Evaluation of Psychiatric Training in the Emergency Room Rudolf Hoehn-Saric
I
N CONTRAST to general medicine, only a few psychiatric diagnoses can be verified by laboratory methods. Thus diagnoses and the consequent management of patients may vary, not only from school to school,‘,’ but often within the same institution from one psychiatrist to another.3*’ In the Emergency Room, a psychiatrist has to make important decisions under pressure of time, often with inadequate information.,’ Moreover, in most psychiatric emergency facilities, residents in various stages of training handle all but the most difficult patients. Therefore we were interested in comparing the psychiatric evaluations of patients seen by psychiatric residents in the Emergency Room with a subsequent reevaluation by senior psychiatrists. In this study, we examined the levels of agreement between such evaluations regarding diagnosis, mental status examination, medication prescribed in the Emergency Room, and the appropriateness of the disposition. We also compared levels of agreements in those categories with the length of residents’ training. METHOD
The Setting This study took advantage of independent reevaluation of all psychiatric patients who are first seen in the Emergency Room at Johns Hopkins Hospital, and who are subsequently referred to the Acute Treatment Clinic. In the Emergency Room, psychiatric residents are availableon a 24 hour basis. During the daytime, a second or third year resident covers the service, while during the night a first year resident on night duty is supervised by a senior resident. The remaining year, he consults with a senior resident on second call if he needs help. Daily morning rounds are held by four faculty members in rotation. The psychiatric services evaluates approximately 2500 patients a year. During the time of the study, 15 residents in the first year of training and 32 residents in the second or third year of training shared the Emergency Room duties. Approximately 15% of psychiatric patients who are seen in the Emergency Room are referred to the Acute Treatment Clinic, which is a part of the Psychiatric Emergency Services and provides crisis therapy on an outpatient basis. Of those patients, about half keep their appointments and are reevaluated in the Acute Treatment Clinic, usually within 2 to 5 days after the Emergency Room visit. These evaluations are done by residents or psychiatric nurse practitioners, who present all patients in rounds to one of four senior psychiatrists, with whom the diagnosis and the treatment program are discussed.
Subjef
ts
Records of 233 patients referred from the Emergency Room to the Acute Treatment Clinic over an I8 month period were examined. This period was selected because complete referral lists for it were available.
From the Departments of Emergency Medicine and Psychiatry; Johns Hopkins School of Medicine, Johns Hopkins Hospital; E~timore, Maryland. Rudolf Hoehn-Saris, M.D.: Associate Professor of Psychiatry and Emergency Medicine, Johns Hopkins School of Medicine, Johns Hopkins Hospital, Baltimore. Reprint requests should be addressed to Rudolf Hoehn-Saric. M.D.. 009 Henry Phipps P.sychiatric Clinic, Johns Hopkins Hospital, Baltimore, Md. 21205. 5’ 1977 by Grune & Stratton, Inc. ISSN 0010-440X. Com.orehensive Psychiatry, Vol. 18. No. 6 (November/December).
1977
585
586
RUDOLF
HOEHN-SARIC
Patients’ median age was 29 (1479), 28% were male and 72% female. Forty-one per cent were white and 59% black. The education level: 53% had not completed the 12th grade, 26% had finished high school, and 21% had at least one year of college. Thirty per cent were single, 34% married, 32% separated or divorced, and 4% widowed. Only 47% of the patients were employed during the time of the initial visit. The median waiting period between the Emergency Room and the Acute Treatment Clinic evaluation was 3 days (Q-20 days); the long waiting period occurred in patients who did not show up on the first appointment and had to be rescheduled.
