Editor - Jon Polan, M. D.
ADMSEP Newsletter page
This is my final President's Column. Tom Mackenzie will become ADMSEP President at our meeting at Whistler. I have enjoyed representing ADMSEP at meetings with other psychiatric education organizations, and feel quite glad that as economic and work force pressures have continued to impose constraints on academic structures and functions, the collaborative bonds forged over the last years among ADMSEP, AAP, AADPRT and the APA have remained. At recent meetings of the Council on Education, work force issues were a topic of serious concern. I was impressed by the respectful discussion among the participants. The finger pointing of former times was absent. ADMSEP was not treated as the "dullard relation" who did not appreciate the enormity of the problem. As you know this collaboration was fostered by the initiative of the APA Office of Education and the Council on Medical Education and Career Development. Jim Shore's tenure as Council Chairman ends in May, 1997, and Jay Scully has resigned as Deputy Medical Director of the APA and the head of the Office of Education to become Chairman of Psychiatry at the University of South Carolina at Columbia. Happily, Jay Scully will assume the Chair of the Council on Education and Jim Shore is chairing the search committee for the head of the Office of Education. I am hopeful that there will be a swift transition to insure continuity of policy about education within the APA. In early January, as part of a chapter review, I was reminded of the Guidelines for a Medical Student Curriculum in Psychiatry and Behavioral Science published by the APA Committee on Medical Student Education in 1994. When I reviewed the Committee's recommendations, I was astonished to see how many topics related to psychological, social, and cultural models of behavior, especially as it influences the doctor-patient relationship, have been incorporated into the Introduction to Clinical Medicine course at SUNY Buffalo, which is coordinated by the Department of Family Medicine. While I experienced a glimmer of satisfaction that psychiatry's traditional emphases have been adopted by others, I felt a large jolt. The biopsychological model had been hijacked. I do hope that as medicine and medical education shift, and goals are reinterpreted, ADMSEP members continue to discuss the teaching mission of psychiatry. While I have no wish for psychiatry to be a lone, self-congratulatory voice proclaiming "loving-kindness" toward patients, I do wish to avoid being pigeonholed into a narrow "specialist's slot" in which our proper focus on the neurobiology of behavior and psychiatric illness is accompanied by our abandoning the long humanistic tradition of psychiatry which has benefited ourselves, our patients, and our students.
In these lean and bottom-line-minded times, we medical student educators need to stick together. One of the things I value most about ADMSEP is the opportunity to get together each year, share, compare notes, and brainstorm about how to make things better. While some of us keep in touch throughout the year, we lose the immediate access to all of our membership that we enjoy at our annual meeting. It was with the thought of finding a way to continue the collegiality of our annual meeting, that I conceived of creating a listserve on the internet. Tom Mackenzie, our president-elect, has been very enthusiastic and supportive of the idea. Tom and I presented the idea to the ADMSEP Council, which gave us the green light to give a listserve a shot. Listserves are software that enable a group of people with common interests to communicate directly with everyone in the group simultaneously through the internet. Communication is free and instantaneous. Dartmouth College allows its faculty to use the software for educational or research purposes. According to our last Directory we have 126 members and 48 have included e-mail addresses. I suspect that within the next couple of years most of us will have access to e-mail. People who have e-mail addresses in the Directory have been added to the listserve. If you haven't received a "welcome message" from the ADMSEP Bulletin (the name of our listserve), please send me an e-mail with your address and I will add you to the list. For the time being, we are limiting subscription to the listserve to ADMSEP members while we get our feet wet. Possible uses for the ADMSEP Bulletin include:
Please feel free to contact me with your ideas and suggestions as we begin this
Mark.H.Reed@Dartmouth.edu phone: (603) 650-1488 fax: (603) 650-1839
The following four articles present a selection of innovative methods of teaching psychiatry to medical students. Each one advances a successful model for grappling with the major issues confronting psychiatric educators today: defining our role in the new primary care-based curricula, applying the powerful new information technologies to teaching, and the parential battle against the stigma of mental illness. Three are updates of work presented at last June's meeting; one will be presented more fully this June - HJP.
