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.