Evaluation of the Records The record of each patient contains the evaluation by the psychiatric resident in the Emergency Room and evaluation by a member of the Acute Treatment Clinic team, which was dictated after rounds with one of the senior psychiatrists. The two evaluations are examined by discrepancies in diagnosis, disposition, medication and mental status. Bugnoses. Since the emergency services are primarily management oriented, the diagnoses were collapsed into 5 broad categories; namely, “nonpsychotic” conditions, schizophrenia, manic-depressive psychosis, psychotic depression, and organic brain syndrome. The “nonpsychotic” conditions included all types of acute situational reactions, neurotic conditions, and personality disorders. The category schizophrenia included acute and chronic conditions. The category organic brain syndrome included all conditions in which an organic condition caused an either transitory or chronic mental dysfunction. Agreement for diagnosis was rated in all cases in which the two evaluations agreed on the diagnosis in terms of the categories listed above. It sufficed that the Emergency Room evaluation contained the Acute Treatment Clinic diagnosis as one of the differential diagnoses. The remaining cases were rated as “discrepant” for diagnosis. Disposition. A discrepancy in disposition was rated when a patient, after the reevaluation by the Acute Treatment Clinic staff, was regarded as unsuitable for outpatient treatment and had to be hospitalized immediately. No discrepancy was rated for patients who were accepted in the Acute Treatment Clinic for outpatient therapy, but had to be hospitalized subsequently. Medication. Discrepancies in medication were noted when a patient who was diagnosed as schizophrenia or manic psychosis in the Acute Treatment Clinic was not covered with antipsychotic medication in the Emergency Room; when a patient who was subsequently diagnosed to suffer from a psychotic depression was not covered with antidepressant medication; and when a patient who was regarded as “nonpsychotic” in the Acute Treatment Clinic had been put on an excessive dosage of antipsychotic medication in the Emergency Room.
Menral Status Examination. If a discrepancy occurred in at least one of these areas (i.e., diagnosis, disposition, medication), then the record was examined further for discrepancies in mental status evaluation. A record was rated discrepant when the psychiatric note of the Emergency Room failed to describe symptoms of thought disorder, hallucinations, delusions, or somatic symptoms which were relevant to diagnosis and disposition, further severe suicidal preoccupation, or signs and symptoms suggesting an organic brain involvement. RESULTS
Tables 1 and 2 show the “discrepancies” in diagnosis, disposition, medication and mental status between the evaluations in the Emergency Room and the Acute Treatment Clinic. Figures are given for the entire sample and for subsamples seen by residents during their first and second half years of training, and residents during their second and third years of training. In the entire sample, discrepancies were noted in approximately 10% of the patients for diagnosis, disposition, medication, and mental status. Discrepancies in diagnoses were noted in 25 patients. Most frequently, an existing or a coexisting organic brain condition was diagnosed in the Acute Treatment Clinic but not in the Emergency Room (n = 7). The next most frequent dis-
EMERGENCY
Table I.
ROOM
PSYCHlATRiC
Discrepancies
TRAINING
587
in the Evaluation of Patients in the Emergency the Acute Treatment Dmgnosis
Length of Trammg
N
Dlspositlon %
Room and the Reevaluation
in
Clinic
N
Medication %
N
Mental %
N
Status 96
1 st Year Residents 0-6MoN=49
8
16
7
14
8
16
11
22
10
14
7
10
6
9
7
10
$8
15
14
12
14
12
18
15
7
6
13
11
8
7
5
4
25
11
27
12
22
9
1 st Year Residents 6-12MoN=70 1 st Year Residents O-12MoN=llS 2nd and 3rd Year Residents N=114 All residents N=233
23
10
crepancy category (n = 6) was patients who were regarded as “nonpsychotic” in the Emergency Room, but diagnosed schizophrenic in the Acute Treatment Clinic. Discrepancy in disposition, i.e., the need for immediate hospitalization of patients referred to the Acute Treatment Clinic for outpatient treatment, occurred in 27 patients, In most of these patients (n = 19), the family was unable to take care of the patient at home. Four patients had to be hospitalized because of severe suicidal risks, and four patients because of coexisting physical illness or the need of an intensive diagnostic work up. Discrepancies in medication were found in 22 patients. In the majority of these patients, the discrepancy in medication reflected the difference in diagnosis (n = 13); in the remaining patients, the diagnoses in the Emergency Room were correct, but the patients who were regarded as psychotic were not medicated in the Emergency Room. Discrepancies in mental status were noted in 23 patients. In 12 patients, the workup in the Emergency Room did not describe thought disorder, delusions, or hallucinations, which categories were elicited in the second examination, In 6 patients, symptoms or signs of an organic brain condition were missed, and in Table 2. Significance
of Disagreement
Between
the Reevaluation
Residents’ Evaluetion in the Emergency
in the Acute Treatment
Room and
Clinic MRiltd
Revdent
Groups’
Dtagnosis
Dspostion
Medmtion
status
1 st year Residents O-6 months vs 1 st year Residents 6-l 2 months
N.S.
