Perspective

The Practice of Psychiatry in the 21st Century: Challenges for Psychiatric Education
Joel Yager, M.D.

o consider how shifting scientic, technological, social, and nancial pressures are likely to significantly alter psychiatric practice, careers, and education in the 21st century, this article reviews trends and innovations likely to have an effect on tomorrows psychiatrists and their educators. The psychiatric profession and its educators can anticipate great change, creating opportunities as well as challenges. Although considerable adaptability will be required to keep up with current trends, personal and professional rewards for psychiatric educators and practitioners are likely to remain substantial. To prepare for what lies ahead, psychiatric educators inevitably confront fundamental questions: What will psychiatric services look like in the future? How will technological and scientic advances shape practice? What do these trends imply for new psychiatric careers? What will psychiatrists need to know? How should they be educated? Who will pay for it? And how will psychiatric educators and their graduates maintain professional satisfaction? This article addresses these questions in relation to social, cultural, institutional, and scientic shifts affecting the profession. What Will Psychiatric Services Look Like in the Future? Although some psychiatric practices will retain the cottage industry, individual ofce, independent-practice model, public, nonprot, and private systems of care, as well as larger individual and group practices, will align practice patterns with the Four As core business values driving contemporary service industries, including medicine. These Four As are AffordReceived December 21, 2010; revised January 31, 2011; accepted February 1, 2011. From the Dept. of Psychiatry, University of Colorado, Aurora, CO; jyager@unm.edu (e-mail). Copyright 2011 Academic Psychiatry

ability (cost), Affability (patient satisfaction), Accessibility (ease of obtaining services), and Accountability (assuring quality outcomes)paralleling business drivers euphemistically referred to as FCB; that is, Faster, Cheaper, Better. Under grinding social, nancial, political, technological, and scientic pressures, systems of care and practices that optimize these core values are likely to succeed better than those that dont. Individual patients (as well as institutional purchasers of healthcare plans) are, overall, becoming more informed and selective consumers. Contemporary media, the Internet, and direct-to-consumer advertising by pharmaceutical companies and healthcare systems have educated the general publics demands. Most Americans now routinely research health information online (1). Patients routinely google disorders, treatments, and clinicians. Expect that most of your patients will have googled you, to learn about your background, performance-, and malpractice-history. What Does the Future Hold for Academic Health Centers in Which We Conduct Research, Offer Services, and Educate? Academic health centers, saddled with complicated organizational structures, multipurposed mission statements, and arcane budgets, are besieged by external and internal pressures. Some do well nancially, at least in specic pockets of activity, thanks to aggressive promotion of highly specialized tertiary-care programs that ll beds. These practices will not always necessarily be sustainable, as society inevitably attempts to contain medical costs. Other centers rely on wealthy donors or specic research expertise that garners windfall grants. However, even the most successful institutions struggle in some programs. Administrators constantly perform creative nancial nagles. Residency training transpiring within institutions must, in turn, accommodate to practice patterns shaped by the constraints and values these multiple forces impose.
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Who Is Your Competition Likely to Be? Behemoth institutions are not always capable of shifting nimbly in rapidly-changing environments. Some academic health centers and departments risk becoming big, ossied dinosaurs, incapable of adaptively dealing with competing models of research, services, and education. Although fundamental scientic ndings often emanate from universities, remember that many of the most innovative and disruptive innovations more frequently originate from extra-university entrepreneurship. In fact, many innovators ee universities to free themselves from bureaucratic pressures that stie creativity. So, who might compete with tomorrows academic psychiatric departments? Consider how the following missions might potentially be conducted efciently, effectively, and cost-effectively:
Clinical services: As primary-care based medical homes and medical neighborhoods more prominently occupy the healthcare landscape, many will design programs to manage psychiatric needs of patients and families (2). Primary-care providers with co-located mental health professionals, including psychiatrists, might provide for patients contending with medical and psychiatric comorbidities (3). Of course, who services these homes and neighborhoods will vary with funding and zoning requirements.

