Academic Psychiatry 25:193-200, December 2001
© 2001 Academic Psychiatry
The "ER" Seminar
Teaching Psychotherapeutic Techniques to Medical Students
Dennis P. McNeilly, Psy.D. and
Steven P. Wengel, M.D.
Dr. McNeilly and Dr. Wengel are at the University of Nebraska Department of Psychiatry. Address correspondence to Dr. McNeilly, Department of Psychiatry, 985580 Nebraska Medical Center, Omaha, NE 68198–5580. E-mail: dmcneill{at}unmc.edu
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ABSTRACT
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The challenge of teaching good communication skills and psychotherapy to medical students was addressed through development of a clerkship seminar that stressed the practical application of psychotherapeutic techniques to the difficult and/or psychiatric patient. Clinical vignettes from television programs such as "ER" were used to illustrate encounters with extremely emotional or personality-disordered patients. Students also examined the dynamic meaning of these encounters, their own countertransference, and their ability to tolerate emotional interchanges with such patients. In addition, the vignettes were used to examine and apply Buckman's model for breaking bad news to patients who have undergone a significant loss. Seventy-two third-year medical students participated and completed pre- and post-seminar questionnaires to assess their knowledge and attitudes toward psychotherapeutic techniques. Students significantly improved in knowledge of countertransference, boundary setting, and how to break bad news. Attitudes toward breaking bad news and recognizing strong countertransference also improved. Some differences in post-seminar knowledge and attitudes were found between male and female students.
Key Words: Medical Students • Media • Emergency Room
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INTRODUCTION
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Early medical student education often fosters the acquisition of facts. Students learn to distill each subject into a simple set of statements about what the subject is, how it works, and the indications and contraindications for referrals (1). When medical students reach their clinical years, however, they will also need a different type of communication skills. Often a medical student's clerkship experience with psychiatric patients involves exposure to patients' strong emotions and the student's own strong emotional reactions to them. Good communication, particularly with "difficult patients," requires interviewing skills (2). It also requires that students recognize, experience, tolerate, and use the strong emotional reactions that they normally repress (3).
The "ER" seminar was undertaken to help third-year medical students during their psychiatry clerkship improve their communication skills with patients. It introduced students to skills often needed for work with psychotherapy patients, such as how to handle patient resistance and recognize poor patient boundaries, how to break bad news to patients, and how to recognize countertransference with patients. These psychotherapeutic techniques were presented in a clerkship seminar that used clinical vignettes from popular television programs such as "ER." These television portrayals of the doctor–patient relationship were often familiar to the medical students. The portrayals also provided the clerkship director a very popular means by which to present a topic often considered irrelevant to the practice of medicine by students.
Reports on the use of movies to teach psychiatry have described depictions in films of mental illness and psychiatry (4–6), psychiatrists (7–11), specific mental disorders, psychopathology, and suicide (12–15). A psychoanalytic approach to the interpretation of films has also been suggested (16). Full-length feature films (17–19) and film segments as teaching tools in psychiatric medical student education have been used to illustrate personality disorders (20), the stigmatization of psychiatry patients, psychiatric symptomatology, interpersonal dynamics, and psychotherapy (21,22). It has been suggested that the major advantage to the use of movies in psychiatric education is that medical students find them more lively and interesting than individually produced illustrations of clinical data. Films often offer realistic and dramatic depictions of character styles, psychopathology, and interpersonal dynamics (21). Although we found numerous reports of the use of films to teach psychiatry, we could not find previously published examinations of popular television programs used to instruct medical students in communication skills.
We anticipated distinct advantages from the use of television clinical vignettes for clerkship directors and students. For psychiatry clerkship directors, videotaped segments of television programs are readily available and easy to update. Because the "ER" television show is well known to most medical students, we hypothesized that the use of this method would have two results. First, it would enhance students' learning as it reduced their resistance to learning about psychotherapeutic techniques; such resistance might arise from either perceived irrelevance to their future medical practice or a nebulous understanding of the concepts themselves. Second, we anticipated that students would continue to apply and reinforce the psychotherapeutic principles introduced in the "ER" seminar as they watched future episodes of the program.
