Nearly 20,000 new medical students matriculate at U. S. medical schools each year. They represent our future medical colleagues and referral sources, as well as potential psychiatric colleagues and even psychoanalytic candidates. Two psychoanalysts and a recent candidate describe the relevance of psychoanalysis for their work with medical students. We hope that you enjoy these accounts and that they inspire you to volunteer at your local medical school.
One of my earliest medical school memories is the day my Clinical Practice small group convened in that first fall soon after orientation. Clinical Practice was a course that brought together the content areas of patient interviewing, health systems, and behavior change with the process of working with peers, witnessing one another at work, providing feedback, and reflecting on one's strengths and weaknesses. The course, very much informed by Rita Charon's work in narrative medicine, challenges students to engage deeply and authentically with one another and asks of the preceptor to build a safe space in which this work can unfold. Every medical school has some version of a course like this, often known as a course on “doctoring.”
On that first day, I did not know my classmates yet and we needed a little nudge to get talking. Our preceptor was a young psychiatrist and he gently and almost imperceptibly began the process of helping us to construct a safe environment in which we could trust one another and confide that, though we were generally enthusiastic to begin our training, many of us had the feeling that we did not know quite what we had gotten ourselves into. Our preceptor helped us normalize these anxieties for one another and allowed us to move forward in our development as doctors-to-be.
A few years later, near the end of my residency, I had the opportunity to become a preceptor in the course, now known as the Foundations of Clinical Medicine. I have been reflecting on what skills those of us trained in psychoanalysis and psychodynamics have that make us particularly well suited to teach these small group courses. Many educators and social psychologists have commented on the importance of group dynamics in teaching, so I will focus on a few psychodynamic principles that have been particularly helpful to me in my work.
On the whole, medical students have tremendous intellectual and psychological resources that can enrich group process. A strong alliance with the group allows students to overcome a certain amount of performance anxiety that is ubiquitous and to contribute to discussions. I have found that maintaining a relatively neutral position in many classroom debates helps to bring the students' multiple perspectives into words. I have also found that a degree of abstinence, particularly in affectively charged group silences, can be useful in allowing the group to contend with their feelings in class.
Every small group has its outspoken members and its shy members, the consensus builders and the strident debaters. Recognizing the prominent transferences at play at any given time can help the facilitator enrich the group process. When I suspect a shy student is quiet because he fears criticism, I might say, “Some of you are keeping the best insights to yourselves.” The range of transferences that come up in the group are rich and varied.
The analyst-teacher has many other skills to offer students and the students reciprocate in spades. I have been very gratified to develop from student to teacher and highly recommend the experience.
My first teaching opportunity came, as a high school senior, when my Latin teacher had to attend a week-long conference, and I was invited to substitute teach the second-year Latin students. Since then, teaching has been an important part of my life. Thus, when, in my last year of residency, there was an opportunity to teach medical students I jumped at it. I have been teaching medical students for more than 20 years, and it is one of the most enjoyable and rewarding parts of my career. It is also an opportunity to re-experience the beginning of medical education.
Janis L. Cutler, M.D., chairs APsaA's Committee on Medical Student Education, is professor of clinical psychiatry and psychiatry clerkship director at Columbia University College of Physicians & Surgeons, and faculty at Columbia University Center for Psychoanalytic Training and Research.
Margaret Hamilton, M.D., is an associate clinical professor of psychiatry at Columbia University College of Physicians & Surgeons and associate director of the Columbia University Center for Psychoanalytic Training and Research.
Jonathan M. Amiel, M.D., is an assistant professor of clinical psychiatry and associate dean for curricular affairs at Columbia University College of Physicians & Surgeons. He was recently a candidate at the Columbia University Center for Psychoanalytic Training and Research.
Andrew C. Furman, M.D., is an associate professor of psychiatry and behavioral sciences at Emory University School of Medicine and an associate teaching analyst at Emory University Psychoanalytic Institute.
One of the most important skills physicians bring to our work is the ability (and enjoyment) of listening to our patients. We begin to understand why they sought our help. It is important, not only to understand their medical problems, but also to understand these problems in the context of the whole person—their bodies, their families, their psyches, their personal histories—their lives. This is not only a skill that must be learned (and taught), it is a privilege of the work we do.