Disorder-focused models of care, including diseasemanagement programs conducted by Big Pharma, already deployed for diabetes and for clozapine management, may well expand if they prove effective, userfriendly, and economically sound. Already, telephone and web-based monitoring and intervention programs for depression and anxiety have been shown to be viable and effective (4, 5). Measurement-based disease-management care will progress as even chronically ill psychiatric patients increasingly use computer-based tools in waiting rooms to rate their clinical status before ofce appointments (6). As scope of practice expands for other professions, notably, advanced-practice psychiatric nurses with prescribing authority, competition by psychiatroids will increase for functions currently performed by psychiatrists (7, 8). Specialties utilizing advanced practicenurses (e.g., family practice, pediatrics, and psychiatry), may see physicians increasingly undertaking additional subspecialty training to remain one step ahead. Further284 http://ap.psychiatryonline.org

more, as routine aspects of care are increasingly assumed by masters-level therapists and paraprofessionals (e.g., case managers and promotoras), some psychiatrists may reshape their practices to incorporate additional patient services provided by teams. Further affecting clinical services, consider the potential impacts of remote site consultation and treatment using telephone, videophone, e-mail, and Internet; that is, instantaneous global communication: anyone, anywhere, 24/7. Consultants can help every remote-dwelling practitioner diagnose and treat local patients. Using tele-medicine, psychiatrists already routinely assist rural primary-care physicians to manage psychiatric disorders (9). SmartPhone apps using HIPAA-compliant encrypted settings will permit SKYPE-like interactions between clinicians and patients located anywhere in the world. Given that psychiatroids anywhere can virtually manage many psychiatric patients located anywhere, outsourcing assessment and even psychotherapy is constrained only by regulatory statutes governing licensing, any of which might be modied in free-trade agreements if health systems think they can offer sufcient quality at the right price and manage the political processes and the outcry. With increasing globalization and falling trade barriers, if a strong business case can be made for the economic advantages, couldnt we outsource elements of psychiatric diagnostic and management? If Walmart and Dell do it, why cant Humana or Kaiser-Permanente?

Medical education: As Einstein showed, time and space are malleable. First, space: Almost anything that can be taught in a classroom can now be taught through web-based, distance-learning, permitting great latitude regarding where teaching programs originate and are transacted. Virtualized laboratory and clinical demonstrations enable students to participate at a distance. And, although hands-on and eyes-on clinical supervision benet from on-site, live teachers, tele-supervision can go a long way toward providing acceptable substitutes. Even for physical examinations, faculty working at a distance can lead trainees through the mechanics with sufcient HD delity to satisfy some quality concerns. Compared with tele-surgery via robotics, telepsychiatry is easy.
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Second, time: 24/7environments offer students educational programming to custom t their temporal needs: evenings, nights, weekends, summers, part-time. The popularity and successes of the University of Phoenix models, designed as no-frills learning venues for working adults seeking off-hours education, exemplify these trends. Which aspects of psychiatric education might utilize these delivery systems? The web permits studentfaculty and patientprovider interactions to become increasingly asynchronous. Complex verbal and nonverbal communications can transact in HD whenever times work best for You and independentlyfor Me. You leave a message/question, or send a (condentiality encrypted) video-clip of a patient interaction, and I respond whenever its convenient. Clinical research: Certain types of translational research favor extra-university settings. Non-academic, clinical-trials organizations, utilizing community practices, have increasingly replaced academic centers for industry-sponsored clinical trials (accounting for more than half of such studies). Pharmaceutical and medicaldevice companies increasingly sidestep delays and hassles imposed by universities Institutional Review Boards by employing time-efcient private IRBs. Parenthetically, todays increasingly restrictive academic zeitgeist regarding Pharma might discourage some excellent clinical researcher-teachers from academic careers and, instead, lead some of the brightest to private practices or industry positions with better nancial rewards. How Might Technological and Scientic Advances Shape Practice? Before considering the following futuristic scenarios (although everything I cite is already happening), please recall that scientic advances are implemented only at the pace that social-cultural shifts and economic realities permit. Todays marvelous discoveries may take decades to work into common practice, depending on provider and practitioner acceptance, utility, and nancingthe Four As. For example, disseminating electronic medical records has been comparatively sluggish. Prototypes abound that are never adopted. That said, the phenomenal speeds with which the web, videogames, smart-phones, and social networking have disseminated illustrate how hot advances can be disruptive, often in little-foreseen ways. Consider how
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the following emerging advances, each already available at least in prototype, might shape psychiatric beliefs and practices; and these represent only a small fraction of whats now on the drawing board. All have implication for curriculum development: Genomics, proteinomics, and epigenetics: When can we expect polymorphism-enhanced psychiatry: YOU on a chip? Soon. With rapidly falling prices for determining individual genomes, personalized medicine might be able to recommend specic prescribing patterns, enabling clinicians to better predict positive treatment response and specic adverse medication effects, such as weight gain with atypical antipsychotics, Stephens Johnson syndrome, and others. With polymorphisms on parade (10 12), Chip Medicine will convey your vulnerabilities to specic disorders, temperament, stress-response proclivities, and other genetically-sensitive characteristics. Beyond genetic polymorphisms, epigenetic proling will further characterize your personal uniqueness, perhaps rivaling genetics in shaping development, psychology, and behavior (13). Might we expect future matchmakers to depend less on eHarmony.com and to match couples based on polymorphisms and epigenetics? Instead of asking Whats your sign? might future dating etiquette require you to ask Whats your allele? and Whats your epigenetic methylation pattern? Neuroimmunology: Understanding how cytokines and related immune functions affect psychopathologymediating brain processes will become increasingly important, for example, as in inammatory and autoimmune-linked neuropsychiatric disorders (14, 15). Advanced neuroimaging and studies of brain circuitry: Nowadays, we can virtually watch the mind boggle, thanks to ever-more-sophisticated imaging technologies, such as 3-D fMRI (16). Brain circuitry in psychopathology is an important driver behind NIMHs new Research Domain Criteria (RDoC) initiative to derive deeper diagnostic understanding by integrating brain, genetics, and behavior (17). Targets include stress and fear circuitry (18, 19); attachment, empathy, and inter-subjectivity, via mirror- and social-neuron systems (20); and the neurobiology of traumatic and neglectful development (e.g., in borderline personality disorder) (21). Studying neurobiological correlates of
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psychological therapies (22) may help clinicians better integrate psychological, interpersonal, and biological domains in treatment. (The next step would be to hook up two side-by-side sets of imaging apparatus to observe couples or parent child interactions or therapy sessions.) Information Technology: Smart-phoneassisted interventions are already happening. SmartPhone Apps touted as personal psychologists offer counseling and advice geared to ones personal characteristics (2325). Programmed to their individual schedules, patients might be prompted to take medications; go to appointments; or record moods, anxiety, and current activities that very moment, all automatically transmitted to the clinicians computer (26). Highly portable iBrain devices that t into headbands can already transmit sleep and other EEG signatures to labs for analysis via cellphones during waking hours or from individuals sleeping at home (27). Such advances greatly extend homebased monitoring systems; and patients medical and psychiatric history, including examinations, lab tests, and medications, can be accessed via chip or through the cloud.

