It would be nearly impossible to find a psychiatric educator to disagree with the notion that all psychiatrists in training have to learn the theory and skills needed to conduct psychotherapy. But what about medical students fulfilling their psychiatry clerkship requirement?
Since most of those third-year students will enter medical fields other than psychiatry, are there far more important knowledge and skills that these students need to master in their four- to eight-week exposure to psychiatry?
A panel of medical educators at the June meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) in Jackson Hole, Wyo., showed that there are different views on the issue among the people who design and oversee these psychiatry clerkships.
Scott Waterman, M.D., believes clerkships are an inappropriate venue in which to instruct future physicians in psychotherapy.
G. Scott Waterman, M.D., is among those who believe that teaching psychotherapy to medical students is largely a waste of valuable time, considering the amount of material that has to be crammed into a few weeks of a psychiatry clerkship. Waterman, an associate professor of psychiatry at the University of Vermont, suggested that if psychiatry clerkship directors asked themselves several questions, the conclusion about whether to teach psychotherapy would become clear.
First, he asked, "How can we best use the limited time clerkships offer for teaching our ever-growing discipline?" Is teaching psychotherapy techniques and knowledge something all physicians need to know? Will it prepare students to assimilate new data in treating and understanding psychiatric disorders?
Furthermore, during what part of the training and education sequence is it logical to teach psychotherapy? Should it come this early in training, when students have had minimal exposure to actual patients?
He indicated that the answers point to clerkships’ being an inappropriate venue in which to instruct future physicians in psychotherapy, particularly since psychotherapy is a "longitudinal treatment, and clerkships are cross-sectional," Waterman said. He noted as well that medical students are rarely receptive to a treatment or theory that lacks a readily evident scientific basis, as is the case with psychodynamic psychotherapy, he said. Trying to cram a psychotherapy teaching module into a short clerkship may have the unintended consequence of reinforcing misunderstandings about it.
Waterman urged psychiatrists who educate medical students to focus instead on teaching clinical evaluation, differential diagnosis, and differential therapeutics. The best way to at least introduce medical students to psychotherapy is to teach its history and the philosophy behind it, he said, and indicate how its principles are "widely agreed upon" by psychiatrists and mental health professionals.
Taking the opposite position on the issue, Theodore Feldmann, M.D., an associate professor of psychiatry at the University of Louisville, maintained that psychotherapy is such an "essential component" of psychiatric practice that it should indeed be a component of medical school psychiatry clerkships.
All patient encounters involve, or should involve, understanding and skills that are in the broadest sense part of the psychotherapeutic framework, he continued. Key concepts such as the unconscious, transference, and countertransference come into play in routine doctor-patient relationships.
While he acknowledged that psychiatry clerkships are far too time limited to instill a comprehensive understanding of psychotherapy, Feldmann emphasized that psychiatric educators should "infiltrate the curriculum" by explaining psychotherapeutic concepts at every opportunity. Doing so, he noted, will make them relevant to the practice of primary care and specialties other than psychiatry.
Of course, selling his idea to medical school course directors can be a challenge, he admitted.
His suggestions for spreading out the teaching of psychotherapy—curriculum content he has helped implement at his institution—included, in the first medical school year, teaching basic interviewing skills, how to conduct a brief mental status exam, and basic counseling and crisis-intervention techniques.
In year two, Feldmann advised teaching theories of personality development, more complex interviewing skills, how transference and countertransference enter the doctor-patient relationship, and theories and techniques of psychotherapy.
Third-year psychiatry clerkships can further expose medical students to psychotherapy by teaching elements of a psychiatric diagnostic formulation, providing supervised psychotherapy experience, having students write up a patient assessment, and writing a paper on psychotherapy. The clerkship at Louisville also provides a computerized cognitive-behavioral therapy experience, which was developed by a faculty member there, he said.
Janis Cutler, M.D., associate professor and co-director of medical student education in psychiatry at Columbia University, agreed that teaching psychodynamic psychotherapy should be done and is in fact quite doable.
During Columbia’s psychiatry clerkships, faculty demonstrate this type of psychotherapy and teach major concepts such as the unconscious, transference, and countertransference, which, she said, are "vital to understanding the powerful relationship between doctor and patient."
"The best way to bring those concepts to life is to demonstrate them in a clinical application of psychodynamic psychotherapy," Cutler said.
Students attend three 90-minute seminars taught by a psychodynamically trained psychiatrist during which one or two patients are presented through detailed process notes and vignettes. The teacher challenges the students to respond as if they were the therapist or the therapist’s supervisor.
This is a "good compromise," Cutler noted, because students "feel as if they’re doing therapy" without actually conducting a rudimentary form of therapy with a patient.
The Columbia program has elicited "extremely positive responses" from students, she said, adding that this degree of exposure to psychotherapy "is a draw for students into the field," particularly those attracted to the idea of developing a stronger relationship with patients than other medical fields allow.
Myrl Manley, M.D., ADMSEP’s president-elect and associate professor of psychiatry at NYU Medical School, joined Waterman in giving a thumbs down—though a "qualified" one—to teaching psychotherapy in medical school clerkships.
One of Manley’s primary concerns is that there is "a danger of devaluing" psychotherapy if students come away with the idea that any type of talking they do with patients qualifies as psychotherapy. "It is an incredibly complex set of skills honed by years of experience," he stressed, and providing a few days’ worth of exposure to the modality shows students "a grotesque caricature of the real thing." In addition, the "mere presence" of medical students, he said, "distorts the process of psychotherapy."
The solution, Manley maintained, is to "teach students about psychotherapy even if we can’t teach them to do it." For example, it is important to teach clerkship students that "all psychotherapies are not the same; there are different theoretical schools that use very different interventions."
Students also need to know that "the choice of a particular psychotherapy for a particular patient is not arbitrary," but are guided by psychiatrists’ "understanding of the indications for particular modalities," he said.
Regardless of whether clerkship directors decide to teach psychotherapy to medical students, Julia Frank, M.D., who directs the psychiatry clerkship at George Washington University’s medical school, insisted that it is critical for students to learn psychodynamic concepts.
A thorough grounding in these ideas will help all physicians better understand what motivates a patient to adhere to or ignore treatment regimens and "forge an alliance" with their patients. It will also show future physicians that "what you see is not what you get." That is, that all patients’ behaviors are molded by life experiences that are "hidden from the observer, unless that observer makes an effort to learn about them," Frank said. ▪