At the ADMSEP Conference last June in Santa Fe, New Mexico, I had the pleasure of presenting my work on a project entitled "Integrating Basic Sciences and Clinical Perspectives: A Computer Learning Program Using Case Studies." The goals of the project were to increase interdisciplinary teaching and learning, and to bring basic science learned in the first two years into the clinical work of the third and fourth years. We chose to use the computer as the medium, and people's lives as the content. Three patients consented to being videotaped discussing their illness and to having their medical records used for this project. Faculty from relevant basic science and clinical disciplines were asked to provide information that would be useful to general practitioners; more than thirty well-known faculty members representing twelve departments made contributions. We then gathered relevant multimedia materials: pathology and histology slides, the videotapes of the patients, graphs, and pictures. After obtaining approval from the Human Subjects Committee, we entered our materials on-line using the software package "Short Rounds," created at Stanford University especially for MD's. Technical support from the Interactive Learning Center at the UCSF Library and its coordinator, Gail Persily, became essential to the project at this stage. The first case is a 37 year old woman with chronic pelvic pain. The content ranges from pathology slides of all possible causes of pelvic pain to doctor/patient relationship concerns. It discusses the neuroanatomy of chronic pain as well as concurrent depression and psychiatric treatment options. Since the patient's brother had committed suicide, there is also a section on the neurobiology of suicide and treatment options for survivors of suicide. Audiovisuals include a videotape of the patient's exploratory laparoscopy and the adhesions that were found. This was the case I showed at the ADMSEP conference last year. It is now required for obstetrics clerkship students. Case 2, a 12 year old boy with cystic fibrosis, comes complete with exciting new research findings about the CFTR gene and microbiology, physiology and biochemistry of CF, as well as new pharmacologic treatments that are shown to prolong the life span of these patients. Psychiatrists have provided information on how to work with children with chronic illnesses at different developmental stages. This case is required in the pediatrics clerkship. Case 3 is a 47 year old, highly successful woman with rapid cycling bipolar disorder and hypothyroidism. We include information on hormonal changes and mood disorders at menarche, pregnancy and menopause, as well as the role of hypothyroidism in depression and its treatment. Also included are new research on the genetics of BAD, as well as a superb psychodynamic formulation of the case. This case will be required in the psychiatry clerkship starting this June. The patient has also agreed to come discuss it with the students during every six-week rotation. During the two years it took to gather, edit, and enter most of this information, our funding came from two UCSF Instructional Improvement Project grants. This year, we are moving the bipolar disorder case on the World Wide Web, which will add greatly to the flexibility of the program and make it available to students at their home work stations; a UC system wide Instructional Technology Development Grant through the UCSF Library is providing the funding for this important enhancement. Throughout the project we have been able to work within a very small budget because much of the work has been completed pro bono: The many hours of faculty time were all contributed; Stanford donated the Short Rounds software; and the UCSF Library's Interactive Learning Center provided host computer space and generous technical support. Our primary expenses, therefore, have been stipends for research assistants and now, as we move onto the Web, for professional programming. Those of you interested in pursuing this new area will find many people working on computers who are delighted to try their hand at educational projects for little remuneration. The challenges we have encountered in using computers for learning are not surprising: The software doesn't do everything it advertises; most good projects take more computer memory than most everyday computers have; and putting projects on computer takes longer than anyone ever anticipates. In addition, each software environment has its own advantages and restrictions. The tapes and slides that Short Rounds handles well do not present well on the World Wide Web; the Web, on the other hand, allows students to browse more freely and to move quickly between related topics. It is easier to update a case on a computer than to reprint a textbook. Students, however, want good reasons for tackling the small print on a small computer screen in preference to reading a textbook. Programs on computer need to be interactive, lively, fun, visually well organized, limited in length, and flexible enough to give some choice in how to use them. We are keeping these requirements in mind as we adapt the bipolar disorder case for the World Wide Web. The superb contributions from faculty of the basic science and clinical departments that challenge us to view these cases from a number of perspectives have been among the most exciting elements of this project. It has also been enlightening to see how the multimedia capacity of computers can be used to illustrate the latest advances in medical research and care. This has been a fascinating project, and a great learning experience for a computer novice like myself. Computers in medical education is an idea whose time has come. I would encourage everyone to answer, "Yes, me!"
