Psychiatry and General Practitioners

To the Editor: Frederick S. Sierles, M.D., et al. (1) showed that future psychiatrists score higher than other medical students on measures of psychiatric knowledge and verbal reasoning and lower on other topics. They then concluded that more attention should be paid to the general medical education of psychiatrists. We question how the authors interpreted their data. The scores on the measures of learning were standardized. Therefore, if some people do better, then some must do worse. Given this obvious situation, isn’t it better for future surgeons to perform above the mean on surgical subjects, future internists in general medicine, and future psychiatrists in psychiatry? Much, if not all, of the differences in Medical College Admission Test and U.S. Medical Licensing Examinations scores most likely can be attributed to student preferences and interests at baseline and the clinical content of the first postgraduate year.

The public health consequences and likelihood of making medical errors because of poor training are different for psychiatrists and nonpsychiatrists. About 20% of the patients seeing primary care physicians have a significant mental disorder (2). Only 23% of the patients with depression treated by primary care physicians received an antidepressant, of whom many receive an insufficient dose (3, 4). Missed psychiatric diagnoses and undertreatment of those properly diagnosed by a primary care physician are serious problems. Is the converse true for psychiatrists? This has not been shown. Most psychiatric patients, we would imagine, have been evaluated and are treated by primary care physicians for any general medical condition before they see or are referred to a psychiatrist. Psychiatrists should advise a patient who has not been seen recently by a primary care physician to do so. Psychiatric patients routinely see primary care physicians; patients seeing primary care physicians do not routinely see psychiatrists. It seems to us that the urgent need is not for future psychiatrists to learn more general medicine but for future primary care physicians to learn more psychiatry.