N.S.
N.S.
p < .lO
p < .05
N.S.
p < .lO
p < .OOl
p < .lO
N.S.
N.S.
N.S.
p < .05
N.S.
N.S.
p < .Ol
1 st year Residents O-6 months vs 2nd & 3rd year Residents 1 st year Residents 6-12
monthsvs2nd
& 3rd year Residents All 1 st year Residents vs 2nd & 3rd year Residents
*Comparison between groups of Residents at different levels of training.
RUDOLF
588
HOEHN-SARIC
another 5 patients, suicidal ruminations, severe vegetative symptoms, or depressive thoughts were not described. The training of the residents reduced, significantly, the discrepancy between the two evaiuations for diagnosis and the description of the mental status+ and had its greatest impact within the first 6 months of residency. Using Chi-quare analysis, the discrepancies between patients evaluated by first year residents during the first 6 months as compared to second and third year residents were significant for diagnoses (p < .05) and mental status (p < .OOl), and suggestive for medication (p < ,lO). On the other hand, disagreements in disposition continued to occur, independently of the length of training. DISCUSSION The patient ~pu1atjon in this study, while not representing a cross section of the Psychiatric Emergency Room population, consisted of a particularly important segment; namely, outpatients in need of immediate and intensive followup care. With this restriction in mind, several conclusions can be drawn. In general, one can state that psychiatric residents, as a group, performed a service in the Emergency Room which was regarded as very satisfactory by senior psychiatrists when they reevaluated the patients. The concordance in diagnosis was higher than reported in other studies,3*1*”probably because of the broadness of the diagnostic categories. The most interesting finding was that within a few months of training, residents and senior staff came close in their agreement on the mental status of patients, and the diagnosis, but even longer training did not diminish the disagreements as to whether a patient could be treated on an outpatient basis or needed hospitalization. It appears that the work on the inpatient service, as well as in the Emergency Room, taught these residents basic psychiatric skills, but not theoptimal management of patients in a crisis. Since only a few residents followed patients whom they saw in the Emergency Room, they obtained little relevant feedback about the effectiveness of their dispositions. The morning rounds in the Emergency Room usually dealt with problems brought up by the resident, and not with problems which the resident failed to see. Feedback from the Acute Treatment Clinic about errors of management was often lost to a resident for whom the work in the Emergency Room was only one of several duties, and who, after severai days, had only vague memories of the patient. Therefore in an optimal training program, a resident should come to the Emergency Service after he has developed su~cient experience on an inpatient service, perhaps in the later part of the first, or during the second year of training. The exposure to Emergency Medicine should be brief, but concentrated, and most important, it should be combined with the follow-up treatment of outpatients seen in the Emergency Room. Further, whenever possible patients should be reevaluated personally by a supervisor. In our experience, the most valuable teaching occurred when a reexamination elicited symptoms or brought out information missed in the first examination, which would not have surfaced in supervisory sessions during which the case, not the patient is presented. A regular reexamination of patients by senior psychiatrists may be difficult to provide in the
EMERGENCY
ROOM
PSYCHIATRIC
TRAINING
589
Emergency Room setting, but should nevertheless devoted to the training of residents.
