ORIGINAL RLSLARCH
Teaching Doctors to Treat Doctors: Medical Student Peer Counselling Med Teach Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/15/15 For personal use only.
JOANNA H. SPIRO, MARCELLA ROENNEBURG and BETTY JOAN MALY Joanna H . Spiro, E D . D, is Assistant Professor, Department of Psychiatry, Medical College of Wisconsin, Marcella Roenneburg, M D ,is Resident, Obstetrics and Gynaecology, Memorial Hospital, Baltimore, Maryland, and Betty Joan Maly, M D , is Assistant Professor, Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Physicians' emotional problems need to be recognized a n d treated. Intervention a n d prevention in this problem area have been attempted at t h e Medical College of Wisconsin through a programme of peer counselling designed to teach student physicians how to recognize a n d treat emotional difficulties faced by their peers. D u r i n g the 18 months that the programme has been i n operation, 20 peer counsellors reported a total 1,185 hours spent in counselling their peers, lending credence to the speculation that doctors will t u r n to their peers for help if, in medical school, there is acceptance of fallibility a n d responsiveness on the part of peers. T h e emotional needs and concerns of men and women who become physicians are receiving the attention of professional organizations and those responsible for train. ing doctors. There is considerable evidence that factors such as fatigue, self-doubt. depression, disillusionment, hostility, boredom and marital problems have led to disturbingly high percentages of dcpressive illnesses, alcoholism, drug abuse, unsatisfactory marriages and suicide among physicians (Blachley et al. 1969; Modlin and Montes 1964: Scheiber 1977; Vaillant et al. 1972). Denial of problems, t h e illusion of infallihility, the privileged position for obtaining informal consultation and the temptation to treat oneself, difficulty in assuming a patient role, and the conspiracy of silence among colleagues all contribute to the lack of early identification of those who need help (Vaillant et al. 1972; Brook et al. 1967; Pearson and Strecker 1960; Murray 1974; Waring 1974). Physician peer groups have often been recomrnendcd as a solution to the problem of so-called physician impairment (Bittker 1976; Talbott et al. 1976). Prevention during medical education has also been specified, involving an efficient student mental health service (Brook et al. 1967) and curricular presentations which emphasize the problems of mcdical marriages, sclf288
medication, stress. alcoholism and conditioning against suicide as a learned behaviour. One report suggested the formation of peer support groups among students (Seigle 1977). We describe here the possibility of fostering peer relationships during medical school that are both supportive and therapeutic, in a n effort to prevent and/or create a potential form of treatment for the impaired physician.
T h e Programme Physicians need to learn that they are not infallible and that it is just as acceptable for them to need help and to seek counselling as i t is for any of their patients. I t is equally important for doctors to recognize and treat fellow doctors who present with symptoms indicative of emotional difficulties. Physicians need to be taught to turn to one another for help and how to give the help that is requested of them. To meet these needs, w e have established a peer counselling programme which trains medical students who are in their second, third, or fourth year to counsel any student who requests their help or is referred to them. T h e total amount of formal training consists of a 12-hour session on a Saturday, followed by four two-hour sessions during the succeeding weeks. Further supervision is available whenever requested. T h e first day of training is a sensitivity session designcd to help students discover how difficult discussion of thcir problems can be. Various exercises and situations are set u p by a therapist for the students to participate in and share their reactions. A t appropriate moments during this lengthy session, the students are asked to listen both to the verbal content and the 'feeling' tone of what is being said. They are also requested to listen without giving advice or providing a solution to the speaker's dilemma. Medical Teacher V o l 2 N o 6 I980
Med Teach Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/15/15 For personal use only.
