The clerkship experience is the forge that shapes the initial clinical identity of most physicians. Medical educators view the clerkship as an opportunity to teach about major disorders and treatments, to reinforce standards of professionalism, and to recruit students into specialties. There is, of course, a more troublesome aspect to this intense education and socialization and there are many reports in the medical education literature of student struggles during the acculturation process with matters of identification, ethics, and emotional development (1–5). Although these struggles are relevant for all specialties, they are particularly pertinent for the psychiatric clerkship. Many medical students have had no contact with psychiatric patients prior to this clerkship, and have negative attitudes.
The clerkship offers an important opportunity to modify these negative attitudes. In fact, studies document that medical students have a more positive attitude about psychiatry and psychiatric patients after the clerkship (6–10). Nonetheless, reports over many years convey that some students anticipate or find the psychiatry clerkship to be stressful, and imagine that a career in psychiatry would continue to be stressful. For example, Kris (11) stated that between 1980 and 1985, 159 medical students consulted the psychiatrist author at the university health service. Eighteen (11%) developed acute anxiety or depression during psychiatry training. Youngner et al. (12) described psychological difficulties for medical students assigned to an inpatient service related to either aggressive patients, or to patients who evoked students’ own psychological issues. Medical students in Gdansk, Poland reported that prior to interviewing patients, they felt anxious or afraid of psychiatric patients, afraid of aggressive or unexpected behaviors, and were worried about their own reactions and their ability to establish rapport (8). Ney et al. (13) reported that students at three medical schools rated the stress of practicing psychiatry as important negative influences on interest in a psychiatric career. This concern does not reflect merely a negative bias toward psychiatry. Cutler et al. (14) wrote that both fourth-year medical students who considered a career in psychiatry and those who never seriously considered psychiatry careers reported equal concerns about expected stress in working with psychiatric patients. The authors advocated open discussion of stress as part of the psychiatry clerkship orientation and teaching.
Despite long-standing concerns about student stress during the psychiatry clerkship, we could find no systematic discussions of its sources. The present study reports what students described as their most problematic experiences of the clerkship in psychiatry during the course of an academic year.
Educators concerned about student responses to the acculturation process of the clerkship year have searched for ways to turn discourse from the overarching question, “what is happening to your patient?” to another important question, “what is happening to you?” Several years ago, the psychiatry clerkship director formalized this question into a weekly teaching conference for all third-year students rotating through a 6-week psychiatry clerkship. Students spend their times on two 3-week clinical assignments: acute inpatient services, consultation/liaison service, or the Psychiatric Emergency Service. Students who are not assigned to the Psychiatry Emergency Service spend one half day a week in an outpatient clinic. There is not a specific order to the rotations, and there are students in each of the services in the first half of the clerkship and in the second half of the clerkship. Each clerk was to come prepared to discuss the worst thing that had happened in the prior week. Everything said in the conference was held to be confidential by both the director and students. The conference used the technique of the critical incident report described by Branch (1), slanted toward negative events, in the expectation that airing troubling issues would allow students to receive support and advice, and perhaps increase interest and morale. Although student participation was always brisk, and student evaluations of the conference among the highest for the clerkship, it was not possible to ascertain how much of the conference content reflected universal concerns, and how much might be influenced by students who chose to talk because they were particularly, perhaps uniquely, troubled.
Therefore, for academic year 2005–2006, we created an anonymous form for the problem patient conference that asked the student to write about a troubling encounter with a patient. The form required the student to describe the episode, the patient behavior that made it difficult, the student’s response, and how the student felt.
The student was required to submit a form the day before each conference. The director collated the responses and presented a summary to the group. Students were then invited to discuss their own cases, or to ask about a case that interested them. The case requirement changed the character of the conference by creating a universal “buy in.” Participation became more general and the conference often took on the character of a support group. As much as possible, the director maintained neutrality and encouraged group process. We will now report the themes that emerged in the conference and in students’ written reports.
The first author collected and reviewed 356 Problem Patient Encounters and identified an initial set of nine themes based upon the student descriptions of their emotional responses during the encounter. Whenever possible, the student’s own words were used to determine the categories, (e.g., “I felt frightened,” “I was frustrated”) (see Table 1
After these categories were established, the first and second authors independently reviewed approximately half of the encounters (54%) and classified each as exhibiting one of these nine themes. Of the 192 encounters classified, the two raters agreed on 153 classifications, or 80%.