As a medical student, I was surprised that in four years of intensive schooling there never was discussion of a topic that had affected my family so much: the stigma of mental illness. I was troubled by this educational gap; from my family's experiences negotiating the medical field with my mentally ill father, I knew physicians should be more sophisticated in their understanding of the cultural stereotypes of people with serious mental illnesses. After I entered psychiatric training, I began to develop a curriculum for first or second year medical students who, during their careers, will treat people, who have mental illnesses, in medical clinics, surgery, and emergency rooms. After eight years of teaching this curriculum to second year Harvard medical students, I received funding from the National Alliance for the Mentally Ill to develop a one-hour module on the stigma of mental illness, for distribution free to medical educators. The format of the curriculum includes a quiz, viewing of a video, followed by discussion. The quiz is a six-minute survey of knowledge and attitudes about major mental illness. The facilitator collects the quizzes and starts the video, taking note of the most frequently missed questions, with an eye to including them in the discussion. The video is 15 minutes long, professionally produced, and includes: 1) media copy including cartoons, advertising, numerous film clips from children and adult films for stereotypical portrayals; 2) an organizational framework of stereotypes so students can recognize them in the future; 3) commentary by Kay Jamison, Lori Schiller, Mike Wallace, and others about the effect of stigma on their lives; 4) a rebuttal of these stereotypes; 5) brief modeling by myself, discussing the effect that stigma had on me as a child having a father with bipolar illness; 6) a brief review of how the viewer can impact this important social problem. Discussion follows with the focus on the students' responses to the video and quiz, and their reflections on their own experiences and fears about mental illnesses. Students often note other stereotypic portrayals on TV or comments by colleagues about The Stigma... (Continued from Page 4) "crazy people." Personal or family experiences may be related. The realization of how cultural stereotypes affect attitudes and care offers a powerful perspective for the students. I am now looking for three or four collaborators who, in addition to including the curriculum in their medical schools, would be interested in working with me to collect and analyze the data from the quizzes and publish the results. Please let me know if you are interested. I look forward to presenting this curriculum at the 1997 ADMSEP annual meeting and urge you to consider it as an adjunct to your teaching. For a copy of it, write, call or fax a request to: Ken Duckworth, M.D., Massachusetts Mental Health Center, 74 Fenwood Road, Boston, MA 02115; voice mail, 617/734-3182; fax 617/734-7915.
For four years I conducted an exercise in appropriate self-disclosure by students to fellow students in the safe environment of professionally facilitated small groups, based on the premise that this would make students aware of their attitudes about substance abuse and substance abusers, and change these attitudes in a positive direction. Students were given the following instructions: Write a two-page essay on an encounter that you have had with a person in your life who is a substance abuser and who has a position in the community which carries significant responsibility and/or authority. At the end of each essay, list 3 points on the subject you would like to address in the small group. The information you provide in your essays will be considered confidential and will be for use by your small group leader(s). Your essays will not be graded. Your group leader(s) will read your essays and consider the areas you list in preparing for the class. The more open you are in writing your essays and in participation in each class, the more productive the classes will be and the better your educational experience will be. For three years this was done as part of the Behavior Science Course with very positive reviews from students and faculty facilitators. Last year it was done in the context of the Introduction to Clinical Medicine (IPM) Course and was almost canceled because three students complained to the IPM Course Director about the essays. I spoke with the entire class before a Physiology Class (everyone is present for a Physiology Class!) and received unanimous and enthusiastic support from them to proceed with the essays. Since instituting the exercise, I have noted the following trends: ¥ For three years students consistently rated the substance abuse small group as the best experience in the Behavior Science Course. ¥ Since 1993 attending psychiatrists at clerkship sites report that medical students are more patient and empathic towards substance abusers. ¥ There was a 50% increase in referrals to the Loyola peer counseling center for substance related disorders in 1993, 1994 and 1995. ¥ An increase in self-referral of Loyola physicians to me seeking out substance abuse treatment. (I always refer such cases to avoid any question of a conflict of interest.) This year the IPM Course Director would not include the essays in the curriculum. I emphasized that the essays focus on attitudes and involved students actively learning about themselves and the subject. However, he did not "want to upset the student body." I believe in an integrated curriculum and will continue to work in this direction, but his decision was a major disappointment for me and the faculty who had been facilitators of these small groups over the past four years. I have presented my experience with this exciting and effective method at two prior national and international meetings (including ADMSEP in 1996), and now in this article, in hopes that it will find a deservedly wider application and acceptance.
