Janis L. Cutler

Discrediting the notion "working with 'crazies' will make you 'crazy'": addressing stigma and enhancing empathy in medical student education.

People with mental illness around the world continue to suffer from stigmatization and limited care. Previous studies utilizing self-report questionnaires indicate that many medical students regard clinical work with psychiatric patients as unappealing, while the professionalism literature has documented a general decline in students’ capacity for empathy over the course of medical school. Through in-depth interviews, this study attempts to better understand the formation of medical students’ perceptions of psychiatry and the implications of that process for a more general understanding of the impact of emotionally-laden experiences on medical students’ capacity for empathy. Forty-seven fourth-year medical students who had expressed interest or performed well in psychiatry were asked a series of questions to elicit their perceptions of the field of psychiatry. Interview transcripts were systematically coded using content analysis and principles of grounded theory. Stigma, stereotypes, and stressfully intense emotional reactions seemed to adversely affect the students’ expected satisfaction from and willingness to care for the mentally ill, despite enjoying psychiatry’s intellectual content and the opportunity to develop in-depth relationships with patients. Teaching faculty need to directly address the stigma and stereotypes that surround mental illness and actively help medical students cope with the stress that they report experiencing during their psychiatry clerkship in order to improve the recognition and treatment of psychiatric illness by newly graduating physicians. More generally, the relationships that we identify among stress, stigmatization, and stereotyping along an empathic spectrum suggest that increased attention should be paid to the stress that empathy can entail. This perspective may allow for the creation of similarly targeted interventions throughout the medical school curriculum to counteract the decline in empathy, the so-called “hardening of the heart,” associated with physician-training worldwide.

“Panic-like” symptomatology in schizophrenic and schizoaffective patients with postpsychotic depression: Observations and implications

Approximately one quarter of a series of 45 schizophrenic and schizoaffective patients with operationally diagnosed episodes of postpsychotic depression were also found to have anxiety symptoms consistent with the panic-attack syndrome. The incidence of such attacks was distributed across all demographic groups. Heuristic and treatment implications of this observation are considered.

Reducing Medical Students’ Stigmatization of People With Chronic Mental Illness: A Field Intervention at the “Living Museum” State Hospital Art Studio

ObjectiveThe authors designed an intervention to reduce beginning medical students’ stigmatization of people with chronic mental illness (CMI).MethodsPre-clinical medical students visited a state psychiatric facility’s “Living Museum,” a combination patient art studio/display space, as the intervention. During the visit, students interacted with artist-guides who showed their work and discussed their experiences creating art. Students completed a self-assessment survey developed to measure attitudes and feelings toward people with CMI after half of the class visited the Living Museum, constituting a Visit/No-Visit cross-sectional comparison.ResultsStudents who visited the Living Museum (N=64), as compared with those who did not visit (N=110), endorsed more positive attitudes toward people with CMI. Among the students who visited, however, those who reported having spoken individually with a patient-artist (N=44), paradoxically, indicated less-positive feelings toward people with CMI.ConclusionAn intervention in which pre-clinical medical students visited patient-artist guides in an art-studio setting generally improved students’ attitudes toward people with CMI. Thus, nontraditional psychiatric settings offer a valuable adjunct to more traditional clinical settings to reduce stigma when introducing medical students to the field of psychiatry.

Commentary on “Shorter Psychiatry Clerkship Length Is Associated With Lower NBME Psychiatry Shelf Exam Performance”