This session is followed by four didactic meetings at which listening skills are emphasized, and principles of intervention are discussed. Role playing is done in which trainees are called upon to handle simulations of the most likely situations that will confront them as counsellors, such as loss of a love relationship, loneliness, fears of incompetency, failing a course, etc. Each student plays both ‘client’ and ‘therapist’ under the direction of therapists, which permits immediate feedback. These sessions also include discussions of the various referral sources available to students and information on how to handle specific situations such as suicide and crisis intervention. T h e counsellors-to-be are taught to recognize and respect their own limitations in terms of time, their own emotional conditions, and their skills. T h e trainees are cautioned to be forthright in stating when they feel that they are unable to handle a situation and to use the various referral sources. After the peer counsellors finished their training, a letter was sent to every medical student in the school, informing the students of the existence of the peer counsellors, the services they felt they were able to provide, and emphasizing that absolute confidentiality would be kept. T h e students were also told that no student had to give his or her name in order to receive counselling and that the issues for counselling did not have to be related to medical school. Lastly, the names and telephone numbers of the peer counsellors were listed along with the times that they were most likely to be reached. In a further effort to promote the concept of doctors helping doctors in times of emotional stress, every freshm a n medical student who sees the school psychologist is assigned, with his or her permission, to a peer counsellor as well, unless the nature of the problem renders such an assignment unsuitable. This freshman class would then be exposed to the concept of peer counselling from matriculation onward.
until 15 April 1978, when the data collection was completed. T h e number of hours reported by each peer counsellor was then totalled, percentages were established and problems were ranked according to average time spent.
Results During the period of data collection, peer counsellors reported a total of 1,185 hours spent counselling their peers. Although not every student at our school has utilized this service, the number of hours donated by the counsellors has been sufficient to provide every student at our school with two hours of personal counselling. An analysis of the type of counselling is shown in Table 1. Our statistics show that the problems encountered by peer counsellors vary widely and closely resemble problems identified in the literature on patterns of physician impairment (See Table 2). Peer counsellors were asked to estimate the amount of time spent on each problem, on a scale of zero to ten. This allowed us to rank the problems in a n order of importance based upon either perceived frequency of a problem and/or amount of time needed to work through a problem (see Table 3). Whether this rank indicates frequency as opposed to difficulty of handling the problem is not distinguishable. Referrals by peer counsellors number 60. These were made to the school psychologist, a psychiatry resident, or other peer counsellors. No breakdown is available. Among all current freshman who are receiving therapy from the school psychologist, 57 students have given their permission to be in therapy with a peer counsellor as well. An important, but unanticipated, finding was that 70 per cent of the peer counsellors reported using other peer counsellors as a support system and/or being used by another counsellor as a support system. No peer counsellor complained of being over-worked. In fact, 95 per cent of the counsellors reported that they felt under utilized.
Evaluation of the Programme Method Table 1. Peer counselling and type of contact. A series of questions was designed to evaluate the peer counselling programme. We wanted to find out how extensively i t was being used by students and what types of problems were most common. Each peer counsellor was then interviewed. O u r data are based on information obtained from 20 peer counsellors, each of whom was asked to quantify the number of hours spent in various types of counselling, the number of referrals received, and the number of referrals made by them. Counsellors were also asked to rate various problems on a scale from zero to ten, 10 being the greatest amount of time spent working on a particular kind of problem. Additional inquiries were made about their workload as peer counsellors and whether or not they used each other as a support system. Data were obtained from 1 January 1977, when peer counselling services were first made available to students,
Medical Teacher V o l 2 No 6 1980
Number Type of contact
of hours
Pcrcentage of total
Formal
Appointments made to talk with a peer counsellor
670
56.0
346
29.2
Conversation and referrals in which student identifies self
157
13.3
Anonymour telephone Conversation and referrals in which student does not identify self
12
1 .o
Casual
Meeting peer counsellors in hallways, between classes, at lunch Telephone
Total
1,185
Table 2. Classification of problems handled by peer counsellors and estimated timespent (Based on 10-point scale: 0 =no time, 10 = all of the time). Major lzye crises Death of family member or close friend
Suicidal risk Dropping out of medical school Loss of a love relationship Wanted/unwanted pregnancy/abortion Loss of personal health Failing a course
1.2 1.3 2.3 4.2 1.2
2.9 4.4
Med Teach Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/15/15 For personal use only.