Like many other psychiatric departments, mine has struggled for over two decades trying to teach an acceptable "behavior science" course. By acceptable, I mean one that the students would rate highly and with which our faculty could feel comfortable. The concept of such a course became popular in medical schools after 1972, when the National Board of Medical Examiners began using the term for a portion of Part 1 of their certifying examination. Unfortunately, the term as conceptualized spans many topics, including behavioral neurology, childhood development, and psychopathology, but also ethics, nontechnical aspects of medical care, physician-patient communication, human sexuality, health care finance, and systems for delivery of medical services.1,2 While it is true that human behavior is a part of all these topics, it is equally true that in some cases the relationship is tenuous and, therefore, very few psychiatric faculty are sufficiently well versed in these different areas to adequately teach them. Even during those years when our school had a nationally recognized medical educator (Nancy C.A. Roeske) delivering the course, the students still saw the material as "soft" (as opposed to "hard" sciences they study during their first two years in the traditional medical school curriculum) and lacking cohesion. Psychiatry was, from time to time, criticized for this within the school's various academic committees. We also had faculty within the department who judged the course harshly, as we had various years in which we did not fill our residency program in the match. This is also similar to experiences of others around the country.3 Despite the poor evaluations by students, we might still be trying to "improve" our behavioral science course if the chairman of our department had not been named to chair a committee on "Humanism in Medicine" for the school. This committee came to the conclusion that our curriculum lacked linear progression, that we tried as a school to place too many humanistic issues into too little curricular time, and that it took too long for our incoming students to be exposed to patient care situations. One of the recommendations was to develop a new course in the freshman year that would include everything that had been taught previously in our behavioral science course, as well as the content of a history-taking course previously taught in the sophomore year, and trips to the "field" for structured observation and interviews of people in clinics, preschools, and retirement homes. The course was to be hosted within general internal medicine, rather than psychiatry. This move was in keeping with the trend to develop more primary-care-oriented curricula within medical schools. The new course was to include teachers from all of the primary care departments (pediatrics and family medicine, as well as general internal medicine), but each primary care teacher was to be paired with a psychiatric co-teacher. The new course was also to serve as the lead-in to another yearlong course for the sophomores, Introduction to Clinical Medicine, which would be redesigned to accommodate a more linear approach to learning about organs and organ systems. There has been much national controversy regarding such a move, including articles both pro and con in our own ADMSEP newsletter.4 Concerns have ranged from loss of power and prestige by psychiatric departments, to fears that students would once again be inadequately prepared for the behavioral science section of Step 1 of the United States Medical Licensing Examination (USMLE). On the other hand, it has been pointed out that this type of course may account for a significant portion of the negative image some medical students have of psychiatry, and that psychiatrists have no special calling to teach everything about humanistic medicine. Our school appointed a committee which included representation from all of the primary care departments noted above, and psychiatry. The committee chair asked for the syllabus from our department's behavioral science course, Introduction to Human Behavior (IHB) as a starting point for planning. She also asked for a "wish list" of all the things our department had wanted to teach in IHB, but had been unable to include, or felt compelled to drop with the advent of new knowledge areas, given the limitations of our one semester time frame. The committee then built the new course from this foundation. The entire process took a year (academic year 1992-93), the final year IHB was taught on our main medical campus. The new course was then piloted on the main campus during 1993-94, with the expectation that our eight satellite medical education centers would take what we learned this first year into account as they prepared their own versions of the new course for the following academic year. The new freshman course was named Introduction to Clinical Medicine 1(ICM-1), and the sophomore course to which it was to linked was renamed ICM-2. Both courses would