Psychotherapy experience for trainees

Sir: Debate within the College has suggested that compulsory psychotherapy experience for psy chiatric trainees would lead to an erosion of opportunity for research experience. Published research is widely seen as a prerequisite for progression through the training grades (Duffet, 1994), yet concern has been raised as to whether it is feasible for trainees to pursue meaningful research before moving into the specialist regis trar/senior registrar grade (Timini, 1995). It may be that trainees involved in research are doing so at the expense of psychotherapy training or vice versa. An alternative, but perhaps less charita ble, viewpoint is that while some trainees are keen to do both research and psychotherapy, others consistently manage to avoid doing both. To investigate this further we conducted a questionnaire survey of psychiatric trainees at registrar level training with the South Thames (West) training scheme based at St George's


Psychotherapy experience for trainees
Sir: Debate within the College has suggested that compulsory psychotherapy experience for psy chiatric trainees would lead to an erosion of opportunity for research experience. Published research is widely seen as a prerequisite for progression through the training grades (Duffet, 1994), yet concern has been raised as to whether it is feasible for trainees to pursue meaningful research before moving into the specialist regis trar/senior registrar grade (Timini, 1995). It may be that trainees involved in research are doing so at the expense of psychotherapy training or vice versa. An alternative, but perhaps less charita ble, viewpoint is that while some trainees are keen to do both research and psychotherapy, others consistently manage to avoid doing both.
To investigate this further we conducted a questionnaire survey of psychiatric trainees at registrar level training with the South Thames (West) training scheme based at St George's Hospital, Tooting, South London. All registrars training in psychiatry in the Region in 1995-1996 received a two-part questionnaire. The first part focused on how many psychotherapy cases the trainee had treated, subdivided into modal ities including cognitive-behavioural and indivi dual psychodynamic psychotherapy. The second part of the questionnaire asked about the number and type of research projects the trainee was involved in.
Fifty-four questionnaires were received from 56 trainees giving a response rate of 96%. Direct involvement in research activity was claimed by 79% of the sample; 93% had treated one or more cognitive-behavioural cases, while 85% had treated one or more individual psychodynamic cases. Kendall's tau correlation coefficients showed no association between number of research projects and number of individual psychodynamic cases treated (r=0.092, P=0.404). There was, however, a significant correlation between number of research projects and number of behavioural cases treated (T=0.336. P=0.003).
These findings do not support the idea that trainees who make time for treating psycho therapy cases do so at the expense of research involvement.

Evidence-based medicine
Sir: I read with interest Schmidt et als editorial on evidence-based medicine (EBM) (Psychiatric Bulletin, December 1996, 2O, 705-707). I would like to add a few pertinent details from Sacket et al (1996)

(also listed in Schmidt et ats article).
Sacket (Director of NHS Research & Development Centre for EBM, Oxford, UK) and co-workers use a comprehensive definition of EBM: ". . . the conscientious, explicit and judi cious use of current best evidence in making decisions about the care of individual patients". Its practice ". . . means integrating individual clinical expertise with the best available external evidence from systematic research". If there is no available evidence that fulfils gold standards, then ". . .we follow the trail to the next best external evidence and work from there".
Schmidt et al depict a scenario where insisting on the best option may augment a patient's resistance to treatment or affect the doctorpatient relationship. A clinical decision process must include the patient's relative preferences (i.e. utilities), or better still, the values that the patient assigns to such utilities. Only when a patient cannot do this might the clinician alone quantify these utilities. In either situation, the final decision may not necessarily favour the option best supported by the external evidence. Thus, Sacket et al argue that external clinical evidence ". . . can never replace individual clin ical expertise and it is this expertise that decides whether the external evidence applies to the individual patient at all, and, if so, how it should be integrated into a clinical decision": that is, EBM strengthens but does not supplant clinical expertise.
Schmidt et al's assumption that many will feel unable to appraise research articles critically is not a strong argument to dismiss EBM. For many it may take some practice to become proficient, but the same applies to the development of most other skills.

Section 3 -hidden consequences
Sir: Detention under Section 3 of the Mental Health Act may have consequences not only for the patient, but also for relatives, staff and other patients. Consider an elderly, confused, informal patient awaiting nursing home placement. Hav ing wandered and been returned with some coercion, Section 5(4)was implemented, because he was on a psychiatric ward. Successive Sections resulted, although it was paradoxical that a man fit to leave hospital was being detained.
Paperwork, resulting solely from use of the Act, can be quantified. Section 5(4) led to four forms and reports (six copies); 5(2) generated nine forms, rights leaflets, etc. (two copies); Section 2 led to 47 forms, pages of reports to managers and tribunal, etc. (135 copies): Section 3 produced 54 pages of reports, appeal decisions, leave forms. Form 39, MHACI,etc. (149 copies). This gave a total in this compli cated, but not unusual, case of 114 original pages and 292 copies. Aftercare (Section 117) paperwork is not included.
Financial considerations are most relevant. He was able to afford his fees -already agreed. However, Section 3 leads to Section 117 after care when fees (over Â£300a week) are fully met by the local authority -indefinitely, since dementia does not improve! A further apparent advantage is speed of discharge as priority appears to be given to patients "detained against their will" over those "informally waiting" in hospital. Other patients may feel disadvantaged. The additional costs of full Section 117 meetings in nursing homes are not insignificant. Pressure not to discharge from Section 117 is felt, since to do so passes the full bill to patient and family.
The impression gained is that articulate, financially successful men tend not to accept confinement to a ward. Section then ensues, and fees are met. Those with more limited financial resources may be more compliant, and their relatively smaller savings are used for their care. Perhaps knowledgeable families realise the bene fits Section 3 brings! If all demented people were deemed unable to consent to care, all might currently benefit from Section 3, to the disad vantage of non-demented nursing home appli cants. Should the financial benefits of Section 3 status be retrospectively paid? Public funds should not be used for people solely because they happen to have been detained under Section 3, a major procedure which can be, in this group of patients, surprisingly arbitrary in application.