as dysfunctional interpersonal patterns (31). Internet avatars and virtual relationships might provide laboratories in which patients work out interpersonal difculties before taking them live, and, in some instances, provide adjunctive lifelong comforting companions; and, of course, we may next have sex therapies via virtual reality-style tele-dildonics (32). Shall we expect personalized matchmaking of patients and therapists? Trainees and mentors? Consider mash-ups where e-Harmony.com meets amplied Facebook proles, based on ever-more-sophisticated datamining of personal habits and characteristics.

Back-engineering the brain may yield neuromorphing, leading ultimately to neuroprosthetics (33) and even mind-prosthetics.

Supercomputing-based advanced articial intelligence (AI): Homeland Security has seen rapid advances in technologies capable of teasing apart emotionally-complex cognitive and emotional states based on real-time analyses of voice and body language (28). Complex adaptive systems using expert-system decision-making based on fuzzy logic and using genetic algorithms that elaborate their own neural nets already show emergent properties such as the capacity to generate creative ideas (29). As AI algorithms become increasingly adept at discriminating truthfulness from deceptiveness, mixed emotional states, and other pertinent personal-signature characteristics in real time, might we expect personalized AI therapist systems nely attuned to individual proles? How close are we to the HAL computer of Stanley Kubricks classic lm 2001? We already see ever-improving virtual-reality technologies morphing with game simulations, as in the Sims. Some are proving to be psychotherapeutically adept (30). Consider, for example, adjunctive psychotherapies based on virtual-reality games confronting cognitive and emotional biases and distortions, as well

Robotics, leading to individually-programmed psychologically-supportive rescue robots, analogous to rescue pets. Combine a Roomba, current Japanese and MIT robot technology, and the SmartPhone personal psychologist, and R2D2 isnt very far off. How might clinicians employ empathic, nonhuman, countertransference-generating computer and robotherapists in practice?
Mega data-mining: Huge data-mining capacities should produce better evidence-based outcomes research. Data drawn from forests of electronic medical records might frequently update comparative benets and risks of various interventions. As federally-mandated and nancially-incentivized performance indicators steadily nudge practitioners toward measurementbased care, such data shouldin theory better inform clinical practice. More discriminating meta-analyses of increasingly transparent industry-designed clinical-trials data should generate a more discerning evidencebase (34, 35).