have the same course director. The school's Office for Student and Curricular Affairs sends out a questionnaire to all students at the end of each course. It contains twenty-seven positively worded questions, such as: Were the course objectives clear; Were those objectives met; Was the text well written; Did the course stimulate your interest in the subject matter; and so forth. Those are rated on a 5 point Likert scale, with 5 being "strongly agree" and 1 being "strongly disagree." The final year of IHB (1992-93) the mean score for all questions was 3.74, which was our best average ever. The first year for ICM-1 (1993-94) the mean score was 3.99 (4 = "agree"). In June of 1995, our first group of students who had been through the new course on the main campus took Step 1 of the USMLE. These students scored 208 on the behavioral science questions, which was higher by 3 points than the national average of 205. Comparing the scores on this section for the students who had been exposed to the new course with the cohort of students at the same campus in the preceding four years who took our IHB course, the students who took ICM-1 did better as a group (208 in 1995 versus an average of 201 for the previous four years). However, the national scores on this section went up 6 points above the average from 1991-1994, as well, so this is not a significant improvement. The students taking ICM-1 also scored 5 points higher than their classmates from the satellite medical education centers, who had received a more traditional behavioral science course. Again, however, the students on the main campus have averaged 4 points higher than the satellite campus students over the prior four years. It can certainly be said that there was no decrement in Step 1 behavioral science scores. In subjective evaluations by the faculty, both those in primary care and in psychiatry, we found pros and cons for the change to the ICM-1 format. Both groups thought that the new course was a positive addition to the freshman year and that the general format was sound. The psychiatric faculty were not convinced that the course did a good job of introducing students to concepts of normal behavior and development. Because the psychiatry co-teachers were required to attend only 5 sessions scattered throughout the year's twenty class meetings (these being the five classes devoted to life cycle stages - infancy and childhood, adolescence, young adulthood, middle age, and older adulthood) the primary care teachers asked for more involvement in the course by psychiatry. Such a request had not been my usual experience at this school up until then. Since this course was developed, several primary care faculty have asked our department for more psychiatric presence in their clinics, and a member of the psychiatry faculty has been asked to take the lead in developing a new multi-departmental junior clerkship. These new initiatives may be related to our collaboration in developing ICM-1, and the more favorable interaction that resulted. The lesson to be learned here is that a move to a primary-care based course which teaches the concepts previously encompassed in a behavioral science curriculum can be successful at teaching students about human behavior and development. It may also enhance the image of psychiatry among her sister departments and with the medical students. Our school had several advantages in being able to make this move successfully, however. First, psychiatry was very active in the design of the new course and has remained visible in its classroom instruction. Given the size of our faculty (50 full time psychiatrists and psychologists) versus the size of our school (280 medical students per class) our department alone could not have managed to staff an initiative of the scope of this new course, which is taught in small groups of six to eight students. Secondly, we are fortunate to have as the designated course director a faculty member from the general internal medicine section who valued her psychiatric education, and who wanted to retain the strengths of the IHM course while looking for improvements within the new ICM-1 framework. Thirdly, we had a basically sound, relevant behavioral science course in place, which had been designed and enhanced by many dedicated faculty members, despite years of poor evaluations. Finally, from the very beginning, we had the support of the psychiatry department chairman, who could see potential benefits to the students from such a radical change, even though it meant giving up some of "our" curricular time. I, for one, as a student advocate, would not wish to attempt such a conversion without such advantages.
1) Bolman, W.M. "The Place of Behavioral Science in Medical Education and Practice." Academic Medicine 70 (1995): 873-878.
2) Sierles, F.S. "Preface." Behavioral Science for Medical Students. Baltimore, MD: Williams & Wilkins, 1993.
3) McLaulin, J.B. and Wallick, M.M. "The Baby and the Bath Water." ADMSEP Newsletter. Spring 1996.
