INT’L. J. PSYCHIATRY I N MEDICINE, VOL. 6(1/2), 1975
TEACHING PSYCHOSOMATIC MEDICINE TO MEDICAL STUDENTS, RESIDENTS AND POSTGRADUATE FELLOWS Franz Reichsman, M.D?
Departments of Medicine and Psychiatty Downstate Medical Center College of Medicine, Brooklyn, hew York ABSTRACT-The teaching objectives of a psychosomatic program are discussed-in particular, to teach skills and methods of observation; to help students to acquire information about mind-body relationships in health and disease; to help future practitioners develop the capacity for clinical reasoning which includes psychological and social considerations; to effect modifications in attitudes and behavior towards patients and their families; and to present to students the model of a physician who has a major interest and considerable competence in two areas of medicine-the psychosocial and the physical-physiologic-biochemical. A description of the general organization of the liaison service is presented, and the specific aspect of teaching programs for medical students, medical interns and residents, psychiatric residents, and liaison fellows are outlined. Implications for the future of liaison teaching are mentioned.
As the title indicates, this article covers the teaching of psychosomatic medicine to groups of “students” at different stages of development and, in some instances, with different professional backgrounds. While some substantive matters, questions and problems concerning all of the above groups will be covered together, at times the focus will be on issues specific for one group or another. While the time-honored term “psycho~omatic~’ will be used in this article, we shall also use “liaison” almost synonymously. The latter term not only avoids the undesirable implications of the former [ 11 ,but can also connote the specific activities of a service or group, e.g., medical-psychiatric liaison. Until not long ago most psychosomatic teaching took place in departments of medicine but more recently psychiatric liaison has also been established with departments of pediatrics, family medicine, obstetricswnecology and surgery. Furthermore, the term “liaison service” conveys that the members of the group are not ‘This study was supported in part by National Institute of Mental Health Training Grants MH 08990 and MH 06317. 2.Professor of Medicine (assigned from Psychiatry), State University of New York, Downstate Medical Center College of Medicine, Brooklyn, New York. Reprint requests to Dr. Franz Reichsman, Box 127,450 Clarkson Ave., Brooklyn, New York 11203.
307 0 1976,Baywood Publishing Co.. Inc.
doi: 10.2190/NMGA-DTP5-CXG1-BM0B http://baywood.com
308 I Franz Reichsman consultants to a nonpsychiatric department but that they are working members of that department. The author will draw on his experience, from 1952 to 1964, first as a fellow and then as staff member of the Rochester Liaison Group, and also on his later experience as the Director of the Liaison Service of the Downstaie Medical Center, State University of New York. Furthermore, he will include considerations derived from observations of psychosomatic services in the U.S., England and on the European Continent. TEACHING OBJECTIVES OF A PSYCHOSOMATIC PROGRAM The general teaching objectives of psychosomatic groups are not different from what the aims of many other clinical services or departments are or ought to be, the latter having been outlined by Reichsman, Browning and Hinshaw 121. At the same time the more specific aspects of teaching psychosomatic medicine have to be emphasized here. The following objectives deserve particular attention: 1) To promote the learning of skills and of methods of observation, specifically learning: a) to elicit from physically ill patients meaningful historical data concerning symptoms and psychosocial matters; b) to make accurate observations of patients’ verbal and nonverbal communications, be it in the form of a complete anamnesis or in brief bedside interviews; c) to organize the obtained data in a coherent and logical manner for written or oral presentations. Such teaching requires that the teacher observe in person the interviewer’s obtaining of primary data and his overall clinical approach to the patient. Members of a well-trained psychosomatic group are uniquely qualified to undertake these tasks within the medical school curriculum, in the settings of a “Medical Interviewing Course,” of rounds on inpatient services and in outpatient clinics. To be effective, teaching must be arranged for small groups of students and, at times, even as a single student-teacher session. Additional learning of interviewing skills and of the approach to the patient are of great importance for all residents and for postgraduate fellows in psychosomatic medicine. In our experience, even those who have completed psychiatric residency training derive much benefit from having their interviews with patients observed and discussed by an experienced teacher, because many residents had been exposed previously only rarely or not at all to such a learning experience and also because the potential for learning in this area through direct supervision continues for many years. 2) To help students, residents and fellows acquire information concerning body-mind relationships in health and in the pathogenesis, course and treatment of a wide variety of diseases. Teaching should include data ranging from psychophysiologic, epidemiologic and general clinical observations to studies of symbolic processes and of interpersonal relationships, with particular attention