be part of the follow-up clinic
SUMMARY
Records of 233 patients evaluated by psychiatric residents in the Emergency Room and subsequently reevaluated by senior psychiatrists in the Acute Treatment Clinic were examined for gross discrepancies in diagnosis, mental status, prescribed medication, and appropriate disposition of outpatients to a crisis clinic. The work in the Emergency Room was rated satisfactory in 90% of the cases. Length of training heightened the agreement between residents and senior staff on the mental status examination, the diagnosis and, to a lesser extent, the medication. There was no relationship between length of training and the agreement about the disposition. This was probably due to the lack of follow-up of the patients by the residents who had seen them in the Emergency Room. It was concluded that for optimal training purposes the Emergency Room experience should be combined with work in a crisis clinic where residents continue to treat patients whom they have referred from the Emergency Room.
REFERENCES I. Cooper JE, Kendell RE, Gurland BJ, et al: Cross-national study of diagnosis of the mental disorders. Some results from the First Comparative Investigation. Am J Psychiatry 125. Supp: 21 29, 1969 2. Gurland BJ, Fleiss JL, Cooper JE, et al: Cross-national study of diagnosis of the mental disorders. Some comparisons of diagnostic criteria from the First Investigation. Am J Psychiatry 125, Supp: 30-39, 1969 3. Beck AT, Ward CH, Mendelson M, et al:
Reliability of psychiatric diagnosis. II. A study of consistency of clinical judgments and ratings. Am J Psychiatry 1l9:35 I-357, 1962 4. Tarter RE, Templer DI, Hardy C: Reliability of psychiatric diagnosis. Dis New Syst 36:30-31, 1975 5. Baxter S, Chodorkoff B, Underhill R: Psychiatric emergencies: dispositional determinants and the validity of the decision to admit. Am J Psychiatry 124:1542- 1548, 1968
I
N CONTRAST to general medicine, only a few psychiatric diagnoses can be verified by laboratory methods. Thus diagnoses and the consequent management of patients may vary, not only from school to school,‘,’ but often within the same institution from one psychiatrist to another.3*’ In the Emergency Room, a psychiatrist has to make important decisions under pressure of time, often with inadequate information.,’ Moreover, in most psychiatric emergency facilities, residents in various stages of training handle all but the most difficult patients. Therefore we were interested in comparing the psychiatric evaluations of patients seen by psychiatric residents in the Emergency Room with a subsequent reevaluation by senior psychiatrists. In this study, we examined the levels of agreement between such evaluations regarding diagnosis, mental status examination, medication prescribed in the Emergency Room, and the appropriateness of the disposition. We also compared levels of agreements in those categories with the length of residents’ training. METHOD
The Setting This study took advantage of independent reevaluation of all psychiatric patients who are first seen in the Emergency Room at Johns Hopkins Hospital, and who are subsequently referred to the Acute Treatment Clinic. In the Emergency Room, psychiatric residents are availableon a 24 hour basis. During the daytime, a second or third year resident covers the service, while during the night a first year resident on night duty is supervised by a senior resident. The remaining year, he consults with a senior resident on second call if he needs help. Daily morning rounds are held by four faculty members in rotation. The psychiatric services evaluates approximately 2500 patients a year. During the time of the study, 15 residents in the first year of training and 32 residents in the second or third year of training shared the Emergency Room duties. Approximately 15% of psychiatric patients who are seen in the Emergency Room are referred to the Acute Treatment Clinic, which is a part of the Psychiatric Emergency Services and provides crisis therapy on an outpatient basis. Of those patients, about half keep their appointments and are reevaluated in the Acute Treatment Clinic, usually within 2 to 5 days after the Emergency Room visit. These evaluations are done by residents or psychiatric nurse practitioners, who present all patients in rounds to one of four senior psychiatrists, with whom the diagnosis and the treatment program are discussed.