Future possibilities for psychotherapy: As mentioned above, advances in virtual-reality and computerbased games might help patients improve their problem-solving skills and deal with emotional sensitivities (36). Conceivably, psychotherapies might be prescribed according to individual nervous-system and information-processing characteristics, perhaps based on patient (and therapist) polymorphism variants. This isnt overly far-fetched, since genetically mediated personAcademic Psychiatry, 35:5, September-October 2011

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ality factors such as interpersonal sensitivity and empathic capacity have been shown to predict better outcomes in psychotherapy, regardless of specic psychiatric diagnoses. How might these advances inform treatment algorithms or manuals? Furthermore, how might psychotherapy supervision use smart programs applied to digitized audio and video recordings to assess treatment compliance? What Exactly Will Psychiatrists Be Doing? Just as today, no single role denition for tomorrows psychiatrist will sufce. Future general-residency psychiatrists are likely to diversify increasingly into a proliferating array of subspecialty eco-niches via formal fellowships leading to added qualications/board certications, other postgraduate studies, and assorted on the job training agendas. Darwinian experiments conducted by healthcare systems and competing psychiatroid professions will determine which types of individual, group, private, public, and tele-practice treatment, administrative, and academic activities will thrive in which sorts of environments, and which are at risk of withering. Psychiatrists are already shifting away from practicing psychotherapy in many areas (37). Certainly, psychiatrists devoted to orthodox psychoanalytic practice represent a dying breed, and other archetypes may go the way of the archeopteryx. Careers: New Areas of Psychiatric Specialization Emerging technological and scientic advances are likely to generate demands for new psychiatric subspecialties. Consider clinical computerologists and informaticists to deal with all manner of computer-associated practice, from web-based disease management through electronic medical records. Medical Informatics graduate programs are busily enrolling all physician specialties. Although psychiatry departments have traditionally relied on their geekiest faculty to devote hours of avocational passion to informatics infrastructure (and/or have increasingly hired nonphysician information-technology [IT] specialists), formalized training and ofcial job roles are likely to blossom for psychiatrists. Psychiatrists trained in virtual-reality game design might specify scenarios to assess and treat a wide assortments of psychiatric dysfunctions, as already demonstrated with phobias, posttraumatic stress disorder, and Aspergers syndrome. Therapies for quirky personalities are in the works.
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New imaging technologies will demand experts to administer and interpret, and to apply increasingly localized interventions involving deep brain stimulation or gamma knife surgery, such as for treatment-resistant obsessive-compulsive disorder. Some neuroradiology and nuclear medicine fellowships already accept psychiatrists for advanced training. Will we see an ABPN added-qualications certicate for psychiatric diagnostic and interventional neuroimaging? Other somatic interventions will evolve from brain and nerve stimulations and research in neuronal neogenesis, involving injected stem cells, or gene therapy to treat depression (38) and other psychiatric disorders, or be based on optogenetically-mediated neural reengineering (39). Combine genomics, proteinomics, epigenetics, and personalized medicine with pharmaceutical advances, and we have tomorrows psychopharmacologists. Focus on cognitive-enhancers, including nootropic agents (intelligence- and memory-enhancing drugs); empathogens; and other hedonics; work out the ethical practice boundaries; and you might produce cosmetic psychopharmcologists (not just drug-pushers). Expect computational cognitive neurobiologists (17), modeling CNS nuclei and networks, to derive new hypotheses regarding psychiatric phenomenology and interventions. And, as now, careers combining clinical practice with administration, entrepreneurialism, health services, and complex organization perspectives will produce Executive-Manager Psychiatrists. MD-MBA, MD-MPH, and MD-LLB fusions, already offered as organized curricula by some universities, will ourish. Many executives will experiment with faster-better-cheaper models, employing nondoctoral-level therapists for assessment, therapy, and disease management (invivo and via tele-medicine). Some entrepreneurs might consider the idea of spot-market pricing underutilized psychiatric beds and services (think PriceLine during low-occupancy periods). Some might package traveling mental health teams to manage psychiatric aftermaths of man-made terror and natural disasters. What Will Psychiatrists Need to Know? For the foreseeable future, general-psychiatry residents will still be expected to master all the usual subjects near and dear to the hearts of the Residency Review Committee: broad bio-psycho-social medical knowledge, clinical skills, professionalism, communication, and systems-based competencies. These and
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other curriculum elements for the 21st Century are noted in Table 1. Residents will continue to require working knowledge in clinical neuroscience and biological psychiatry, including advances in genetics, proteonomics, epigenetics, neuroimmunology, and imaging; multiple perspectives on developmental and adult psychology, psychopathology, and phenomenology, including, for example, perspectives from evolutionary psychology and psychiatry (40 43); social psychology; family system and transactional perspectives (both functional and dysfunctional), as well as epidemiology, cultural anthropology, and knowledge of pertinent local and national health systems. Teaching the art of diagnosis will require some shape-shifting: DSM-5, due in 2013, will differ moderately from previous DSM systems, with added attention to dimensional cross-cutting, and, perhaps, cultural issues. With DSMs anticipated integration into the ICD (World Health Organizations International Classication of Diseases) system, future diagnoses may be individually modied online as merited by changing data. Or, at the least, the entire DSM may be revised roughly every decade or two. In any event, the average psychiatrists career may span three or four editions. The bottom line may be, dont get too attached to your diagnoses (44, 45). The curriculum challenge will be teaching how to think about diagnosis. Our accelerating world may provoke disorders related to new technologies (such as Internet addictions), rapid and premature vocational obsolescence, multiple role strains, and adult attentional-overload syndromes; and, as mentioned, NIMHs RDoCs project anticipates newer ways to slice diagnostic pies.
TABLE 1. Curriculum Elements for 21st-Century Psychiatry

