Acad Psychiatry 32:460-462, November-December 2008
doi: 10.1176/appi.ap.32.6.460
© 2008 Academic Psychiatry
The Teaching of Psychiatry to Non-Psychiatrists: The Patient as a Person
Philip R. Muskin, M.D.
Received August 10, 2007; revised February 5, 2008; accepted February 13, 2008. Dr. Muskin is Professor of Clinical Psychiatry at Columbia University College of Physicians and Surgeons in New York, and Chief of Consultation-Liaison Psychiatry at Columbia University Medical Center in New York. He is also on the faculty at Columbia University Psychoanalytic Center for Training and Research. Address correspondence to Philip R. Muskin, M.D., 622 W. 168th St., Mailbox #427, New York, NY 10032; prm1{at}columbia.edu (e-mail).
Psychiatry, as a major medical discipline, is an integral part of the education of all physicians. Many patients have psychiatric disorders that affect their lives, regardless of whether they present in the psychiatric or medical setting for treatment. All patients expect their physicians to understand them, even if they are themselves unaware of their own psychologies. "Evidence," such as it is, does not convince anyone not to teach a specialty. Some things for which there is no evidence today will have evidence in the future; likewise, evidence of which we seem sure today may not be as "true" in the future. We know there are facts about diagnosis and treatment that we need to know, but we are not always sure what those facts are. In this light, I will not present "evidence," though I will reference some of the literature that applies to what I am discussing. What I propose to do is to raise a few questions about what, how, when, and to whom we teach psychiatry.
For those of us who are psychiatric clinician/educators, it may seem obvious that we should be teaching psychiatry to nonpsychiatric physicians. As the majority of students who become physicians will not become psychiatrists, one focus of our attention should be upon medical students. Medical students learn that they must know what will be on the exam, and much of what is conducive to a pencil and paper test may not be of value beyond the examination. As there appears to be a disconnect between teaching about psychiatry and the recognition of psychiatric disorders in the primary care setting, what students are learning may be different from what we are teaching. The next group to consider is medical/surgical residents. How should we address teaching psychiatry to people dedicated to learning another specialty? Finally, there are many physicians currently in practice whom we never had a chance to teach as medical students and residents. These physicians take care of the majority of patients in the country.
There are not enough psychiatrists to provide the necessary care to all of the patients with psychiatric disorders, with and without other medical disorders. Even if we did dramatically increase the size of psychiatric residencies, there still would not be enough psychiatrists in all areas. Reports from the Agency for Healthcare Research and Quality (AHRQ) indicate that as many as 24% of admissions to community hospitals are for patients with a mental health or substance abuse diagnosis (1, 2). A substantial proportion of outpatient medical visits are for mental health reasons alone, or mental and other medical reasons. There will never be an adequate number of providers to take care of all of the patients in need of mental health services. Psychologists cannot replace psychiatrists, no matter what various states decide to legislate. Like it or not, we have to teach psychiatry to nonpsychiatrists if we want patients to receive the care they deserve. In this issue, Einat and George (3) investigate how the attitudes of Doctor of Pharmacy students toward psychiatry and psychiatric patients can be positively changed via education. Rural pharmacists may fill a gap in providing care in areas without psychiatrists. Their study addresses the perception that psychiatry lacks an evidence base and provides data on the biological basis of mental illness. It suggests that attitudes about the stigma of mental illness and the willingness to provide pharmacological treatment to psychiatric patients can be improved with an active learning environment.
Here’s the rub: physicians who do not become psychiatrists are not all that interested in psychiatry. There is nothing defamatory about this statement (I hope) as it seems obvious to me. Physicians who become psychiatrists are not all that interested in surgery and internal medicine. Not uninterested, just not all that interested. If they were, they would have chosen another specialty. We want to know that which interests us. Beyond that knowledge, we want to know what we think we will need to know, even if it is not all that interesting to us. It seems to me that educators have to remind themselves that students may not share their interest in the topic. The challenge becomes what to teach, how to teach it, and how to vary both of those variables depending upon who the audience is at the time. Leigh’s article in this issue (4) illustrates this challenge quite well. There appears to be a difference of opinion between psychiatry and primary care training directors regarding the adequacy of psychiatry training. In a survey of 1,544 U.S. primary care and psychiatry program directors, 85% of psychiatry training directors felt that psychiatry training in their primary care programs was minimal to suboptimal compared to the 64% of family practice training directors who felt the psychiatry training was optimal to extensive. The majority (89%) of psychiatry training directors were dissatisfied with the training while 46% of primary care training directors were satisfied (a significant difference at p<0.001). They concluded that better communication between the training directors would lead to "optimal curriculum development."
