Alison M. Heru

Medical Student Mistreatment Results in Symptoms of Posttraumatic Stress

ObjectiveThe authors assessed medical student attitudes regarding mistreatment and symptoms of posttraumatic stress in those students who reported exposure to mistreatment.MethodsThird- and fourth-year medical students (N=71) responded to questions from a vignette in which a student is mistreated and then described any mistreatment they had witnessed or experienced. They also discussed related symptoms of posttraumatic stress subsequent to the mistreatment. The revised Impact of Event Scale was the primary outcome measure.ResultsNinety percent of respondents reported sympathy for the student in the vignette and supported her discussing the incident with peers, the resident, and administration. Seventy-three percent reported witnessing or experiencing mistreatment, suggesting symptoms of posttraumatic stress, with no differences in scores across the intended field of study, age, or gender.ConclusionIn a supportive environment, medical students will discuss their experiences of mistreatment. Symptoms of posttraumatic stress can occur from mistreatment.

Quality of life and family functioning in caregivers of relatives with mood disorders.

This study examines the quality of life of caregivers of hospitalized relatives with mood disorders. Caregivers reported poor social, physical and emotional functioning. Family functioning was poor in the areas of roles, communication and affective involvement. It is significant that problem-solving, affective responsiveness and behavior control are within the normal range, indicating that these families do have strengths. Subjective burden but not objective burden was correlated with a poorer quality of life. Less than 30% of caregivers received help from other relatives and less than 5% sought help from outside organizations like NAMI, MDDA or VNA.

Using role playing to increase residents' awareness of medical student mistreatment.

The teacher—learner relationship is subject to both internal and external influences that may lead to mistreatment and harassment of the student. The student who is mistreated may mistreat students when he or she becomes a teacher. The author describes an experiential program for residents at Brown Medical School from 1999 to 2002 in which residents, through role playing, helped produce teaching videotapes on medical student mistreatment. Fourteen residents had participated in the program to date. They reported that they had benefited from an increased awareness of the effects of student mistreatment and had learned how to handle mistreatment more effectively. They also reported increased sensitivity to others and improved self-awareness, qualities that they planned to incorporate into their professional identities and that should help them avoid mistreatment of students and residents later in their careers. Because preventing mistreatment from being transmitted to the next generation is an important way to increase medical professionalism, the author recommends that role-playing exercises dealing with mistreatment be a part of all residency education.

Sexual harassment in medical education: liability and protection.

The prevalence and frequency of sexual harassment in medical education is well documented. On the graduation questionnaire administered by the Association of American Medical Colleges in 2003, 15% of medical students reported experiences of mistreatment during medical school. On items that specifically address sexual mistreatment, over 2% of students reported experiencing gender-based exclusion from training opportunities, and unwanted sexual advances and offensive sexist comments from school personnel. Sexual harassment of medical trainees by faculty supervisors is obviously unethical and may also be illegal under education discrimination laws. In two cases in 1998 and 1999, the U.S. Supreme Court clarified that schools may be held liable under Title IX of the Education Amendments of 1972 for the sexual harassment of their students. In 2001, the Office of Civil Rights of the Department of Education released revised policy guidelines on sexual harassment that reflect the Supreme Court rulings. Medical school administrators should undertake formal assessments of the educational environment in their training programs as a first step toward addressing the problem of sexual harassment. The authors recommend that medical schools implement measures to both prevent and remedy sexual harassment in their training programs. These constructive approaches include applying faculty and student education, establishing a system for notification and response, and creating an institutional structure to provide continuous evaluation of the educational environment.

Supervisor-trainee relationship boundaries in medical education

Despite concerns about the prevalence and ramifications of medical student mistreatment, the boundaries of faculty-student relationships have not been studied systematically in medical training programs. This study aimed to identify behaviours that occur with some frequency and potentially raise issues related to boundaries in the supervisor-trainee relationship. An anonymous questionnaire was distributed to the mailboxes of 154 residents in the departments of psychiatry, internal medicine, and obstetrics and gynaecology at four hospitals affiliated with Brown University Medical School. Residents were asked to report whether they had encountered specific behaviours from supervisors during medical training, the frequency of these experiences, and the professional status of the supervisor involved in each episode. There was a significant reported incidence of behaviours related to academic/professional boundaries, personal boundaries, and dating boundaries. Some of these behaviours raise issues related to exploitation. The major sources of these reported boundary behaviours were hospital-based clinical faculty, university-based academic faculty, and senior house staff. The potentially adverse effects of boundary behaviours on the individual student, the teacher-student relationship, and the doctor-patient relationship are discussed. Future research is recommended to clarify the limits of appropriate behaviour between supervisors and trainees in the medical learning environment.