The average length of United States medical school psychiatry clerkships has been gradually declining over the past 30 years, from 6.4 weeks, in 1982 (1), to 6 weeks, in 1999 (2), to 5.5 weeks, in 2010 (3). Alexander and Bostwick report being recently put in the unenviable position of having the shortest required psychiatry clerkship in North America (4). We can all empathize with the frustration that this reduction might entail, given that their 3-week clerkship is half the length recommended by the Association of Directors of Medical Student Education in Psychiatry in its 2006position statement (5).Alexander andBostwick are to be commended for moving beyond their frustration to examine the impact of the reduction in clerkship length on their students’ shelf scores in a thoughtful and scholarly fashion. Their challenging situation offers us an opportunity to think about the meaning and impact of clerkship length. On the most concrete level, clerkship length might be viewed as an indicator of worth by a number of different stakeholders, from deans to department chairs to teaching faculty to students. Medical school faculty committee meetings devoted to divvying up time within an impacted curriculum can generate intense “turf battles” and hard feelings. Although these disputes are often fueled by financial considerations, the significance of the implied value judgment that accompanies those distributions should not be minimized. Clerkship directors and faculty faced with a reduction in clerkship length might feel as if they have been demoted, and that a value judgment has been made against them and their field. Psychiatrists are particularly vulnerable to this assumption, given the uphill battle that we and our patients have faced for full acceptance within the house of medicine. Recognizing that time-allocation and prominence of placement in the curriculum are important aspects of the “hidden curriculum,” (6) psychiatric educators must be concerned about the underlying message that a shortened clerkship sends to students and colleagues.The importance of these factors may be reduced but will likely not be eliminated by such alternate models for clinical training as the longitudinal clerkship experience (7). The longitudinal clerkship experience is an example of an alternate model for clinical training. What is the impact of psychiatry clerkship lengthreduction on students’ acquisition of knowledge?Alexander and Bostwick reasonably turn to shelf examination scores to address this question. As their manuscript’s title indicates, “shorter psychiatry clerkship length is associated with lower NBME psychiatry shelf exam performance.” As they acknowledge, their ingeniously-obtaineddata donot allow them to move beyond that association to make any conclusions about causality. First, their comparisons are limited by the lack of randomized assignment; the difference in shelf exam performance between the groups could be explained by the greater interest in psychiatry held by the students who chose the additional 3-week exposure. Second, a significant difference in shelf exam scores was found only in comparing those students who spent 6 weeks on their psychiatry clerkship with students who spent 3 or 4 weeks. Third, students’ performance on the shelf exam was not significantly different between those students who spent 4 weeks from those who spent 3 weeks in their psychiatry clerkship. It is possible that the data reflect a genuine reduction in acquired knowledge when the clerkship length is reduced to 4 weeks from 6. Furthermore, it is possible that the lack of difference between the exam scores of students who spent 4 weeks on the clerkship from those who spent 3 weeks reflects a genuine lack of difference in knowledge acquisition. It may be that there is a floor effect, and that students will “crack the books” sufficiently to learn the knowledge Received February 3, 2012; revised February 29,March 14, 2012; accepted March 20, 2012. From the New York State Psychiatric Institute and the Department of Psychiatry, the College of Physicians and Surgeons of, Columbia University, New York, NY. Send correspondence to Dr. Cutler; e-mail: cutlerj@nyspi.columbia.edu Copyright

Taking it personally: exploring medical students' emotional responses and professional roles during the psychiatry clerkship.