Should we be teaching human development, theories of psychopathology, psychiatric diagnosis, and treatment of psychiatric disorders to all medical students? The answer is a qualified yes. The qualification is to what extent this knowledge is going to be useful to the practicing physician. It is helpful but not necessary to have a grasp on how we change throughout childhood, and how life events influence us. The various theories of both development and psychopathology are important for psychiatrists, but do not really aid other physicians. What may be more useful is to try to educate medical students about how to recognize factors that make it difficult for people to cope with illness and maintain wellness, and result in patient-physician interactions that are stressful and unproductive (5). This is not a matter of diagnosing a personality disorder, or an axis I disorder. It reflects perceiving the question: who is the person who is this patient? Theories of how the person came to be as he or she is matter little when the patient is unable to adhere to a medical regimen, or behaves in a manner that prevents the physician from rendering treatment. What does matter is how to recognize and deal with the person in such a way as to provide the medical care needed, including recognition that as people, we have emotions and thoughts that may encumber our efforts. This is much more complex than a lecture about psychopathology. It requires an integration of material and hands-on training using simulated patients. Such education could start during medical school. Medical students spend a lot of time learning about the science of medicine. This is crucial for their foundation in understanding diagnosis, treatment, and new advances in medicine. The foundation we must teach must also include an understanding of the genetics, neurochemistry, neuroanatomy, and neural circuitry of normal and abnormal mental function. In the most recent literature, it has become clear that response to an antidepressant may have more to do with the patient’s genetics and less to do with which medication was chosen for treatment (6).
Having a foundation about patients as people, even if the students could not list the diagnostic criteria for a disorder, could prove quite useful in a medical career. A major obstacle to this approach is that it is labor intensive. Large lectures would be a small but crucial part of such education. In order for the material to have any value, students would need to learn communication skills, spend time with simulated patients, and be observed by faculty who could aid students in learning how to interact with patients effectively. This would occur before they had clinical experience, before they felt the intense pressure of limited time and unlimited responsibilities, and before they encountered the "hidden curriculum" during clerkship (7). The experiences should be sensitive to the maturation process of medical students over the 4 years (8).
Training during the first 2 years of medical school is not sufficient. As part of each student’s clinical clerkship, continued education via one-to-one and small group experiences would be required to bring the knowledge and skills learned into the real world of the emergency department, clinic, operating room, and inpatient ward. Ideally, this would be done with patients the students were involved with clinically and with both psychiatric and nonpsychiatric faculty. The students’ reactions to the patients would be part of the education, not as something to conceal, but as a vital part of how the best physicians interact with their patients. This is labor-intensive education, far more draining on faculty resources than a large lecture to the entire class. For the vast majority of the students, this would be a diversified educational experience in preparation for their residencies and their careers as physicians. Inpatient and outpatient settings would both work well.
Is this teaching psychiatry? These experiences would be with patients who have the spectrum of medical and surgical illnesses, but the focus would be on the person with the illness. Some of the patients would have a comorbid psychiatric disorder, some would have character pathology of importance, some would have psychological reactions to their illness, and some would just be patients coping with their illness. The psychiatry learned in this setting would be integrated into the students’ knowledge base, not separated off as it can be when psychiatry is taught in a block as psychiatry.
Who would do this? Few institutions have a large enough faculty to undertake this task. Thus, it is easy to brush off the idea as not practical. Let me suggest that there are resources that could be tapped for this type of education. Psychiatrists in the community who are not on the faculty might be an excellent source of teachers, psychiatric residents another. One of the additional benefits of this type of training is it would allow medical students to see psychiatrists in a different light. It would reinforce that psychiatrists are physicians, not alienists.