For some physicians, this skill comes easily, based on something innate or experiences in their past lives; for others it must be learned; for all, it can be improved upon over time. Those who learn it well become better physicians, more able to help their patients and less likely to get bored as they age. Our training as psychoanalysts focuses on this kind of intense listening. Our unique skills make us ideal teachers for young physicians in the art and science of listening. Analysts are an important resource in medical education.
For most medical students, the introduction to a psychiatry course is not only their first exposure to psychiatry, but for many it is also their first exposure to interviewing patients. While the class is designed to teach them about psychiatric illness and diagnosis, it is also an opportunity to introduce the students to a way of thinking about patients, not simply as a list of symptoms, but as individuals with unique histories and lives that determine their reactions to their illnesses. It is not really useful for either physicians or patients to get entrapped in the “disease” model. “I just saw a myocardial infarction.” “I am a diabetic.” The human beings, physician and patient have disappeared. This introductory psychiatry course enables students to become better physicians. I make the point to my students that my goal is to help all of them, whatever type of physician they want to be, to learn how better to listen to their patients. This ability to listen will enable them to diagnose and care for their patients more skillfully, effectively, and humanely.
Medical students (and others) are often anxious in the presence of psychiatric patients. They don't know what to expect; they don't know how to act. My task is to humanize these patients for the students; to help the students see that psychiatric patients are individuals. Their illnesses have varying degrees of severity, but all of them can benefit from being listened to and understood. This will enable these future physicians to reduce some of the stigma of mental illness that unfortunately is so prevalent in our society.
What can a psychoanalyst teach medical students about ascending cholangitis? More than you might initially imagine. Approximately seven years ago, the Emory University School of Medicine made a significant change to its curriculum, a change designed to expose the medical students to clinical work earlier in their career and to move away from the traditional two years of basic sciences followed by two years on the “wards.” Fundamental to this change was an integration of the clinical and the basic sciences and a shift from primarily lecture-based teaching to small group interactions with an emphasis on problem-based and group-based learning. From the first day of school, students were assigned to a small group with whom they would meet regularly, often two to three times a week over their medical school years, to learn from each other and from a small group adviser. The adviser's role was to guide the students as they became doctors, learning about history taking and the physical examination, anatomy and pathophysiology, as well as what it meant to become a physician and to care for another in a meaningful and therapeutic way.
As a psychiatric and psychoanalytic educator, I jumped at the chance to move out of my comfort zone and into the world of general medical education. My peers were mostly internists; I was the sole psychiatrist. Although I initially questioned what I could bring to the table, after all, we would be spending exponentially more time on pulmonary medicine, or gastroenterology or endocrinology, than we would on psychiatry, let alone dynamic psychotherapy, I realized that as a psychiatrist and psychoanalyst, I had certain skills and stood at a certain vantage point that could be uniquely helpful. My not being an expert was to my advantage. I could model and explore how a physician thinks and struggles through problems, how we relate to patients and families, how we wrestle with death and with nakedness and with anger, without necessarily knowing the answers. I viewed myself as a guide for learning and for forming an identity, not as the giver of received wisdom or the arbiter of arcana. This stance, not unlike the therapeutic stance we know well from our own clinical experience, promoted their growth as physicians. They could be dumb with me, or afraid, or triumphant, or mortified. All the while, they learned about illness and suffering and science and themselves.
As for psychoanalytic ideas proper, I integrated core dynamic principles into our thinking about patients and their illnesses, the doctor-patient relationship, and the myriad of feelings that emerge in the process. The concepts of resistance, transference and countertransference, and unconscious forces and motivations are all of importance in thinking through the clinical encounter. My goal has not been for the students to think of these ideas as psychoanalytic, but as part and parcel of the human condition and necessary for good doctoring. I rarely discuss psychoanalysis proper; my agenda is different. I want my students to think of these ideas as normal and commonplace and helpful. Not as only a part of an esoteric and sometimes baffling therapy, but as ideas that are ubiquitous and natural. I do, of course, slip. I cannot help but mention that the eponymous Charcot's triad (of ascending cholangitis) is named for the same man who so heavily influenced Freud in his work on hysteria.
I have found these experiences to be profoundly rewarding and urge other analysts, if given the opportunity, to get involved in medical education. The change in the students over the four or more years is astounding, all the more so because they have been shaped and informed by dynamic ideas. The students have not become analysts. They have become better doctors.
Editor's Note: For more information, contact Janis L. Cutler at .