In 1998, Stony Brook Medical School made the decision to shorten the length of the third-year psychiatry clerkship (1), a decision similar to that of other institutions. A previous 6-week clerkship was shortened to 4 weeks in order to allow more time for the pediatric clerkship, which was increased from 8 to 12 weeks.
While condensing clerkship programs has proved to have been a regrettable national trend, Stony Brook made the unique decision of giving back the 2 weeks required for the fourth-year psychiatry course that would address psychiatric issues that present themselves in medical outpatient settings. We detail the development of this course, focusing on the curricular issues that we felt were of essence, how we implemented the curriculum, and what the experience has been after 5 years of offering the course.
In designing the course, several underlying issues of both psychiatric and general medical education became driving principles in determining the content. These were as follows.
The first consideration in creating the course was what to name it. We chose Psychiatry in Medicine to emphasize the core goals related to improving general medical practice with principles, neuroscience, and clinical tools from the field of psychiatry.
There was significant concern that students would not accept a new required fourth-year course with enthusiasm, especially a psychiatry course. In addition, the 2-week time frame made actual clinical patient care impossible. The great challenge was how to deliver a 2-week course that would appeal to senior students’ need for clinical relevance.
We determined that the best approach would be to have a small group, seminar-based course, deriving its clinical context from three sources:
We predicted that students would make use of patient encounters they had experienced and be able to integrate the concepts of the course since it might have been applied to those cases. The only way to achieve such a process was to ensure small classes that would allow active student participation. Thus we decided on a seminar based course, with no more than 12 students per offering. Since the average senior class size is 120 students, we offered the course 12 times per year.
We offer 17 distinct seminars, which last from 1–2 hours each, during the 2 week period. The following is a brief description of each of the seminars.
We utilize a documentary video I Have Cancer (8) to immediately ground the purpose of the course in a tangible clinical framework. This video follows a man in his thirties from shortly after being diagnosed with pancreatic cancer to his death 2 years later. Interviews are conducted with the patient, his wife, the oncologist, and a psychiatrist involved in treating his pain as well as a postoperative delirium at the end of his life. Many of the themes of the course come up in this realistic clinical context. These include communication about terminal illness, palliative care, recognizing and treating depression, impact of illness on the patient’s family, pain management, and countertransference issues.
3. Psychosomatics of Coronary Artery Disease (CAD)
Students are exposed to the extensive research literature on the pathophysiologic connection between the stress response system and heightened sympathetic nervous system activity and the pathogenesis and activity of CAD. The goal is to have students understand the importance of diagnosing depression and anxiety disorders, as well as uncovering the presence of significant life stressors, that may be contributing significantly to their patients’ CAD. Approaches for educating patients about these factors and referring them for treatment are discussed.
4. Psychodynamics of Doctor/Patient Communications
The goal is to teach basic psychodynamic processes that regularly come into play in doctor/patient relationships. Emphasis is placed on understanding transference and countertranference and on defense mechanisms that commonly arise in patients and doctors. Particular attention is paid to projection. The teaching video Doctor What’s Wrong With Me (9) is used. This is a fictional representation of a female middle-aged patient with chronic IBS, having an exacerbation after her husband dies and adult son cuts off relations with her. Powerful negative interactions with a medical resident caring for her illustrate how transference, countertransference, and projection can add to an already challenging situation. Difficulties involved with educating the patient about the role of stress in her illness and diagnosing and treating her depression are also depicted.
5. Substance Abuse in Medical Settings
The goal is to teach students how to recognize, assess, and treat alcohol and substance abuse when the patient is not identifying the illness spontaneously. Interview techniques that lower patients’ defensive avoidance of truth telling are emphasized.
The emphasis is on pharmacological management, including narcotic and non-narcotic analgesics. Behavioral treatments, including biofeedback, are also presented.
Students are exposed to the literature examining the placebo effect in its protean manifestations. Emphasis is placed on theoretical models and possible physiological mechanisms, including the role of conditioned reflexes. Studies pointing to physician attitude and behaviors that can enhance positive placebo effects, or promote negative ones, while prescribing active treatments are included with the goal that students will see that how they communicate their treatment plans can effect outcomes related to placebo mechanisms.
8. From Noncompliance to Self-Management
This seminar analyzes behavioral and especially social theory as it applies to patient compliance in chronic illness. It puts forward a model of negotiating treatments in ways that respect patients’ comfort level and motivation, including their personal habits, levels of anxiety in dealing with their illness, and social-family dynamics that may impede compliance. The student learns specific interview techniques to improve self-management that they practice by role play.