The "ER" seminar, "Psychotherapeutic Techniques I & II," took place during the second week of a six-week third-year medical student clerkship in psychiatry. As one of twelve lecture topics, it was the only didactic treatment of psychotherapy in the four-year psychiatry medical student curriculum. The primary psychiatry course occurs during week two of a six-week Neurology/ Ophthalmology/ Psychiatry course in the second-year curriculum. Introductions of behavioral medicine topics are incorporated into a first-year course entitled "Integrated Clinical Experience" that the Department of Family Medicine facilitates.
Recent articles have described the significant decline in enrollment in psychiatric residencies. An anti-psychiatry bias, based on a suspected lack of scientific rigor in psychiatry, has also been observed among nonpsychiatric members of the teaching staff, peers, and house staff. At the same time, students' post-clerkship attitudes (23) have been found to be the strongest predictor of eventual specialization in psychiatry. In light of these two trends, the authors of the "ER" seminar believed it would help reinforce the idea that communication skills are as important to good medical practice as clinical acumen (24) and would foster positive student attitudes towards psychiatry.
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METHODS
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Subjects for this study were 75 third-year University of Nebraska medical students (39 males and 36 females) in the UNMC 1999–2000 psychiatry clerkship. Data on the subjects' age and past educational background were not available for this study. As a part of the clerkship, student subjects participated in two 90-minute seminars, "Psychotherapeutic Techniques I and II" (outlined in Appendix 1). A clinical psychologist led the seminars, which covered one of the 12 didactic topics included in the 6-week clerkship. The study was exempt from Institutional Review Board approval because it met all necessary qualifications for an educational instructional exemption.
The first part of the seminar introduced students to a psychotherapeutic treatment of patient symptomatology. Students were provided a brief overview of psychodynamic, behavioral, and humanistic-existential theories and were reminded of the DSM-IV diagnostic criteria for personality disorders. Students were asked to discuss "difficult" patients who did not readily accept the usual definitions of the treatment relationship (25) or who showed intractability and a disproportionate use of medical services ((26,27). As an aid to discussion, students were shown videotaped clinical vignette segments of emotionally charged patient–physician interactions selected from hospital television drama series such as "ER."
The videotaped sequences chosen for the seminar consistently portrayed patients with certain personality disorders. Five video selections used in the first part of the seminar portrayed patients symptomatic of histrionic, antisocial, borderline, and narcissistic personality disorders. All subjects viewed the same five segments. A facilitator led the students in a discussion of how to communicate with the "difficult patients" portrayed. Students were asked to examine and apply the importance of good communication skills, proper patient boundaries, and personal countertransference to patients considered "difficult." This discussion also provided students the opportunity to examine their own emotional reactions to patients, which type of patients they found personally difficult, and what communication and interpersonal skills they needed to enhance.
The second part of the seminar introduced students to Buckman's six-step protocol for breaking bad news to patients who have recently undergone a significant loss (28). Students were asked to apply Buckman's six-step model to six video portrayals of physicians breaking bad news to patients. The six video segments from hospital television dramas included portrayals of a medically complicated and terminal geriatric patient, a young female patient with breast and ovarian cancer, a young adult male recently diagnosed as HIV-positive, a cancer patient with obsessive-compulsive traits, and grieving relatives of recently deceased patients. These depictions of doctor–patient interactions were selected for their strong emotional portrayal of loss, intensity, and human tragedy. All students in the study viewed the same six video selections.
A primary goal of the seminar and a focus for the student's discussion was to facilitate their application of psychotherapeutic techniques to patients whom they found "difficult" or who might meet DSM-IV criteria for a personality disorder. As students viewed the videotaped portrayals of doctor–patient interactions, they were asked to place themselves in each of the "ER" scenarios. Students were asked to consider their own countertransference, their use of boundaries, and how they would break bad news to the patients portrayed in the video selections. They were also encouraged to specify, verbatim, what they would say to the patient in the videotaped scenario rather than give a theoretical response.