Consistent with the Four As, clinical skills will include fundamentals required to ensure high patient satisfaction. Foremost are those consistent with giving good face: therapeutic listening, inquiring, and interacting, all common elements across all psychotherapies. Were now seeing trans-theoretical psychotherapies, where separate schools are replaced by increasingly practical, outcomes-oriented, and evidence-based deconstructions of psychotherapies into their effective elements: the psychotherapy toolbox (46, 47). Toolbox elements mined from psychodynamic, supportive, cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), interpersonal, couples, family, group, and other approaches might become the focus of education and training: empathic and nuanced listening to what is being said and to what is unspoken and avoided; focused inquiry; grappling with interpersonal and intrapersonal conicts, dysfunctional attitudes, schemas and behaviors; working with families and signicant others; and even educating and counseling. Using the toolbox, psychotherapy training may focus on how best to combine elements, align patient therapist match-ups, and integrate increasinglyavailable virtual, computer-mediated, and in-vivo psychotherapeutic adjuncts. Given that psychiatrists increasingly work in clinical and administrative teams and in positions of authority, suitable instruction and competencies in group and organizational dynamics will be increasingly important for successful careers, particularly for chief residents and transition to practice seminars (48, 49). Most importantly, trainees will require skills in lifelong learning, deaaling with constantly accelerating da-

UPGRADES in: molecular biology, genetics, epigenetics developmental and systems/circuit neurobiology and neuroimaging developmental psychology/psychopathology, including evolutionary psychology psychiatric diagnoses, including transactional psychopathology, cultural issues IT-based information access and evidence-based practice propaganda analysis: discriminating evidence from spin pharmacological and other biological treatments psychotherapy toolbox for individuals, couples/families, groups integrating technological interventions into psychiatric practice epidemiology, health-behavior related cultural anthropology, health services health economics and regulatory issues organizational dynamics PLUS whatever else the RRC mandates

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tabase versions, increasingly utilizing web-based resources, professional social networking, and participating as contributors to and benefactors from survey monkeys, gathering and distributing frequent updates on medication effectiveness and adversities, data-mining the wisdom of crowds. Key to lifelong-learning is critical thinking. Educators must ignite and nurture trainees crap-detectors (50), specically, their abilities to discern and deconstruct all sorts of propaganda: deceptive research and marketing studies from the pharmaceutical-industrial complex, the psychoanalytic-industrial complex, the CBT-industrial complex, and other special-interest groups. Trainees require prociency in separating facts from factoids and spin (51). No Small Order: How Should Psychiatrists Be Educated? Traditional training has relied on time-based immersion. In competency- and outcomes-based models, trainees graduate after demonstrating mastery of competencies, regardless of the time to mastery. For practical work-force reasons, time-based scheduling is likely to prevail. But where individual learning programs, portfolios, and competencies can be cultivated, outcomes and trainee satisfaction are likely to improve. Most clinical learning will undoubtedly continue via apprenticeships, relying on modeling, coaching, scaffolding, articulation, reection, and exploration of new possibilities (52). Educators will increasingly utilize principles of adult learning: Increased knowledge integration into workow: Medical record templates will increasingly link to decision-algorithms, practice guidelines, UpToDate, MicroMedix, and other current evidence sources, facilitating just-in-time learning, where information appears at point of use. Active learning and self-instruction trumps passive learning: Problem-based and scenario-based learning (focusing on specic cases and instances), including team-based learning, seem more effective than traditional lectures at imparting knowledge and skills.
Web-based instruction: Web-based learning laboratories can demonstrate anything from psychopathol

