More than two decades ago, Aubrey Lewis delivered a visionary Bradshaw lecture to the Royal College of Physicians (Lewis, 1958). The address centred upon the place of scientific method as applied to the art of psychiatry. In his concluding remarks, Lewis emphasised the ardours and perils of guessing. Nowhere is the temptation to guess more clearly illustrated than in multiple choice examinations.

We were recently asked by one of the editors of the Psychiatric Bulletin to comment on the June 1991 issue of the Archives of General Psychiatry because of its exclusive neurobiological approach that month. Having thus been given our brief and now having carefully read the issue, we feel obliged to warmly congratulate the Archives for a superb issue and a superb Journal that has consistently set high standards for the reporting of neurobiological research as applied to psychiatry. The June issue this year was the first to report the use of magnetic resonance spectroscopy (as opposed to imaging) in vivo (more of this later) and had many more excellent contributions on the action of lithium on neurotransmiter and second messenger systems and papers on the role of serotonin and endorphins in a variety of conditions.

The multidisciplinary team approach is considered by the Royal College of Psychiatrists to be a valuable instrument in modern psychiatric practice (Rawnsley, 1984). In addition, it is assumed by the 1983 Mental Health Act in Section 117 concerning joint Health and Social Service responsibility for statutory aftercare and in Sections 57 and 58 where consultation with other disciplines by the second opinion doctor is required. The benefits of this way of working include a broader perspective in care provision, consistency of approach, continuity of care, and improved communication between disciplines (Pollock, 1986).

It has long been felt that there sometimes occur certain dire situations, often involving the police, where our special experience has been felt to be valuable. I am unsure how well established this claim is but wish to describe one recent occasion when I was called upon in this way, in the hope that it might help others in deciding what they might have to contribute.

Until recently, a doctor beginning a career in psychiatry would usually apply for a combined SHO/registrar rotation lasting approximately 3½ years. Trainees could expect promotion from SHO to registrar after about 18 months, subject to passing the Part I of the MRCPsych examination and also to their educational and clinical progress having been judged to be satisfactory by the scheme tutor and organising committee. Life has changed! The emergence of Achieving a Balance (Department of Health, 1988), the proposals of which are intended to be phased in over the next ten years, has meant that scheme organisers have had to quickly change the basis on which their rotations are run. This paper is an account of how this has been done in the SE Thames Region.

In an attempt to discover what can be learnt from records kept on suicide victims, all data collected by one health district about suicides occurring in patients in close contact with psychiatric care over four years were examined.

Keele received its Charter as the University College of North Staffordshire in 1950. The first Vice Chancellor was Lord Lindsay, formerly the Warden of Magdalen College, Oxford. In the pre-war years Lindsay was a frequent visitor to the Potteries, presenting lectures within the Workers Education Association. He was unusual as an Oxford don not only in this respect but also in his approach to university education. He was closely involved in the development of the Modern Greats degree at Oxford and had strong views on the need for a broad liberal university education. Keele was founded on this principle as a teaching university offering a four year degree, the foundation year requiring students to study arts, sciences and humanities. At its inception the university was housed in a Victorian stately home, Keele Hall, and several ex-army huts. For the first decade of its life a “community of scholars” ethos was strongly emphasised and academics as well as students were required to live on campus. There were weekly small group student seminars involving academics from the three different disciplines. The academics look back on these seminars fondly, although it is not clear whether the students derived the same enjoyment from these interdisciplinary talking shops.

This paper draws the attention of psychiatrists to the developing field of neural networking in the belief that the models created in this discipline demonstrate several functions central to cerebral performance.

Recent reports have highlighted the continuing lack of adequate provision for the difficult or offender patient. The move to community care, coupled with the closing of the larger institutions, has put a strain on traditional forensic services. They are being increasingly asked to deal with the difficult, nonoffender (Glancy) patient in addition to their more traditional offender-type (Butler) patient. This paper describes how one unit has developed to serve the needs of Rotherham and neighbouring health authorities. We do this by illustrating the current lack of provision and by describing the types of patient treated over a two year period.

Psychological and psychiatric issues represent a significant proportion of the workload of all doctors. Nonetheless junior doctors often have an unsatisfactory knowledge of psychiatry. Previous studies have examined how hospital doctors say they manage psychological problems (Mayou & Smith, 1986), and attitudinal factors among medical students (Wilkinson et al, 1983).

Charles Shaw, in a number of articles and his Hospital Handbook (Shaw, 1989, 1990) has played a key role in outlining the principles of medical audit. He arbitrarily divides the process of medical audit into four phases. The philosophical phase which seems to have been negotiated, is whether the medical profession should be involved; the organisational phase; who should lead the process, and the resources required; the practical phase, what should be audited and the methods used; and the invasive phase, how the general concepts and the details of audit are communicated through publication. He goes on to describe a variety of methods of audit including the review of adverse events and general statistics, the assessment of randomly selected records, and finally the review of a topic (which includes medical record review). Another approach in planning audit is through understanding of the organisation itself (Donabedian, 1966) and evaluating quality of care in terms of the structure of the organisation (bricks and mortar, staffing, beds, technology etc.), the process of care, and this may include length of stay, broad out-patients statistics, and perhaps more controversially, face to face contact, group interaction, home visits, day hospital attendance and so on. Finally, and most complex, is outcome.