Subjef
ts
Records of 233 patients referred from the Emergency Room to the Acute Treatment Clinic over an I8 month period were examined. This period was selected because complete referral lists for it were available.
From the Departments of Emergency Medicine and Psychiatry; Johns Hopkins School of Medicine, Johns Hopkins Hospital; E~timore, Maryland. Rudolf Hoehn-Saris, M.D.: Associate Professor of Psychiatry and Emergency Medicine, Johns Hopkins School of Medicine, Johns Hopkins Hospital, Baltimore. Reprint requests should be addressed to Rudolf Hoehn-Saric. M.D.. 009 Henry Phipps P.sychiatric Clinic, Johns Hopkins Hospital, Baltimore, Md. 21205. 5’ 1977 by Grune & Stratton, Inc. ISSN 0010-440X. Com.orehensive Psychiatry, Vol. 18. No. 6 (November/December).
1977
585
586
RUDOLF
HOEHN-SARIC
Patients’ median age was 29 (1479), 28% were male and 72% female. Forty-one per cent were white and 59% black. The education level: 53% had not completed the 12th grade, 26% had finished high school, and 21% had at least one year of college. Thirty per cent were single, 34% married, 32% separated or divorced, and 4% widowed. Only 47% of the patients were employed during the time of the initial visit. The median waiting period between the Emergency Room and the Acute Treatment Clinic evaluation was 3 days (Q-20 days); the long waiting period occurred in patients who did not show up on the first appointment and had to be rescheduled.
Evaluation of the Records The record of each patient contains the evaluation by the psychiatric resident in the Emergency Room and evaluation by a member of the Acute Treatment Clinic team, which was dictated after rounds with one of the senior psychiatrists. The two evaluations are examined by discrepancies in diagnosis, disposition, medication and mental status. Bugnoses. Since the emergency services are primarily management oriented, the diagnoses were collapsed into 5 broad categories; namely, “nonpsychotic” conditions, schizophrenia, manic-depressive psychosis, psychotic depression, and organic brain syndrome. The “nonpsychotic” conditions included all types of acute situational reactions, neurotic conditions, and personality disorders. The category schizophrenia included acute and chronic conditions. The category organic brain syndrome included all conditions in which an organic condition caused an either transitory or chronic mental dysfunction. Agreement for diagnosis was rated in all cases in which the two evaluations agreed on the diagnosis in terms of the categories listed above. It sufficed that the Emergency Room evaluation contained the Acute Treatment Clinic diagnosis as one of the differential diagnoses. The remaining cases were rated as “discrepant” for diagnosis. Disposition. A discrepancy in disposition was rated when a patient, after the reevaluation by the Acute Treatment Clinic staff, was regarded as unsuitable for outpatient treatment and had to be hospitalized immediately. No discrepancy was rated for patients who were accepted in the Acute Treatment Clinic for outpatient therapy, but had to be hospitalized subsequently. Medication. Discrepancies in medication were noted when a patient who was diagnosed as schizophrenia or manic psychosis in the Acute Treatment Clinic was not covered with antipsychotic medication in the Emergency Room; when a patient who was subsequently diagnosed to suffer from a psychotic depression was not covered with antidepressant medication; and when a patient who was regarded as “nonpsychotic” in the Acute Treatment Clinic had been put on an excessive dosage of antipsychotic medication in the Emergency Room.