Teaching Psychosomatic Medicine Using Problem-Based Learning and Role-Playing

ObjectiveProblem-based learning (PBL) has been implemented in medical education world-wide. Despite its popularity, it has not been generally considered useful for residency programs. The author presents a model for the implementation of PBL in residency programs.MethodThe author presents a description of a PBL curriculum for teaching psychosomatic medicine to PGY 2 members in a psychiatry training program. The goals of PBL are to encourage self-directed learning; enhance curiosity, using case-based, con-textualized learning; promote collaborative practice; and support patient-centered care. The addition of role-playingexercises helps PGY 2 residents to develop their skills from simply developing a differential diagnosis to being able to construct biopsychosocial formulations, and it provides these residents an opportunity to practice presenting case formulations to the patient and family.ResultsResidents and faculty enjoyed the PBL role-playing sessions. Residents wanted the learning objectives given to them rather than generating their own learning objectives, to move through the cases faster, and to receive more information and more cases.ConclusionTeaching psychosomatic medicine, using PBL and role-playing, allows many of the proposed Academy of Psychosomatic Medicine residency core competencies to be met. However, further refinement of the PBL method needs to take place in order to adapt its use to residency programs.

Family-oriented patient care through the residency training cycle.

ObjectiveBecause family oriented patient care improves patient outcome and reduces family burden, clinical family skills of communication assessment alliance and support are part of core competencies required of all residents. Teaching residents to “think family” as part of core competencies and to reach out to families requires change in the teaching environment.MethodsThis article advocates teaching residents family skills throughout the training years as an integrated part of routine patient care rather than in isolated family clinics or a course in “family therapy.” It reviews family skills required of residents in all treatment settings and family skills that are specific to inpatient, emergency room, outpatient, and consultation-liaison services.ResultsFamilies can be seen in multiple treatment settings throughout resident training using recent research to support appropriate interventions for patients and caregivers.ConclusionThe process of establishing change in the training environment requires a commitment on the part of the training faculty to include families, but is possible within the current training framework.

Family Therapy: The Neglected Core Competence

Family therapy is a neglected core competency in psychiatric residency training programs. Recent attempts to remedy this omission include a redefinition of family therapy as “family skills,” which is the basic requirement for all residents to be able to ally with and communicate with families and provide psychoeducation (1) or “family interventions,” which, for the child psychiatrist, refer to “a coordinated set of clinical practices that attempts to alter family interaction, family environment, and parental executive function (p 407)” (2). Competence in working with families is important because family interventions are effective interventions for many adults (3) and children (4) with psychiatric illnesses. Working with families also has a sustained, albeit poorly recognized, benefit for other family members. What can be done to help residency programs incorporate training in family skills and family interventions into the curriculum? This editorial outlines the rationale for including families, and delineates teaching goals and resident competencies that can reasonably be expected. Key components of making this change happen are the identification of role models, mainly psychiatrists who work with families, and support from the Chairs and Residency Directors in each Department of Psychiatry.

Gender and the Gaze: A cultural and psychological review

The hidden mores of the workplace are now coming under close scrutiny by women and are challenged when found to constitute a hostile environment. In the case of Jane, prolonged looking or gazing was the basis for a complaint of hostile environment. Cultural and psychological theories of the gaze are discussed, with reference to the development of gender identity and the sexualization of the gaze.

When Your Patient Has Children: How the Clinician Can Support Good Parenting

Most of our patients have children. All clinicians need to know how best to support good parenting in their patients. A parent with mental illness can benefit from understanding how to talk with their children about mental illness. This chapter describes parenting and mental illness from four perspectives: the child, the parent, the child psychiatrist, and the adult psychiatrist. Children of parents with mental illness, when asked, can clearly state what they would like from the mental health system. Parents want to avoid drawing attention to their family as they are fearful of being judged negatively. Child psychiatrists have developed family-based interventions that can prevent psychiatric symptoms and illness in children. Adult psychiatrists need to encourage and support their patients in discussing mental illness as a family, and to consider the development of care plans, should the parent become ill. All clinicians should be able to provide age-appropriate family interventions to competently involve children in the office and hospital setting.