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BOUNDARY ISSUES FOR THE MEDICAL STUDENT

EDUCATION DIRECTOR

 Carl Greiner, M.D., Chair

University of Nebraska College of Medicine

Omaha, Nebraska 

Brenda Roman, M.D.

Wright State University School of Medicine

Dayton, Ohio 

Steve Wengel, M.D.

University of Nebraska College of Medicine

Omaha, Nebraska

 Medical student education encompasses a broad range of interpersonal boundaries, including academic, social, emotional, and sexual.  Several significant tensions can occur in almost all teaching environments.  Almost all schools have had negative experiences between lonely teachers and students.  A perspective from empathy and ethics can provide increased astuteness in alerting to potential boundary violations.  We will discuss:

 Ø      Appropriate role modeling and healthy connections with students

Ø      Grading in an honest and reflective manner

Ø      Respectful regard toward students’ future

 Dr. Brenda Roman will consider sexual/emotional boundaries in the teaching setting. 

Dr. Steve Wengel will discuss grading concerns. 

Dr. Carl Greiner will review the role of empathy and ethics and consider the distinctions between mentoring and recruiting. 

Questions will be encouraged.

PSYCHIATRY IN A GENERALIST CURRICULUM

 Philip Freeman, M.D., Chair

Boston University School of Medicine

Boston, Massachusetts

Psychiatry in a Continuity 3^rd Year Generalist Curriculum

James K. Boehnlein, M.D.

Oregon Health Sciences University

Portland, Oregon

Objectives:   At the end of this presentation participants should be able to:

1)                 Describe the rationale for including psychiatry content in a third-year generalist continuity curriculum.

2)                 Identify specific psychiatry content that should be included in such a curriculum, such as assessment and management of violence, alcohol abuse, and the acting out, personality disordered patient.

3)                 Describe the process of multidisciplinary committee recruitment and content development in such a curriculum.

 Abstract:  Over the past year at the Oregon Health Sciences University, the third year medical student curriculum has been revised to include a longitudinal introduction to specialty topics relevant to generalist practice.  All third year students meet together for a two-day period at the beginning of each 6-week clerkship block.  Over the course of the year the students are exposed sequentially to topics that have universal relevance to generalist practice, such as dermatology, otolaryngology, chronic pain and rehabilitation, palliative and long-term care, and mental health.  To develop the mental health block, a multidisciplinary committee was formed that included psychiatry and primary care faculty, and senior medical students. 

This presentation initially will describe the process and politics of how this committee was formed at the medical school level.  The process of how the specific mental health topics were developed will also be presented, including the rationale for focusing upon violence (PTSD, domestic violence, violence in the office setting), alcohol abuse, and personality disorders that are difficult to manage in the primary care setting.   The structure and format for each topic (didactic, small group discussion, panel) also will be presented.

Ample time will be available for audience input and discussion that includes their own experiences in curriculum reform.

Integrating Child Psychiatry Into the Core Psychiatry Clerkship:  A Spectrum of Approaches

Tamara L. Gay, M.D.

University of Michigan

Ann Arbor, Michigan

 E. Cabrina Campbell, M.D.

University of Pennsylvania

Philadelphia, Pennsylvania 

The ADMSEP internet listserve was instrumental in providing information from our members about the various ways in which child psychiatry is being integrated into required clerkships.  Elaboration of the three basic models elicited will be discussed. 

1)                 “The primary site model” in which students spend most of their time on a child/adolescent service, 

2)                 “The split rotation model” in which students divide their time between an adult service and a child/adolescent service, and

             3)                 “The outpatient exposure model” in which students spend one or two half-day sessions per                            week in the child/adolescent clinic.

The ADMSEP listserve dialog was key in the development of a new clerkship site, at the University of Michigan child/adolescent inpatient unit.  A full-needs assessment was conducted, and program planning with the appropriate child psychiatry faculty was initiated.  In October 1999, our site became operational, and by June 2000 we anticipate 14 students will have rotated at this site (2 students/4-week clerkship).

 Audience participation will be encouraged to compare and contrast the advantages of the different clerkship models as well as to contribute to the discussion about the implementation of a new clerkship site.

 A Continuum of Community-Based Outpatient

Clerkship Experiences

 Robert M. Goisman, M.D.

Harvard Medical School

Massachusetts Mental Health Center

Boston, Massachusetts

Kenneth S. Thompson, M.D.

University of Pittsburgh School of Medicine

Western Psychiatric Institute and Clinic

Pittsburgh, Pennsylvania

Educational Goals and Objectives:

By the conclusion of this talk, participants will be able to:

             1)                 Discuss strategies for developing and maintaining student interest in community psychiatry;

2)                 Discuss similarities and differences between outpatient-based clerkships and those based on inpatient services; and

3)                 Describe the impact of greater and lesser degrees of geographical and administrative distance from a medical center upon the clerkship experience.

 Abstract:

While a shift towards ambulatory care characterizes the provision of all medical services, medical student education continues to center upon tertiary medical center-based inpatient training.  Even among students interested in primary care community practice, few are made aware of community psychiatry.  Some psychiatry departments have developed programs to engage students in community psychiatry and teach them how to deliver care in settings which resemble the community settings in which they are likely to work.  We describe such programs in two medical schools.

 To engage students in community psychiatry at the University of Pittsburgh, there has been a focus on working through local chapters of the American Medical Student Association, the Student National Medical Association, and the local Psychiatric Interest Group.  This effort consists of psychiatric faculty liaison to these organizations, providing educational opportunities and support to student-organized volunteer activities with homeless persons and in distressed communities.

An additional strategy used at Pitt has been to connect community psychiatric training with other community medicine training efforts.  These include offering community psychiatric “tracts” within summer interdisciplinary service learning clerkships and with the “Area of Concentration Program,” a unique program for students to engage in a multiyear, reflective service learning curriculum; completion allows students to graduate with a certificate of distinction.

The Massachusetts Mental Health Center (MMHC) is jointly administered by the Commonwealth of Massachusetts and by Harvard Medical School.  After its inpatient service was privatized and transferred to a general hospital, students were assigned to its 60-bed Day Hospital (DH) Service as one option during their four-week clerkship.  On the DH, with a typical patient length of stay of three months, students are assigned to one of three teams, where they interact with patients and co-lead or observe groups in three psychosocial rehabilitation “tracks”:  Life Skills, Dialectical Behavior Therapy, and Dual Diagnosis, each of which uses manualized psychosocial interventions to complement other treatment modalities.  Students report satisfying experiences with their groups, gain appreciation of the role of non-physical colleagues in mental health care, and find the experience to exemplify the “biopsychosocial” approach emphasized in their pre-clinical education.

Questions raised include:

How can student organizations help develop interest in community psychiatry? 

How can community medicine experiences incorporate community psychiatry? 

How comparable are community psychiatric placements to traditional inpatient settings in their teaching of basic clerkship skills, e.g., differential diagnosis, basic clinical psychopharmacology, basic psychosocial therapeutics, disposition finding, suicide and violence assessment, and substance abuse assessment? 

How can faculty be supported in these roles and the work be disseminated?

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