4.4
3.1 4.3 2.3 2.1
Problems with relationships
3 Workload 4 Self-concept 5 Failing a course, exam anxiety
6 Fear of incompetency 7 Loss of love relationship 8 Deprivation, delayed gratification, and substitute gratification 9 Sexual concerns 10 Loss of personal health 11 Leave of absence or change of program 12 Incompatibility with superiors, dropping out of medical school 13 Anxiety over health and financial problems
6.7 3.3
2.1
1.4 6.1 2.8 5.1
1.2
gratification
3.8
Other E.g., relocation during training; systems intolerance
2.0
Discussion a n d Recommendations T h e numbcr of hours and the frequency with which our peer counsellors were called upon emphasizes the need for and the utilization of such a programme. Although over half of our peer counsellors' time was spent in formal counselling, a very substantial portion was contributed by casual contacts between students and counsellors. Even though smaller percentages of time were spent in anonymous and identified telephone counselling, these are essential means of contact for some students. We believe that our estimates of total hours spent are conservative. I t is often difficult for a peer counsellor to remember all the counselling he/she has done and even more difficult, at times, to distinguish and separate the occasions when one is approached as an identified peer counsellor and when one is approached as a friend. Despite the overlap which exists, we feel that our counsellors' estimates are low. T h e extensive use of peer counsellors, as well as the number of students willing to work with both the school psychologist and a peer counsellor, demonstrates the acceptance of this programme as a n integral part of medical education. This also gives credence to our speculation that doctors will turn to peers for help if, in medical school, there is acceptance of fallibility and responsiveness on the part of peers. Psychological factors which are present in medical school but which go unrecognized have bccn identified as precursors of suicide, mental illness, malignant tumours, hypertension, and coronary occlusion (Thomas 1976).
290
1
2 Loneliness and isolation
Anxiety attacks
Exams Sexual concerns Fear of incompetency Incompatibility with superiors Financial problems Problems with relationships Workload Health Death and dying Loneliness and isolation Leave of absence or change of programme Self-concept Drugs and/or alcohol Deprivation, delayed gratification, and substitute
Table 3. Student problems ranked according to time spent by peer counsellors.
Poor self-image, damaged self-esteem and covert d e pression, anger and fear appear to contribute substantially to academic failure, poor performance during and after medical school and premature death (Thomas 1976). Given these concerns, one would expect medical educators to have established preventive programmes in medical schools. However, to our knowledge, we are the first to institute and report on a peer counselling programme for medical students designed to prevent emotional illness both during training and later professional life.
References Rittker, T.. Reaching out to the depressed physician, journal of' the American Medical Assoczat~on,1976. 236, 1713.1716. Rlachley, P. H . . Disher, W. and Roduncr. G.. Suicidc by physicidns. National Institute of Menlal Health- Bullettn of Suicidology, 1969. 1-19, Brook, M . F . . Hailstone, J . D.and McLaughlin. E. J . , Psychiatry illnrss in the medical profession, Amarican Journal of Psychuitry, 1967, 113, 1013 1023. Modlin. H. C. and Montes. A.. Narcotics addiction in physicians, Amencanjournal of Psychiatry, 1964, 121, 358.365. Murray, R , P5vchiatricillnessindoctors, Lancet, 1971. 1, 1211.1212 Pearson. M . and Strecker, F... American Journal 01 Psychiatrj, 1960, 116, 915.919. Scheiber. S . C . , Emotional problems of physicians: I . Nature and extent ofproblems. Arzzona Medicine, 1977, 3 4 , 323 325. Seigle. R., l'he Impaired Phyiczan- What Can Be Done?, Report from the OSR discussion group of the AAMC. Novrmber, 1977. .l'albott, G. D., Holderfield, H . . Shoemaker, K. and Atkinson. E.. l ' h e disabled doctors plan for Georgia, Journal o f f h e Medical Association 01 Georgia, 1976, 65, 71.76. 'l'homas. C . B . . What becomes of medical students: The dark side, T h e / o h m Hopkzns MedzcalJournal, 1976. 138, 185-195. Vaillant, G . . Sabowale, N. and McArthur. C.. Some Psychologic Vulnerabilities of physicians, New England journal of Medzczne, 1972. 287, 372.375. Waring, E. M.,Psychiatric illnesses in physicians: A review, Corn prehewiue Psychiatry, 1974, 15,319-529.