Ideally, this education would continue during residency training. This is no longer thought of as modern consultation-liaison psychiatry (9). Shrinking resources have limited the ability of consultation-liaison services to provide this type of education. It still exists in institutions that have liaison psychiatrists who work with medical and surgical teams. As with medical students, volunteer psychiatrists and psychiatric residents could also help solve the shortage of salaried consultation-liaison faculty.
In this issue, Hunter et al. (10) give an excellent example of how educating family practitioners about the diagnosis and treatment of patients with mental disorders does not require a classroom. E-mail consultation between mentors (mental health practitioners) and the family practice physicians provided rapid information when and where necessary. The consultations were for pharmacotherapy (53%), psychotherapy (34%), treatment review (27%), and diagnosis (24%). A survey of the participants’ revealed high satisfaction, with 88% of the family practitioners reporting an improvement in their ability to provide mental health care. Of note, the paper describes how the mentors did more than provide facts, suggesting readings as well as fostering the development of the "student."
Assuming it is not possible to set up this type of internet consultation approach, what approaches provide education for physicians already in practice? They are a tough group to reach. They are busy, they are experienced, and they need to get CME credit. Courses could be created by academic institutions for half or whole day training, not in psychiatric diagnosis, but in psychiatric aspects of medical illness. There are programs for practicing physicians that demonstrate improvement in their communication skills and better diagnosis/treatment of patients with depression (11). In the current climate, it is not likely that pharmaceutical companies would sponsor such programs; however, creative educators could submit grant applications to pharmaceutical companies to underwrite such education. Who could do this? I would suggest collaboration between the two organizations best situated to respond to this challenge: the Association for Academic Psychiatry and the Academy of Psychosomatic Medicine. Collaboration between the experts in education and the experts in working with nonpsychiatric physicians would best serve the millions of patients who expect all of their physicians to be understanding of them as people and thus provide the most effective treatment for all of what ails them.
|
REFERENCES
|
- Owens P, Meyers M, Elixhouser A, et al: Care of adults with mental illness and substance abuse disorders in U.S. community hospitals, 2004. HCUP Fact Book number 10. AHRQ Publication No. 07-0008. Agency for Healthcare Research and Quality, 2007
- Saba DK, Levit KR, Elixhauser E: Hospital Stays Related to Mental Health, 2006. Healthcare Cost and Utilization Project AHRQ 2006 Statistical Brief #62, 2008
- Einat H, George A: Positive attitude change toward psychiatry in pharmacy students following an active learning psychopharmacology course. Acad Psychiatry 2008; 32:515–517[Abstract/Free Full Text]
- Leigh H, Mallios R, Stewart S: Teaching psychiatry in primary care residencies: do training directors of primary care and psychiatry see eye to eye? Acad Psychiatry 2008; 32:504–509[Abstract/Free Full Text]
- Ciechanowski PS, Katon WJ, Russo JE, et al: The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001; 158:29–35[Abstract/Free Full Text]
- Paddock S, Laje G, Charney D, et al: Association of GRIK4 with outcome of antidepressant treatment in the STAR*D cohort. Am J Psychiatry 2007; 164:1181–1188[Abstract/Free Full Text]
- Hafferty FW: Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med 1998; 73:403–407[Medline]
- Marcus ER: Empathy, humanism, and the professionalization process of medical education. Acad Med 1999; 74:1211–1215[Medline]
- Lipsitt DR: Psychosomatic medicine: history of a "new" specialty, in Psychosomatic Medicine. Edited by Blumenfeld M and Strain J. Lippincott Williams & Wilkins, 2006, pp 3-20
- Hunter JJ, Rockman P, Gingrich N, et al: A novel network for mentoring family physicians on mental health issues using e-mail. Acad Psychiatry 2008; 32:510–514[Abstract/Free Full Text]
- Gerrity MS, Cole SA, Dietrich AJ, et al: Improving the recognition and management of depression: is there a role for physician education? J Family Practice 1999; 48:949–957
Get information about faster international access.
Privacy Policy
Copyright © 2008
Academic Psychiatry.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
REFERENCES