Disagreements occurred most frequently for two pairs of categories. One of these pairs consisted of “Patient Behavior Evokes a Personal Response” and “Patient Undermining Behavior Evokes Student Anger or Contempt.” While these two categories differed with respect to intent of the patient behavior, both categories appeared to elicit comparable feelings (anger, contempt) in the students. The other pair involved “Identification with Patient” and “Student’s Own Issues Provoke Boundary Blurring.” The distinction in this case appeared to be largely semantic, whether the student focused on the patient’s predicament or his or her own issues. In both situations, there was a strong reaction that arose from the perceived similarity of the patient and the student. Given the difficulties that the raters had in differentiating these two pairs of categories, each pair was collapsed into a single category. The distinction between psychiatric and medical categories proved not to be useful and was discarded.
The remaining 164 encounters were then categorized. Across the total 356 encounters, 49 (14%) were classified as student intimidated/frightened, 118 (33%) as student frustrated/helpless, 89 (25%) as student experiences strong negative reaction, 77 (22%) identification/own issues evoke disturbing response, 17 (5%) student involved in staff/systems conflict, 5 (1%) ethical issues, and 1 (less than 1%) medical issue complicated treatment. Given these percentages, we focused our analyses on four categories: intimidation/frightening behaviors, frustration/helplessness feelings, negative reaction, and identification/own issues.
While the intention of the clerkship teaching schedule was to have a problem patient conference weekly during the 6-week clerkship, because of differential schedules from rotation to rotation, there was some variability with respect to precisely when and how many conferences were held during the 6-week rotation. Because we were interested in examining change from the early part of the rotation to the later part, we focused our analyses on groups that had two or more assessments, with at least one in the first half of the rotation (weeks 1 and 2) and one in the second half (weeks 4 and 5). In three of the eight clerkship rotations, a meeting in week 3 included encounters in the preceding weeks, and this was included as a first half meeting. In one group, a meeting in week 4 or 5 included encounters in week 3, and this was included as a second half meeting. Otherwise, meetings in week 3, being precisely in the middle of the rotation, were not included in the analyses.
presents the proportion of encounters in each category for male and female students for the first half and the second half of the rotation. In order to examine gender differences, we conducted a z test comparing the proportion of encounters classified in each of the four categories for males versus females, combining the first half and the second half data. There were no gender differences for any of the four categories. Next, we conducted a z test comparing the proportion of encounters in the four categories in the first half versus the second half of the rotation, combining male and female reports. This analysis showed that the proportion of encounters classified as intimidating/frightening behaviors significantly declined from the first half (18.3%) to the second half (7.6%) of the rotation (p<0.01, two-tailed). None of the other categories differed from the first to the second half of the rotation. Finally, we examined whether males or females separately differed from the first half to the second half. For female students, there was a trend for an increase in frustration responses from the first half (29%) to the second half (44%) of the rotation (p<0.10, two-tailed).
Psychiatry clerks are disturbed by some encounters with patients on a regular basis. It is of interest that these difficulties did not emerge during clinical rounds with any frequency. None of the issues that recurred in problem patient conferences appeared in student course assessments done anonymously and online, nor were they discussed during clerkship debriefing sessions. Clearly, there is more going on under the surface of the clerkship than is readily apparent and that affects students’ professional development. It is not clear why these issues are not raised. Do students feel it is not acceptable to raise them? Do they fear these issues imply the student is not capable? Do students perceive there is no time for such discussion? It would not appear to be that students consider the issues unimportant. When we created a conference devoted to their concerns, students had no trouble providing examples and valued the conference.
Before our study, we would have anticipated that a common adverse response to psychiatry was fear of patients. To our surprise, this was a fairly modest early response that often reflected inexperience with psychiatric patients. For example, a student described a decompensating patient with paranoid schizophrenia whose behavior was bizarre, “his gibberish made me fear for my life!” Rather quickly in the course of the clerkship students came to feel that patients were not dangerous, generally, and their fears dissipated. In fact, we sometimes felt that students did not respond with appropriate fear. There were several reports of students placing themselves or remaining in harm’s way. What was common to these reports was the students’ awareness of danger, critical feelings toward those who placed them in the danger situation, fear, and unwillingness or inability to leave. After the fact, the students could not explain their own behavior. Of course, the necessity of leaving an interview when feeling threatened was emphasized during the orientation to psychiatry. We need to teach this principle more effectively.
