Commentary 128 http://ap.psychiatryonline.org Academic Psychiatry, 29:2, May-June 2005 Comments on Psychiatric Education Donald F. Klein, M.D., D.Sc. Dr. Klein is with the New York State Psychiatric Institute, New York, New York. Address correspondence to Dr. Klein, 1051 Riverside Drive, BOX 22, New York, NY 10032; donaldk737@aol.com (E- mail). Copyright  2005 Academic Psychiatry. T he articles in this special issue of Academic Psychiatry provide laudable attempts to bring psychiatric edu- cation into the twenty-first century. Since clinical prac- tices, data and theories are swiftly changing (not always for the better), the authors who contributed to this issue confronted a Hydra-headed task. Until recently, direct, fee-for-service, private medical practice predominated. The doctor could, in principle, regulate the time and effort addressed to each patient. Professional education consisted of learning the tools of the trade and staying current with the increased and transforming information. The articles in this issue em- phasize the debate on postgraduate education and on mastering new practice-relevant evidence. Realistic education must address the realities of con- flicting educational interests as well as the limitations of current practice. Managed care and insurance require- ments severely limit professionals’ ability to set their own timetable. This constricts the possibility of ade- quate diagnostic evaluation and, more crucially, the abil- ity to closely monitor the patient’s progress (or regress). Because of insufficient knowledge, much practice re- mains at the trial and error level, and thus mistakes will occur. Good care requires the ability to detect mistakes, most of which are rectifiable, given the opportunity for early detection. However, the reimbursable “Med- Check” allows only a superficial grasp of fluctuating clinical reality. This amounts to de-professionalizing medical practice, since patients’ needs conflict with fi- nancial limitations on their care. Additionally, it is dif- ficult for students to invest in learning difficult tech- niques when they know that the circumstances defining actual practice prevent their use. Collectively, the articles in this issue do not address the problem of putting avail- able knowledge to actual use. Furthermore, the apparent flood of psychopharma- cological and biological knowledge still does not provide an adequate basis for a knowledge-based psychiatric practice. Most psychiatric interventions still depend on conventional wisdom, flimsy as that may be. Given the evidence-based medicine (EBM) emphasis on teaching tools for searching the Internet’s databases for relevant facts and the proliferation of algorithms and guidelines, my emphasis on the insufficiency of the knowledge base for psychiatric practice may appear overdrawn. However, it is important that we determine which questions our current knowledge base answer ob- jectively. Such questions should address whether a particular psychopharmacological agent has been determined to be safe in a sample of relatively healthy, well-defined, uncomplicated patients and whether it is statistically su- perior to placebo a properly controlled double-blind randomized trial. Questions that are partially addressed or completely unanswered include: 1) Should maintenance psychotropic medication doses remain at the normal treatment level, or should they be lowered? 2) If so, for how long? 3) What are the differential indications for choosing one treatment plan over another? 4) What is the usual drug regimen, given the normal treatment response? 5) Is there a substitute for titrating a dosage upward, to the point of disturbing side effects (e.g., establishment of therapeutic blood level ranges appropriate to the pa- tient’s age, sex,) 6) Should treatment fail, what should be the next course? 7) What is the necessary frequency of monitoring during maintenance? 8) How much time should be available for an adequate survey of the patient’s current status?