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to the vicissitudes of the physician-patient relationship. Thus, this aspect of teaching includes the areas which Lipowski, in the introductory chapter of this volume [l] , subsumes under the “science” aspects of psychosomatic medicine. 3) To help medical students particularly, but also those at more advanced stages of training, to develop the capacity for clinical reasoning (problemsolving). This entails imparting to them the value of including, from the very beginning of their diagnostic process, psychological and social data in their step-by-step, logical thinking about the diagnostic problem at hand. 4) To effect modification in attitudes and behavior. Perhaps the most important attitude to be imparted is that of a less mechanistic, of a more humanistic and at the same time scientific approach toward patients and their families. While such teaching is done in departments of psychiatry, it is of the essence-particularly for medical students and medical residents-that it be done also in relation to the physically ill. Despite good intentions in many nonpsychiatric clinical departments, the humanistic aspects of patient care are often forgotten because of the house staff’s fascination with the “organic” aspects of the patient’s illness. By demonstrating the benefits which patients derive from a humanistic-scientific approach, a psychosomatic group can fill a major gap in undergraduate and postgraduate medical education. 5 ) To present to medical students and to house officers the model of a physician who has major interest and at least reasonable competence in two areas of medicine-the psychosocial and the physical-physiologicbiochemical-which traditionally have been separated to such an extent that most physicians tend to focus almost exclusively on one or the other. While this objective is inherently present in the previous ones, it deserves to be singled out separately because of its central importance. When students, house officers and liaison fellows are inspired by such models, they will usually continue to strive toward acquiring more expertise in both major areas and to use it in patient care, teaching and research, as they progress through their professional careers. GENERAL ORGANIZATION OF A LIAISON SERVICE In this writer’s view-which differs from that expressed by Ross and Levine  -liaison services should resist the temptation of accepting offers by general hospitals to have “psychosomatic beds” in a geographically separate area of the institution. Having beds in a separate area has had two major disadvantages in some hospitals where it has been tried: 1) it strongly reinforced the nonpsychiatrist physicians’ and nurses’ tendency to regard only the patients in these beds as “psychosomatic” and to look at the other patients on their service as having “organic disease” in whom psychological factors need not be considered; 2) these beds often ended up being occupied by patients the nonpsychiatric service wanted to rid itself of, e.g., psychotic patients (who should have been transferred to a psychiatric ward) or patients who were poorly
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motivated and, at the same time, psychologically extremely ill. While t‘he members of the liaison group should engage in diagnosis and management of some of these patients also, they can ill afford concentrating their efforts on such a patient population. The liaison service of the Downstate Medical Center has been organized along the lines of the Rochester model [4,5] ,a model created by the imaginative and inspiring leadership of George Engel. At the same time, we have modified our organization for the needs of the very different setting in Brooklyn: a huge city hospital, large medical school classes and a student population with a rather different orientation. We assign four teams, each consisting of one liaison staff member and one liaison fellow, to four wards of the medical service, i.e., to one half of the service at a time. Each assignment lasts for n9 less than three months and thus provides the members of the liaison group the opportunity to get well acquainted with the physicians, nurses and medical students on the ward. Because of their close working relationships with medical house officers and attending physicians on their assigned ward and because of their easy and prompt availability to, house officers on other wards without direct liaison coverage at a given time, the members of our group are looked upon as being part of the Department of Medicine, rather than as outsiders coming in for consultation. In this respect it has also been very helpful to us to have gained the strong support of the departmental chairman in medicine. This support has included assigning to us-after initial resistance to do so-two hours per week for rounds with third year medical students, assigning us ample office space within the Department of Medicine, and verbalizing from time to time his view of the liaison group as an integral part or as “one of the pillars” of the medical service. At the same time, we have had wholehearted support by the successive departmental chairmen in psychiatry who have considered our work on the medical service an important continuing activity of the Department of Psychiatry and have supplied a large part of our staff members’ salaries, the smaller part of which has come from two National Institute of Mental Health Training Grants. TEACHING OF MEDICAL STUDENTS In our experience the teaching of medical students has been a particularly productive and rewarding endeavor, because the greatest impact of psychosomatic teaching seems to occur during the earliest phase of clinical experience: we have found many students receptive to and educable in psychosomatic medicine. Our main teaching occurs in weekly sessions of the medical interviewing course in the second year, which is part of the introduction to clinical medicine, and iii weekly liaison rounds for third year students while they are clinical clerks in the Department of Medicine, each of the two types of sessions being two hours in duration.
