Analysts began a new approach to teaching psychiatry residents in the fall of 1998 in a research project funded jointly by the American Psychoanalytic Foundation, the Cincinnati Psychoanalytic Institute, and the Research Fund of the American Psychoanalytic Association. Analysts from Cincinnati are teaching a two-year course in psychodynamic psychiatry to thirty psychiatry residents at the University of Kentucky using a low-cost, high-quality telemedicine system. The course follows a structured curriculum published by David Goldberg in the Journal of Psychotherapy Practice and Research (1998, vol. 7) that links the teaching of psychoanalytic concepts to the natural clinical experiences and developmental phases of residency education.
The project addresses a number of research questions. The overall goal is to determine if telemedicine is an effective method for teaching psychiatry residents psychoanalytic theory, psychodynamic formulation, and psychotherapy skills. Residents will be assessed on their core knowledge and clinical skills in psychodynamic psychiatry through formal testing as well as through assessment of their use of clinical material. The researchers will follow residents' satisfaction with the technology and the development and change in their career interests (especially regarding psychotherapy and psychoanalysis).
Although training in psychodynamic psychiatry is required for all psychiatry residents, few programs have studied how psychodynamic concepts are learned or applied. Because fewer and fewer analysts work at academic medical centers, the teaching and supervision of residents in many programs has been assumed by non-analytically trained faculty members. This is an especially difficult problem at universities in small to medium-size cities without an analytic institute or practicing analysts in town. It is further compounded at many programs by the lack of an organized teaching plan integrated with residents' natural clinical experiences. For instance, a course on psychoanalytic theory may be difficult to relate to the work residents are currently doing.
Several researchers have found that both the time allotted to teaching residents and the experience required of residents in analytically oriented psychotherapy have been markedly reduced. A 1988–89 survey reports a decline in all of the following:
Teaching time devoted to analytically oriented subject matter.
Analytically oriented resident caseloads.
The percentage of department chairs whose primary orientation is psychoanalytic.
The percentage of faculty who are graduates of an institute.
The percentage of residents who have had some form of personal treatment.
Although these findings are ten years old, it is likely that the numbers have worsened, given the current economic forces affecting departments of psychiatry, the dramatic reductions in insurance coverage for psychotherapy, the financial debt that many residents carry as they start training, and the emphasis on biological and brief psychotherapeutic treatments. Despite these worrisome statistics, a recent survey of educators and psychotherapy supervisors by the American Association of Psychiatric Residency Training strongly supports ongoing training and experience in psychodynamic psychotherapy.
When I simultaneously became residency training director in psychiatry at the University of Kentucky and a candidate at the Cincinnati Psychoanalytic Institute, I began to think about how to enhance psychotherapy teaching in a program without analysts. The hour-and-a-half commute from Cincinnati to Lexington seemed to be a severe hurdle for analysts coming in for weekly teaching. I contacted Rob Sprang, the head of the large telemedicine program at the University of Kentucky, to explore the possibility of teaching a psychotherapy course via telemedicine.
Telemedicine refers to the use of telecommunications technology to enhance health-care services. Most programs use interactive video technology to support patient care, teaching, research, or administrative programming, but telemedicine can be as simple as telephone-based “ask-a-nurse” programs or the 911 systems implemented in many areas.
The University of Kentucky Medical Center has an interactive two-way video telemedicine program that links seven regional medical centers, two primary care centers, and seventeen community mental health centers. The telemedicine network in Kentucky is a closed network, linked together by dedicated T-1 lines. Each partner site has spent from $50,000 to $150,000 to purchase equipment and connect to the network, and recurring monthly costs for these partner facilities range from $1,000 to $1,400. This network transmits at an extraordinarily high speed to provide flawless picture quality for a wide variety of administrative, educational, and clinical applications.
The ViaTV 8 x 8 system has proven a cost-effective means to deliver clinical and educational health-care services. It is available at retail audio/video stores for approximately $400 per unit. The technology is POTS (“plain old telephone service”)-based videoconferencing that can transmit fully interactive video and audio through a simple analog phone line.
Debra A. Katz, M.D., is the residency training director for the General Psychiatry and Child and Adolescent Psychiatry programs in the Department of Psychiatry, University of Kentucky College of Medicine. She is a second-year candidate at the Cincinnati Psychoanalytic Institute. Contact her by e-mail at .