Feeling frustrated was the most frequently described problem patient encounter, and among women, frustration tended to increase during the course of the clerkship. Students felt frustrated by the difficulties inherent in interviewing patients with thought disorders, and by patients’ lack of insight or adherence to treatment. Sometimes they felt frustrated because they were overwhelmed. For example, a student described a manic patient who wrested control of the interview. He then proceeded to propose marriage and demanded to leave so that he could locate a suitable marital abode.
Situations that evoked strong emotional reactions or students’ own issues produced some of the most vigorous discussions about the process of socialization as a physician. Student identification with patients often caused distress. For example, a student described a patient of similar age and background after a suicide attempt, “I kept thinking how much he was like me, yet how different his life had become.” Clerks found that their identification with the medical team was incomplete, and they occasionally experienced the medical situation from the patient’s point of view. A student described an elderly retired professor who was now delusional with dangerous behavior. He reminded the student of his own former professor. The student was uncomfortable institutionalizing him against his will.
Sometimes a student’s response forced some introspection about social stigma and intolerance toward mental illness. A student described an emergency room evaluation of a man with suicidal ideation precipitated by job stress. “I could not empathize with him. I [had done this job] for a summer and survived. That was what I kept thinking. I felt very guilty for feeling that way, but I felt very irritated at this person who should not want to commit suicide.”
A couple of other themes occurred less frequently, but are worthy of note. Students are vulnerable to patient disapproval and criticism, even when this is psychotic in origin. A student reported an interview of a patient with delusional disorder who became agitated and suspicious. “The interview made me feel inadequate in my interviewing skills … I could not help but feel the patient was trying to cause me to feel in the wrong. The way he ‘answered’ my questions with more questions made me feel really diminished (whatever confidence I had left of me as a mere medical student was taken away).” Because psychiatric symptoms are often enacted in the context of an interpersonal interaction, it is often difficult for clerks to retain clinical distance when they are rebuffed or rejected. They probably require more support in these matters than they routinely receive.
Four women reported sexual touching by male patients, and four women reported sexually provocative language. In all cases, women students were unsure about how much “the patient role” should influence student response and discussion ranged from ignoring the episode to responding with ordinary outrage. Men were uncertain whether it was more respectful to “protect” the women, or let them handle the situation.
It is probable that most of the tensions and stresses reported by students are latent or expressed in muted fashion during other clerkships. Perhaps the greater intimacy of patient relationships, tolerance of intense affect, and absence of instruments and procedures that provide “technical protection,” are factors that ramp up the perceived stress in psychiatry as compared to other specialties. The format of asking students to write about problem patients was a useful way of getting at the issues that were of concern to them, and once the topics were elicited, discussion proceeded easily.
Student response to the problem patient conference was overwhelmingly positive and course evaluation comments emphasized the usefulness of examining their emotional responses to patients, and its application to all areas of medicine. Perhaps the most telling endorsement of the conference was that third-year student representatives to The Clinical Years Committee requested that the conference be extended to other clerkships. This suggestion was greeted with interest and hopefully will be expanded in future years.
While the literature about the third year of medical school indicates that the process of learning clinical medicine is stressful, there is the suggestion that the psychiatry clerkship is viewed by students as particularly stressful, and this perception may discourage students from choosing psychiatry as a specialty. This study reports six types of encounters that students found stressful during their psychiatry clerkship. Their concerns were reviewed and discussed during a weekly conference that they found useful during the clerkship and for their medical education in general. The content of student stress did not emerge in detailed course assessment or in debriefing meetings. This suggests that candid responses from students about the stress points of psychiatry require time and respectful listening. In our experience, students do not expect that faculty can eliminate stressors, but they do look for empathic acknowledgment of the struggles inherent in gaining clinical competence.
The authors thank Anne Banas, M.D., for translation.