9. The Family of the Medically Ill Child
This seminar focuses on managing the concerns of parents and extended family of severely ill pediatric patients. Students learn specific techniques to improve communication with and caring for the family.
Students receive both didactic and hands on experience in a sleep lab. Emphasis is on recognizing, evaluating, and treating common sleep disorders, especially sleep apnea.
11. Evolution and Behavior
This seminar reviews research from sociobiology and familiarizes students with aspects of both normal and pathologic human behavior that may have evolutionary etiologies.
12. Developmental Disorders
Students are taught principles of stress management, including relaxation training and cognitive behavior approaches to problems such as anger management. They are exposed to the content of an 8-week program we use for cardiac patients at Stony Brook Medical School. Techniques for discussing referral to such programs with resistant patients are given. Issues of self-care and using such techniques to help manage students’ own stressors, especially as they are about to begin residency, are also highlighted.
14. Standardized Patients
This component of the course makes use of videotapes made of all our students after the third year while interviewing standardized patients. This is an evaluative required exercise as well as a formative teaching tool. The four patients used were:
All the cases require attention to psychosocial factors as well as evaluation of psychiatric symptoms and mental status in medical settings where they are often overlooked. Each case is discussed in separate sessions allowing detailed supervision about integrating psychiatric and medical inquiry, diagnostic formulation, treatment planning, and interview technique.
15. Managing Difficult Patients
Students are taught about common Axis II diagnoses that provoke characteristic difficulties in the doctor/patient relationship. They discuss cases from their clinical experience and receive supervision. Emphasis is placed on developing awareness of their own negative reactions and techniques to manage these feelings in order to competently care for these patients.
16. Affective Disorders in Medical Settings
Throughout the course, depression and anxiety come up in many seminars. This one focuses on the fact that patients rarely spontaneously describe emotional distress and psychiatric symptoms but rather focus on physical complaints. Further, these physical complaints often have multiple etiologies including nonpsychiatric ones, and it is these that tend to get worked up and treated.
We identify several factors in both the doctor and the patient that contribute to the problem and how to manage them. Included in these are:
Students are asked to reflect on how this combination of physician and patient resistances engenders a don’t ask/don’t tell process that inhibits patients from describing important psychological and emotional symptoms and teaches them that emotional and psychological problems are not relevant to medical health care. If, in fact, doctors routinely asked about these issues in most medical encounters, patients would have a changed expectation and be more likely to discuss these emotional concerns. We therefore make it a goal for students to include a brief psycho-social screening in all initial evaluations and during the ongoing care of all their patients. By establishing a baseline component of psycho-social assessment in all patients, it becomes much more likely that severe conditions, such as major depression, will also be evaluated rather than overlooked.
We also discuss common psychopharmacological mistakes made by general physicians, including inadequate dosing of antidepressants for depressed patients, and inappropriate use of PRN benzodiazepines for patients with panic disorder and other chronic anxiety disorders who require regular dosing of anxiolytic medications.
This is the final seminar and serves as a wrap-up as well as introducing new information. We begin with a discussion about how patients’ anxiety and defense mechanisms often, if not usually, prohibit full integration of very frightening medical news, especially when first presented. We read the opening scene from the play Wit (10), in which a professor is being told for the first time she has stage 4 ovarian cancer, and a research protocol is discussed in lieu of standard treatment. During the scene, we hear the patient’s thoughts and discover that while she is nodding and agreeing verbally to the recommendations and indicating she understands, her mind is in fact wandering as she engages in intellectualization while she fantasizes about doing her own research on cancer, for example. She signs an informed consent without having attended to important details of her decision as a result. This leads to technical considerations for the student in anticipating and managing this common phenomenon, as well as a lively conversation about informed consent.
Additionally, research about psychoneuroimmunology is presented with emphasis on possible mechanisms through which attending to patient’s emotional needs may have a salutary effect on the disease process. Clinical examples of both group and individual psychotherapy with cancer patients are also given with emphasis on the psychological benefits cancer patients can derive regardless of having an effect on the cancer prognosis.