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In the former exercise, a thirty-minute interview of a physically ill patient by one of a group of seven to eight students in the instructor’s presence is followed by a discussion which focuses-in various admixtures-on: the student’s clinical approach to this patient (including his interviewing techniques); the group’s observation of the patient’s verbal and nonverbal behavior; hypotheses or conclusions which can be formulated on the basis of the primary data obtained, e.g., the patient’s affects, his character structure, the relationship between psychosocial factors and the onset, aggravation or alleviation of physical illness; and, last and least, diagnostic considerations, physical and psychologic. On third year liaison rounds for groups of six to nine students we continue, in some sessions, to supervise the students’ interviewing techniques but more often a student’s case presentation is followed by a thirty minute patient interview by the liaison attending physician and then by a group discussion. In the latter the same topics as in the second year sessions are taken up but in greater depth and with much greater emphasis on diagnostic teaching, including the processes of clinical problem solving. Additional topics for discussion include the vicissitudes of the doctor-patient relationship, psychophysiologic considerations and the management of the patient from a holistic viewpoint. Clearly, not all topics can be discussed at any one session. What is taken up is determined primarily by the flow of the clinical material on a given day. We consider it essential that such rounds take place while the students work on a nonpsychiatric service. Only while assigned continuously to such a service can they accomplish a complete workup and get a holistic view of the patient. While many students are open to the liaison approach, they do have their own resistances toward learning psychosomatic medicine. These resistances stem from: a) the input overload they experience during the clinical curriculum (to learn about the psychosocial dimension-in addition to all the other material to be absorbed-becomes “too much,” in varying degrees, for some of them); b) students’ inability to perceive the relevance for their future careers of eliciting psychosocial information from patients with physical illness (many understand this relevance only later on and have stated to the author, years after leaving medical school, that they subsequently understood the importance of what they had learned in liaison sessions and found it very useful in their professional activities); c) students’ emotional problems which interfere with their approach to patients, problems which the psychosomaticist, as a teacher, can help the student to deal with (this matter has been discussed in some more detail by Groen [ 6 ] ) . These resistances can be overcome, at least partly, by appropriate and imaginative psychosomatic teaching. It has proven particularly helpful when the teacher has included in the session some substantive material from the biologic area. In each of his medical-psychiatric liaison sessions the author includes at
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least one major concept or significant fact from internal medicine or basic science. This tends to make the student much more receptive to learning data in the psychosocial area. We do not look at this approach as an attempt at “seduction” of students but as an effort to help them identify with the teacher who has interest and knowledge in the biologic as well as in the psychosocial aspects of medicine. In addition to these main teaching exercises for small student groups, we have found it useful-as have other liaison services-to give a few lectures and demonstration interviews to whole classes of students. We have given such sessions in the first year course, “Life Threatening Illness, Dying and Death,” in the second year course, “Human Behavior,” and in the third year lecture series sponsored by the Department of Medicine. While interviews of patients in these teaching exercises have been received very favorably by our students, the lectures have met with a mixed reception. Nevertheless, many students have learned and retained material from our lectures, as evaluated by their answers to a psychosomatic question which is part of their final written examination in third year medicine. We also offer to fourth year students a two-month clerkship in liaison medicine in which they are assigned to a medical ward and are engaged in working up patients holistically (i.e., physically and psychosocially) and in depth, under our close supervision. We have attempted to attract to this clerkship particularly those students who do not plan a career in psychiatry. Despite our efforts, a majority of the students applying for and serving the clerkship has had the intention to enter the field of psychiatry. TEACHING OF MEDICAL INTERNS AND RESIDENTS At our institution, as at many others, the medical house officers are engaged very intensively and for long hours every day in the care of inpatients. Furthermore, as many of them are preoccupied with the biologic aspects of medical diagnosis and management, they tend, in our experience, not to become genuinely engaged in psychosomatic conferences arranged for larger groups or even purposely avoid such conferences. Hence, we have tied our main teaching effort to the many consultation requests by house officers. After having elicited psychosocial data in depth (from the patient, a close relative and the professional staff, particularly the nurses), the liaison fellow or staff member meets with the house officers taking care of this patient and communicates his findings and specific recommendations in detail. In this setting we find most interns and residents interested not only in the psychosocial aspects of their own patient’s illness but in learning also some of the principles of psychosomatic medicine as related to diagnosis and management. We have found it productive to supervise a small group of interested medical residents throughout the academic year in one-hour weekly sessions. Dr. Vernon H. Sharp initiated and carried on this endeavor and Dr. Norman B. Levy
