Acknowledgements100489741Paragraph100489742The authors thank Dr. Brian Hodges for his editorial assistance.

o the Editor: Patients with personality disorders present a common challenge to all physicians and are associated with increased medical and functional morbidity. Unfortunately, they are often inaccurately diagnosed in medical settings and labeled "problem" patients, reflecting the strong countertransference feelings they evoke. The failure to recognize these feelings may lead to harmful physician behaviors (1).

We describe a resident-driven psychiatry clerkship pilot course at Dalhousie University, developed to teach medical students about personality disorders and countertransference. The format was adapted from University of Toronto’s Dealing with the Difficult Patient clerkship course (2) to meet curriculum needs at Dalhousie. The Challenging Patient was offered to third-year students in 4×1.5-hour weekly sessions during their psychiatry rotation between April and September 2001. Thirty-six clerks attended the course, four to seven students per session. Thirteen of 20 third- to fifth-year residents voluntarily participated as tutors.

A detailed tutor’s manual is available. The introductory session began with a video clip from the comedy , followed by a discussion about whether the characters have personality disorders. Using inviting clinical anecdotes and popular film characters, the different personality disorders were reviewed and etiologic biopsychosocial parameters were considered. Reflecting on students’ clinical experiences, basic principles of transference and countertransference were introduced.

Sessions 2, 3, and 4 introduced the borderline, narcissistic, and dependent personality disorders, respectively. The format of each session was similar; session 4 will be summarized. Beginning with a scene from the film students reviewed the characteristics and biopsychosocial dimensions of dependent personality disorder. A role-play between a volunteer clerk and a "clingy, somatizing" standardized patient (20—30 minutes) followed. "Time-outs" were taken during impasses, with guidance sought from peers regarding interviewing techniques and practical management suggestions. During "time-outs" and following the role-play, students were asked to reflect on the range of feelings experienced. They were encouraged to consider where these feelings came from, what patient information they might provide, and the consequences of these feelings going unnoticed. After the interview, students reviewed practical management strategies for dependent personality disorders.

The achievement of the course’s educational aims was evaluated. After each session, students evaluated residents’ teaching performance using the Clinical Teaching Assessment Form (3). A letter of explanation accompanied the evaluations, explaining their purpose and their voluntary and confidential nature. They were administered and collected by an administrative assistant after the resident teacher left to minimize response bias and ensure blinding.

Course evaluations were completed by 29 of the 36 students (80.6%). The course was rated as "relevant to my needs," "interesting" and "enjoyable" by all respondents. Video and role-play were rated as valuable teaching aids for all, with the exception of one student who was "undecided" about the role-play. The course was an "overall worthwhile experience" for all, with 83% responding "strongly agree" and 17% "agree." Of a maximum possible 144 resident teacher evaluations, 105 were completed (72.9%). Overall, residents were rated highly by the medical students.

All students found the course relevant to their needs, an important aim as learning is most effective and motivating in this context (4). The role-play scenarios were developed to highlight challenges personality disorders present to all clinicians, not only psychiatrists. The popular video clips were valued and provided an excellent base for discussion. Like sharing past clinical encounters, they were intended to reinforce existing cognitive schema (4). They also set the tone of learning about personality disorders as enjoyable and interesting.

Role-play was also highly rated, where students reflected "in-action" during the interview and "on-action" during time-outs to negotiate interview impasses (4). In this process, one moves beyond theory to a deeper awareness of one’s feelings, thoughts and behaviors toward achieving the insights necessary to solve a problem. It is difficult to develop a critical stance to examine one’s emotions. We observed that peers sharing their feelings helped normalize the interviewers’ responses and promoted further self-reflection. Self-reflection training during medical school cultivates an improved psychosocial perspective and maintains boundaries in the undifferentiated physician (5). The Toronto, Ont., Canada, group demonstrated students’ capacity for reflectivity versus reflexivity with their original course (2).

The high resident ratings may reflect their unique position to teach undergraduates about psychosocial domains. Close in age and experience, residents may create a safe environment for students to share ideas and feelings. High ratings on the item "establishes rapport," suggest such an environment was created. Residents are among the most important role models for medical students. Inferring from the strongly rated item "enthusiastic and stimulating," our students may have identified with residents’ enthusiasm. Such identifications may engender more positive attitudes toward psychiatry, leading to improved patient care and recruitment (6).

Residents have consistently been shown to lack the essential skills of promoting learner participation and providing feedback (7). In contrast to earlier findings, the item most highly rated was "actively involves students," which we attribute to the experiential learning strategies. "Providing direction and feedback" was also rated highly, implicit in the role-playing.

We have learned that the course achieved its educational aims and that residents were perceived by medical students as effective teachers of important psychosocial domains; however, the absence of a comparison group and additional outcomes limit our ability to evaluate the impact of the course on student knowledge, skills and attitudes. Future research should address these limitations, for example, by comparing performance on an observed structured clinical interview. Additional limitations include the potential for selection bias, both with students responding to evaluation requests and resident volunteers favoring the outcome.

Notwithstanding these limitations, based on our initial results the course has since been integrated as a core component of the undergraduate curriculum and is now in its fourth year. We are happy to share our detailed syllabus or offer advice to interested resident groups so they may benefit also from collaboration with the Toronto, Ontario, Canada group, enhancing the culture of resident and undergraduate teaching in their programs.

The authors thank Dr. Brian Hodges for his editorial assistance.