This expands videoconferencing capability to anywhere that has a telephone line. The technology makes use of simple, readily available peripheral devices such as standard televisions, camcorders, and telephones and does not require the use of a computer. Because the system is operated from a telephone keypad, it requires minimal setup and training. The university, through Kentucky TeleCare, is using this system to provide physical and behavioral health-care services to nursing homes, public schools, and patients' homes as well as in this psychotherapy training project.
Although nothing has been published on how students acquire skills in psychodynamic psychiatry through telemedicine, the literature on a number of educational applications would support this possibility. These include continuing medical education (CME) courses, the transmission of grand rounds to distant sites, ongoing case conferences, and weekly seminars. The ability to enhance residency training with courses taught by expert teachers at distant sites is a developing area of tele-medicine application. If residents can learn material and develop clinical skills through telemedicine teaching, programs lacking expertise in important areas would be able to improve their offerings.
Beginning in September 1998, all psychiatry residents at the University of Kentucky are meeting in a classroom for one hour, once per week, for a total of thirty-six weeks over two years. This course in psychodynamic psychiatry follows the model curriculum developed by Goldberg and is being taught by Fedor Hagenauer and Edward Kohn from Cincinnati and Charles Brenner from New York via telemedicine. The course was designed as an introduction to the practice of psychodynamic psychotherapy for psychiatry residents with little to no psychotherapy experience.
Residents began with clinical techniques and conceptual frameworks that can be readily understood and applied to clinical work; they will then move to a more sophisticated theoretical understanding of the psychotherapy process, models of the mind, and psychotherapeutic interventions. The first stage of learning will concentrate on the basic conceptual framework of dynamic psychotherapy and the focus and goals of this form of treatment. The later parts of the course will focus more directly on the therapy process, dynamic formulations, and the beginning appreciation of defense and transference phenomena.
This approach enables residents to rapidly begin working with patients and helps them see the broad applications that psychodynamic thinking can bring to many aspects of general psychiatric clinical work. The course places less emphasis on theory than on gaining clinical skills and thinking psychodynamically, working with clinical experience from both students' and teachers' caseloads.
A large-screen television, external video camera, and high-quality speaker phone will be used along with the video system at the University of Kentucky and at either the Cincinnati Psychoanalytic Institute or Brenner's site in New York. A telemedicine technician will be present at the university site to operate the camera. This will enable residents asking questions or gesturing to be seen close-up by the teacher. Analysts and residents will be able to converse as they would in a regular classroom. Participants at each site will be able to adjust the view on their television screens to fit their preference (e.g., split screen to view both themselves and individuals at the other site, close-up of themselves, view of entire room at a distant site, etc.) A blackboard and equipment to transmit handwritten information or overheads will be readily available. VCRs will be available at both sites with which to view clinical material.
Through formal testing after teaching sessions and comparison of standardized yearly examinations for psychiatry residents, researchers will rigorously assess residents' core knowledge and clinical skills in psychodynamic psychiatry. Residents' written psychodynamic formulations in response to clinical material will be rated by blinded non-teaching analysts before and after each year of the course, using a structured scoring system. Residents' psychotherapy skills will be assessed using the Supervisor Report methodology. Ronald Krasner developed this instrument (published in Academic Psychiatry, 1992, vol. 16) and is serving as a consultant to this study. Residents' satisfaction with the technology will be assessed using a standardized satisfaction survey before and after the course. Residents will also be surveyed about career goals, biological or psychological orientation, and interest in psychotherapy and psychoanalytic training before and after the course.
Because this course uses a structured curriculum, it could easily be expanded to other teaching sites. If residents in this study demonstrate significant gains in psychodynamic knowledge and skills, analysts could begin to offer psychotherapy teaching and supervision through telemedicine to psychiatry residents or other mental health professionals. By exposure, analysts would begin to serve as role models and mentors to trainees who may not have had prior contact with analysts.
A number of other exciting educational opportunities might make use of telemedicine technology. These include accessing supervision, grand rounds, mentorship opportunities, organizational meetings, CME courses, and seminars at analytic institutes or academic medical centers. The American Psychoanalytic Foundation is purchasing a number of telemedicine units for a pilot project organized by Lee Shershow, chair of the Committee for New Psychoanalytic Centers. Analytic institutes in Portland, Ore., and Minneapolis have begun using this equipment to link candidates at these sites with classes at the San Francisco and Denver institutes, respectively.
Effective telemedicine teaching may have strong implications for the ability of analytic institutes to influence developing psychiatrists and other mental health professionals at critical points during their training, to stimulate residents' interest in psychotherapy and psychoanalysis, and to re-involve analysts in residency education.
Photo by Mervin S. Stewart