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continued it after Dr. Sharp’s departure from our institution . The house officers chose to present primarily some of their outpatients from the “Follow-up Clinic” (i.e., patients followed after discharge from the inpatient service). Because they found patients with juvenile diabetes mellitus particularly difficult management problems, these patients became the primary focus of the conferences. TEACHING OF PSYCHIATRIC RESIDENTS
Our service has made arrangements with the Department of Psychiatry to have all twenty of their first year residents attend, in groups of six to seven, the
weekly liaison case conference for three successive months. This experience exposes them to patients with physical illness and to some of the current concepts and data in our area. While this allows only for an introduction to the psychosomatic approach, it gives the residents the opportunity to ascertain their interest or the lack thereof in this area. Hence, when they later choose third year electives, they are in a position to do this in a more knowledgeable manner. We accept them for an elective of no less than six months with the proviso that no less than one half of each working day be spent on our service. We have resisted the opportunity to have all third year residents rotate through our service, for two reasons. First, many psychiatric residents are not interested in the psychosocial aspects of patients with physical illness and therefore these residents are poorly motivated learners in this area. Second, although third year psychiatric residents have acquired much knowledge in behavioral science in general, they need and deserve individual supervision and teaching in the psychosomatic area. Our group would not be able to give a productive learning experience to the entire class of third year residents, and we doubt that many other liaison groups have the manpower to do this. After completion of their training, some of the former residents have become active on liaison services at other institutions, mostly as directors of these services. The others are engaged in the private practice of psychiatry, including psychotherapy with “psychosomatic” patients. TEACHING OF LIAISON FELLOWS Similar to the practice of other liaison services, our fellowships are at least one year in duration but we have preference for a two-year training period. Of the two pathways leading toward this fellowship-psychiatric residency training or training in a nonpsychiatric specialty (in our setting, internal medicine)-a majority of our fellows have gone through the former pathway. While there has been no paucity of applicants who had a background in internal medicine or general practice, we have considered some of them not sufficiently well-trained or motivated. Whenever a worthwhile candidate appeared-no more than one per year-the departmental chairman in medicine has given us one of his residency
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salaries for supporting the fellow. This has been most important because our NIMH Grant for training internists does not carry stipends for trainees. Our training program is quite similar in some respects whether the fellows came with medical or psychiatric background, eg., in regard to intensive teaching of medical interviewing or the imparting of a wide spectrum of concepts and data in the psychosomatic area. At the same time we take into account the different background of the two groups. Fellows with a medical background need basic teaching in behavioral science, with special emphasis on psychopathology and psychodynamics. Fellows who have completed psychiatric residency training are strongly encouraged to refresh and add to their previous knowledge of internal medicine. It is not our intent to make them internists but rather to add to their understanding of body-mind relationships, to better their relationships to medical house officers and attending staff (by understanding and speaking their language), and to help them become more effective teachers of medical students. The teaching of students adds, in our experience, greatly to the learning processes of fellows and, therefore, we make it an integral part of their training. Some fellows also derive much profit from participating in psychosomatic research. We encourage this activity but do not make it mandatory. For fellows interested in long-term psychotherapy of patients with physical illness we provide weekly supervisory sessions with one of our staff members or with one of the members of the Downstate Psychoanalytic Institute who has had special experience with psychosomatic patients. Thus, the training of the fellows is individualized, according to their interests and career plans. Most of our former fellows have entered academic medicine, spending all or most of their time on medical-psychiatricliaison services, some of them engaging to a minor extent in the private practice of psychiatry or internal medicine. Thus, all five of the author’s associates had been fellows on our service. Other former fellows have joined other institutions, usually as directors of liaison services. A small minority has entered the private practice of psychiatry, with emphasis on diagnostic and therapeutic work with patients who have physical illnesses. Thus, the teachers of psychosomatic medicine have come primarily from the group which had a full training period, i.e., the liaison fellows.