Medical Teacher V o l 2 No 6 1980
Teaching Doctors to Treat Doctors: Medical Student Peer Counselling Med Teach Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/15/15 For personal use only.
JOANNA H. SPIRO, MARCELLA ROENNEBURG and BETTY JOAN MALY Joanna H . Spiro, E D . D, is Assistant Professor, Department of Psychiatry, Medical College of Wisconsin, Marcella Roenneburg, M D ,is Resident, Obstetrics and Gynaecology, Memorial Hospital, Baltimore, Maryland, and Betty Joan Maly, M D , is Assistant Professor, Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Physicians' emotional problems need to be recognized a n d treated. Intervention a n d prevention in this problem area have been attempted at t h e Medical College of Wisconsin through a programme of peer counselling designed to teach student physicians how to recognize a n d treat emotional difficulties faced by their peers. D u r i n g the 18 months that the programme has been i n operation, 20 peer counsellors reported a total 1,185 hours spent in counselling their peers, lending credence to the speculation that doctors will t u r n to their peers for help if, in medical school, there is acceptance of fallibility a n d responsiveness on the part of peers. T h e emotional needs and concerns of men and women who become physicians are receiving the attention of professional organizations and those responsible for train. ing doctors. There is considerable evidence that factors such as fatigue, self-doubt. depression, disillusionment, hostility, boredom and marital problems have led to disturbingly high percentages of dcpressive illnesses, alcoholism, drug abuse, unsatisfactory marriages and suicide among physicians (Blachley et al. 1969; Modlin and Montes 1964: Scheiber 1977; Vaillant et al. 1972). Denial of problems, t h e illusion of infallihility, the privileged position for obtaining informal consultation and the temptation to treat oneself, difficulty in assuming a patient role, and the conspiracy of silence among colleagues all contribute to the lack of early identification of those who need help (Vaillant et al. 1972; Brook et al. 1967; Pearson and Strecker 1960; Murray 1974; Waring 1974). Physician peer groups have often been recomrnendcd as a solution to the problem of so-called physician impairment (Bittker 1976; Talbott et al. 1976). Prevention during medical education has also been specified, involving an efficient student mental health service (Brook et al. 1967) and curricular presentations which emphasize the problems of mcdical marriages, sclf288
medication, stress. alcoholism and conditioning against suicide as a learned behaviour. One report suggested the formation of peer support groups among students (Seigle 1977). We describe here the possibility of fostering peer relationships during medical school that are both supportive and therapeutic, in a n effort to prevent and/or create a potential form of treatment for the impaired physician.
T h e Programme Physicians need to learn that they are not infallible and that it is just as acceptable for them to need help and to seek counselling as i t is for any of their patients. I t is equally important for doctors to recognize and treat fellow doctors who present with symptoms indicative of emotional difficulties. Physicians need to be taught to turn to one another for help and how to give the help that is requested of them. To meet these needs, w e have established a peer counselling programme which trains medical students who are in their second, third, or fourth year to counsel any student who requests their help or is referred to them. T h e total amount of formal training consists of a 12-hour session on a Saturday, followed by four two-hour sessions during the succeeding weeks. Further supervision is available whenever requested. T h e first day of training is a sensitivity session designcd to help students discover how difficult discussion of thcir problems can be. Various exercises and situations are set u p by a therapist for the students to participate in and share their reactions. A t appropriate moments during this lengthy session, the students are asked to listen both to the verbal content and the 'feeling' tone of what is being said. They are also requested to listen without giving advice or providing a solution to the speaker's dilemma. Medical Teacher V o l 2 N o 6 I980
Med Teach Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/15/15 For personal use only.