A pre-seminar questionnaire was administered to each rotation group of students during their orientation session to the psychiatry clerkship. The seven-item questionnaire (Appendix 2) assessed students' prior attitudes and knowledge of countertransference, patient boundaries, and how to break bad news to a patient, and their pre-clerkship attitudes toward psychotherapy skills. Tabulation of the four knowledge-based questions was based on the students' total number of correct responses. Tabulation of the three attitude questions was based on the students' responses to a 7-point Likert-type scale with response choices that ranged from "strongly disagree" (coded as 1) to "neither agree nor disagree" (coded as 4) to "strongly agree" (coded as 7). The same questionnaire was administered to each group of students at the conclusion of their psychiatry clerkship. Post-seminar responses were tabulated for the full 73-student group and for the students by gender. Student responses to the pre- and post-seminar questionnaire were tabulated and recorded by trained staff.
Student responses from the pre-seminar and post-seminar questionnaires were recorded, matched, and analyzed. Seventy-five third-year medical students rotated through the UNMC Department of Psychiatry clerkship from July 1999 to May 2000. Three of these students who did not complete the pre-seminar questionnaire were excluded from the study. Thus, a total of 72 students were included in the final study analysis.
Between-group and within-group comparisons for the full group and gender subgroups were made of the students' paired pre-seminar and post-seminar responses to the seven survey questions. Frequencies, means, and percentages were computed and compared for the categorical variables. Paired-samples t-test analyses were used for pre-seminar and post-seminar between-group comparisons analyzing the responses of the full group and the gender subgroups.
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RESULTS
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Table 1 depicts students' responses to the knowledge-based questions included in the pre- and-post-seminar questionnaire. Comparison of the full group's knowledge of countertransference, patient boundary importance, establishment of patient boundaries, and how to break bad news showed the students' knowledge significantly improved from pre-seminar to post-seminar.
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TABLE 1. Student responses to knowledge questions on pre-seminar and post-seminar questionnaire: full student group and gender subgroups
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Gender subgroup comparisons found both male and female students improved in post-seminar knowledge of countertransference and the steps to break bad news. Female students showed a significant improvement in their knowledge of countertransference, the three things to do establish patient boundaries, and the six steps involved when breaking bad news. However, no significant pre- and post-seminar difference was found in female students' knowledge of the importance of setting boundaries or in male students' knowledge of what to do when establishing boundaries with difficult patients (see Table 1).
Table 2 presents the students' responses to the attitude questions included in the pre-and-post-seminar questionnaire. In the full student group, an overwhelming majority reported improved attitudes toward a plan to break bad news and what to do when they experience strong countertransference. No significant difference was found, however, between the full student group's reported attitudes toward psychotherapy skills as "important to all medical students to learn, no matter what area of medicine they eventually decide to pursue."
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TABLE 2. Student responses to attitude questions on pre- and post-seminar questionnaire: full student group and gender subgroups
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Gender subgroup comparisons of reported pre- and post-seminar attitudes revealed significant pre/post differences for both male and female students in their reported "plan to break bad news" and "what to do when I have strong countertransference." However, a significant difference was found among male students, but not among female students, in their post-seminar attitudes toward the importance of psychotherapy skills. Female students' attitudes toward the importance of psychotherapy skills for all medical students remained unchanged following the seminar (see Table 2).
Finally, although this was not specifically assessed by the quantitative questions included on the pre-and-post-seminar questionnaire, the vast majority of students expressed very positive personal reactions and enthusiasm for their experience in the "ER" seminar. As observed by the seminar director during the seminar discussions, students in all of the clerkship rotations appeared engaged and energized in the discussions and appreciative of a creative attempt to present clinical material through a familiar medium. Most students reported that they benefited from this teaching exercise; however, because the questionnaires were not anonymous the possibility should be noted that they may have done so in order not to offend a faculty member.
