Each week, William Sledge, professor of psychiatry at Yale and a faculty member at the Western New England Psychoanalytic Institute, meets with a group of residents to go over their cases. Sledge interviews one of their most difficult patients and teaches interviewing skills and management techniques. Although the busy residents work in a high-volume urban clinic, they look forward to these weekly meetings with Sledge and give his conference consistently high marks. What, you may ask, is so unusual about a psychoanalyst conducting weekly case conferences with residents? Simply that these residents aren't psychiatric residents; they're medical residents working in primary care clinics at a VA hospital in West Haven, Connecticut, and at the Yale–New Haven Hospital.
Sledge is one of several psychoanalysts who spend at least part of their work week teaching in primary care settings. Not long ago, psychoanalysts taught in a myriad of such venues, including medical clinics, first- and second-year medical school courses, and community agencies. Yet with fewer and fewer analysts in full-time academic positions at medical schools, this type of teaching has diminished, and analysts have focused primarily on private practices and institute teaching. Meanwhile, the complexion of American medicine has once again shifted away from superspecialization, and training in primary care areas has risen in popularity and importance. More than ever, analysts who teach primary care physicians agree not only that they have much to offer these clinicians but also that this teaching is crucial to rebuilding the alliance between psychoanalysis and the medical community.
At Yale, Sledge is Associate Chair for Education in the department of psychiatry. He cites his interest in medicine and his enjoyment of his own medical internship as the impetus for his pursuit of projects that involve studying and teaching medical housestaff. After conducting research on the lives of medical interns, he began teaching PGY-1 psychiatric residents who were doing their medical internships. His seminars focused on such issues as the hateful patient, death and dying, and treatment of the elderly. Sledge found that residents were relieved to talk about these often neglected topics. The program was subsequently expanded to include all of the medical interns, and today Sledge conducts his weekly case conference for all of the residents doing their ambulatory medicine rotation in the primary care clinics of the VA hospital and at Yale–New Haven. He has written extensively on this work.
On the West Coast, Miriam Tasini approaches the primary care setting from a slightly different angle. Tasini, a senior faculty member at the Los Angeles Psychoanalytic Institute and Associate Professor of Psychiatry at UCLA, is director of consultation-liaison at the West L.A. VA hospital. She currently heads a unique program in which PGY-3 psychiatry residents rotate through the primary care clinic as psychiatric consultants and teachers. During their three-month rotation residents spend two days a week in the clinic, where they are supervised by Tasini and her staff on how best to communicate psychiatric and psychodynamic concepts to primary care clinicians. Tasini was also instrumental in developing a four-week rotation for internal medicine residents through the psychiatric consultation-liaison service. Designed to help them learn about psychiatric diagnosis and psychosomatics, the rotation also taught them about personality styles and individual coping skills.
New York Hospital's extensive training for primary care residents is also run by a psychoanalyst. Philip Luber, a psychoanalyst at the New York Psychoanalytic Institute and the Columbia University Center for Psychoanalytic Training and Research, is director of the hospital's training program in psychosocial medicine. The program, for primary care residents, traditional internal medicine residents, medical students, and hematology/oncology fellows, includes case-based seminars, psychosocial rounds, formal medical interviewing courses, and case presentations in which Milton Viederman, director of the consultation-liaison service and a training and supervising analyst at Columbia, interviews patients and teaches interviewing skills. Primary care residents have particularly extensive training in interviewing and, in addition, rotate through the outpatient psychiatry department. Luber not only directs these programs; he also teaches in them and, with a third-year psychiatric resident, coleads a group for somatizing patients. The program has been such a success in the hospital's department of medicine that the department of surgery is now interested in having its residents take similar training.
Although their programs differ, Luber, Tasini, and Sledge agree that psychoanalysts bring something unique to the teaching of primary care. Clearly, as psychiatrists, they can help primary care clinicians become more sensitive to such psychiatric diagnoses in their patients as dementia, depression, anxiety disorders, substance abuse, and character disorders. But as psychoanalysts they can do much more. Behind all of the programs described above is the desire to help primary care clinicians become more dynamically sophisticated with respect to their relationships with patients. For example, Sledge encourages residents to consider that patients do not always mean what they say, and to realize that a patient's professed chief complaint might not actually be what brought him or her into the office.
“When a patient says, ‘I'm not depressed,‘ the residents tend to leave it at that,” remarks Sledge. “They don't allow themselves to use other information. I encourage them to look beyond the words at facial expressions, body language, and other clues to the patient's deeper feelings.”
Tasini's interest in this work is rooted strongly in the idea that as a psychoanalyst she can offer primary care clinicians a richer understanding of human behavior. Her goal is to instill in residents the idea that each person is different, and to enable them to appreciate how the individual's personality and defenses affect the way he or she deals with illness. She encourages these primary care doctors to look beyond their own responses and to realize that not everyone deals with illness in the same way. “It's important for them to learn to diagnose,” Tasini comments, “but it's also important for them to identify the basic psychology of human beings.”
Luber, who has always enjoyed working with primary care doctors, says that his greatest satisfaction is “training doctors to be more empathic, psychologically minded clinicians.” His psychosocial rounds are designed to give primary care residents a chance to present problem patients who, for example, are somatizing, noncompliant, or drug-seeking; however, the “hidden agenda” is the physicians' countertransference toward their patients. In particular, he encourages residents
to talk about patients who make them angry, and he helps them to see that by acknowledging their feelings they can actually learn a great deal about what problems the patient may have. One of his techniques involves constructing a differential diagnosis for “patients who make us angry,” and reminding residents that in one study the most disliked patients were those suffering from undiagnosed dementia.