A LOOK INTO THE FUTURE
While teachers of psychosomatic medicine will continue in the future to face certain difficulties, the author believes that we can look forward to much further growth and development in such teaching. The causes of the difficulties are likely to be twofold, the first stemming from the attitudes of psychiatric and nonpsychiatric departmental chairmen. The
Teaching Psychosomatic Medicine / 3 15 skepticism of many chairmen of nonpsychiatric departments concerning the potential contributions of a liaison program and, therefore, their resistance to participate in such endeavors is likely to continue although probably with decreasing frequency and intensity. In addition, reluctance to setting up liaison services will probably continue also on the part of chairmen of departments of psychiatry. This reluctance is understandable in terms of the many choices open to these chairmen concerning the various areas of behavioral science which can be developed and the priorities that need to be established. Furthermore, some will continue to believe that developing a liaison program will create for them unusually great administrative “troubles” because of the inherent, intricate relationships with another department. Secondly, the relatively small number of well-qualified potential teachers entering the psychosomatic field is not likely to increase in the near future. In part this has stemmed from the slow development of psychosomatic research resulting perhaps in a lack of intellectual excitement in and lesser attraction to the field on the part of young physicians. Even more important, many physicians continue to be much more comfortable when having their base of operation and their identification with one department rather than two. (In this connection it is worth noting that a good many physicians who had been active in liaison programs gradually moved entirely into one specialty, often into psychiatry .) While these tendencies will continue, there is an increasing awareness in many institutions of the need to improve the delivery of health care by imparting psychosomatic knowledge and know-how to medical students, physicians, nurses and other health workers. In the U.S., in the United Kingdom and on the European continent, existing psychosomatic services are being developed further and new ones are being started. It is recognized correctly by many in our field that for many years psychosomatic medicine will have to be taught by groups highly trained in this area. Only after additional generations of medical students and house officers will have been trained effectively by such groups will the time have come for psychosocial aspects of medicine to be taught by physicians in various nonpsychiatric specialties who will have gained sufficient knowledge in psychosomatic medicine. In the past, the traditional setting of liaison teaching has been primarily on inpatient services. While psychosomatic teaching should continue on such services, there are needs for and advantages to extending in a major way this teaching to outpatient settings, including community clinics. It may not always be feasible to pursue psychosocial explorations as deeply in outpatients as in inpatients, but this is likely to be a relatively minor disadvantage. Of much greater importance for the learning of the liaison approach would be the dominance and obvious significance of many outpatients’ symptoms which are perceived, even by novices in psychosomatic medicine, as being clearly determined by psychosocial factors. Furthermore, we must not underrate the
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opportunity to improve the delivery of health care by teaching psychosomatic medicine in settings in which so much health care is given, at present without much consideration of psychosocial factors.
REFERENCES 1. Lipowski ZJ: Introduction: current trends in psychosomatic medicine. Int J Psychiat in Med 5:303-308,1974 2. Reichsman F, Browning FE, Hinshaw JR: Observations of undergraduate clinical teaching in action. J Med Educ 39:147-63, 1974 3. Ross WD, Levine M: Training in Psychosomatic Medicine. Adv Psychosom Med 4:14-22, 1964 4. Engel GL, Greene WA Jr, Reichsman F, et al: A graduate and undergraduate teaching program on the psychological aspects of medicine. J Med Educ 32:859-71, 1957 5. Schmale AG Jr, Greene WA Jr, Reichsman F, et al: An established program of graduate education in psychosomatic medicine. Adv Psychosom Med 4:4-13, 1964 6. Groen JJ: Teaching Psychosomatic Medicine to Medical Students. Adv Psychosom Med 4:75-83, 1964 7. Levy NB, Sharp VH: Stress-alleviation in the clinical management of diabetes mellitus: liaison supervision of medical residents (in press)