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DISCUSSION
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Our primary objective was to develop a psychiatry clerkship seminar that helped third-year medical students improve their communication skills with patients. It introduced students to skills often used during psychotherapy, such as handling patient resistance, recognizing poor patient boundaries, breaking bad news to patients, and recognizing countertransference with patients. We invited students to apply those skills to videotaped segments of doctor–patient interactions and clinical vignettes taken from popular television programs such as "ER." We found that students responded very positively to the opportunity to discuss psychotherapeutic communication skills and apply them to clinically relevant portrayals of patients and physicians who exhibited extremes of emotion.
An analysis of students' responses to pre- and post-seminar questionnaires found a significant improvement in students' post-seminar level of knowledge about countertransference, the importance of setting patient boundaries, how to establish boundaries, and the steps involved in breaking bad news. Such a finding of improved student knowledge would be more important if the students' knowledge were also shown to be durable. It might therefore be helpful for us to reassess this same group of students at a later point in their medical school education.
One surprising set of results was a finding of no improvement in female students' knowledge of the importance of setting patient boundaries, and no improvement in male students' knowledge of what steps to take when establishing patient boundaries. This lack of improvement in both males and females may have been due to inadequate pedagogy, the way the subject matter was presented, possible differences in prior training of the male and female students, and/or differences in learning style. This is an area in which further research would be important and potentially revelatory for medical students' curriculum and pedagogy, and one that will require further examination by the "ER" seminar directors.
Another surprising finding was that 93% of students endorsed the value of psychotherapy in both the pre- and post-seminar questionnaire. This lack of change may have reflected an acquiescence response set and the medical students' attempt to provide an expected response to the questionnaire. Although most students reported positive attitudes toward knowledge of psychotherapy skills, they may have provided the "appropriate" response rather a reflection of their true feelings or behaviors. Students may also have been uncertain of what "psychotherapy skills" actually are. Thus, before we can attribute true attitudinal change, further validation of this question that includes a more readily operationalized definition of "psychotherapy skills" may be necessary. Future research initiatives by the present authors will also seek to compare these attitudinal measures with direct observation of student–patient interactions in clinical settings or with standardized patients.
This report on an "ER" seminar highlights an educational method in which the instruction and application of psychotherapeutic principles and dynamics to medical students can be a positively received educational experience during the clerkship year. The medical students' post-seminar results show an improvement of their knowledge and attitudes after the "ER" seminar experience. The results may also highlight the need for further study of how the educational needs of male and female medical students may differ, particularly when it comes to instruction concerning the appropriate use of boundary-setting with difficult patients.
The primary limitations to our findings are the small number of subjects (N=72) and the absence of age and educational background demographics due to a change in university computer databases. The students' skills or knowledge in a live format were not measured; such measurement could be the next step in formalizing the assessment of the value of the seminar. Thus, the results of this study may need to be more broadly tested before they can be regarded as generalizable. Further validity analysis of the three attitude questions posed to the medical students in the pre- and post-seminar questionnaires may suggest an acquiescence response set, and this would require more examination of these questions.
Another limitation on the ability to replicate and generalize from the study is the nonstandardization of the videotaped vignettes. The results may have been affected by students' familiarity with the clips, which gave them more than one opportunity to think about and process them. On the other hand, repeated use of video clips allows incremental education on new topics, which is good for learner continuity. In this instance, however, copyright restrictions prohibit further reproduction of the videotapes for purposes of attempting to replicate the study.
The "ER" seminar provides clerkship directors another possible medium through which to meet the challenge of teaching psychotherapy to medical students. The practical application of method with material in this seminar was positively received by medical students who might otherwise physically or mentally absent themselves from a topic often considered irrelevant to the practice of medicine. Familiar hospital television portrayals of the doctor–patient relationship also provided students the potential for ongoing learning and reinforcement of their learning. One can hope that these students will never again be able to watch one of their favorite television programs without examining and applying the communication skills and psychotherapeutic techniques they learned in the "ER" seminar.
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ACKNOWLEDGMENTS
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The authors thank Ms. Shelly Montgomery for her invaluable assistance throughout this study. This paper was previously presented at the 26th Annual Association of Directors of Medical Student Education in Psychiatry Meeting, Santa Fe, NM, June 15–18, 2000.
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ABSTRACT
INTRODUCTION