All of these analysts agree that the primary care physicians they teach appreciate the unique perspective analysts can offer them in work with patients. Luber feels that primary care clinicians are looking for just this type of approach. “A lot of primary care doctors,” he notes, “are turned off by psychiatrists, whom they view as not being very psychologically minded. They feel that ail psychiatrists do is make DSM-IV diagnoses and write prescriptions for Prozac. That doesn't really help them. We have the expertise to help them understand their patients' coping styles—for example, what predisposes a given patient to get depressed. We think psychologically, and they appreciate that.” Sledge finds that somehow the primary care physician attending in the clinic, who is not required to attend his seminars, nevertheless always seems to end up sitting in and listening attentively.
These educators know that teaching the principles of psychodynamics to primary care residents is not like teaching them to psychiatry residents. “Never use jargon,” warns Luber. “Everything you teach has to lead to practical management techniques.” Words like unconscious, transference, and countertransference have no place here; for Sledge the challenge is to put these concepts into words that primary care residents can understand and relate to nondefensively. “When I'd use the word unconscious, their eyes would glaze over,” muses Sledge. “Instead I ask about how people do things that they don't intend to do, or about ideas the patient may have but not be aware of.” He encourages psychoanalysts teaching in primary care settings to find out what language the residents are using and to stay with it; he remarks that “when you stay in their territory, things go very well.”
Tasini notes that she is basically teaching the principles of ego psychology, though with a different lexicon. “You have to keep everything in everyday English,” she advises. “You don't say ‘ego function’; you say ‘coping skills.‘ You have to stay away from sounding like an analyst—people feel patronized and it antagonizes them.”
Luber stresses the need to teach in tandem with primary care instructors. He relies strictly on a team teaching approach, coleading every seminar and discussion session with a primary care internist. This integrated technique makes the psychoanalyst a more legitimate member of the team and lends him or her greater credibility in the eyes of trainees. Interestingly, Luber often finds his coleader asking residents how they feel about their patients and asking them as well for differential diagnoses.
Psychoanalysts can offer the primary care physicians they teach information about making psychiatric diagnoses, insight into their patients' behavior, and, most important, increased understanding of their reactions to their patients. However, teaching in primary care settings can also offer a great deal to psychoanalysts. Luber, Tasini, and Sledge enjoy their work and feel it is a good way of keeping in touch with mainstream medicine.
For Luber, who considered a career in internal medicine, his work offers him an excellent means of combining his interests in medicine and psychiatry. Many analysts with medical training may feel isolated from the medical profession at large, and even an hour a week teaching medical interviewing may help reconnect them to the world of clinical medicine. “It's a way of keeping in touch with medicine,” remarks Sledge. Tasini finds great satisfaction in realizing that she has had a role in sensitizing developing clinicians to the psychodynamics of their patients. “It is a most rewarding experience,” she notes, “to receive a request for consultation from a former student that indicates that he or she understands the dynamics of the situation.” Luber remarks that he receives many requests for consultations from primary care clinicians, not only for their patients, but also for themselves, their families, and their friends, reminding us that this type of teaching can yield interesting referrals.
Yet these clinicians are keenly aware that the importance of what they do extends beyond their individual needs to the future of psychoanalysis as a whole. With the possibility that primary care providers will function as the gatekeepers of American medicine, it is essential not only that these clinicians have a clear understanding of what psychoanalysts do, but also that they value what psychoanalysis can offer their patients and themselves. Only psychoanalysts can provide this information to primary care providers. Sledge stresses that teaching primary care clinicians, particularly residents and students, is an important component of this process because it puts psychoanalysts in a setting in which they can demonstrate their expertise.
“When a psychoanalyst provides these clinicians practical information that they can understand and use, it's not lost on them,” states Sledge. “I'm providing something that's valued and respected and that helps people understand what psychoanalysts do.”
Tasini believes strongly that this type of teaching activity is crucial to the future of psychoanalysis. Analysts, she says, must “become involved in disseminating psychoanalytic ideas by participating in the training of primary care physicians. Not only will the understanding of intrapsychic factors significantly change and improve the ability of these practitioners to care for their patients, but hopefully it will help psychoanalysis once again become part of the mainstream of medicine.” She feels that in order for psychoanalysts to regain credibility among their medical and surgical colleagues, they have to think of themselves as more than analysts. “You have to be a doctor, a psychiatrist, and a psychoanalyst all at the same time,” she notes.
Luber feels that analysts have met resistance in the medical community by isolating themselves, a policy he considers “disastrous.” He believes that just as in the analysis of our patients we have to deal with resistance and foster the therapeutic alliance, so we have to understand the resistance of the medical community to psychoanalysis and build alliances with our medical colleagues. He finds he has tremendous difficulty recruiting analysts to volunteer a mere six hours per year teaching primary care residents, and he thinks this is due both to a lack of understanding about how important this work is and to a general feeling among psychoanalysts that they are not part of the general medical community.
“We have to work with them and collaborate with them,” he stresses. “We have to meet them where they are and deal with their fears.” If that is the prescription, it is certainly something we are well trained to do.