4) Hassenfeld, I. and Manly, M.R.S. "Debate." ADMSEP Newsletter. Spring 1994.
In the past, the director of medical student education (DMSE) and residency training director (RTD) may have had limited contact with each other. As priorities for education change, there are at least four resources issues that would benefit by a closer working relationship. These thoughts are based on a lengthy tenure as a DMSE and a newer position as RTD. 1) The diminishment of financial resources will require more creative and resourceful responses to didactic and curricular demands. Cuts in Medicare funding for residency education can be considered an issue of "when" rather than "if." HCFA funding provides a general floating for the educational boat; as we face diminishments, general support for residencies may fall on the departmental budget. Specific attention to funds for medical student education does not seem to be on the political screen. A realistic appreciation of the requirements of medical student, residency, and fellowship teaching can be a sobering experience. Although DMSEs have been generally less involved in funding discussions, it will be incumbent upon the medical student educator to become a reader on financial issues and political directions to make sense of what are likely areas for cuts. The RTD could be a helpful resource on funding issues. 2) Faculty are finding greater demands for clinical productivity, which places a higher premium on garnering didactic and supervisory time. Even dedicated teaching members on the full-time faculty are facing increasing pressure to meet a financial target. Some institutions are blessed with a volunteer faculty that provides substantial teaching and supervision for their appointments. Volunteer faculty are finding significant financial stresses in both the managed care and private sectors. Except for unusual university circumstances, it would be difficult for the volunteer faculty to make significant replacement for full-time faculty teaching. It would be an important survey for ADMSEP to determine what recent changes have occurred in volunteer faculty support, if any. A newer term of "educational efficiency" has been gaining ground. The mix of faculty instruction, computer-aided instruction, videotape, and other media is being reconsidered. Improved resident involvement in medical student education can be an exciting endeavor. If the department has a firm commitment that teaching is an opportunity, there may be minimal difficulty in gaining resident participation. A program that allows for small group teaching and didactics for more senior residents has been successfully done at our institution. "How to Teach" programs can be offered with a clear focus on how to be a successful teacher. The residents' wish to teach coupled with faculty supervision and mentoring can be an engaging experience for medical students. We have formally included teaching as an expectation for incoming residents. We are developing questions regarding teaching expectations as part of our interview process for new residents. 3) Opportunities for students and residents to see outpatients can place the RTD and DMSE in conflict. This issue may have the greatest variability among programs. If the program has extensive connections with state hospitals or community health agencies, there may be little concern. Programs that have the majority of patients through managed care contracts may experience greater difficulty in providing adequate patient experiences for residents. Faculty may find the outpatient time particularly geared for revenue generation. Finding a role for students can become more of a challenge. Close discussion about meeting both RRC requirements for residents and LCME requirements for students can become burdensome. Regularly scheduled meetings between the DMSE, RTD, and fellowship directors can lead to a thoughtful (and challenging) reviewing of needs. At minimum, the chairman will have the opportunity to appreciate the range of educational requirements within the department. 4) A concerning prospect is the "cannibalization" of resources within the educational division. For example, a powerful fellowship may attempt to garner resources out of proportion to its role in the department. There are encouraging notes for the DMSE. Medical school deans clearly see their constituency as the medical students. The size, role, and distribution of residencies are under reevaluation. Preserving and promoting medical student education will tend to capture the ear of the dean. There has been a beginning "shift in power" between directors of medical student education and residency training directors. DSME need to be forceful in securing resources for the educational endeavor. Residency... (Continued from Page 6) We appear to be past the unfortunate period of finding culprits for "decreased recruitment." Developing a sense of the legitimate tasks of DMSE and RTD can be helpful. The AADPRT and ADMSEP liaisons can help build bridges in responding to our joint educational needs. It is my estimation that we both face striking economic forces and that our best approach is to find responses that can allow us to work together in providing a stimulating education for the next generation of primary care physicians and more limited group of psychiatric residents.
