rare than usually thought, but those afflicted frequently to to the physical specialties, whose treatment does not benefit them. It is important to recognize the illness, since there is tentative evidence that it may respond to treatment with pimozide.
