Treating and Evaluating Trainees
To the Editor: I read the entire issue of Academic Psychiatry (Volume 32, Issue 1, 2008) devoted to the care of our “peers” (i.e., medical students, residents, and colleagues) with great interest. In the issue, Kavan et al. (1) argue against the Liaison Committee on Medical Education (LCME) provision MS-27A (“The health professionals who provide psychiatric/psychological counseling or other sensitive health services to medical students must have no involvement in the academic evaluation or promotion of the students receiving those services”). They (1) suggest that medical students may not get optimal medical care due to this provision. Being frequently involved in the dual relationship of treating and evaluating medical students and some nonpsychiatry residents, I agree with their argument. It is always easy to take the high road approach and suggest all possible conflicts of interest. I am not saying that these conflicts do not exist and/or are not important. I am questioning their relative value in many situations. As argued on the principle of nonmaleficence (1), it may be better to treat someone in a situation with a potential conflict of interest (treating versus evaluating) than to leave her or him without help. Kavan et al. (1) suggest that medical students who matriculate to medical schools in rural areas often have few, if any, alternatives to faculty experts. True, but as I illustrate below, the situation is similar even at one large medical school located in a large metropolitan area.
I would like to use this letter to discuss further the complexity of taking care of our peers. I believe that there are additional deficiencies to be considered before drawing any conclusions about the LCME recommendations.
Some of these deficiencies are:
1. Lack of organizational structure and resources. Our medical school and our university lack organized centralized psychiatric/psychological services for students. There are some not-so-centralized and not well-organized services available. Medical student advisers refer students mostly to faculty members. The main university campus has a psychologist-staffed clinic without psychiatry staffing. This situation is probably similar to many medical schools and universities. It seems that we need to study this on a national level to help us in the discussion with LCME.
2. Lack of adequate insurance coverage. I have seen many students with inadequate insurance coverage, especially in the area of psychotherapy. We need to find out whether all medical schools provide solid mental health insurance coverage for students, including psychotherapy.
3. Lack of availability of psychiatric care in general. The general shortage of psychiatrists seems to be even more palpable when our advisers try to get help for medical students. Thus, they frequently end up approaching our faculty members—the easiest available resource.
4. Lack of experience and common sense. I remember two cases where the lack of experience and/or common sense among the medical school administration staff was an issue. In the first case, after a suspected (but denied) suicidal attempt by a medical student “the school” (i.e., staff) wanted to put this student on 6-month leave with outpatient treatment. I successfully argued that the leave would be counterproductive and that outpatient treatment would suffice. In another case, I attended the medical student Promotion and Tenure Committee on behalf of one of my student patients, and I argued unsuccessfully against measures taken against this student. I was quite surprised that the membership of the medical student Promotion and Tenure Committee did not include a single psychiatrist. I wish that psychiatrist participation in this committee would become the rule rather than the exception everywhere.
5. Lack of available psychotherapists. In my experience, an even bigger difficulty than finding a psychiatrist has been the difficulty finding psychotherapists willing to see students for long-term psychotherapy.
6. Lack of education about mental illness, availability of help, and danger of self-treatment. I have seen positive results of screening for depression among medical students within the frame of mental health week and similar events. Nevertheless, some students either do not know what to do when they score high on a depression scale or just shrug their shoulders and think that they “will handle it.” I was amazed to find that almost one-sixth of Michigan psychiatrists (!) admitted that they treated themselves for depression in the past, and that almost 43% would consider self-medicating if afflicted with mild or moderate depression (2).
In view of all these issues, I suggest that we support the second argument of Kavan and colleagues (1) in which they suggest that students may benefit from access to psychiatric faculty who may potentially or even definitely be involved in their evaluation and promotion. Unless our society can provide easily accessible and affordable independent multispecialty clinics for medical and other students and residents staffed by experts in the field, students should be allowed to be treated by the faculty. So far, the LCME MS-27A has been just another unfunded mandate, so frequently and easily imposed by federal and other agencies.
We should initiate a substantial dialogue with the LCME regarding health services for trainees, and “offer wisdom” (1). However, we also need to provide data supportive of our suggestions, recommendations, and wisdom. Maybe one of the academic professional organizations could initiate a survey to gather information on what services are available to our trainees around the country. Such data would help us to argue for more realistic provision or even funding.
Recommendations for improving the care of our peers should include provisions for centralized independent psychiatric and psychological services for trainees; adequate insurance coverage for trainees, including psychotherapy coverage; psychiatrist membership in medical student promotion and tenure committees; better training for counseling staff; and improved mental health education.