Menral Status Examination. If a discrepancy occurred in at least one of these areas (i.e., diagnosis, disposition, medication), then the record was examined further for discrepancies in mental status evaluation. A record was rated discrepant when the psychiatric note of the Emergency Room failed to describe symptoms of thought disorder, hallucinations, delusions, or somatic symptoms which were relevant to diagnosis and disposition, further severe suicidal preoccupation, or signs and symptoms suggesting an organic brain involvement. RESULTS
Tables 1 and 2 show the “discrepancies” in diagnosis, disposition, medication and mental status between the evaluations in the Emergency Room and the Acute Treatment Clinic. Figures are given for the entire sample and for subsamples seen by residents during their first and second half years of training, and residents during their second and third years of training. In the entire sample, discrepancies were noted in approximately 10% of the patients for diagnosis, disposition, medication, and mental status. Discrepancies in diagnoses were noted in 25 patients. Most frequently, an existing or a coexisting organic brain condition was diagnosed in the Acute Treatment Clinic but not in the Emergency Room (n = 7). The next most frequent dis-
EMERGENCY
Table I.
ROOM
PSYCHlATRiC
Discrepancies
TRAINING
587
in the Evaluation of Patients in the Emergency the Acute Treatment Dmgnosis
Length of Trammg
N
Dlspositlon %
Room and the Reevaluation
in
Clinic
N
Medication %
N
Mental %
N
Status 96
1 st Year Residents 0-6MoN=49
8
16
7
14
8
16
11
22
10
14
7
10
6
9
7
10
$8
15
14
12
14
12
18
15
7
6
13
11
8
7
5
4
25
11
27
12
22
9
1 st Year Residents 6-12MoN=70 1 st Year Residents O-12MoN=llS 2nd and 3rd Year Residents N=114 All residents N=233
23
10
crepancy category (n = 6) was patients who were regarded as “nonpsychotic” in the Emergency Room, but diagnosed schizophrenic in the Acute Treatment Clinic. Discrepancy in disposition, i.e., the need for immediate hospitalization of patients referred to the Acute Treatment Clinic for outpatient treatment, occurred in 27 patients, In most of these patients (n = 19), the family was unable to take care of the patient at home. Four patients had to be hospitalized because of severe suicidal risks, and four patients because of coexisting physical illness or the need of an intensive diagnostic work up. Discrepancies in medication were found in 22 patients. In the majority of these patients, the discrepancy in medication reflected the difference in diagnosis (n = 13); in the remaining patients, the diagnoses in the Emergency Room were correct, but the patients who were regarded as psychotic were not medicated in the Emergency Room. Discrepancies in mental status were noted in 23 patients. In 12 patients, the workup in the Emergency Room did not describe thought disorder, delusions, or hallucinations, which categories were elicited in the second examination, In 6 patients, symptoms or signs of an organic brain condition were missed, and in Table 2. Significance
of Disagreement
Between
the Reevaluation
Residents’ Evaluetion in the Emergency
in the Acute Treatment
Room and
Clinic MRiltd
Revdent
Groups’
Dtagnosis
Dspostion
Medmtion
status
1 st year Residents O-6 months vs 1 st year Residents 6-l 2 months
N.S.
N.S.
N.S.
p < .lO
p < .05
N.S.
p < .lO
p < .OOl
p < .lO
N.S.
N.S.
N.S.
p < .05
N.S.
N.S.
p < .Ol
1 st year Residents O-6 months vs 2nd & 3rd year Residents 1 st year Residents 6-12
monthsvs2nd
& 3rd year Residents All 1 st year Residents vs 2nd & 3rd year Residents
*Comparison between groups of Residents at different levels of training.
