Wanted: Psychoanalysts to teach principles of psychodynamics and psychoanalysis to groups of young people who may or may not have any interest in the subject matter or even be aware that it is still being taught. Hours: Often during prime office hours. Salary: None. Benefits: None. Potential for Career Advancement: Usually none.
Sound appealing? Ready to apply? Probably not. According to the experience of members of the Committee on Medical and University Education (CUME), fewer and fewer psychoanalysts today are willing or able to devote their time to teaching medical students. This problem was a major focus of the committee's spring meeting and is an ongoing issue facing the Subcommittee on Medical Student Education.
For years analysts have played an important role in the education of medical students. Clearly, analysts are the teachers of choice to introduce students to basic psychoanalytic concepts in psychiatry courses and clerkships. With their unique understanding of human behavior and psychodynamics, analysts are also invaluable teachers in courses on interviewing (both medical and psychiatric), the patienl/physician relationship, human development, and human sexuality. All of these are topics central to the current emphasis on primary care in medical education. But given the many important functions that analysts can serve in the medical schools, why at present are so few participating?
The answer would seem to lie as much with the medical schools themselves as with psychoanalysts. The complexion of most psychiatry departments has changed radically over the last twenty years. Gone are the departmental “teaching lines” which once supported so many analysts. Today full-time academic psychiatrists are more likely to be psychopharmacologists or bench researchers who support themselves through outside grants. Negative attitudes toward psychoanalysis in some departments may also contribute to the shortage of analysts teaching in medical schools. CUME members cite examples of curricula completely devoid of any psychodynamic teaching. Some analysts who have tried to become involved in teaching medical students have found themselves actively excluded. As most analytic institutes have no affiliation with a medical school, their members' participation in such teaching is often more difficult to arrange than it might be.
Yet some of the problems surely lie within psychoanalysis. Lynn Reiser, director of medical student education in the department of psychiatry at the Yale School of Medicine and chair of the CUME Subcommittee on Medical School Education, reports that finding analysts willing to devote time to the teaching of medical students is a difficult task. The committee has identified a number of factors contributing to this situation. Since few analysts remain in salaried positions at medical centers, analysts must take time from their practices, often during prime office hours, if they wish to teach in medical schools. Some institutes have been slow to realize that analysts must travel to medical schools to teach, and that students cannot be expected to come to their offices. With a limited amount of time to devote to teaching, many analysts feel it is better spent teaching students who have demonstrated an interest in psychoanalysis—analytic candidates or at least psychiatric residents. The problem is compounded when institutes themselves discount the importance of teaching medical students and regard it as less prestigious.
But however the blame is apportioned, psychoanalysts should be concerned about their waning influence on the medical curriculum. Roger MacKinnon, director of the Columbia University Center for Psychoanalytic Training and Research, stresses the importance of introducing the principles of dynamic psychiatry to medical students early in their training. “That's when they're the most idealistic and impressionable,” he notes. “When they enter medical school they're interested in people; when they exit they're interested in illnesses.” MacKinnon believes that analysts who teach courses in interviewing, general psychiatry, and the patient/physician relationship can instill in young medical students an interest in the human mind and in behavior. He also believes that it is important for medical students to see psychoanalysts, particularly young faculty, as doctors working in the context of a medical center rather than as outsiders playing a peripheral role. Only through participation in medical training can analysts pass on to the next generation of physicians, in every specialty, an understanding of psychodynamics and the therapeutic value of psychoanalysis and psychotherapy.
The relation between psychoanalytic teaching in medical schools and the recruitment of physicians into psychoanalysis is not trivial. Thirty years ago, when most psychiatric teaching was done by psychoanalysts, many medical students went into psychiatry in order to become analysts. Today, however, medical students may not encounter an analyst until they have already entered their psychiatric residency. This is unfortunate, because the teachers medical students meet early on often serve as role models, for both values and professional behavior, and as regards eventual choice of career. In one rather telling instance, a student taught by an analyst in the first-year psychiatry course sought out his old teacher when deciding whether to embark on a career in psychiatry. “You were the first psychiatrist I really met,” he told the analyst. “To me, you are psychiatry.” Had the course been taught by a psychiatrist of strictly biological orientation, it seems fair to assume, the student's image of psychiatry would have been quite different. As it is, he will forever link psychiatry with psychoanalysis and psychodynamics.
A number of psychoanalysts serving as directors of residency training and medical student education have come together under the aegis of CUME to discuss model curricula, to write texts for students, and to represent psychoanalysis at national meetings of such groups as AADPRT. Despite these efforts, however, the problem of recruiting analysts to teach medical students remains. Although salaries, benefits, or even the prospect that all of their students will be eager to learn cannot be used to draw analysts to this work, other incentives are well within the realm of possibility. Medical school teaching can be linked more closely to advancement within both local institutes and The American. In the past, psychodynamic teaching in the medical schools was done mostly by voluntary faculty; the difference is that this teaching was valued. Too often today, faculty members, particularly younger ones, want to teach only advanced students. They perceive, often correctly, that this type of teaching is more likely to be recognized by the curriculum and executive committees of their institute. To remedy this, medical school teachers should be given recognition within the institute through the awarding of prizes and committee posts. Each institute could designate a member as liaison to area medical schools and establish a committee on medical school teaching. The role for psychoanalysts in standard general psychiatry courses should be stressed, as well as less traditional roles such as teaching medical interviewing and leading psychiatry clubs.
Arnold Cooper, current chair of CUME, describes the special joys and intellectual challenges of teaching bright young students who ask the kind of naive and “obvious” questions that can force us to rethink our conceptions. He reminds us that medical students are “extraordinarily
eager to learn, frightened of the responsibility they are assuming, and grateful for the understanding they can gain about their patients and themselves from a psychodynamically informed psychiatrist.” Apart from the issue of recruitment into psychoanalytic training, Cooper argues, analysts should be alert to any opportunity to play a vital role in the education of young doctors, helping them care for patients and thereby demonstrating the role that psychoanalysis can play in health care today. CUME, in step with The American's ongoing efforts to position psychoanalysis within a rapidly changing health care system, will soon be making recommendations on these issues to Board and Council.