This session is followed by four didactic meetings at which listening skills are emphasized, and principles of intervention are discussed. Role playing is done in which trainees are called upon to handle simulations of the most likely situations that will confront them as counsellors, such as loss of a love relationship, loneliness, fears of incompetency, failing a course, etc. Each student plays both ‘client’ and ‘therapist’ under the direction of therapists, which permits immediate feedback. These sessions also include discussions of the various referral sources available to students and information on how to handle specific situations such as suicide and crisis intervention. T h e counsellors-to-be are taught to recognize and respect their own limitations in terms of time, their own emotional conditions, and their skills. T h e trainees are cautioned to be forthright in stating when they feel that they are unable to handle a situation and to use the various referral sources. After the peer counsellors finished their training, a letter was sent to every medical student in the school, informing the students of the existence of the peer counsellors, the services they felt they were able to provide, and emphasizing that absolute confidentiality would be kept. T h e students were also told that no student had to give his or her name in order to receive counselling and that the issues for counselling did not have to be related to medical school. Lastly, the names and telephone numbers of the peer counsellors were listed along with the times that they were most likely to be reached. In a further effort to promote the concept of doctors helping doctors in times of emotional stress, every freshm a n medical student who sees the school psychologist is assigned, with his or her permission, to a peer counsellor as well, unless the nature of the problem renders such an assignment unsuitable. This freshman class would then be exposed to the concept of peer counselling from matriculation onward.
until 15 April 1978, when the data collection was completed. T h e number of hours reported by each peer counsellor was then totalled, percentages were established and problems were ranked according to average time spent.
Results During the period of data collection, peer counsellors reported a total of 1,185 hours spent counselling their peers. Although not every student at our school has utilized this service, the number of hours donated by the counsellors has been sufficient to provide every student at our school with two hours of personal counselling. An analysis of the type of counselling is shown in Table 1. Our statistics show that the problems encountered by peer counsellors vary widely and closely resemble problems identified in the literature on patterns of physician impairment (See Table 2). Peer counsellors were asked to estimate the amount of time spent on each problem, on a scale of zero to ten. This allowed us to rank the problems in a n order of importance based upon either perceived frequency of a problem and/or amount of time needed to work through a problem (see Table 3). Whether this rank indicates frequency as opposed to difficulty of handling the problem is not distinguishable. Referrals by peer counsellors number 60. These were made to the school psychologist, a psychiatry resident, or other peer counsellors. No breakdown is available. Among all current freshman who are receiving therapy from the school psychologist, 57 students have given their permission to be in therapy with a peer counsellor as well. An important, but unanticipated, finding was that 70 per cent of the peer counsellors reported using other peer counsellors as a support system and/or being used by another counsellor as a support system. No peer counsellor complained of being over-worked. In fact, 95 per cent of the counsellors reported that they felt under utilized.
Evaluation of the Programme Method Table 1. Peer counselling and type of contact. A series of questions was designed to evaluate the peer counselling programme. We wanted to find out how extensively i t was being used by students and what types of problems were most common. Each peer counsellor was then interviewed. O u r data are based on information obtained from 20 peer counsellors, each of whom was asked to quantify the number of hours spent in various types of counselling, the number of referrals received, and the number of referrals made by them. Counsellors were also asked to rate various problems on a scale from zero to ten, 10 being the greatest amount of time spent working on a particular kind of problem. Additional inquiries were made about their workload as peer counsellors and whether or not they used each other as a support system. Data were obtained from 1 January 1977, when peer counselling services were first made available to students,
Medical Teacher V o l 2 No 6 1980
Number Type of contact
of hours
Pcrcentage of total
Formal
Appointments made to talk with a peer counsellor
670
56.0
346
29.2
Conversation and referrals in which student identifies self
157
13.3
Anonymour telephone Conversation and referrals in which student does not identify self
12
1 .o
Casual
Meeting peer counsellors in hallways, between classes, at lunch Telephone
Total
1,185
Table 2. Classification of problems handled by peer counsellors and estimated timespent (Based on 10-point scale: 0 =no time, 10 = all of the time). Major lzye crises Death of family member or close friend
Suicidal risk Dropping out of medical school Loss of a love relationship Wanted/unwanted pregnancy/abortion Loss of personal health Failing a course
1.2 1.3 2.3 4.2 1.2
2.9 4.4
Med Teach Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/15/15 For personal use only.
