Lisa A. Mellman

Medical students as teachers: How preclinical teaching opportunities can create an early awareness of the role of physician as teacher

Background: As future physicians, questions about when medical students realize they will have to teach remain under-explored. Aim: To understand when students serving in pre-clinical teaching roles make the connection between teaching and being a physician. Methods: Medical students involved in a peer instruction program included: (1) archived first-year student interview candidate data (n = 60/150); (2) focus groups of first-year students selected as instructors (n = 16/60); and (3) focus groups of second-year students (n = 16/24) who taught for the program. A modified extended-term mixed-method research design involved data from the pre-hire interviews and post-hire focus group. Results: Prior to teaching, none of the first year interviewees made an explicit connection between teaching and being a physician. The new instructors selected to teach minimally made a connection and only after prompting. The majority of the experienced instructors did make the connection; however, and did so spontaneously. Conclusion: It was only after they taught medicine-related material that students saw the benefits of teaching as a way of preparing for becoming a physician and not merely as a way to review or help their peers.

Obstacles to Early Career Psychiatrists Practicing Psychotherapy

Though psychiatric residents are expected to be competent psychotherapists on graduation, further growth in skill and versatility requires continued experience in their ongoing career. Maturity as a psychotherapist is essential because a psychiatrist is the only mental health provider who, as a physician, can assume full responsibility for biopsychosocial patient care and roles as supervisor, consultant, and team leader. Graduating residents face an environment in which surveys show a steady and alarming decline in practice of psychotherapy by psychiatrists, along with a decline in job satisfaction. High educational debts, practice structures, intrusive management, and reimbursement policies that devalue psychotherapy discourage early career psychiatrists from a practice style that enables providing it. For the early-career psychiatrist there is thus the serious risk of being unable to develop a critical mass of experience or a secure identity as a psychiatric psychotherapist. Implementation of parity laws and the Affordable Care Act (ACA) will affect the situation in unpredictable ways that call for vigilance and active response. Additional service and administrative demands may result from the ACA, creating ethical dilemmas about meeting urgent patient needs versus biopsychosocial standards of care. The authors recommend 1) vigorous advocacy for better payment levels for psychotherapy and freedom from disruptive management; 2) aggressive action against violations of the parity act, 3) active preparation of psychiatric residents for dealing with career choices and the environment for providing psychotherapy in their practice, and 4) post-graduate training in psychotherapy through supervision/consultation, continuing education courses, computer instruction, and distance learning.

Important medical decisions: Using brief motivational interviewing to enhance patients' autonomous decision-making.

Goals. The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. Background. As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. Method. A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. Discussion. The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient’s best interests by psychotherapeutically addressing his anxious, fear-based ambivalence. (Journal of Psychiatric Practice 2013;19:98–108)

Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research.The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient’s responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

Complex Sexualized Transferences When the Patient is Male and the Therapist Female

The expression of sexual feelings toward the therapist is a common development in psychotherapy regardless of the gender constellation of the dyad. Much of the literature on this topic has been written about female patients by male therapists, though, and some authors (1, 2) have suggested that male patients either are too inhibited to express sexual feelings to a female therapist or tend to act out such transferences by involving themselves in outside sexual relationships. In the last 20 years or so, however, a growing literature written by women clinicians has suggested otherwise (3–7). In primitively organized male patients, sexualization may be deceptive since it often represents only the phenomenological surface of the transference, and female therapists need to be aware of underlying aggressive and dependency themes beneath such transferences (7, 8). Resident-therapists beginning to learn psychotherapy may be surprised by this inextricable connection between aggression, dependency, and sexuality in such patients, as the following case presentation will illustrate.

Academic and Career Counseling for Medical Students and the Complex Role of the Student Affairs Dean

What does the Dean of Student Affairs at a medical school actually do, and what qualities does it take to be successful? Medical students, residents, and faculty interested in a career in medical education that includes advising trainees are likely to consider the position of Clerkship Director or Residency Training Director as the prototype for such careers. The position of Student Affairs Dean in a medical school is another option for those interested in medical-education careers. This subject has scarcely been written about (1–3), yet psychiatrists are overrepresented in this position (4). This article is intended to give academic psychiatrists an “inside view” of the job. The Dean of Student Affairs guides students throughmedical school, often oversees career and academic counseling, and is charged with the well-being of the students. To accomplish these goals, the Student Affairs Dean interacts with multiple stakeholders in a school, including the Dean of the School, students, faculty, and ancillary offices, to ensure that students are successful. Themultifaceted role of the Student Affairs Dean requires understanding how physician identity is formed; the myriad challenges of being a medical student, including barriers to learning, such as depression, anxiety, substance abuse, and learning disabilities; and awareness of the expectations of “millennial” and “Generation-X” students. Facility in working with complex systems is also useful. Since the end-goal of medical school is to match welltrained physicians to residency, or, if desired, to a position as a physician in an alternative field, the Student Affairs Dean is charged with ensuring the success of this endeavor. Academic and career advising is central to this mission. Advising, in many schools, occurs through structured programs termed “Advisory Dean,” “Learning Community,” or “College” programs, which are usually embedded within the Office of StudentAffairs. The nomenclature varies, but the goals are relatively common. This growing trend of “advising programs” is designed to provide 1) a structured environment for students to form a relationship with a faculty member/ mentor; 2) exposure to career opportunities and assistance with residency decisions; 3) opportunities to learn about humanism and professionalism; and 4) a forum to discuss curriculum and the school environment with a group of peers. Some programs have developed around themes where students join on the basis of common interests, whereas others randomly assign students to a society or dean with whom they “partner” for their time at medical school. Some programs are specifically geared to career-advising and helping students structure their career plans and their fourth-year curriculum. Others, such as learning communities, may have dedicated space for the group to gather, and career-advising and core-teaching both occurring within the group (5–9). To understand the role of advising within the role of the Student Affairs Dean, it is vital to understand the stakeholders in a medical school and the culture of the students.