Book Review: "Messages From the Interior: A Psychiatrist's Life"
by Walter Turke, M.D., L.F.A.P.A. - Vantage Press, 1996
Walter Turke has given us an account of his extraordinarily eventful life, from his impoverished Brooklyn childhood, to his visit to Nazi Germany on the eve of World War II, to his education in Iowa, to his service as a psychiatrist in the Navy, to his extensive travels to remote locations worldwide, to his varied career (as a private practitioner in Hollywood, a state hospital psychiatrist, a community psychiatrist, an academic psychiatrist), and finally to his bout with cancer. Throughout the book Walter shares with his readers fascinating vignettes of his patients. I was repeatedly impressed by the candor, unflinching honesty, and unfailing humor with which he writes about himself, his family, his many friends and acquaintances, and his patients. Walter approached life with the unbridled enthusiasm, undiminished curiosity, and wide-eyed wonder of the young boy he once was. I am unable to detect one drop of cynicism in the entire book. Walter and I are contemporaries. So I especially resonated with his work as a change agent in a state hospital during the era of community psychiatry. I also appreciate and admire the account of the individual psychotherapy he conducted over eight years with a severely ill man with schizophrenia. Walter's dedication to and patience with this patient are truly remarkable and undoubtedly kept him alive and helped him to trust and improve his life despite a debilitating illness. I regret that young psychiatrists will not have an opportunity to do this kind of work in this, the era of managed care. It is easy to see why Walter gets regular teaching awards from his students at Michigan State. You will be able to read "Messages from the Interior" in one or two sittings. I highly recommend it. It's a trip!
Otto Thaler's career spanned fifty years of psychiatry at the University of Rochester. A psychoanalyst and student of George Engel and John Romano, he was a constant advocate for each person's uniqueness and worth. The basis of his method was kindness and attentiveness to an individual's experience that went beyond a specific theory or medical discipline. To many of his students, who honored him with teaching awards, he personified the essential qualities of being a physician. ADMSEP members vividly recall his passionately eloquent advocacy for behavioral science as the core of psychiatric education during a scintillating debate at our 1992 meeting.
During Fred Hine's long career at Duke University, he was known as a man of extraordinary good cheer and good will. As Duke's Director of Inpatient Psychiatry, he increased the number of beds sixfold; as head of the psychiatry department's medical education program, he helped establish a new curriculum at Duke in the 1960s in which psychiatry played a major role. His leadership as a psychiatric educator was evidenced by his presidency of ADMSEP and authorship of three books on behavioral science and the treatment of mental illness. Duke students and house staff honored him with teaching awards.
Chase Kimball enjoyed a distinguished career as a pioneer of consultation/liaison psychiatry at Yale University and the University of Chicago. His research demonstrating that the preoperative mental status examination predicted postoperative outcome was a model of how psychiatric knowledge could enhance the care of all medical patients. He was an innovative educator, advocating cross-cultural experiences for medical students, such as rotations on Native American reservations, before this idea came into vogue. His leadership within ADMSEP is well-known to many of our members, in his capacities as program chair of a number of memorable meetings, and as president. We will miss the friendship and guidance of these three esteemed colleagues and offer our heartfelt condolences to their families. (Appreciation is expressed to the University of Rochester and Dr. H. K. H. Brodie of Duke University, for eulogies of Drs. Thaler and Hine, respectively, from which parts of the above were paraphrased, and to Dr. Fred Sierles for information on the career of Dr. Kimball. - HJP)
Many of us experience disappointment when we encounter medical students in their fourth year on other services, or as house-officers in medicine and surgery, who seem not to know much psychiatry. And yet these same students, who seemed so knowledgeable by the end of their third-year psychiatry clerkship, perform very well on the psychiatry portion of step II of the USMLE for which they sit toward the end of their fourth year. The phenomenon of state-dependent learning (SDL) may account for students' apparent loss of working psychiatric knowledge after they leave the clerkship.