4.4
3.1 4.3 2.3 2.1
Problems with relationships
3 Workload 4 Self-concept 5 Failing a course, exam anxiety
6 Fear of incompetency 7 Loss of love relationship 8 Deprivation, delayed gratification, and substitute gratification 9 Sexual concerns 10 Loss of personal health 11 Leave of absence or change of program 12 Incompatibility with superiors, dropping out of medical school 13 Anxiety over health and financial problems
6.7 3.3
2.1
1.4 6.1 2.8 5.1
1.2
gratification
3.8
Other E.g., relocation during training; systems intolerance
2.0
Discussion a n d Recommendations T h e numbcr of hours and the frequency with which our peer counsellors were called upon emphasizes the need for and the utilization of such a programme. Although over half of our peer counsellors' time was spent in formal counselling, a very substantial portion was contributed by casual contacts between students and counsellors. Even though smaller percentages of time were spent in anonymous and identified telephone counselling, these are essential means of contact for some students. We believe that our estimates of total hours spent are conservative. I t is often difficult for a peer counsellor to remember all the counselling he/she has done and even more difficult, at times, to distinguish and separate the occasions when one is approached as an identified peer counsellor and when one is approached as a friend. Despite the overlap which exists, we feel that our counsellors' estimates are low. T h e extensive use of peer counsellors, as well as the number of students willing to work with both the school psychologist and a peer counsellor, demonstrates the acceptance of this programme as a n integral part of medical education. This also gives credence to our speculation that doctors will turn to peers for help if, in medical school, there is acceptance of fallibility and responsiveness on the part of peers. Psychological factors which are present in medical school but which go unrecognized have bccn identified as precursors of suicide, mental illness, malignant tumours, hypertension, and coronary occlusion (Thomas 1976).
290
1
2 Loneliness and isolation
Anxiety attacks
Exams Sexual concerns Fear of incompetency Incompatibility with superiors Financial problems Problems with relationships Workload Health Death and dying Loneliness and isolation Leave of absence or change of programme Self-concept Drugs and/or alcohol Deprivation, delayed gratification, and substitute
Table 3. Student problems ranked according to time spent by peer counsellors.
Poor self-image, damaged self-esteem and covert d e pression, anger and fear appear to contribute substantially to academic failure, poor performance during and after medical school and premature death (Thomas 1976). Given these concerns, one would expect medical educators to have established preventive programmes in medical schools. However, to our knowledge, we are the first to institute and report on a peer counselling programme for medical students designed to prevent emotional illness both during training and later professional life.
References Rittker, T.. Reaching out to the depressed physician, journal of' the American Medical Assoczat~on,1976. 236, 1713.1716. Rlachley, P. H . . Disher, W. and Roduncr. G.. Suicidc by physicidns. National Institute of Menlal Health- Bullettn of Suicidology, 1969. 1-19, Brook, M . F . . Hailstone, J . D.and McLaughlin. E. J . , Psychiatry illnrss in the medical profession, Amarican Journal of Psychuitry, 1967, 113, 1013 1023. Modlin. H. C. and Montes. A.. Narcotics addiction in physicians, Amencanjournal of Psychiatry, 1964, 121, 358.365. Murray, R , P5vchiatricillnessindoctors, Lancet, 1971. 1, 1211.1212 Pearson. M . and Strecker, F... American Journal 01 Psychiatrj, 1960, 116, 915.919. Scheiber. S . C . , Emotional problems of physicians: I . Nature and extent ofproblems. Arzzona Medicine, 1977, 3 4 , 323 325. Seigle. R., l'he Impaired Phyiczan- What Can Be Done?, Report from the OSR discussion group of the AAMC. Novrmber, 1977. .l'albott, G. D., Holderfield, H . . Shoemaker, K. and Atkinson. E.. l ' h e disabled doctors plan for Georgia, Journal o f f h e Medical Association 01 Georgia, 1976, 65, 71.76. 'l'homas. C . B . . What becomes of medical students: The dark side, T h e / o h m Hopkzns MedzcalJournal, 1976. 138, 185-195. Vaillant, G . . Sabowale, N. and McArthur. C.. Some Psychologic Vulnerabilities of physicians, New England journal of Medzczne, 1972. 287, 372.375. Waring, E. M.,Psychiatric illnesses in physicians: A review, Corn prehewiue Psychiatry, 1974, 15,319-529.
Medical Teacher V o l 2 No 6 1980