ogy video-clips to entire treatments. Clinicians may be lured into learning pertinent basic sciences via the so-called Trojan Horse approach (53), starting with clinical cases and working down to basic science presentations. Recent innovations are available through Science Magazines SPORE awards (Science Prize for Online Resources in Education) (54). Web-based classroom programs such as Blackboard host web-based courses permitting participants to engage in synchronous and/or asynchronous group-format discussions. Groups of training programs, combining resources to develop critical masses of educators and trainees, can easily organize web-based trans-university courses. A small-group, problem-based project for educators: Which curriculum components best lend themselves to web-based learning? Which do better with traditional faceto-face methods? What hybrids are most sensible and costeffective? Evaluating Psychiatric Competencies Residency Review Committees will continue to keep raising the bar for assessing professional competencies, and the American Boards may well do the same regarding Maintenance of Certication. The challenge is to ascertain how meaningful, reliable, valid, and non game-able the proposed requirements are, so that they dont simply represent hollow bureaucratic exercises. Assessment methods (55) will include simulation-interactive videos. During residency, the process-folio method may be most practical for documenting psychotherapy and other competencies (56). Who Will Pay for It All? Financing educational mandates will remain problematic. The future of graduate medical education funding via the Centers for Medicare and Medicaid Services (CMS) is uncertain. Some Federal funding may become available through health-nance reform, for improving electronic medical records, comparative-effectiveness research, and informatics, for example, through the National Library of Medicine. Private foundations may fund projects aligned with their missions. Small grants are available through many Deans Ofce initiatives in educational development. As usual, considerable efforts for educational innovation will come from volunteerism among individual faculty and via collaborations develhttp://ap.psychiatryonline.org 289

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oped through such organizations as AADPRT, AAP, and ADMSEP.

How Will We Maintain Professional Satisfaction? Psychiatry has traditionally enjoyed high career satisfaction, as compared with other medical specialties, although its relative satisfaction has dropped in recent years. With increasing pressures resulting in decreased autonomy in institutional settings, how will the professional satisfaction of psychiatrists measure up in the future? Although challenges are clear, in my view, psychiatrys satisfactions will remain considerable. First, psychiatry is intrinsically hugely satisfying, offering sustained doctorpatient relationships and deep, comprehensive understandings of humanity, plus attractive lifestyles, regular hours, and a relatively low callburden. Second, psychiatrys treatments are increasingly effective. We have more to offer regarding accountability. Finally, one of psychiatrys central contributions, more than many other medical specialties, is to offer meaning. Psychiatry contributes substantially to generating and sustaining the cultures signicant narratives (and myths) regarding human nature. Thanks to phenomenal knowledge growth in neuroscience, developmental psychology, and other bio-psycho-social domains, as our sciences get better, so do our stories. The deep professional satisfactions of psychiatric educators have always included, and will continue to include, helping to synthesize and disseminate the cutting-edge, evidence-based cultural narratives for our trainees and for society. For psychiatric educators and practitioners, professional satisfaction correlates with such activities as keeping up with professional advances, helping grow the profession by contributing to new knowledge, participating in professional and political organizations to benet patients and families, and improving the work environment in small ways on a daily basis,. All these activities are easily achievable by tomorrows psychiatrists. Psychiatric educators will continuously upgrade their own pedagogical skills, using resources that include medical school-wide programs for teaching scholars and organizations focusing on medical education; these include AADPRT, AAP, AATP, ADMSEP, APA, AAMC, and others. At the end of the day, professional satisfaction and
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self-esteem depend on the daily mirror test (57) how well we can look ourselves in the eye and call our efforts honest, heartfelt, professionally interesting and worthwhile contributing in some manner to the general good and to others well-being. The Bottom Lines Psychiatrys core values of honesty, integrity, compassionate caring, and respect for patients will endure and be valued. Psychiatrys ideas and interventions are better than ever, and will only improve further. Fostering career satisfaction in trainees and in ourselves will require increasing paradigm and career exibility. The tools we require to do the job are now available.
At the time of submission, the author reported no competing interests.

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