RUDOLF
588
HOEHN-SARIC
another 5 patients, suicidal ruminations, severe vegetative symptoms, or depressive thoughts were not described. The training of the residents reduced, significantly, the discrepancy between the two evaiuations for diagnosis and the description of the mental status+ and had its greatest impact within the first 6 months of residency. Using Chi-quare analysis, the discrepancies between patients evaluated by first year residents during the first 6 months as compared to second and third year residents were significant for diagnoses (p < .05) and mental status (p < .OOl), and suggestive for medication (p < ,lO). On the other hand, disagreements in disposition continued to occur, independently of the length of training. DISCUSSION The patient ~pu1atjon in this study, while not representing a cross section of the Psychiatric Emergency Room population, consisted of a particularly important segment; namely, outpatients in need of immediate and intensive followup care. With this restriction in mind, several conclusions can be drawn. In general, one can state that psychiatric residents, as a group, performed a service in the Emergency Room which was regarded as very satisfactory by senior psychiatrists when they reevaluated the patients. The concordance in diagnosis was higher than reported in other studies,3*1*”probably because of the broadness of the diagnostic categories. The most interesting finding was that within a few months of training, residents and senior staff came close in their agreement on the mental status of patients, and the diagnosis, but even longer training did not diminish the disagreements as to whether a patient could be treated on an outpatient basis or needed hospitalization. It appears that the work on the inpatient service, as well as in the Emergency Room, taught these residents basic psychiatric skills, but not theoptimal management of patients in a crisis. Since only a few residents followed patients whom they saw in the Emergency Room, they obtained little relevant feedback about the effectiveness of their dispositions. The morning rounds in the Emergency Room usually dealt with problems brought up by the resident, and not with problems which the resident failed to see. Feedback from the Acute Treatment Clinic about errors of management was often lost to a resident for whom the work in the Emergency Room was only one of several duties, and who, after severai days, had only vague memories of the patient. Therefore in an optimal training program, a resident should come to the Emergency Service after he has developed su~cient experience on an inpatient service, perhaps in the later part of the first, or during the second year of training. The exposure to Emergency Medicine should be brief, but concentrated, and most important, it should be combined with the follow-up treatment of outpatients seen in the Emergency Room. Further, whenever possible patients should be reevaluated personally by a supervisor. In our experience, the most valuable teaching occurred when a reexamination elicited symptoms or brought out information missed in the first examination, which would not have surfaced in supervisory sessions during which the case, not the patient is presented. A regular reexamination of patients by senior psychiatrists may be difficult to provide in the
EMERGENCY
ROOM
PSYCHIATRIC
TRAINING
589
Emergency Room setting, but should nevertheless devoted to the training of residents.
be part of the follow-up clinic
SUMMARY
Records of 233 patients evaluated by psychiatric residents in the Emergency Room and subsequently reevaluated by senior psychiatrists in the Acute Treatment Clinic were examined for gross discrepancies in diagnosis, mental status, prescribed medication, and appropriate disposition of outpatients to a crisis clinic. The work in the Emergency Room was rated satisfactory in 90% of the cases. Length of training heightened the agreement between residents and senior staff on the mental status examination, the diagnosis and, to a lesser extent, the medication. There was no relationship between length of training and the agreement about the disposition. This was probably due to the lack of follow-up of the patients by the residents who had seen them in the Emergency Room. It was concluded that for optimal training purposes the Emergency Room experience should be combined with work in a crisis clinic where residents continue to treat patients whom they have referred from the Emergency Room.
REFERENCES I. Cooper JE, Kendell RE, Gurland BJ, et al: Cross-national study of diagnosis of the mental disorders. Some results from the First Comparative Investigation. Am J Psychiatry 125. Supp: 21 29, 1969 2. Gurland BJ, Fleiss JL, Cooper JE, et al: Cross-national study of diagnosis of the mental disorders. Some comparisons of diagnostic criteria from the First Investigation. Am J Psychiatry 125, Supp: 30-39, 1969 3. Beck AT, Ward CH, Mendelson M, et al:
Reliability of psychiatric diagnosis. II. A study of consistency of clinical judgments and ratings. Am J Psychiatry 1l9:35 I-357, 1962 4. Tarter RE, Templer DI, Hardy C: Reliability of psychiatric diagnosis. Dis New Syst 36:30-31, 1975 5. Baxter S, Chodorkoff B, Underhill R: Psychiatric emergencies: dispositional determinants and the validity of the decision to admit. Am J Psychiatry 124:1542- 1548, 1968