HISTORY OF SDL RESEARCH
SDL was first described by a pharmacologist in 1937 when he observed that dogs who had learned a task after curare had been administered were not able to access the learned behavior in the non-drug state. Since then SDL has excited considerable interest in the field of drug research. It has been found that a variety of changing stimuli and conditions affect the recall of learned material. These include:
(1) all centrally acting agents, e.g. alcohol, benzodiazepines, stimulants, nicotine (SDL may help explain the phenomenon of "alcohol blackouts." Memory for "blackouts" can often be retrieved in a subsequent alcoholic state.);
(2) changing environmental cues, e.g. light conditions (Monkeys in lighted conditions have poor recall of skills they learned under conditions of total darkness.);
(3) changes in affective state, e.g. depression, mania (It is difficult for patients to remember events and how they felt in one mood, when they are in another mood.);
(4) levels of arousal, e.g. sleep deprivation (Well-rested medical interns find it difficult to access learning which they acquired during the sleep-deprived state.).
The anatomy of SDL is not well understood. It is believed that the hippocampal region, which comes on line relatively late in development, is the repository of memories for which there is a strong component of place and time. Disruption of this area by drugs or extreme anxiety may result in stored memories of context-free experiences, which cannot be readily accessed. Other areas in the limbic lobe, possibly the amygdala, are the sites of emotional memory where the quality of experiences are encoded and stored. The mechanism by which emotional and cognitive aspects of memory are dissociated probably occurs in this region of the brain. To sum up, the more that contextual stimuli resemble conditions prevailing at the time of the original memory storage, the more that retrieval is likely. Thus memories are likely to be reactivated when a person is exposed to a condition or is in a somatic state like the state that was in effect when the original memory was stored. Reactivation of past learning by contextual stimuli is relatively automatic (unconscious).
SDL APPLIED TO CLINICAL EDUCATION
Applying SDL to medical students' apparent failure to retain information an skills learned during their psychiatry clerkship, the following hypotheses are advanced: (1) SDL is operating in all clerkships, not only in psychiatry; (2) students experience poor recall in both directions; i.e. they will have equal difficulty recognizing delirium in a surgical patient, and the signs of hypofunction of the adrenal in a psychiatric patient; (3) while it is unlikely that medical students, as a whole, are in significantly different states of arousal or emotions on different clerkships, it is likely that the environments of clerkship settings differ significantly from one another. The following are, what I believe, some significant differences in the environment of the psychiatry clerkship as compared with those of medicine and surgery:
PSYCHIATRY person centered low technology egalitarian encourages expression of feeling
MEDICINE/SURGERY organ/disease centered high technology hierarchical encourages suppression of feeling
Whether or not these differences are great enough to result in SDL is a matter for research to determine. Anecdotal support is easy to find; e.g. students report that on their medicine clerkship, any interest they may have in the details of a patient's life that doesn't directly and obviously bear on the patient's disease not only goes unrewarded, but this interest is actively discouraged. PROPOSED SOLUTIONS Overcoming SDL effects may be approached in multiple ways. Research indicates that SDL can be overcome by overtraining, i.e. overtrained skills are less susceptible to SDL effects. This is not a practical alternative in the crowded curriculum that constitutes medical education. Another research finding is that identifying and adding a sufficient number of cues that were present at the time of the original learning will increase the likelihood of retrieval. Thus an approach which may be feasible and effective in overcoming SDL, and making it more likely that students will retain working knowledge that they can carry over to subsequent clerkships, would be to emphasize the medical causes of psychiatric symptoms psychiatric clerkships while doing the converse with the psychiatric disorders that mimic medical and surgical conditions on the medical and surgical clerkships (as is done to some extent by consultation/liaison psychiatrists). We can further diminish specialty specific cues by designing generic or "combined" clerkships which approach patients' problems as multiply determined (Problem-based learning in the preclinical years, at its best, takes this approach.). And, finally, we can design evaluation instruments (extended matching, multiple choice, case-based examinations and standardized, patient-based, clinical skills examinations) that cut across specialty lines (After all, this is the way actual patients present. Patients do not sort themselves by specialty.). The true test of a test item, which effectively cuts across specialty lines, is whether or not medical students can correctly identify the specialty of the faculty member who constructed it.
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