For almost 20 years planning for the mentally ill and mentally handicapped has focused on a shift of care from hospital to community, the advantages and difficulties of this process generating much discussion and interest. The hospital population of the mentally handicapped is currently at the forefront of this change, planning impetus now being propelled by alterations in funding with budgets being transferred from NHS to local and social services. One consequence is the closure, or planned closure, of large mental handicap hospitals situated at the periphery of urban centres, with residents being moved to small group homes and hostels within the towns and cities the hospitals once served. The change should prove beneficial for a majority of residents although the process continues to generate debate.

There are many studies in the medical literature attempting to confirm the value of a comprehensive physical examination in the psychiatric in-patient population. An appraisal of the literature and review of psychiatric admissions in a large teaching district offers some evidence to the contrary.

The speciality of substance misuse has expanded way beyond the treatment of alcoholism and drug addiction as incorporated in the now defunct term ‘addictions’. ‘Substances’ include the illegal (e.g. heroin and amphetamines), socially acceptable (e.g. alcohol and tobacco), medically prescribed (e.g. benzodiazepines) and household products (e.g. glue and lighter fuel). ‘Misuse’ covers that use of substances which has resulted in or may lead to physical, psychological and social problems.

Professor Michael Peckham's appointment as Director of Research and Development for the National Health Service in England reflects a new phase in central government's concern to influence health care research. Responding to the House of Lords' 1988 report Priorities in Medical Research, and to continuing doubts about the effectiveness of the Department of Health's own research management division, Professor Peckham's remit is to control all the research and development activities funded through the NHS - estimated at over £200 million.

There have been several surveys of prescribing for psychiatric patients (Muijen & Silverstone, 1987; Johnson & Wright, 1990) indicating inappropriate prescribing and a tendency towards polypharmacy. Most studies have looked at prescriptions for psychiatric patients in all settings (out-patients, day-patients and in-patients) in conglomeration rather than just out-patients. Out-patients experience a comparatively lesser degree of supervision (hence a greater risk of non-compliance) and have other opportunities to acquire prescriptions (e.g. through general practice). With this in view a pilot study to observe prescribing pattern in a follow-up clinic was performed.

The presentation of factual material to an audience has become a routine part of psychiatric training, be it a case presentation, a journal article or original data. It can be seen as an anxiety-provoking task that bears little relevance to everyday practice. But it can become a creative endeavour with its own reward. Organising the material so that it can be easily understood clarifies your own thinking on the subject. The medium of a presentation both passes on information and enables quick and useful feedback. And, most importantly, it provides a deadline to work towards. Over the year a tradition of oral advice about conference presentation technique has been built up among research workers with the Team for the Assessment of Psychiatric Services. This team is evaluating the closure of Friern and Claybury Hospitals and has presented preliminary work at a yearly conference since 1986. This advice has usually been passed on during the frantic weeks that build up to our annual conference. This essay is an attempt to set down in writing some of those guidelines.

There is an increasing interest in the role of audit in medical practice. Less emphasis has been placed on audit by trainees and it has traditionally involved the use of log books or case books for examination purposes. One type of log book simply lists the diagnoses of consecutive cases seen. Such a record is used in the Viva part of the Examination for Membership of the Royal College of General Practitioners. Another form of log book, often referred to as a case book, usually involves a more detailed account of the cases seen by the trainee. Case books form part of the Examination for Membership of the Royal College of Obstetrics and Gynaecology as well as the MRANZCP and Canadian Psychiatric Examination.

The MCQ has now become firmly established as an integral part of post-graduate psychiatric examinations. In my experience a number of trainees have particular difficulty with MCQ tests such that they find them threatening, and in some cases a repeated stumbling block to the advancement of their careers. A minority within this group may consider the MCQ test to lie in the realm of the arcane and mysterious and find themselves subject to repeated worry and frustration. While advice on techniques for answering is plentiful (sample textbooks and manuals on examination technique) I am not aware that there has been any focus to date on study technique. I would like to suggest a personal approach for MCQ study (based on successful application) which I believe fully integrates MCQ with general psychiatric study and emphasises the potential of ‘MCQ thinking’ in refining ones overall psychiatric knowledge.

Dr Michael Robinson, of the London School of Hygiene and Tropical Medicine, dealt with more general aspects and Dr Ann Gath, Registrar of the College and Chairman of the Medical Audit Working Party, with aspects of particular relevance to psychiatry.