Medical students have been observed to experience the psychiatry clerkship as emotionally stressful and professionally difficult (1). Although countertransference responses of many sorts exist across clerkships and throughout the professional lifespan of all physicians (2), students in the psychiatry clerkship often face the particular stress of caring for interpersonally challenging patients as they simultaneously work to establish their own professional identities (3, 4). For this reason, aspects of countertransference that relate to role-expectations, including expectations of patients and of themselves as healthcare providers, loom especially large. We have developed an approach to help students understand and manage feelings relating to role-expectations in the therapeutic relationship. At the outset of the psychiatry clerkship, in describing differences between psychiatric and medical/surgical services, we advise students that they may find the clerkship emotionally stressful and encourage them to share their emotional responses to patients with their supervisors. We discuss the “differential diagnosis” of such reactions and their clinical utility. We employ an “empathic spectrum,” ranging between extremes of over-identification and disengaged lack of empathy/withdrawal, to conceptualize students’ typical struggles to find a balance that fosters both empathic connection and professional distance (1). In a group-reflection session later during the clerkship, we introduce a framework for exploring role-expectations in emotionally stressful clinical situations. This session forms part of an across-clerkships course on the patient–doctor relationship and reflective practice, an increasingly prominent theme in medical education (5). We ask students to submit a written reflection, describing an experience that evoked an “intense emotional response.” Students’ responses are then discussed in a seminar centered on recognizing countertransference andusing thisunderstanding toachieveamore balanced, empathic stance. The framework depicted in Figure 1 has served as a helpful reference during this discussion. Focusing on the contribution of role-expectations to students’ emotional responses, the framework schematizes students’ views of their patients’ and their own roles and responsibilities in the therapeutic relationship. The vertical axis represents the patient’s agency with regard to his or her psychiatric illness. At one end, illustrated at the top of the axis, students view patients as fully accountable for their symptoms. At the other end, students view patients as subject to, or eclipsed by, their illnesses, and not held responsible (6). The horizontal axis represents students’ views of their roles, ranging from, at one end, “owning” patients’ problems and bearing responsibility for fixing them, to, at the other end, allocating responsibility to the patient and supporting patients’ struggles (7). Students in the “ownership” position are vulnerable to rescue fantasies, where, in the extreme supportive position, students may feel impotent and unfulfilled. Although represented graphically as continua, the dimensions depicted on the vertical and horizontal axes may be more helpfully viewed as dialectics, or opposing principles, challenging students to embrace both poles simultaneously. Although the framework’s concepts are familiar to doctors, particularly psychiatrists, they may be more novel for medical students just beginning to assume clinical responsibility. In reviewing students’ reflective writings and in the group discussion, it has been our experience that their emotional responses in difficult clinical encounters often relate in part to the underlying role assumptions depicted in Figure 1. Students who report frustration or anger with their patients often feel thwarted in their attempts to fix the problem by the patient’s behavioral choices. Holding patients responsible for causing their problems while holding themselves responsible for solving them places students in the upperleft quadrant of the framework. Patients signing out of the hospital prematurely, suffering a relapse of a substance-use disorder, or sabotaging the pass they had been eagerly anticipating often evoke this response in their healthcare providers. Students who feel guilty or dutiful regarding their care of the patient or are drawn toward overextending themselves to protect their patients can be conceptualized as being in conflict with the patient’s illness, as represented by the lower-left quadrant. Students who feel sad or helpless Received June 8, 2011; revised July 5, July 29, 2011; accepted August 12, 2011. From the Department of Psychiatry, Columbia University College of Physicians & Surgeons and New York State Psychiatric Institute, New York, NY. Address correspondence to Michael J. Devlin, M.D.; e-mail: mjd5@columbia.edu Copyright

A Qualitative Study of Factors Affecting Morale in Psychiatry Residency Training.

ObjectiveResident morale is an important yet poorly understood aspect of the residency training experience. Despite implications for program quality, resident satisfaction, patient care, and recruitment, little is known about the variables influencing this complex phenomenon. This study sought to identify important factors affecting morale in psychiatry residency training.MethodsThe authors conducted four semi-structured focus groups at a moderately sized, urban, psychiatry residency program during the 2013–2014 academic year. They used qualitative data analysis techniques, including grounded theory and content analysis, to identify key themes affecting resident morale across training levels.ResultsTwenty-seven residents participated in the focus groups with equal distribution across post-graduate years (PGY) 1–4. Five major conceptual categories affecting resident morale emerged: Sense of Community, Individual Motivators, Clinical Work, Feeling Cared For, and Trust in the Administration.ConclusionsMorale is an important topic in residency education. The qualitative results suggest that factors related to a Sense of Community and Individual Motivators generally enhanced resident morale whereas factors related to a lack of Feeling Cared For and Trust in the Administration tended to contribute to lower morale. The authors describe the possible interventions to promote stronger program morale suggested by these findings.

Why I Love Being an Academic Psychiatrist

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