Students fill out computer based evaluation forms for all courses at Stony Brook Medical School. We use a 5-point scale system in which students are asked if they agree that components of the course were of high standard. The question deemed most relevant as a survey of student response to Psychiatry in Medicine for this article was, “I believe the course will be beneficial to my career as a physician.” For the 442 respondents over the 5 year period studied 201 students (45%) “strongly agreed”; 176 students (40%) “agreed”; 46 students (10%) were “neutral”; 10 students (2%) “disagreed”; and 9 students (2%) “strongly disagreed.”
We compared this with the same question asked after the third-year clerkship in psychiatry. Of the 552 respondents over the same 5 years, 169 students (31%) “strongly agreed”; 235 students (43%) “agreed”; 88 students (16%) were “neutral”; 38 students (7%) “disagreed”; and 22 students (4%) “strongly disagreed.” Thus, 85% of students agreed or strongly agreed that psychiatry in medicine would benefit their career as compared to 74% for the third-year psychiatry clerkship. Four percent of students disagreed or strongly disagreed that psychiatry in medicine would benefit their careers compared to 11% for the third-year psychiatry clerkship.
Students are also free to write comments about any aspect of the course. In general these have been extremely positive and express an enthusiasm and respect for the relevance of the material, a belief that it was well placed in the fourth year, and a belief that their practice habits would be changed by the course. Criticisms included wanting the material earlier in their training and a desire for hands-on opportunities.
Faculty involved in the course have been unanimously enthusiastic and feel that the tremendous effort required to give repeated iterations of the course have been well worthwhile, especially in terms of student responsiveness in the seminars.
The very high degree of student satisfaction with psychiatry in medicine indicates that our basic assumptions about the relevance of the material and the timing of the course were correct. Having spent the third year seeing all kinds of patients during their clerkships, fourth-year students are quite aware of many of the issues in the course but have not received clinical training as to how to manage these problems. For example, they welcome learning about how to talk to patients about psychiatric issues and treatments in ways that reduce resistance and in fact are generally accepted and appreciated by patients. They are fascinated to learn about the pathophysiologic mechanisms by which stress, depression and other psycho-social states can promote medical illness and that treating these conditions can improve medical as well as psychiatric outcomes. They say that they will use this knowledge in the future care of their patients.
Despite the fact that it has been long recognized that much of the material in this course should be routinely included in medical school curriculum and that academic psychiatry should reexamine what it chooses to teach (3), as far as we know, Psychiatry in Medicine is the first such course to be required in the clinical years in any U.S. medical school. Whereas some of the basic science and theory is presented in preclinical courses at Stony Brook and most schools, the information needs to be grounded in clinical care and specific techniques must be taught so students can learn how to integrate the knowledge and apply it. If we look at the decades long concern that depression is underdiagnosed and undertreated in medical settings, for instance, where do we believe the problem exists? We certainly teach students quite a bit about depression in typical second-year psychiatry basic science courses and again in the third-year clerkships, yet students, and physicians also, often do not bring this information to their patients in medical settings. This is because we have not taught them how to manage the very real impediments that get in the way. These impediments include the tendency to separate medical and psychiatric problems and selectively attend to the medical ones when patients are in medical rather than psychiatric settings, our society’s general aversion to talking about mental health reflected in both patient and physician behavior, and time demands on physicians. Students must be taught not only that they should overcome these impediments, and why they should, but also how to do so, in an efficient manner, as part of their clinical training.
Given the importance of the material to patient care, we believe that courses like psychiatry in medicine should be required in all U.S. medical schools. This might necessitate some redistribution of overall clinical teaching time so that less time is spent on severe psychopathology, such as seen on inpatient psychiatry units, given the competing demands for time in the overall curriculum. A debate on this matter would be a valuable undertaking as psychiatry examines how it can best meet the educational needs of medical students.
We believe that the fourth year has significant advantages as the time to present this course in the fourth-year curriculum. First, students have the clinical experience to appreciate the importance of the content of the course and to be trained about how to deal with the content in clinical settings. In addition, the fourth year typically has some time for newly required courses without having to subtract that time from another clinical course. Finally, the fourth year provides an opportunity to integrate clinical and basic science knowledge and move toward preparing future physicians to be comprehensive and inclusive in patient care. Integrating psychiatry and medicine is an example of this process.
Future work should investigate whether students actually utilize the lessons learned in the course in their patient care, as residents and beyond. It is also important to recognize that just because much of the content of psychiatry in medicine addresses deficits in standard treatment, we must seek to offer similar training to residents as well as practicing physicians in our academic medical centers.